Arthur Kellermann
Encyclopedia
Dr. Arthur L. Kellermann, M.D., M.P.H., F.A.C.E.P. (born 1955) was recently named the Director of RAND
Health. He was the founding chairman of the department of Emergency Medicine
at Emory University
in Atlanta, Georgia
, USA, and founding director of the Center for Injury Control at Rollins School of Public Health
, a collaborating center for injury and violence prevention of the World Health Organization
. His writings include more than 200 scientific and lay publications on various aspects of emergency cardiac care, health services research, injury prevention
and the role of emergency department
s in the provision of health care
to the poor.
Kellermann co-chaired the Committee on the Consequences of Uninsurance of the Institute of Medicine
of the United States National Academies
, of which he is an elected member. Kellermann holds career achievement awards for excellence in science from the Society for Academic Emergency Medicine, and the Injury Control and Emergency Health Services Section of the American Public Health Association
. As a 2006-2007 Robert Wood Johnson Foundation
Health Policy Fellow, he joined the Professional Staff of the United States House Committee on Oversight and Government Reform in Washington, D.C. In 2007 he was presented with the John G. Wiegenstein Leadership Award by the American College of Emergency Physicians
, their highest award.
Kellermann is well known for his research on the epidemiology
of firearm related injuries and deaths. In a 1995 interview, Kellermann saw firearm and other injuries not as random, unavoidable acts but as preventable public health priorities: "I grew up around gun
s. My dad taught me how to shoot when I was eleven or twelve years old. Firearms are fascinating pieces of equipment. I enjoy the sport of shooting
, although I rarely shoot anymore. However, as a clinician, as someone who is committed to emergency medicine, it is equally evident to me that firearm violence is wreaking havoc on public health
."
In this polarized debate, Kellermann’s studies quantifying the risk of mortality associated with gun ownership attracted criticism from pro-gun organizations and individuals. The National Rifle Association
of America contends that Dr Kellermann “severely understates defensive uses of guns,” and that his “conclusions provide anti-gunners propaganda.” Kellermann’s findings have been linked to the June, 1996 Republican-led decision of the U.S. House Appropriations Committee to strip US$2.6 million from the budget of the National Center for Injury Prevention and Control at the U.S. Centers for Disease Control – the exact amount previously set aside for NCIPC/CDC research into the causes and effects of firearm-related death and injury.
He concluded that "the advisability of keeping firearms in the home for protection must be questioned". Critics of this study noted that it was restricted to firearm-related deaths, effectively excluding incidents in which gun owners used their firearm to injure and frighten away an intruder. But the study also excluded incidents in which individuals were non-fatally injured in a firearm accident, criminal assault or suicide attempt, as well as instances in which a homeowner used a gun to threaten or terrorize another member of the household, as sometimes occurs in the context of domestic violence. A subsequent Kellermann-led study identified both fatal and nonfatal injuries occurring in homes in 3 cities – Seattle WA, Memphis TN, and Galveston TX. It noted that for every time a gun in the home was used in a self defense or legally justifiable shooting, there were four accidental shootings, seven criminal assaults or homicides, and 11 attempted or completed suicides. (J of Trauma, August, 1998. pp: 263-267). He then developed the now much disputed 43:1 ratio that states every time a gun is used in self-defense, it is 43 times more likely to be used in a homicide, suicide, or accidental shooting.
, burglaries
, assault
s, and homicide
s in Seattle, Washington
and Vancouver, British Columbia, a city "similar to Seattle in many ways" that had "adopted a more restrictive approach to the regulation of handguns
." The study found that
The study concluded that restricting access to handguns may reduce the rate of homicide in a community by reducing the lethality of assaults.
study
of the rates of all homicides in the victim's home in Cleveland, Ohio
, Memphis, Tennessee
, and Seattle over five years, in homes where a gun was kept versus homes where a gun was not. This study found that
These results confirmed the 1986 finding that, in the net, a firearm in the home represents a greater risk overall than the protection it may offer against intruders, either indirectly or by discouraging potential assaults. Kellermann noted that the study demonstrates the pervasiveness of domestic assault, as compared to better publicized crimes such as home invasion
, but continued to stress the role of handguns in increasing the lethality of such assaults.
Critics of Kellermann's 1993 paper responded with a number of objections, some accurate (e.g. the study population was urban and therefore higher risk in general, compared to suburban or rural areas; that residents of homes where there is a risk of fatal domestic violence typically are more aware of the fact than external researchers), and some inaccurate (e.g. that members of rival gangs were tabulated as "family member or intimate acquaintance"; that the data was cherry-picked). Particular attention was paid to the fact that Kellermann did not release his data immediately upon publication. SUNY-Buffalo's Lawrence Southwick, among others, publicly speculated "that Kellermann's full data set would actually vindicate defensive gun ownership." http://www.reason.com/9704/fe.cdc.html
However, Centers for Disease Control and Prevention
grants do not require the individual investigator to make data public until there are no more publications to be developed from them. After publishing additional analyses, Kellermann released the dataset to the Inter-university Consortium for Political and Social Research
, the world’s largest archive for social science research http://www.icpsr.umich.edu/. ICPSR released the data for public access on May 30, 1997 http://search.icpsr.umich.edu/ICPSR/query.html?nh=25&rf=0&ws=0&ty0=w&tx0=kellerman&fl0=&col=website&col=abstract&col=series&op0=%2B&tx1=ICPSR&op1=%2B&fl1=archive%3A&ty1=w&tx2=restricted&op2=-&fl2=availability%3A&ty2=w
In 1996, lobbyists for the National Rifle Association
began pressuring Congress to eliminate the CDC’s National Center for Injury Prevention and Control (NCIPC) which had funded much of Kellermann’s research. Although the effort was ultimately unsuccessful, the House voted to cut the NCIPC’s funding by $2.6 million, precisely the amount it had spent on the firearms research the previous year. http://www.washingtonpost.com/wp-srv/national/longterm/trigger/trigger1.htm. The money was ultimately restored by the Senate, but earmarked for traumatic brain injury prevention. The final appropriation language included the following statement: “[N]one of the funds made available for injury control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control”. These words appear in every CDC grant announcement to this day. http://www.cdc.gov/about/business/funding.htm
and public health
, including studies of emergency cardiac care, use of diagnostic technologies in the emergency department, and a promising treatment for traumatic brain injury. He has also published research on the role of emergency departments in providing health care to the poor, the role of insurance http://www.kaisernetwork.org/health_cast/uploaded_files/Kellermann_Testimony.pdf and the situation of the uninsured http://energycommerce.house.gov/107/hearings/02282002Hearing499/Kellermann839.htm. In recent years, he has written about domestic preparedness to respond to different forms of terrorism http://www.washingtonpost.com/wp-dyn/content/article/2005/08/04/AR2005080401826.html. Kellermann was very instrumental in the planning and implementation of the American Heart Association's "Racing the Clock to Restart Atlanta's Hearts" initiative, one of the largest cardiopulmonary resuscitation and automated external defibrillator programs in the nation. He also played an important role in the Institute of Medicine
’s three-volume report on the Future of Emergency Care in the United States, http://www.iom.edu/emergencycare.
RAND
RAND Corporation is a nonprofit global policy think tank first formed to offer research and analysis to the United States armed forces by Douglas Aircraft Company. It is currently financed by the U.S. government and private endowment, corporations including the healthcare industry, universities...
Health. He was the founding chairman of the department of Emergency Medicine
Emergency medicine
Emergency medicine is a medical specialty in which physicians care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute...
at Emory University
Emory University
Emory University is a private research university in metropolitan Atlanta, located in the Druid Hills section of unincorporated DeKalb County, Georgia, United States. The university was founded as Emory College in 1836 in Oxford, Georgia by a small group of Methodists and was named in honor of...
in Atlanta, Georgia
Atlanta, Georgia
Atlanta is the capital and most populous city in the U.S. state of Georgia. According to the 2010 census, Atlanta's population is 420,003. Atlanta is the cultural and economic center of the Atlanta metropolitan area, which is home to 5,268,860 people and is the ninth largest metropolitan area in...
, USA, and founding director of the Center for Injury Control at Rollins School of Public Health
Rollins School of Public Health
The Rollins School of Public Health is the public health school of Emory University. Founded in 1990, RSPH has more than 850 students pursuing master's degrees and over 100 students pursuing doctorate degrees...
, a collaborating center for injury and violence prevention of the World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
. His writings include more than 200 scientific and lay publications on various aspects of emergency cardiac care, health services research, injury prevention
Injury prevention
Injury prevention are efforts to prevent or reduce the severity of bodily injuries caused by external mechanisms, such as accidents, before they occur. Injury prevention is a component of safety and public health, and its goal is to improve the health of the population by preventing injuries and...
and the role of emergency department
Emergency department
An emergency department , also known as accident & emergency , emergency room , emergency ward , or casualty department is a medical treatment facility specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance...
s in the provision of health care
Health care
Health care is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers...
to the poor.
Kellermann co-chaired the Committee on the Consequences of Uninsurance of the Institute of Medicine
Institute of Medicine
The Institute of Medicine is a not-for-profit, non-governmental American organization founded in 1970, under the congressional charter of the National Academy of Sciences...
of the United States National Academies
United States National Academies
The United States National Academies comprises four organizations:* National Academy of Sciences * National Academy of Engineering * Institute of Medicine * National Research Council...
, of which he is an elected member. Kellermann holds career achievement awards for excellence in science from the Society for Academic Emergency Medicine, and the Injury Control and Emergency Health Services Section of the American Public Health Association
American Public Health Association
The American Public Health Association is Washington, D.C.-based professional organization for public health professionals in the United States. Founded in 1872 by Dr. Stephen Smith, APHA has more than 30,000 members worldwide...
. As a 2006-2007 Robert Wood Johnson Foundation
Robert Wood Johnson Foundation
The Robert Wood Johnson Foundation is the United States' largest philanthropy devoted exclusively to health and health care; it is based in Princeton, New Jersey. The foundation's mission is to improve the health and health care of all Americans...
Health Policy Fellow, he joined the Professional Staff of the United States House Committee on Oversight and Government Reform in Washington, D.C. In 2007 he was presented with the John G. Wiegenstein Leadership Award by the American College of Emergency Physicians
American College of Emergency Physicians
The American College of Emergency Physicians is the first and largest professional organization of emergency medicine physicians in the United States. It was founded in 1968 and is now headquartered in Irving, Texas. As of 2009 ACEP has over 28,000 physician members.The college exists to support...
, their highest award.
Kellermann is well known for his research on the epidemiology
Epidemiology
Epidemiology is the study of health-event, health-characteristic, or health-determinant patterns in a population. It is the cornerstone method of public health research, and helps inform policy decisions and evidence-based medicine by identifying risk factors for disease and targets for preventive...
of firearm related injuries and deaths. In a 1995 interview, Kellermann saw firearm and other injuries not as random, unavoidable acts but as preventable public health priorities: "I grew up around gun
Gun
A gun is a muzzle or breech-loaded projectile-firing weapon. There are various definitions depending on the nation and branch of service. A "gun" may be distinguished from other firearms in being a crew-served weapon such as a howitzer or mortar, as opposed to a small arm like a rifle or pistol,...
s. My dad taught me how to shoot when I was eleven or twelve years old. Firearms are fascinating pieces of equipment. I enjoy the sport of shooting
Shooting sports
A shooting sport is a competitive sport involving tests of proficiency using various types of guns such as firearms and airguns . Hunting is also a shooting sport, and indeed shooting live pigeons was an Olympic event...
, although I rarely shoot anymore. However, as a clinician, as someone who is committed to emergency medicine, it is equally evident to me that firearm violence is wreaking havoc on public health
Public health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" . It is concerned with threats to health based on population health...
."
In this polarized debate, Kellermann’s studies quantifying the risk of mortality associated with gun ownership attracted criticism from pro-gun organizations and individuals. The National Rifle Association
National Rifle Association
The National Rifle Association of America is an American non-profit 501 civil rights organization which advocates for the protection of the Second Amendment of the United States Bill of Rights and the promotion of firearm ownership rights as well as marksmanship, firearm safety, and the protection...
of America contends that Dr Kellermann “severely understates defensive uses of guns,” and that his “conclusions provide anti-gunners propaganda.” Kellermann’s findings have been linked to the June, 1996 Republican-led decision of the U.S. House Appropriations Committee to strip US$2.6 million from the budget of the National Center for Injury Prevention and Control at the U.S. Centers for Disease Control – the exact amount previously set aside for NCIPC/CDC research into the causes and effects of firearm-related death and injury.
Kellermann's published studies on gun ownership
Kellermann states that as an emergency room doctor, he noted that the number of gunowners injured by their own gun or that of a family member seemed to greatly outnumber the number of intruders shot by the gun of a homeowner, and therefore he determined to study whether or not this was in fact true.1986
In his first publication on the subject, in 1986, Kellermann studied all gunshot related deaths in Seattle over six years, and found that- 54% of firearm-related deaths occurred in the home where the gun was kept
- 70.5% of these (firearm-related deaths in the home where the gun was kept) involved handgunHandgunA handgun is a firearm designed to be held and operated by one hand. This characteristic differentiates handguns as a general class of firearms from long guns such as rifles and shotguns ....
s - 0.5% of these (firearm-related deaths in the home where the gun was kept) involved an intruder shot while attempting entry
- 1.8% of these (firearm-related deaths in the home where the gun was kept) were judged by police as self-defense
- there were 1.3 times as many accidental firearm-related deaths in the home where the gun was kept as self-protection shootings
- there were 4.6 times as many criminal firearm-related homicides in the home where the gun was kept as self-protection shootings
- there were 37 times as many suicideSuicideSuicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...
s in the home where the gun was kept as self-protection shootings.
He concluded that "the advisability of keeping firearms in the home for protection must be questioned". Critics of this study noted that it was restricted to firearm-related deaths, effectively excluding incidents in which gun owners used their firearm to injure and frighten away an intruder. But the study also excluded incidents in which individuals were non-fatally injured in a firearm accident, criminal assault or suicide attempt, as well as instances in which a homeowner used a gun to threaten or terrorize another member of the household, as sometimes occurs in the context of domestic violence. A subsequent Kellermann-led study identified both fatal and nonfatal injuries occurring in homes in 3 cities – Seattle WA, Memphis TN, and Galveston TX. It noted that for every time a gun in the home was used in a self defense or legally justifiable shooting, there were four accidental shootings, seven criminal assaults or homicides, and 11 attempted or completed suicides. (J of Trauma, August, 1998. pp: 263-267). He then developed the now much disputed 43:1 ratio that states every time a gun is used in self-defense, it is 43 times more likely to be used in a homicide, suicide, or accidental shooting.
1988
In 1988, Kellermann published a study comparing robberiesRobbery
Robbery is the crime of taking or attempting to take something of value by force or threat of force or by putting the victim in fear. At common law, robbery is defined as taking the property of another, with the intent to permanently deprive the person of that property, by means of force or fear....
, burglaries
Burglary
Burglary is a crime, the essence of which is illicit entry into a building for the purposes of committing an offense. Usually that offense will be theft, but most jurisdictions specify others which fall within the ambit of burglary...
, assault
Assault
In law, assault is a crime causing a victim to fear violence. The term is often confused with battery, which involves physical contact. The specific meaning of assault varies between countries, but can refer to an act that causes another to apprehend immediate and personal violence, or in the more...
s, and homicide
Homicide
Homicide refers to the act of a human killing another human. Murder, for example, is a type of homicide. It can also describe a person who has committed such an act, though this use is rare in modern English...
s in Seattle, Washington
Seattle, Washington
Seattle is the county seat of King County, Washington. With 608,660 residents as of the 2010 Census, Seattle is the largest city in the Northwestern United States. The Seattle metropolitan area of about 3.4 million inhabitants is the 15th largest metropolitan area in the country...
and Vancouver, British Columbia, a city "similar to Seattle in many ways" that had "adopted a more restrictive approach to the regulation of handguns
Gun control
Gun control is any law, policy, practice, or proposal designed to restrict or limit the possession, production, importation, shipment, sale, and/or use of guns or other firearms by private citizens...
." The study found that
- both cities had similar rates of burglary and robbery
- in Seattle, the total rate of assaults with any weapon was modestly higher than that in Vancouver
- rates of homicide by means other than guns were not substantially different in the two study communities
- the rate of assaults involving firearms was seven times higher in Seattle than in Vancouver
- the rate of being murdered by a handgun was 4.8 times higher in Seattle than in Vancouver.
The study concluded that restricting access to handguns may reduce the rate of homicide in a community by reducing the lethality of assaults.
1993
In 1993, Kellermann responded to the criticism of his 1986 paper with a case-controlCase-control
A case-control study is a type of study design in epidemiology. Case-control studies are used to identify factors that may contribute to a medical condition by comparing subjects who have that condition with patients who do not have the condition but are otherwise similar .Case-control studies are...
study
of the rates of all homicides in the victim's home in Cleveland, Ohio
Cleveland, Ohio
Cleveland is a city in the U.S. state of Ohio and is the county seat of Cuyahoga County, the most populous county in the state. The city is located in northeastern Ohio on the southern shore of Lake Erie, approximately west of the Pennsylvania border...
, Memphis, Tennessee
Memphis, Tennessee
Memphis is a city in the southwestern corner of the U.S. state of Tennessee, and the county seat of Shelby County. The city is located on the 4th Chickasaw Bluff, south of the confluence of the Wolf and Mississippi rivers....
, and Seattle over five years, in homes where a gun was kept versus homes where a gun was not. This study found that
| Variable | Adjusted Odds Ratio | 95% CI |
|---|---|---|
| Any household member used illicit drugs | 5.7 | 2.6-12.6 |
| Home rented | 4.4 | 2.3-8.2 |
| Any household member hit or hurt in a fight in the home | 4.4 | 2.2-8.8 |
| Case subject or control lived alone | 3.7 | 2.1-6.6 |
| Gun or guns kept in the home | 2.7 | 1.6-4.4 |
| Any household member arrested | 2.5 | 1.6-4.1 |
- 23.9% of homicides occurred in the victim's home
- 35.8% of the controls (homes where there was not a homicide) kept a firearm in their home
- 45.4% of all victims of homicides in their home kept a firearm in their home
- 62% of victims of firearm homicides in their home kept a firearm in their home (correction to original paper)
- other protective measures, (reinforced doors, deadbolts, burglar alarms, and bars on the windows) were associated with small (about 0.8 times) reductions in risk of homicide in the home
- after adjusting for other factors (such as a police-report history of violence in the home, a convicted felon in the home, drug or alcohol abuse in the home, race, etc.) there remained an independent 2.7 times increase in risk of homicide, specifically associated with a firearm in the home; this risk was not attributable to any particular "high risk" subgroup(s) identifiable by the above factors but was evident to some degree in all subgroups
- this risk was essentially entirely attributable to being shot by a family member or intimate acquaintance with a handgun which was kept loaded and unlocked in the house
- this risk was significantly less than the increased risk due to sociological factors (rental of a home instead of ownership, living alone) but close to that associated with the presence of a convicted felon in the home (see table at right).
These results confirmed the 1986 finding that, in the net, a firearm in the home represents a greater risk overall than the protection it may offer against intruders, either indirectly or by discouraging potential assaults. Kellermann noted that the study demonstrates the pervasiveness of domestic assault, as compared to better publicized crimes such as home invasion
Home invasion
Home invasion is the act of illegally burgling or entering a private and occupied dwelling for the purpose of committing a crime Home invasion is the act of illegally burgling or entering a private and occupied dwelling for the purpose of committing a crime Home invasion is the act of illegally...
, but continued to stress the role of handguns in increasing the lethality of such assaults.
Critics of Kellermann's 1993 paper responded with a number of objections, some accurate (e.g. the study population was urban and therefore higher risk in general, compared to suburban or rural areas; that residents of homes where there is a risk of fatal domestic violence typically are more aware of the fact than external researchers), and some inaccurate (e.g. that members of rival gangs were tabulated as "family member or intimate acquaintance"; that the data was cherry-picked). Particular attention was paid to the fact that Kellermann did not release his data immediately upon publication. SUNY-Buffalo's Lawrence Southwick, among others, publicly speculated "that Kellermann's full data set would actually vindicate defensive gun ownership." http://www.reason.com/9704/fe.cdc.html
However, Centers for Disease Control and Prevention
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention are a United States federal agency under the Department of Health and Human Services headquartered in Druid Hills, unincorporated DeKalb County, Georgia, in Greater Atlanta...
grants do not require the individual investigator to make data public until there are no more publications to be developed from them. After publishing additional analyses, Kellermann released the dataset to the Inter-university Consortium for Political and Social Research
Inter-university Consortium for Political and Social Research
ICPSR, the Inter-university Consortium for Political and Social Research, was established in 1962. An integral part of the infrastructure of social science research, ICPSR maintains and provides access to a vast archive of social science data for research and instruction , and offers in...
, the world’s largest archive for social science research http://www.icpsr.umich.edu/. ICPSR released the data for public access on May 30, 1997 http://search.icpsr.umich.edu/ICPSR/query.html?nh=25&rf=0&ws=0&ty0=w&tx0=kellerman&fl0=&col=website&col=abstract&col=series&op0=%2B&tx1=ICPSR&op1=%2B&fl1=archive%3A&ty1=w&tx2=restricted&op2=-&fl2=availability%3A&ty2=w
In 1996, lobbyists for the National Rifle Association
National Rifle Association
The National Rifle Association of America is an American non-profit 501 civil rights organization which advocates for the protection of the Second Amendment of the United States Bill of Rights and the promotion of firearm ownership rights as well as marksmanship, firearm safety, and the protection...
began pressuring Congress to eliminate the CDC’s National Center for Injury Prevention and Control (NCIPC) which had funded much of Kellermann’s research. Although the effort was ultimately unsuccessful, the House voted to cut the NCIPC’s funding by $2.6 million, precisely the amount it had spent on the firearms research the previous year. http://www.washingtonpost.com/wp-srv/national/longterm/trigger/trigger1.htm. The money was ultimately restored by the Senate, but earmarked for traumatic brain injury prevention. The final appropriation language included the following statement: “[N]one of the funds made available for injury control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control”. These words appear in every CDC grant announcement to this day. http://www.cdc.gov/about/business/funding.htm
Other work
Firearm injury prevention research accounts for a minority of Kellermann’s research output. Only 30 percent of his papers address the issue. He has published extensively in other areas of emergency medicineEmergency medicine
Emergency medicine is a medical specialty in which physicians care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute...
and public health
Public health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" . It is concerned with threats to health based on population health...
, including studies of emergency cardiac care, use of diagnostic technologies in the emergency department, and a promising treatment for traumatic brain injury. He has also published research on the role of emergency departments in providing health care to the poor, the role of insurance http://www.kaisernetwork.org/health_cast/uploaded_files/Kellermann_Testimony.pdf and the situation of the uninsured http://energycommerce.house.gov/107/hearings/02282002Hearing499/Kellermann839.htm. In recent years, he has written about domestic preparedness to respond to different forms of terrorism http://www.washingtonpost.com/wp-dyn/content/article/2005/08/04/AR2005080401826.html. Kellermann was very instrumental in the planning and implementation of the American Heart Association's "Racing the Clock to Restart Atlanta's Hearts" initiative, one of the largest cardiopulmonary resuscitation and automated external defibrillator programs in the nation. He also played an important role in the Institute of Medicine
Institute of Medicine
The Institute of Medicine is a not-for-profit, non-governmental American organization founded in 1970, under the congressional charter of the National Academy of Sciences...
’s three-volume report on the Future of Emergency Care in the United States, http://www.iom.edu/emergencycare.