Monday, May 30, 2011

Hands On

When Rene Ismael Martinez collapsed while playing soccer last November 7th, his friend and teammate, Luis San Ramon, could think of just one thing: Rene’s young children and what they would do without their dad. The thought was grimly real; 44-year-old Rene had just suffered a sudden cardiac arrest. This notion would be enough to paralyze most people – freezing them like a driver at a red light. But not Luis, he managed to block out the background noise so he and another teammate could attempt to resuscitate Rene. The other man was Alejandro Higareda, the assistant director of operations at Marin Academy High School; trained in CPR and basic life support as a pre-requisite for his job. Alejandro knew to perform chest compressions fast and deep, sternum to backbone while keeping count in his head and giving direction to Luis (who was providing rescue breathing) and others. This powerful CPR, the force of which at first worried some onlookers, proved to be life-saving. Later described by one of the responding paramedics from Novato Fire as “simply awesome,” Alejandro’s forceful chest compressions kept blood circulating through Rene’s body for the five or so minutes it took help to arrive. Alejandro was just doing what he’d been trained to do – with the help and support of bystanders who urged him on – and he had no idea how profoundly important his actions were for Rene.
This past May 19th at the First Annual Marin EMS Survivors’ celebration, Rene Martinez walked onto the stage with Luis, Alejandro, and a crowd of paramedics, firefighters, doctors, nurses, and medical communications specialists (dispatchers and interpreters). It had been a little over six months since that day on the soccer field, and if we hadn’t just heard the story, no one in the audience would have guessed that Rene had so recently suffered a cardiac arrest. Through an interpreter, Rene tearfully thanked everyone on stage for saving his life.
Rene is one of the lucky ones. Nationwide, over 200,000 people a year suffer a cardiac arrest and of these only 2-8% survive long enough to be discharged from the hospital. Some of these never fully recover brain function. But Rene regained mental faculties by the time he reached the hospital. I know, because I was there that day and asked his doctor, Bob Stein, how it could be that his patient, who had just suffered a prolonged cardiac arrest, was now awake and talking to the staff? I don’t recall exactly what Dr. Stein replied, but I now know the explanation. Without a doubt, Rene’s remarkable recovery was due to the simply awesome CPR he received from Alejandro. This CPR kept his brain oxygenated while his heart was stalled (weakly fibrillating like a SonicCare toothbrush low on batteries.) Thus, after the Novato Fire paramedics used an electronic defibrillator to re-start his heart (re-charging the battery, if you will), Rene’s brain was able to quickly recover.
Rene Martinez was one of seventeen Marin residents who survived an out-of-hospital cardiac arrest last year. This number represents a 15% survival rate – much better (albeit with a small sample size) than national averages. But could it be better? What would it take to do better? A new hospital? Defibrillators in every home? No, nothing that drastic. All it would take is every citizen knowing how to do CPR (a simple, physical act that can be performed by a third-grader.) And now, it’s easier to learn CPR than ever – as new evidence and guidelines suggest that hands-only CPR (that is without rescue breaths) is at least, if not more, effective in adult patients with cardiac arrest than traditional CPR with mouth-to-mouth breaths.
I asked our new County Public Health Officer, Dr. Jason Eberhart-Phillips, about the importance of bystander training for CPR. “Heart attacks,” he wrote, “remain one of the leading causes of out-of-hospital death in Marin County. When heart attacks happen, bystanders who phone 911 and begin CPR can greatly increase the chances of survival. Effective chest compressions can move oxygen-rich blood to the heart and brain, keeping a victim alive until emergency responders arrive on the scene.”
So, wondering how you can be prepared to be a hero among us like Luis and Alejandro? Or how you can feel confident that your fellow citizens would save you like they did Rene Martinez? It’s simple, really. Rehearse. This is, as Malcolm Gladwell and many others have counseled, good advice for anyone, in any profession. Learn something, practice it, and when the time comes, memory will kick in. So, for those interested in learning proper CPR (this is yet one more thing that the movies do not get right), here are some options…
First, you can sign up for a basic life support course or encourage your employer to offer one (Alejandro is extremely appreciative that Marin Academy provided his training). Second, you can pay attention to where Automated External Defibrillators (AEDs) are kept – you will notice them in gyms, at malls, and in airports. And yes, there is an app for this too. Finally, this Saturday you can come out to one of multiple sites in Marin and receive free (non-certified) training in hands-only CPR and AED use from local EMTs, paramedics, nurses, and doctors. The training will take less than ten minutes of your time and just might help you save someone’s life. As Alejandro Higareda will attest, this is both an opportunity and an honor, and one best informed by rehearsal.


Hands-Only CPR and AED Training. Presented by Marin County Emergency Medical Services. This Saturday, June 4th 10am-2pm. Locations include: Vista Point, Strawberry Village, Toby’s Feed Barn, The Village, Red Hill Shopping Center, Town Center, Northgate Mall, Mill Valley Depot Plaza and Vintage Oaks at Novato.
Interested in volunteering to help the trainers? Call Karrie Groves at 415-473-3214.

Monday, May 23, 2011

Red Light Camera. California Vehicle Code.

For those interested in such details as the state vehicle code...

V C Section 21455.5 Traffic Signal Automated Enforcement Photographic Records
Traffic Signal Automated Enforcement: Photographic Records

21455.5. (a) The limit line, the intersection, or a place designated in Section 21455, where a driver is required to stop, may be equipped with an automated enforcement system if the governmental agency utilizing the system meets all of the following requirements:

(1) Identifies the system by signs that clearly indicate the system's presence and are visible to traffic approaching from all directions, or posts signs at all major entrances to the city, including, at a minimum, freeways, bridges, and state highway routes

(2) If it locates the system at an intersection, and ensures that the system meets the criteria specified in Section 21455.7.

(b) Prior to issuing citations under this section, a local jurisdiction utilizing an automated traffic enforcement system shall commence a program to issue only warning notices for 30 days. The local jurisdiction shall also make a public announcement of the automated traffic enforcement system at least 30 days prior to the commencement of the enforcement program.

(c) Only a governmental agency, in cooperation with a law enforcement agency, may operate an automated enforcement system. As used in this subdivision, "operate" includes all of the following activities:

(1) Developing uniform guidelines for screening and issuing violations and for the processing and storage of confidential information, and establishing procedures to ensure compliance with those guidelines.

(2) Performing administrative functions and day-to-day functions, including, but not limited to, all of the following:

(A) Establishing guidelines for selection of location.

(B) Ensuring that the equipment is regularly inspected.

(C) Certifying that the equipment is properly installed and calibrated, and is operating properly.

(D) Regularly inspecting and maintaining warning signs placed under paragraph (1) of subdivision (a).

(E) Overseeing the establishment or change of signal phases and the timing thereof.

(F) Maintaining controls necessary to assure that only those citations that have been reviewed and approved by law enforcement are delivered to violators.

(d) The activities listed in subdivision (c) that relate to the operation of the system may be contracted out by the governmental agency, if it maintains overall control and supervision of the system. However, the activities listed in paragraph (1) of, and subparagraphs (A), (D), (E), and (F) of paragraph (2) of, subdivision (c) may not be contracted out to the manufacturer or supplier of the automated enforcement system.

(e) (1) Notwithstanding Section 6253 of the Government Code, or any other provision of law, photographic records made by an automated enforcement system shall be confidential, and shall be made available only to governmental agencies and law enforcement agencies and only for the purposes of this article.

(2) Confidential information obtained from the Department of Motor Vehicles for the administration or enforcement of this ( )1 article shall be held confidential, and may not be used for any other purpose.

(3) Except for court records described in Section 68152 of the Government Code, the confidential records and information described in paragraphs (1) and (2) may be retained for up to six months from the date the information was first obtained, or until final disposition of the citation, whichever date is later, after which time the information shall be destroyed in a manner that will preserve the confidentiality of any person included in the record or information.

(f) Notwithstanding subdivision ( )2 (e), the registered owner or any individual identified by the registered owner as the driver of the vehicle at the time of the alleged violation shall be permitted to review the photographic evidence of the alleged violation.

(g) (1) A contract between a governmental agency and a manufacturer or supplier of automated enforcement equipment may not include provision for the payment or compensation to the manufacturer or supplier based on the number of citations generated, or as a percentage of the revenue generated, as a result of the use of the equipment authorized under this section.

(2) Paragraph (1) does not apply to a contract that was entered into by a governmental agency and a manufacturer or supplier of automated enforcement equipment before January 1, 2004, unless that contract is renewed, extended, or amended on or after January 1, 2004.

Amended Sec. 1, Ch. 496, Stats. 2001. Effective January 1, 2002.
Amended Sec. 1, Ch. 511, Stats. 2003. Effective January 1, 2004.
Amended Sec. 230, Ch.328, Stats. 2010. Effective January 1, 2011.
The 2010 amendment added the italicized material, and at the point(s) indicated, deleted the following:
1. “Article ”
2. “(d)”

Monday, May 16, 2011

Public Health - Just Due It?

“Program Goal: To improve the safety of our community for vehicular, bicycle and pedestrian traffic” – The San Rafael Police Department (SRPD) on the Automated Red Light Photo Enforcement System

“Oh No!!” – This author after receiving a red light camera ticket in the mail.

According to publicly available data, the advent of red light violation enforcement by cameras in the city of San Rafael has been associated with a twelve percent decrease in accidents at camera-enabled intersections. Between November 2008 and April 2009 there were 48 accidents at the intersection of 3rd and Irwin in central San Rafael, compared to 43 between November 2009 and April 2010. The prevention of five accidents (none of the accidents were fatal by the way) is nothing to sniff at, although, from a scientific standpoint, it is far from proof that these cameras improve public safety. Consider the other possibilities. Have accidents decreased because yellow light times have been extended (from 3.0 to 3.5 seconds)? Or, have motorists intentionally avoided 3rd and Irwin and chosen other routes instead? Or is this finding a statistical fluke? One thing that is not at all flukish is the amount of money collected in fines from violators. The current fine is $479, of which the city of San Rafael receives 30%, and with the addition of court and traffic school fees, the sum approaches $600. If you consider that since its inception, the city has averaged roughly 467 violations/month, over a six-month period, the yield (in fines charged per prevented crash) works out to an estimated $268,000. Expensive. Perhaps too expensive?

But, is it possible that a city that utilizes red light camera enforcement increases safety not just at the enforced intersections, but across the entire city? This is consistent with James Q. Wilson’s “broken-window” theory (embraced by former New York police commissioner William Bratton) that visible disorder in a neighborhood leads to greater lawlessness citywide. So rather than look at San Rafael in isolation (I was unable to get city-wide data on crashes from the SRPD), it makes sense to take a larger view of the effect of red light camera enforcement. And I should stress that, nationwide, this is not a trivial problem – according to the Insurance Institute for Highway Safety (IIHS) there were over 2 million intersection related crashes in 2009, resulting in 7,538 deaths.

Just this past February, one of the largest studies to date on this topic was published by the IIHS. The report, lead authored by Wen Hu, compared cities with and without red light camera enforcement programs across two time periods (1992-1996 and 2004-2008). The investigators looked not just at the enforced intersections, but citywide, to discern differences between those with and without red light camera enforcement. The authors report a 21% greater decline (35% vs 14%) in fatal red light crashes in cities with camera enforcement versus those without it. The investigation also reports an estimated 17% decrease (versus expected rates) in fatal crashes at signalized intersections in cities with cameras. This study has a lot of strengths – it is big – looking at 62 U.S. cities (14 with camera programs and 48 without) and focusing on an important outcome (fatal crashes). It also does a reasonable job of creating a nationwide sample and of adjusting for population (crash rates per 100,00 in population) and accounting for outside influences (what researchers call confounders) such as population density and land area. In sum, it is reasonably convincing. But, there are important caveats and limitations.

One of these is the question of conflict of interest – the IIHS is funded by the insurance industry, an industry that benefits not only if there are fewer car accidents but also if more drivers accumulate points on their license (increased fees for these drivers). But, let’s give them the benefit of the doubt and assume that they are interested in studying road safety in an unbiased fashion. So, what then are the limitations of the study? First, those cities implementing cameras had a higher baseline rate of crashes (65% higher) – meaning they had larger room for improvement. Second, there were significant differences in rates across cities (crashes increased by 165% in Raleigh, NC while decreasing by 75% in Chandler, AZ). Third, the “control” group – those without cameras – has two major outliers whose crash rates more than tripled across the study period. Removing these two cities from the analysis might have led to much more modest results. Fourth, the analysis could not account for changes in yellow light times or other interventions that might have been the true cause of decreased fatal crashes. Finally, this data excluded crashes from illegal turns on red (the vast majority of red light tickets in most locales are for illegal turns). Thus, this study is unable to inform the question of whether policing failure to come to a complete stop on red benefits the public welfare. So, what does this all mean? Well, in my opinion it means that the jury is still out on the public health impact of red light camera enforcement.

On the other hand, the jury is no longer in deliberation for my red light camera enforcement citation. Well, to be clear, there was no jury – just an honorable Superior Court judge and a twelve second videotape. My judge was not sympathetic to the plea that a failure to come to a complete stop on red was not equivalent (penalty-wise) to that of busting through a straight-ahead intersection. Oh well. For myself and others perps, we can take heart that our fine money is not only supporting the San Rafael Police Department (and Redflex Systems of Phoenix AZ), but also a whole host of public services ($ amounts based on the previous penalty schedule of $445): $8.92 County General Fund, $17.15 Criminal Justice Facilities Fund, $ 13.72 Courthouse Construction Fund, $19.60 EMS, $9.80 DNA Identification Penalty Assessment, $13.72 Maddy EMS, $3.43 Automated Fingerprint ID System Fund…and the list goes on. Sometimes a state budgetary crisis and a public health initiative can become inextricably linked. Public health…just due it?

Caught by the Camera

Several weeks ago, on a leisurely weekend morning drive, I exited the 101 into central San Rafael. Life was good, I was on my way home and feeling mellow. Little did I know, I driving myself right into a public health debate…I approached the traffic light at 3rd street; as I did so, it turned yellow. With a full line of sight, sparse traffic at a full stop on the other side of the intersection, and no pedestrians, I performed an incident-free rolling left turn onto 3rd street. I thought nothing of it, until a few weeks later when I received something in the mail. What, might you posit, did I acquire?

1) A letter of acclaim for a safely executed “California Coast” one-way turn.
2) A friendly reminder to come to a complete stop at all signaled intersections.
3) A not-so-friendly notice from some guy in Phoenix offering me an opportunity to appear at the Marin County Superior Court.

Well, anyone else who’s been snagged by red light camera enforcement in San Rafael knows the correct answer. This experience and its price tag (over $600 in fines and fees!) inspired me to take a close look at the rapidly growing, but controversial, practice of using cameras to police busy intersections. In this two part series, I’ll let you know what I’ve discovered, but first some history…

For much of the past century, traumatic injuries were considered unpredictable “accidents” rather than a treatable disease processes (like atherosclerosis). Under this paradigm, the root causes of accidents were broken down into three categories: 1) bad luck, 2) the well-deserved result of stupidity, or 3) something arranged by the mafia. Prevention efforts, to the extent they existed, were predicated on warnings such as “Don’t drive too fast and watch out for drunken drivers,” and “Don’t associate with the mafia.” Thus, civilians of the 1960s were duly warned, but not particularly safe. Fortunately, in the mid-1960s, a handful of public health leaders began to transform this concept of “accidents” and in particular motor vehicle “accidents.” Foremost was William Haddon Jr., the seminal director of the National Highway Traffic Safety Administration and the first person to champion the idea that there’s nothing “accidental” about energy transfer resulting in traumatic injury. According to Haddon, it didn’t matter whether the energy transfer came from a high-speed projectile (bullet) or from rapid deceleration in a car crash, the energy transfer’s effects on human anatomy could be studied and modified. Accidents, Haddon argued, and car accidents especially, weren’t unpredictable or random after all and therefore a vehicle hitting a wall shouldn’t be called an accident but rather a crash. Furthermore, the outcome of a crash, in terms of human injury, wasn’t inevitable but instead dependent on key variables such as speed, object malleability and passenger restraint. Haddon attempted to classify and study these variables using a conceptual tool that came to be known as Haddon’s Matrix – a simple 3x3 grid identifying the factors leading to poor outcomes in trauma. One axis of the matrix lists three time periods: “pre-event,” “event,” and “post-event” and the other lists three physical components: “human,” “vector” and “environment.” From his matrix, Haddon extracted ten conceptual strategies for injury prevention – half of which involve the “event” phase of injury and predominantly support “passive” injury protection – protection that is built into existing systems and not dependant on individual compliance. To illustrate, strategy number four recommends “modifying the rate of spatial distribution of the release of the hazard from its source.” This is a long-winded way of saying that an absorbed blow is less destructive, which of course is the concept behind airbags. Strategy number five suggests that we “separate in time or space the hazard being released from the people to be protected,” which simply means that the farther you are from the action the safer you are (e.g. a pedestrian on a sidewalk is less likely to be struck by a car than one on the shoulder).

Today, Haddon’s strategies sound like common sense, but before Haddon, American culture wasn’t hip to prevention. Haddon’s goal was to inspire a paradigm shift, to make prevention groovy – in a long-winded academic way. It worked - nowadays we accept that there are strategies, such as seat belts, air bags and highway speed limits that prevent or limit injury in car crashes. We recognize that crashworthy vehicles save lives and that vehicle occupant fatalities (per mile of travel) decreased by two-thirds between 1964 and 1990. Without a doubt, this is an incredible public health accomplishment, one that has been achieved with very modest impact on personal liberty.

With success like this, it’s not surprising that a whole new generation of pre-event interventions have been proposed to further limit the carnage on our streets before it occurs. One of these is red light camera enforcement, which strives to limit injury and death from intersection collisions. On its face though, red light camera enforcement feels more like Big Brother than airbags or widened shoulders. It also is not passive – it relies on individual citizen’s knowledge, fear and compliance to be effective. This is in contrast to a more automatic strategy, like lengthening yellow light times. So, believe me, when I started looking into this I certainly hoped to discover that the red light strategy does not work. But, it turns out that a recent analysis from the Insurance Institute for Highway Safety (IISH) suggests that it most likely does. There are, however, some serious caveats. Next time, I’ll breakdown the IIHS study and delve into these caveats. In the meantime, does anyone know a good traffic lawyer?