Should commuter trains carry defibrillators?

The Chicago Tribune (http://www.chicagotribune.com/health/chi-metra-defibs-09-oct09,0,5601601.story) reported on October 9, 2009, that a commuter suffered a heart attack during his commute the previous day and despite efforts to administer CPR on board the train, the man died. Would an AED (automated external defibrillator) have saved his life? And, policy wise, should Metra and other operators of commuter trains be required to have AEDs aboard?

The article reports that defibrillators cost between $1200 and $2500. Is that a lot of money to spend on reviving a person in cardiac arrest? Of course, posing the question that way is too easy--of course if we see a person in cardiac arrest, we are likely to think we should spend $2500--or $25,000, or $250,000--to provide the medical care needed to take care of that person.

But that isn't the right way to pose that question, because ex post, or after an cardiac incident occurs, we will want to spend whatever it takes to care for the individual. It's a bit like waiting until a house fire breaks out and then asking the homeowner if he is willing to contribute money towards the local fire department. I"m guessing the answer to that one would be "yes."

So what is the right way to pose the question? We need an ex ante approach: we need to say, what is it worth to lower the risk of a certain event happening?

In this case, we can ask, how many lives would be saved if we required AEDs on Metra's commuter trains? What would it cost to install and maintain these AEDs? And is that expense worth paying, given the likely impact on fatalities averted?

Some evidence suggests that AEDs are as cost-effective as many other health interventions:

• A somewhat dated (1998) article by Nichol et al. in the journal Circulation (http://www.circ.ahajournals.org/cgi/content/full/97/13/1315 ) offers some evidence that public (lay) use of AED's would be cost effective by "usual" U.S. standards: the authors estimate a median cost of $44,000 per QALY (quality adjusted life year) saved by use of the devices.
  

• A study of the use of AEDs on commercial aircraft (2001, Groeneveld et. al; http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102273455.html ) of AEDs' cost effectiveness found that "Placing AEDs on all passenger aircraft with concurrent BLS [basic life support] training would cost $49,800 per QALY gained compared to no AEDs and no BLS training."
  

• A more recent study (2009, by Nichol et al., here: http://www.annemergmed.com/article/S0196-0644(09)00101-2/abstract ) estimated a mean cost of $46,700 per QALY saved by use of AEDs by lay responders.
  

In the U.S., we often apply a "rule of thumb" in which interventions or treatments that cost less than $50,000 per QALY saved are cost effective, and by that measure, these studies suggest that AEDs meet that standard.

What does that mean for Metra or other operators of commuter trains? Well, the impact of the devices on lives saved will depend in part on how many people ride the train and are at risk of going into cardiac arrest. If a train only carries 10 people all day long, it's hard to believe that installing an AED would be worth it--meaning, the likely effect on averted fatalities (reflecting 10 people, 24 hours a day, having some underlying risk of going into cardiac arrest) would be small, so that the cost per QALY saved is likely pretty high. But if a train carries 1000 people--or 4000 people--or ???? people--all day long, then the number of expected averted deaths will be greater and, consequently, the $ cost of per each gained QALY will be lower.

So, my recommendations would be:

• Require Metra to install AEDs on trains that meet some sort of minimum usage standard.
  

• Allow Metra to recoup the cost of the AEDs through its ticket prices. After all, the beneficiaries of the installation are quite clearly the passengers.
  

While these steps would not prevent every death from cardiac arrest in public spaces, they would mean higher survival rates and better outcomes for a reasonable outlay of dollars.

The Chicago Tribune reports today (September 6, 2009; here) that nearly half the city's library "pages" (staffers who reshelve books) were laid off recently, leading to stacks and stacks of unshelved books in libraries throughout the city. Certainly this is just one more example of local spending cutbacks, driven by serious budget problems in our nation's cities, counties, and states. But, wait, there's more.....if you read to the end of the article, you find this:

But library volunteers aren't allowed to do work that paid union workers would normally do.

Library administrators said their hands are tied with regards to bringing in free help.

"We're definitely very, very busy, and not having as much staff isn't great in that situation," Lednicer said. "Obviously, more hands is more help but we have to abide by the union contract, as well."

So, in other words, volunteers can't show up to help out--even with a fairly low-skilled, routine task such as reshelving books. That seems silly--it's not as if the task at hand requires a lot of skill, talent, or experience--and, frankly, it's not as if the consequences of having a few misshelved books are so terrible that they would outweigh the benefits of enjoying many correctly shelved books. Bad PR for the Mayor, too, in my view--he can't even get union contracts that make sense here--so how will all the contracts with skilled workers pan out?

Even New York Times columnists dislike Windows Updates.....

It is always gratifying to be ahead of The New York Times, where I read Gail Collins' piece today on all the, ahem, "issues" that arise with updating our computers, phones, etc. so frequently. I wonder if I have even bothered with any updates since I posted on this topic a few months ago? Probably not--thank heavens! That's probably why my machine has been so stable recently......

Biking: to wear a helmet or not?

OK, so President Obama rode his bike without a helmet while on vacation on Martha's Vineyard (
http://featuresblogs.chicagotribune.com/features_julieshealthclub/2009/08/obama-bike-helmet.html). More power to him, I say! I usually wear my helmet when I ride, for sure, as you can see from various biking photos I have previously posted (for example, http://aneconomistdoesthelaundry.blogspot.com/2008/06/we-biked-driveagain.html). But honestly...vacation, on an island bike path, .....I mean, I rode the other day while on my New England vacation--riding an old, ill-fitting bike from our beach house's shed, wearing no helmet, as we didn't pack them for our vacation--and it was great! My family and I even rode along roads with cars--not a great idea, I suppose, but we were pretty careful and boy was it liberating to ride in such a pretty place, even if we didn't have all the equipment we are accustomed to.

Tracking in the public schools

Today's New York Times ("No Longer Letting Scores Separate Pupils" ) reports on an "unusual experiment" in which middle school students in Stamford, Connecticut, are no longer tracked by (some) measure(s) of academic ability. In the article, the local schools superintendent points out that the tracking system has served some students well but not others: “There are certainly people who want to maintain the status quo because some people have benefited from the status quo,” he said. “I know that we cannot afford that anymore. It’s not fair to too many kids."

My goodness, where has the New York Times been? Not in Evanston, Illinois, surely, where educators have been twisting themselves into pretzels at elementary, middle school, and even high school levels to introduce and deepen the "differentiated instruction"-al techniques the experts say are needed in mixed ability classrooms. (In fairness, the article does describe the Stamford school district as one of the "last bastions of rigid educational tracking.") For example, several recent items in the Evanston Roundtable on Districts 65 (here ) and 202 (here) describe and comment on Evanston's efforts to better serve struggling students while maintaining rigorous programs for all.

So, one question is, is this policy change (removing some sort of tracking and establishing "mixed" classes) Pareto improving--leaving at least one person better off than s/he was before, while leaving everyone else at least as well off as before? The super's remarks suggest that his answer is "no"--that is, the policy change will help some students and hurt others. Of course, that could still mean the policy is potentially Pareto-improving--meaning, the "gains" for some outweigh the "losses" to others. So, even if the policy creates some "losers", we might still think the policy is a good one.

Other education experts quoted in the article make a different claim: that establishing mixed ability classes will actually help all students (hence, be truly Pareto improving). For example, the article reported an argument that "research is showing that all students benefit from mixed-ability classes." According to one expert, "[w]e see improvements in student behavior, academic performance and teaching, and all that positively affects school culture."

My views? As often, they are both mixed and strongly held. I think that by middle school age, the range of kids' academic achievements is vast. I don't think "mixed" classrooms serve either end of the spectrum well in terms of the academics. I think the kids who need more challenge and depth will get bored (a problem more easily addressed at home in language arts than in mathematics, I would guess), and I think the kids who need more catching up and enrichment may get overwhelmed and disheartened.

In terms of non-academics--developing social skills, empathy, and so on--I think mixed ability classes might be pretty helpful. Kids do need to know there is a "range" of people out there, with different strengths and weaknesses, and they need to learn to value each person for who s/he is.

I do worry, though, that relying on mixed ability classes throughout middle or even high school could backfire, as students who don't do well in these mixed classes end up being labelled as failures, and students who thrive in them feel somewhat uppity and judgmental--thus reinforcing the feelings of entitlement and privilege that can abound in honors and AP classes throughout our schools.

No easy answers, I'm afraid, for struggling students. As a friend once said in regards to some pathetic-looking houseplants of mine, they needed more--or less--of something. But what exactly is it that these students need more--or less-- of? More hours of schooling and time on task? Better quality instruction (that would be teachers)? Less time playing video games? More high achieving peers? That's what we need to know.

Musings on Mothers Day, Bicycling, and Sons

I'll be brief--yesterday was Mother's Day, and as in previous years, my fondest hope for the day (aside from getting just a wee bit of special treatment at home) was getting in a nice bike ride (see a previous post here ).

Luckily, the weather cooperated, and a friend and I rode to Northerly Island and enjoyed the city and lake views from there. Later in the day, I even went bike shopping, so maybe this will finally be the year I will upgrade my equipment.....

.....which brings me back to the title of my post. At the bike shop, I also looked a bit at bikes for my oldest son, as he probably needs a larger bike this year. But where was the fun in that, really? I mean, what about all those great bikes we used to have in our family--"Runnin' from the Law," "Mud Runner", "Major Damage", and so on......now those were the days, when the kids so completely embraced their wild inner selves when on two wheels. Now, we actually bike--you know, miles and miles. Fun in its own way, but I sometimes miss the picture of my kids "runnin' from the law....".

Hope to have 2009 Bike the Drive photos posted in a few weeks....

Race, Housing, and Public Policy

Whoa, the title of this post is way too ambitious. All I want to do here is mention the latest book I haven't read, "Family Properties: Race, Real Estate, and the Exploitation of Black Urban America," by Beryl Satter. I've read a couple of reviews of the book (see here ) and have added it to my Amazon cart (that's how I keep track of things I wish I had time to read), and here's my main reaction so far: why do books about race, housing & lending discrimination, redlining, and so on never identify or deal with the unscrupulous landlords, speculators, and contract sellers? Who were these people, and what are their stories? There's always some "passive voice" at work here--the New York Times quotes from the book, which refers to: "...fabulous enrichment for speculative contract sellers and their investors, debt peonage or impoverishment for many black contract buyers....."


So, who got rich from this terrible behavior? I fear the answer is "our family, our friends, and our neighbors." That is, it was presumably whites who lived.....where? on the north side, the northwest side, the southwest side.....or in Evanston, Glenview,......in other words, it's not some abstract intangible entity who did these things. It was people--people like me. Who were they? What were their motivations? We have oral histories, and books by historians and sociologists, mostly focused on whites who left (Louis Rosen's book) or blacks who came (Satter's book, Making the Second Ghetto by Arnold Hirsch) ....but what about the speculators themselves? Maybe not such a nice group of people--but what do we know about them? Aren't we curious? Don't we worry that some of our city's suburbs were built up by unsavory people and tainted money coming from the post-war white flight from our central city? Not to be too dramatic, but it's as if we were discussing the Holocaust and not asking the question of who actually did the bad things.

This is not to say that we shouldn't also hear the stories told by Satter and others and that we shouldn't attempt to learn from our terrible public policy mistakes (refusing to offer mortgage insurance in black neighborhoods, for example). I am a policy person at heart, myself, so I am all about trying to improve our policies. But in this instance, I find that the "numbers" and "facts" I tend to rely on are simply not enough for me to understand what went on here.

OK, I"m done! Back to my day job......

OK, what's with those annoying Windows Updates?

I admit it--I've had it with those Windows updates (try here, but note they force you to use IE as your browser, those dogs!). The updates seem to be shoved through the pipe several days a week, and even though I have altered my computer's update settings to avoid "automatic updates," I am constantly having to close down annoying little dialog boxes telling me that my updates are ready to install, "just click here." Enough already!

Why is this so annoying? Well, for one thing, because you never ever EVER have an idea of how long the updates will take to install, whether a restart of your computer will be required, or what other aspects of your computer's operations will be affected by a particular set of updates. So, you take your computer life into your hands when you click "OK, install, please!" Could take 2 minutes, could take 20 minutes, and might blow away all your printer definitions, for example--not something to be done when you're facing a deadline.

Sure, some IT folks like to think of these updates as some type of routine maintenance we just need to "budget for", you know, maybe akin to brushing teeth, or washing the dishes after dinner. The problem with those analogies, though, is that those other activities are predictable in terms of time needed, and they are limited in terms of consequences when things go wrong. I mean, what if you try a new brand of toothpaste? What's the worst thing that could happen? You won't like the taste. There, done. [Sure, you could have an allergic reaction, but have you ever heard of that happening? Me either.] Now, think about installing these updates as "routine maintenance" for your computer--and what is the worst thing that could happen? No, you don't want to even imagine it. Could be BSOD, blown away files, corrupted printer definitions, inability to find archived email messages--you get the picture.

And what about that advice often given, suggesting the "oh, just set it to download and install automatically at 3 in the morning on Thursdays" strategy? Well, that approach does in general address the "will it take 2 minutes or 20" question, but it still leaves you vulnerable to the "OMG, I don't have any printer definitions" prospect. Furthermore, I learned the hard way (from leaving my machine in hibernation mode overnight, as is my custom) that the forced shutdown and restart that accompanies these automatic installations can cause some serious problems--my new PalmOS software (version 6.2.2) has a bit of a bug, so that if you force a system shutdown before properly closing the application, files get corrupted, and you cannot perform a hotsync operation until you've replaced the corrupted database files with some backups. Ridiculous.

Does this mean I'm ready for a Mac? I don't think so! My sons push me on this all the time, but they will clearly lose this argument. I mean, how likely am I to give in that pressure, when I am probably the only economist remaining on the planet still happily using WordPerfect (sold by Corel) instead of Word? They will have to pry my hands off the reveal codes feature if they ever want me to abandon WordPerfect for Word......

Agreeing with the Vatican

OK, it doesn't happen often.....in fact, maybe the last time I agreed with the Vatican was in 1965, when the Second Vatican Council was formally closed and I was all of 5 years old. In any event, the Vatican announced last week that Bishop Williamson's apology regarding his repeated Holocaust denials wasn't any good. According to the Chicago Tribune (February 27, 2009):

"An apology from a bishop who denied the Holocaust wasn't good enough, the Vatican said Friday, adding that he must repudiate his views if he wants to be a Roman Catholic clergyman."

See http://www.chicagotribune.com/news/nationworld/sns-ap-eu-vatican-holocaust-denial,0,4070673.story for the full story.

Lawn furniture: what's not to like?

Well, it will compromise my secret identity, but here's a link to what I have to say about lawn furniture in the street: http://theexpiredmeter.com/?p=1812

Read it and weep!

Ice skating at the Midway Ice Rink

December 31, 2008

The First Clothesline?

The Wall Street Journal ("Veggie Gardens and Other Ideas for the Obamas: Advocates Are Pushing Bushels of Suggestions; Clothesline for a Day", January 17-18, 2009) reports that all kinds of kooks and zealots for one cause or another are hard at work, lobbying and advocating for an Obama White House embrace of their passion:

Ben Davis, a marketing entrepreneur in San Francisco, has gathered more than 800 signatures on a petition to encourage the Obamas to install a clothesline at the White House, for at least one day. "It would send a signal to the nation and world that reducing energy consumption is patriotic and that line-drying one's laundry is part of the acceptable social fabric of our nation." Alexander Lee, a leader of that movement and founder of a group called Project Laundry List, in Concord, N.H., points to a photo taken around 1910 that suggests there was once a clothesline at the White House.

This comes on the heels of an article in the New York Times (December 4, 2008) which included Laura Bush's remark that the East Room of the White House used to contain Abigail Adams' clothesline.

Way to go! Installing a nice T-style clothesline on the White House grounds would surely send a message.....but what would it mean?

Ice skating.....the real deal

The New York Times reported that the canals in the Netherlands froze over for the first time in years, bringing young and old, Dutch and not, onto the ice. People blame climate change and other factors for the nonfreezing years, but everyone seemed happy in this photo.

This Economist Goes Centro!

Newsflash: this economist can now do the laundry in her new high efficiency washing machine! Wheee! Here's a photo, taken with my new Centro (OK, so it's not a great camera)--



Yep, I finally took the plunge and bought a new phone--another smartphone by Palm, this one called the Centro. AT&T was giving the phones away, so I took one (had to take blue, as the black phones were all gone!). It was surprisingly easy to set it up, update new desktop software, and even sync to get all my old info (from my Treo 650) to my new device. I even added email capabilities (via gmail). Too bad I ended up with a corrupted address book file that caused me 4 hours of headaches today (featuring hot sync troubles, uninstalling and reinstalling software, soft resets, hard resets, etc.), all finally resolved by a patient tech support person in 45 minutes on the phone.