Speeding to the rescue can have deadly results Ambulances rack up disproportionate crashes, leading some to doubt value of ‘running hot’

03/21/2002

By Robert DavisReprinted with permission of USA Today

Denver paramedic Otis McKay Jr. saw the fear in the young woman’s eyes just before he mowed her down with his 5-ton ambulance.

The seasoned paramedic had seen people die before. But watching 19-year-old Virginia Magalhaes-Rosa trying in vain to outrun his out-of-control ambulance in December 2000 — seeing her disappear beneath the flashing lights in the grille of the rig — haunts him every time he turns on his siren.

”I’m still spooked when I drive Code 10 (Denver lingo for an emergency run),” McKay says. ”I see shadows, I see cats, I see birds, I see leaves falling from the trees. Any sudden move in the periphery. I don’t think you ever get over that.”

Paramedics toil to save lives. But those inside the breakneck world of emergency medical services have long known of a huge danger that is rarely acknowledged to outsiders: Ambulances are among the most dangerous vehicles on the road, involved in a disproportionate number of crashes.

Now, however, more experts are questioning publicly the time-honored belief that seconds, or even minutes, are crucial to survival when transporting a patient to an emergency room. There is, in fact, no scientific proof that ”running hot” — street slang for operating with lights and siren — saves lives.

”You can’t prove from the literature that EMS (emergency medical services) saves more lives than it takes,” says Jeff Clawson, chairman of the certification board for the National Academies of Emergency Dispatch based in Salt Lake City.

”Speed has never saved anybody’s life. Period,” says W.H. ”Bill” Leonard of Medical Transportation Insurance Professionals, one of the top insurance underwriters of ambulances across the nation.

Running hot doesn’t even shave off much time, according to previous studies. One found that lights and siren reduce response times by 106 seconds in big cities and by 43.5 seconds in rural areas.

Clawson says it’s a myth that the public expects a lights-and-siren response to every emergency. ”That’s not what the American public thinks,” he says. ”They want it to come out right and not kill people in crosswalks when they don’t need to.”

Yet, ambulances are 13 times more likely to be involved in an accident than other vehicles in terms of the number of accidents per miles driven, according to a study in Houston in 1993. That study found that ambulances also are five times more likely to be involved in a crash that causes an injury.

Worse, an ambulance is an unforgiving vehicle to collide with — especially on an emergency run.

In fatal, multi-vehicle ambulance crashes between 1980 and 2000, the number killed in the other vehicle was 21 times greater than the number of ambulance drivers who died, according to a USA TODAY analysis of National Highway Traffic Safety Administration data. More than three-fourths of the fatalities were people who were not in the ambulance.

But because there are relatively few fatalities each year — 33 in 2000 (the last year for which complete data were available) out of millions of ambulance calls — federal officials say there is no pattern that triggers any alarms.

”There is not a lot of data out there,” says Jeffrey Runge, a former street medic and emergency room doctor now heading the National Highway Traffic Safety Administration. His agency collects data on fatal accidents and sets response guidelines. ”It tells me there is not a huge safety problem.”

Many in the industry disagree. ”This is a very, very big problem,” Leonard says.

A need for ‘the growler’

By some estimates, there are 15,000 ambulance crashes a year, though nobody keeps a complete count. Medics often are cleared of wrongdoing even when they crash while running a red light because ”failure to yield to emergency vehicle” laws give the medics the upper hand legally.

Even so, across the nation both male and female medics have served time for killing others while running hot. In those cases, the medic was found guilty of crimes such as driving negligently or recklessly. And an ambulance accident can cost an emergency medical system millions of dollars.

In an effort to curb these crashes, there are two major strategies at work in some cities across the nation to make emergency medical response safer.

First, the same kind of ”black box” technology that has helped make passenger jets safer is now monitoring some ambulances.

Mounted under the ambulance’s front seat is the box that medics call ”the growler.” By measuring more than 25 parameters of the vehicle’s operation, such as acceleration, braking and the use of seat belts, lights and sirens, this black box gives medics — and their supervisors — a precise picture of their every move on the road.

The boxes give audible cues to drivers when they are nearing or exceeding predetermined parameters for accelerating, braking and turning. When a medic takes a turn too fast, the growler clicks like a Geiger counter. If the medic exceeds the preset limit for a full second, the tone changes and the driver knows he or she has just been hit with a computerized violation of the driving policy.

The boxes, installed on only a minority of the nation’s ambulances, appear to have corralled the driving behavior of nearly 300 medics in the Florida system in a matter of weeks.

”We’ve seen direct results from this,” says Scott Springstead, operations supervisor for Sunstar Emergency Medical Services of Pinellas County. ”We’ve seen a reduction of 20-to-1 in the severity of our crashes.”

Mirrors still get clipped and fenders get bent, but there have been no big accidents, he says.

Despite success, the boxes, also called ”Big Brother” and worse by some medics, aren’t always popular. They threaten one of the primary perks of the job: Running hot through crowded streets is a thrill.

”Our workforce is young, largely male, and we all drive with a little testosterone when we shouldn’t,” Springstead says. ”There was a little bit of that bravado, a little bit EMT and a little bit race-car driver. That’s a bad attitude to take in an ambulance with you.”

But he says he can still drive fast, observe the limits of the black boxes and be certain that his city will see no change in response times.

”The message is, we have a job where minutes matter and seconds matter, and we need to be aware of that,” Springstead says. ”But rather than just floor it and cross your fingers, there is a science to how you can navigate your vehicle. We have a responsibility to the safety of our citizens.”

More selective about response

Another method that some cities are using to reduce the number of fatal ambulance crashes is smarter dispatch. If medically trained dispatchers can determine that the person on the other end of the phone line does not need a crew to rush to the destination — the theory goes — accidents can be prevented and lives saved.

Though many crews in the nation’s fragmented and diverse emergency medical systems can recall emergencies where their fast action saved lives, those calls are rare. People who are choking, bleeding to death or in cardiac arrest are few and far between in the modern emergency medical system. And those cases are easy for medically trained dispatchers to identify on the phone. When the situation is desperate, help can be sent in a hurry, Clawson says.

But the more common calls to 911 come from people who are not suffering life-threatening problems. In big cities, routine cases — people who lack insurance, do not have a doctor and simply need access to basic health care — clog the system.

This creates a backlog of runs and adds a sense of urgency to the medically mundane.

”This keeps the ambulances stretched thin,” says Leonard, a former street medic. Paramedics may be tempted to use lights and siren to transport a patient from a nursing home to a hospital, he says, to get back in service faster to be available to help people who are more likely to be saved.

Many of the fatal accidents have occurred as ambulances raced to the hospital with patients on board who were relatively healthy and medically stable. Others have occurred when medics were rushing to the side of a person with a sprained ankle or other non-emergency, USA TODAY found.

Some emergency medical systems are making medical judgment calls in the dispatch center to reduce the number of times their ambulances respond with lights and siren. Medically trained dispatchers can be more selective about what gets a hot response.

In Virginia, the Richmond Ambulance Authority uses both the black box ”growler” in the rig and state-of-the-art emergency medical dispatching to sort through calls.

In a darkened room full of colorful computer terminals displaying maps with ambulances and people in need across the city, street medics are at the consoles working the radios and phones.

On a recent day, as one medic gathered information and gave advice to a person having an allergic reaction, another radioed a colleague in an ambulance to start driving toward the address.

The ambulance was rolling within seconds, but the medic who was still on the phone determined that the case of hives did not need a lights-and-siren response. There was no trouble breathing. There was no immediate threat to life.

The medic gave simple medical instructions, including advice to call back if anything changed before the ambulance arrived.

”The emphasis in emergency medicine,” says Jerry Overton, the system’s executive director, ”is right here in dispatch.”

Hurtling into a pedestrian

But even the emergency medical systems that take steps to reduce the risk of crashes can’t prevent every tragedy.

In Denver, where paramedics sort calls in the dispatch center and medics get advanced driver training, running hot is still a danger.

It was a cold evening in December 2000 as Otis McKay drove his ambulance past the Cathedral of the Immaculate Conception where people were out looking at Christmas lights.

Virginia Magalhaes-Rosa was walking with others near the majestic steps of the cathedral.

As McKay responded to a call for a man with chest pain, he had a green light at an intersection. A van in the left lane stopped at the green light, and McKay passed the van on its left, cruising by in the left turn lane at about 35 mph.

As the ambulance came up beside the van, the van’s driver, Jose Campos-Ortega, inexplicably turned toward the ambulance.

”My partner yelled, ‘Watch out! Here he comes!’ ” McKay says.

The van struck the ambulance near the front tire, damaging the brakes and steering system.

As the ambulance veered across two lanes, McKay saw that he was heading straight for pedestrians in front of the church. He tried to steer toward the stairs of the church. ”I’m thinking I’d rather hit the building than the pedestrians,” he says. ”I’m stomping on the brakes, and the vehicle is slowly coming to a stop.”

But when the rig hit the curb, the braking and steering systems failed completely.

”The force of the vehicle hitting the curb shot me from going left back onto the sidewalk,” he says. Magalhaes-Rosa, a Brazilian immigrant, had been running toward the church, ”but when she saw that I was steering toward the church, she changed her mind and ran on the sidewalk.

”She is literally running in front of me. It sounds like a horrible cartoon,” McKay says. ”She is trying to outrun the speed of the ambulance. I watched her go underneath the vehicle.”

When the rig stopped, McKay called for help on a police radio. His partner told the ambulance dispatcher to send one ambulance for the man with the chest pain and another for the woman.

McKay climbed beneath the ambulance, ”hoping she will roll over and call me names and scratch and kick me.” She only gazed and gasped a few times.

He pulled her out, snaked a breathing tube down her throat and into her trachea, started an intravenous line and loaded her into another ambulance that raced her to the nearby trauma center.

She died hours later.

Campos-Ortega pleaded guilty to careless driving resulting in death and received 18 months’ probation. He is still paying for Magalhaes-Rosa’s funeral as part of his restitution.

McKay was cleared, but he is forever changed. ”You cover it up and paint over it, but once a good guy kills a person, the only thing you can do is swallow it and go on the best you can,” he says.

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New voluntary court system helps mentally ill inmates get their lives back on track

11/24/2002

Jenni BergalReprinted with permission of Sun Sentinel

It’s lunchtime in Room 510 of the Broward County Courthouse, and the judge is clearly worried about the disheveled prisoner with matted hair and glassy eyes sitting shackled before her.

The man has been languishing in the county jail for days on a minor trespassing charge. He’s a schizophrenic and alcoholic who says he’s been living on the streets and not taking medication for his illness.

In the middle of the hearing, Judge Ginger Lerner-Wren picks up the phone and dials a local mental health program. At first she cajoles the administrator. Then she becomes stern and emphasizes that “the court” really wants this man to get treatment and shelter.

Lerner-Wren hangs up the phone and announces that a bed is waiting for him.

“God bless you, judge,” the man yells.

She smiles and calls the next case.

That’s a typical scene at the Broward County Mental Health Court, a unique blend of justice and social services, or as Lerner-Wren often calls it, “therapeutic jurisprudence.”

The county court, the first in the nation when it was created in 1997, has become a model for more than two dozen communities from Anchorage, Alaska, to Brooklyn, N.Y.

In Florida, mental health courts have cropped up in Sarasota, Osceola, Lee and Alachua counties. Palm Beach and Orange counties are seeking funding to start courts and Okaloosa County is launching one in January.

Law enforcement officials estimate the court has saved the Broward jail system at least a million dollars a year.

The goal is to stop mentally ill defendants arrested on misdemeanors such as disorderly conduct, loitering, petty theft and public drinking from rotating in and out of jail and get treatment for them. In its five years of operation, the court has offered help to hundreds of offenders who otherwise would have been in jail, records show.

“The court needs to give our people a sense that somebody with authority cares,” Lerner-Wren says. “On a daily basis, that’s what we’re striving for.”

For defendants who participate, criminal charges are put on hold. The judge evaluates the case, consults with the court’s social workers and issues an order specifying treatment and rules they must follow. “This is not a trial court. This is a treatment court for people who have some kind of mental health condition,” the judge tells new defendants. “It is purely voluntary.”

Some defendants need a case manager. Others require a live-in program and intensive therapy. Many also are substance abusers needing drug or alcohol treatment.

It’s a heavy load, especially because it’s a part-time court. Lerner-Wren maintains her regular criminal docket and holds mental health court hearings during her lunch hour on weekdays. On Thursdays, she schedules a full afternoon of status conferences to monitor defendants’ progress.

The court has no budget and operates with only two employees: a $40,000-a-year county-funded court monitor from Henderson Mental Health Center and a $45,000-a-year licensed clinical social worker from the Florida Department of Children & Families.

Unlike most courts, where a hush falls as the judge appears, mental health court is often a free-for-all. Attorneys and social workers mill about in front of the judge, chatting about defendants’ histories. Nova Southeastern University psychology doctoral student interns screen prisoners who are in manacles, jail jumpsuits and black flip-flops, and report their findings to the judge.

“How many times have you been in the hospital for mental health reasons?” the students ask.

“Do you have a place to live?”

“Are you hearing or seeing anything?”

Some prisoners mumble incoherently to themselves or scream obscenities. Others wait patiently for the judge to call on them. Those out on bond sit on benches in the audience, often with family members or friends.

Lerner-Wren asks how they’re doing and poses the question: “Is there something this court can do for you?”

“The defendants are treated with more respect than they probably ever had before,” says Danielle Levin, a Broward assistant state attorney assigned to the mental health court. “In other courtrooms, people acting inappropriately are either not brought into court or judges don’t want to deal with them. This judge talks directly to them.”

Kimberly Warner, 37, who first came to the court after an indecent-exposure arrest three years ago, was “very, very ill,” as the judge puts it.

Warner, a schizophrenic, says she had suffered a nervous breakdown and couldn’t cope. To make matters worse, she was doing crack. “I was on the verge of suicide,” she says.

Lerner-Wren sent Warner to a residential treatment program, where she stayed for more than a year. But after she was released and got her own apartment, she relapsed and was arrested on lewdness charges.

Lerner-Wren gave her another shot. Warner moved to a different program and stayed clean. After six months, she transferred to a board and care home, but still attended day treatment and took medications.

At an August hearing, Lerner-Wren handed a glowing Warner a “certificate of achievement” for completing treatment and making “terrific progress.”

Around the courtroom, there was a burst of applause.

“This court has helped me a lot,” Warner said, tears welling in her eyes. “It helped me get my life together.”

Jail, release, jail again

Mental health court was born of crisis.

It stemmed from the highly publicized case of Aaron Wynn, a young man who suffered brain damage in a motorcycle accident in the mid-1980s. He couldn’t control his anger and acted out with his fists. For years, his parents had tried unsuccessfully to get him help as he moved between the mental health and criminal justice systems.

In 1993, Wynn was arrested in Hollywood after a woman, 85, he knocked down outside a grocery store hit her head on the pavement and died. Wynn was charged with manslaughter but found incompetent to stand trial.

Wynn’s case prompted a 1994 grand jury report that blasted the jails filled with mentally ill inmates — an estimated 6,500 to 10,000 a year — who got little, if any, treatment from the county’s fragmented mental health system.

The same year, Broward Circuit Judge Mark A. Speiser, then head of the court’s criminal division, created a mental health task force of attorneys, social service experts, police and advocates.

The task force found that mentally ill people were being arrested for minor offenses and locked up in overcrowded jails because they couldn’t make bond, sometimes as little as $25. Some would remain for days or weeks without treatment. Finally, they would plead guilty or no contest and be released, only to be rearrested for similar crimes.

“Severely mentally ill people would sit in jail after being arrested for rummaging through a Dumpster or standing in a parking lot screaming or walking naked into a Denny’s,” says Doug Brawley, the Broward chief assistant public defender who supervises the county court division. “They’d be sentenced to time served, get released from jail and be on their way. And they’d go right back out and do the same thing again. Nobody was helping those people.”

A U.S. Department of Justice study appears to bear out the task force’s findings. It revealed that in 1998, an estimated 283,800 mentally ill offenders were locked up in the nation’s jails and prisons, representing 16 percent of prisoners. Those in local jails who had been arrested for “public order” offenses served on average 1.3 months more than offenders who weren’t mentally ill.

“I was very frustrated as a judge,” Speiser recalls. “Our jails were swelling with people who had mental health issues. By releasing them, we were doing a disservice to them and the community. It was like a merry-go-round.”

Deinstitutionalization, the sweeping movement to empty psychiatric hospitals that started in the 1960s, compounded the problem. The number of patients in state and county psychiatric hospitals dropped from 558,922 in 1955 to 54,836 in 2000, according to U.S. Department of Health and Human Services statistics, but community programs to help treat them didn’t grow to meet the demand.

Chief Assistant Public Defender Howard Finkelstein, who represented Aaron Wynn and was a member of the task force, says he brought up the idea of a mental health court out of frustration.

“Judge Speiser asked what I wanted,” Finkelstein says. “I said I wanted a mental health court. Everyone thought about it — and said OK.”

The court would accept defendants arrested on misdemeanors, but not domestic violence or driving under the influence. It would take those arrested for battery, but only if the victim consented.

And it would not include anyone arrested on a felony charge unless it had been reduced to a misdemeanor.

Most important, task force members had to find a judge to make it work.

They chose Lerner-Wren, who had just been elected to the county court bench in the fall of 1996. She had served as the Broward County Public Guardian, responsible for overseeing the health and welfare of disabled adults who were incapacitated. She also had worked for an advocacy center monitoring a settlement agreement over a federal class action lawsuit against South Florida State Hospital, the region’s mental hospital.

Broward Chief Judge Dale Ross appointed her to run the new court, which opened for business in June 1997.

“The court came to be out of desperation,” says Lerner-Wren, 43. “But it has turned out to be a great vehicle that pulls these bits and pieces of a very broken and fragmented mental health system together.”

Those who work in the judicial system are quick to assert that the court is making a difference in the lives of the mentally ill.

“The mental health court has helped a great deal,” says Broward Sheriff Ken Jenne. “The judge has developed a real good balance. She isn’t getting suckered, but she’s also sympathetic.”

Jenne says the court was badly needed, not only from a treatment standpoint, but also from a fiscal one.

Broward Sheriff’s Office statistics show that it cost taxpayers an additional $638,000 last year to feed, clothe and provide medication to mentally ill inmates in the jails.

From March through October of this year, the county jails made 342 referrals to mental health court, or about 42 a month, statistics show. While sheriff’s officials don’t keep statistics on exactly how much that may have saved them, they point out that it costs about $235 a day to care for a mentally ill inmate.

“At the end of the day, this community is 100 times better having the mental health court,” the sheriff says.

`A lost soul’ saved

For 48-year-old Scott Cormiea, mental health court was the end of the line.

A homeless alcoholic suffering from severe depression, he couldn’t hold a job. He ended up on the streets, feeding himself by rummaging through trash bins. He says he tried to kill himself by walking in front of a bus and by drinking himself to death.

“I turned into an animal living on the street,” Cormiea says. “I kept hearing voices to kill myself because I was worthless.”

Fort Lauderdale police arrested Cormiea on New Year’s Eve 2000 on a charge of trespassing at a gas station. In September 2001, he was cited again for drinking a beer while sitting on a milk crate on the sidewalk.

Later that month, he was brought to jail on a warrant for an open-container charge and was referred to the mental health court.

Cormiea was hearing voices and was suicidal when he first appeared before Lerner-Wren, records show. The judge ordered him into a crisis unit for evaluation.

Once stabilized, Cormiea went to live at “Cottages at the Pines,” a mental health court program based at a cluster of brightly painted houses that once belonged to doctors on the grounds of South Florida State Hospital in Pembroke Pines.

The cottages are designed mainly for homeless mentally ill defendants from the mental health court. Fifteen beds are reserved for court-ordered defendants and nine are for homeless people referred by county staffers.

Participants in the $1.25 million-a-year program, run by Henderson Mental Health Center and funded by the state and county, receive therapy, sign up for disability benefits and work on developing social skills and reconnecting with their families. When they’re done, they usually move into their own apartments or board and care homes.

In April, Cormiea had been living at the cottages for six months. He was attending Alcoholics Anonymous meetings, had signed up for computer courses and planned to get his own apartment.

“I was in such bad shape, but I managed to turn myself around,” Cormiea said. “I’d be dead right now if not for this program. I was a lost soul.”

Cormiea left the cottages in June and moved into an apartment. He hasn’t been arrested since, court records show.

Like Cormiea, about three in 10 defendants who appear before Lerner-Wren report substance abuse problems and an equal number are homeless, according to an annual progress report released by the court.

Many others live with family members or friends. Some are professionals. About a quarter are women, many of whom have been arrested on prostitution, theft or alcohol- or drug-related charges.

One of the court’s biggest obstacles is the lack of treatment beds in the community for defendants in her court, Lerner-Wren says. Nor are there enough programs to help mentally ill offenders who are substance abusers, women who’ve been abused or those looking for work, she adds.

“These are huge problems in the state of Florida,” says Lerner-Wren, who was appointed in May to the 15-member President’s Commission on Mental Health.

About two-thirds of the cases that come before the court are resolved after the initial hearing before Lerner-Wren. The rest are continued and monitored, according to a study by the University of South Florida’s Department of Mental Health Law and Policy.

For defendants who receive mental health services and appear to be stable, Lerner-Wren often withholds adjudication, which means there is no record of a criminal conviction, and closes the case. She usually does the same for defendants who successfully complete treatment.

Court records show that about 12 percent of defendants aren’t appropriate for the court. Some might not be mentally ill. Others may have a violent history.

And some defendants choose not to participate. They might not believe they have a mental health problem or be motivated to help themselves. If the charge is minor and they have no outstanding warrants, Lerner-Wren usually will close the case and order them not to return to the place where they trespassed or shoplifted.

Janis Blenden, the court’s clinical social worker, says that while there’s a good team in place, the court misses many people or can’t find services for them.

“We see a lot of alcoholics and homeless people who are not mentally ill,” Blenden says. “We can’t help them. In the long term, they don’t qualify for benefits.”

Swift-moving process

Most new defendants who appear before Lerner-Wren are sent from magistrate’s court, held via television, in the main jail. Nova doctoral students attend morning hearings to screen inmates and pinpoint those who appear to have mental health problems. Inmates’ names also are matched against a list of current and former clients kept by Henderson Mental Health Center.

Judges, public defenders, assistant state attorneys, police officers, social workers, family members and advocates also can recommend a defendant to the mental health court.

The process usually moves quickly, often within 24 hours of the arrest.

A mentally ill defendant arrested on Monday night, for instance, would appear in magistrate’s court the next morning and could be in front of Lerner-Wren by lunchtime Tuesday.

The whole idea is to divert mentally ill inmates from jail as quickly as possible.

For Lerner-Wren, getting help on the spot is the normal course of business.

When inmates complain they aren’t receiving psychotropic medications, she’ll phone the jail and insist that they get their meds.

“Honestly, when the judge calls and says, `I need you to do something,’ that’s going to jump up on the list of things that need to be done,” says Timothy Ludwig, mental health coordinator for the county jails. “She takes a personal interest in each case.”

Not all cases get to the mental health court quickly, however. Some defendants have a pending felony charge, which must be disposed of before they would be eligible for the court. Others get lost in the jail system.

“If they’re not known by the mental health system, someone has to notice them,” says Levin, of the state attorney’s office. “If they’re quiet and don’t display overt signs, the jail’s not going to recognize it.”

Lerner-Wren requires defendants or their case managers to update her regularly about progress, every week or two at first, then every month or so. A case can remain in her court for up to a year.

Those who continually violate her orders are expelled from the program. Some are transferred back to criminal court or taken into custody if they commit a new crime.

Lerner-Wren frequently tells defendants that it’s up to them to take their medications and manage their illness. Sometimes she’s like a stern parent, scolding those who fail to follow her orders.

To one defendant, she warns: “You’re starting to rack up a history. If you don’t take your medications, there will be consequences. You’re going to see harsher and harsher sentencing.”

Sometimes the judge is like an adoring teacher, handing out certificates to those who have succeeded.

“You have really moved forward,” she tells one defendant. “We’re so pleased with your accomplishments and growth.”

Lerner-Wren is proud of the court, noting that visitors have come from as far as the United Kingdom and South Africa to see it in action. Congress also liked the idea, and in 2000, passed legislation creating up to 125 pilot mental health courts throughout the country.

Evelyn Miller, president of the Broward County chapter of the National Alliance for the Mentally Ill, says her group thinks the mental health court has made a difference.

“It’s a wonderful thing that these people can be offered treatment, rather than sit in jail because of their illness,” Miller says. “You have to help those who need it the most.”

Public safety first

Not everyone is a success story. Some mental health court participants are what the attorneys call “frequent fliers” who keep getting arrested again and again.

At 5-foot-11 and 525 pounds, Kalvin Williams was hard to forget, Lerner-Wren says, when he became one of the first defendants in her court.

Williams, 45, suffers from a “schizoaffective disorder,” in which patients experience severe mood swings and some of the psychotic symptoms of schizophrenia. He has been arrested dozens of times, usually for creating a public nuisance. He often screams at people, using obscenities, in public places, court records show.

The judge tried sending him to intensive case management and residential programs, to no avail. Now Lerner-Wren says she won’t take Williams’ cases.

“I feel very disappointed because he has had many opportunities,” the judge says. “But you have to respect choice. This is not the court for him.”

But mental health court officials are less likely to worry as much about offenders like Williams as they do about those who are violent. They say their deepest fear is that one of their defendants will commit a heinous crime, leading to demands that the court be shut down.

“We don’t want anything bad to happen that could cause all of this good to be placed in jeopardy,” says Lee Cohen, the Broward assistant state attorney in charge of the county court division. “If it did, I hope it wouldn’t kill the court.”

Lerner-Wren says the State Attorney’s Office does a national criminal background check on every defendant and presents her the history. She wants to weed out those with prior serious violent offenses and send them back to regular court.

“We’ve been very sensitive about this,” she says. “Public safety is of utmost importance.”

Unlike drug courts, where success is measured by whether participants stop using drugs, the mentally ill will continue to be mentally ill, so experts have to use other measures to evaluate.

The most obvious is recidivism. Until recently, statistics were hard to come by — the court, which has no administrative unit, never kept them. This year, however, the Broward court administrator’s office analyzed data from October 2001 through September 2002 and found that 27 percent of mental health court participants had been rearrested during that time. Eight percent had returned to the mental health court.

Lerner-Wren says the recidivism is “surprisingly low.”

“It’s awesome that seven out of 10 aren’t re-offending,” she says. “It demonstrates that treatment works and recovery is possible.”

The court does appear to be offering mentally ill defendants more help than a regular court, according to initial findings from the two-year University of South Florida study.

The study compared a sampling of mentally ill defendants processed in a regular county criminal court in Hillsborough County with those who appeared in Lerner-Wren’s court.

It found that mental health court defendants felt they were treated with more respect and fairness than their counterparts, and that it was much more likely they would get follow-up treatment, such as therapy or medication management.

Respect and compassion

“Broward County has clearly been a national leader. This court seems to be a significant success,” says John Petrila, a USF professor who co-authored the study.

Ultimately, how well the mental health court works depends on what you want it to do, adds Norman Poythress, another co-author and USF professor.

“Legislators look at how much does it cost. Criminal justice looks at whether it reduces crime and how many dollars it saves us in bed days in jails,” Poythress says. “Advocates look at whether their relatives are treated with respect.”

Court officials say that the one thing they know is that mentally ill offenders who walk into Room 510 usually leave with a feeling that someone cared about them.

“Whether we’re making a difference, I don’t know,” says Finkelstein, of the public defender’s office. “I just know that on the day-to-day direct human interchange that goes on in that court, the quality of justice and compassion we give these people is something Broward County should be proud of.”

This reporting project was supported by a Kaiser Media Mini-Fellowship in Health.

Jenni Bergal can be reached at jbergal@sun-sentinel.com or 954-356-4592.

The Henry J. Kaiser Family Foundation

Health Care in Cuba

By Mason Essif April 21 – May 2, 2001

For ten days the six Fellows of the 2000/2001 Kaiser Media Fellowship program explored and evaluated the health care system of Cuba. They met with doctors, nurses, administrators, experts and government officials. The topics ranged from housing conditions to mental health and from STD/HIV prevention to cardiac surgery. While most of the time was spent in Havana, a few days were spent traveling into the mountains to analyze how universal access is guaranteed in the remote and rural areas.

While we were exposed to so much during the trip I divided my video material into four main areas: The Embargo, HIV/AIDS, Primary Care and Natural Medicine. Each segment strings together fragments of discussions with the experts in hopefully a rational manner. There is no narration just these excerpts and pictures of some of the sites and sounds encountered.

OverviewThe Embargo HIV/AIDS Primary CareNatural Medicine

The Henry J. Kaiser Family Foundation

Alcon Receives Warning from FDA

Problems Involving Test Batches are Fixed, Drug Manufacturer Says

12/09/2000

By Sarah LundayReprinted with permission of The Dallas Morning News

Alcon Laboratories Inc. has received a warning letter from federal regulators, saying the drug maker failed to meet several quality and safety standards during a recent inspection.

The problems could alter the purity of the company’s products, according to the Nov. 17 letter from the Food and Drug Administration.

Alcon, a subsidiary of Swiss-based Nestle SA, produces eye-care products and technologies, including surgical instruments, prescription drugs and contact lens care products. It employs 2,600 people at its Fort Worth facility.

Company spokeswoman Mary Dulle said the problems found during the inspection involved test batches of products that would not have been distributed to consumers. She also said that Alcon has since remedied those problems.

“We absolutely believe that there is no possibility of contamination of our product,” Ms. Dulle said.

FDA investigators who visited Alcon’s drug and device manufacturing plant in October documented “serious deviations” from the agency’s regulations governing manufacturing quality, according to the letter.

Michael Chappell, Dallas district director for the FDA, said the Alcon case continues as an open investigation until regulators review the company’s corrections.

“We don’t necessarily consider the matter closed until we go back and check that they follow the criteria they said they would and that it would actually solve the problem,” Mr. Chappell said Friday – the date specified in the letter as the deadline for Alcon to fix the defects.

Ms. Dulle declined to discuss the products involved in the testing cited by FDA inspectors.

The warning letter cited several areas of concern, including:

•Failing to clean, maintain and sanitize equipment to prevent malfunctions or contamination.

•Failing to establish appropriate written procedures to prevent microbial contamination in drug products.

•Failing to assure and document that automated equipment used in manufacturing, processing, packaging and holding of drug products will perform its intended function.

Ms. Dulle said any problems investigators found were related to manufacturing lines that were being used for testing at the time of the inspection. Still, Alcon acted quickly to fix problems, Ms. Dulle said.

“It’s a warning letter, so they’re trying to bring something to your attention in a big way,” Ms. Dulle said. “We’re really trying to work with FDA so we don’t get these letters.”

The company has received two other warning letters since 1998 on separate incidents. In both cases, Alcon responded quickly and the cases were closed satisfactorily, Ms. Dulle said.

The Henry J. Kaiser Family Foundation

At the Heart of Race and Health Care

11/27/00

By Linda Wright Moore Reprinted with permission of Philadelphia Daily News

Dr. Charles Bridges, assistant professor of surgery at Penn’s medical school and clinical director of cardiac surgery at Pennsylvania Hospital, understands that racial disparities in health care are much more than skin deep.

That premise is clear in his latest research, a study of differences in the death rates of blacks and whites who undergo coronary bypass surgery. His study was published last week in the Journal of the American College of Cardiology.

Bridges and his colleagues found that fewer than 4 percent of all patients studied died as result of coronary artery bypass surgery – but that black patients were 29 percent more likely to die than whites. And that’s even when other known risk factors, such as age, kidney failure and heart failure, were taken into account.

So what’s going on?

“Race is probably a marker for other biological variables that may have to do with cell function that protects people from heart disease,” Bridges hypothesized.

“These cells may work differently in some black patients, so that they tend to have less protection and more severe heart disease at an earlier age. . .So blacks may have higher mortality, not because they are black, but because of a different biology.”

That biological difference might be shared by some black people – and by people of other races as well.

But to sort it all out will require more research.

Expensive, extensive research. And on Wednesday President Clinton signed into law a measure that could help fund research like Charles Bridges’.

The new law could be a foundation and a first step toward eliminating wide and persistent health disparities that cause millions of Americans to live sicker and die sooner than most of their fellow citizens.

First introduced in June 1999 by U.S. Rep. Jesse L. Jackson Jr., D-Ill., the legislation that became the Minority Health and Health Disparities Research and Education Act of 2000 was strongly supported by Democrats. But the proposal was almost derailed when conservative House Republicans circulated a memo claiming the bill contained “several racial set-asides and quotas” for grant and loan programs.

The bill was rescued by Republican Sen. Bill Frist, who represents a Tennessee constituency of low-income blacks and Appalachian whites. Frist expanded the bill to include all health disparities – including those experienced by poor whites.

Now, the new law calls for:

Annual spending of at least $100 million for research on health disparities.

$50 million for studies to identify causes of health disparities and explore strategies for eliminating them.

$21 million for education programs to help doctors learn techniques of “culturally competent” care.

Unspecified funding for repayment of educational loans to health professionals who conduct research on minority health or health disparities.

Add in the budget of the existing Office of Research on Minority Health and the total for research into how race affects health is nearly $250 million per year.

“To address this problem with a more targeted approach, we need better data and understanding of the factors that drive the problem,” said Marsha Lillie-Blanton, an African-American who is vice president of the Kaiser Family Health Foundation, where she directs policy research and grants on access to care for vulnerable populations.

“In the past, most researchers studying us were not people who understand us and our communities. This [new law] will train minority researchers and invest in research targeting the needs and problems of minority and disadvantaged communities.”

Money and a solid hypothesis drive research. Along with new dollars under the minority health and disparities law, the nonprofit Center for the Advancement of Health recently announced a $1.5 million pilot program funded by the W.K. Kellogg Foundation, “to train a new generation of minority scientists” to research and solve disparities in health care.

These new resources will enable scientists like Charles Bridges to expand their research.

“We need to systematically investigate biological differences that we found in black patients, such as more severe heart disease at a younger age,” Bridges said. “We also need long-term studies. What about one-year or five-year or 10-year mortality? That would take years, and it would be expensive.”

Expensive and complicated – because, even if race is a factor in medical outcomes, it’s not in itself an answer to the question of eliminating racial disparities in health. “We cannot treat race, but we can treat biological factors,” Bridges pointed out.

So it becomes essential to figure out how biology, poverty, access and culture apply to minority health by asking an array of questions that have clinical and social implications.

“We need to look at the influence of socioeconomic variables,” Bridges said. “Are blacks getting service from the same surgeons as everyone else, or does a certain, limited group of surgeons treat blacks? Are there differences that correlate to where blacks live and the quality of care available in their communities?”

The only downside to the creation of a center devoted to minority health is the risk of “ghetto-izing” research on minorities into a niche with minimal funding, Lillie-Blanton said. The $250 million authorized to begin studying minority health and health disparities is just 1.4 percent of annual National Institute of Health spending.

“It’s not the answer, but it provides an opportunity we haven’t had before to develop research by people who are more knowledgable about our community,” said Lillie-Blanton. “It’s information that will help to leverage what kinds of research should be done in the other divisions of NIH, with larger sums of money.”

The other big problem underlying the issue of health disparities is access – the problem of being less likely to be referred for bypass surgery, heart transplants, angioplasty or catheterization.

“We need to educate physicians and patients about the benefits of these interventions,” said Bridges, “especially where there is no economic barrier to paying for the procedure.”

Bridges said often poor communication between doctor and patient results in less aggressive care for some minority patients, but attitudes about race are also a factor. “We cannot deny that there is a difference in physician attitudes that gets manifest as patient access,” Bridges said. “I have had several African-American patients who, prior to meeting me, had declined to have surgery.

“When I was able to communicate to them the risks, benefits and alternatives in a manner which they found clearer, less threatening and more sensitive to their views, in several cases they agreed to undergo procedures that were necessary.”

One component of the new law specifically calls for education efforts in “culturally competent” care, to help doctors – who are primarily white and male – learn to more effectively treat patients who will be, increasingly, non-white as the nation’s demographics shift in the 21st century.

Along with money, research takes time. And so does changing the way patients are treated. For now, according to Bridges, the best way to reduce race-based disparities in health is for patients and doctors to decide on the appropriateness of heart surgery and other cardiac treatments based on “established clinical data, independent of race.”

Dr. Thomas LaVeist, a professor and researcher at the Johns Hopkins School of Public Health, is also studying the touchy issue of why whites and blacks get different treatment for cardiac problems.

“The new resources that will flow from the center for minority health are important for researchers who have been toiling for years in the area of disparities in health, and haven’t been able to get the support they need,” LaVeist said.

“Although the center itself has a relatively modest budget now, hopefully, that budget will grow.”

2001/02 Kaiser Media Fellowships program:Poynter Institute program on computer-assisted health reportingMonday, November 12-Wednesday, November 14, 2001

Location: The Poynter Institute for Media Studies, 801 Third Street South, St. Petersburg, Florida 33701 (Tel: 727-821-9494; fax: 727-821-0583; www.poynter.org)Hotel accommodations: The Hilton Hotel, 333 1st Street South, St. Petersburg, FL 33701 (Tel: 727-894-5000; fax: 727-894-7655)

Program Faculty

• Mike Wendland, Poynter Institute Fellow; Technology Columnist, The Detroit Free Press, Wendland’s High Tech Talk, NBC-TV News Channel’s weekly technology reports, and CBS-WXYT Radio/Detroit weekly call-in show on computers and the Internet. Former on-air reporter, WDIV-TV/Detroit (1980-98); investigative reporter, The Detroit News (1970-80); author “Wired Journalists: Newsroom Guide to the Internet” published 1996 by the Radio and Television News Directors Foundation;
  • Internet reporting
• Debbie Wolfe, Technology Training Editor, St. Petersburg Times
  • Spreadsheet reporting
• Chris Adams, reporter, Washington D.C. bureau, The Wall Street Journal (1995/96 Kaiser Media Fellow)
  • Case studies: using a major health care database–what to look for, how to handle the data, how to use it in reporting. Including reporting for the award-winning 1995/96 New Orleans Times-Picayune series on health care fraud and nursing home scams in Louisiana, and reporting for the Wall Street Journal on the FDA.

PROGRAM Breakfast will be available in the hotel restaurant from 6:30am onwards. The Poynter Institute is approximately 10 minutes walk from the hotel. There will be an informal buffet lunch each day at the Poynter Institute. Dress is casual.

Sunday, November 11

7:00pm: Introduction to program/Dinner–Mike Wendland Bayview Room (15th floor), The Hilton Hotel

Monday, November 12

9:00am-5:00pm: The Poynter Institute, computer room –Internet reporting, Part 1: Mike Wendland –Introduction to spreadsheets, Part 1: Debbie Wolfe –Using spreadsheets for a story: Chris Adams –Downloading from the Internet: Mike Wendland/Debbie Wolfe 6:40pm: Walk from hotel 7:00pm: Dinner, Bertoni’s restaurant, 16 Second Street North (Tel: 727-822-5503)

Tuesday, November 13

9:00am-5:00pm: The Poynter Institute, computer room –Introduction to spreadsheets, Part 2: Debbie Wolfe –Internet reporting, Part 2: Mike Wendland –Case studies: Chris Adams –Data clean-up 6:40pm: Walk from hotel 7:00pm: Dinner, Moon Under Water, 332 Beach Drive NE, (Tel: 727-896-6160)

Wednesday, November 14

9:00am-3:00pm: The Poynter Institute, computer room –Introduction to spreadsheets, Part 3: Debbie Wolfe –Organizing and managing computer-assisted reporting projects: Mike Wendland –Wrap up pm: Fellows Depart

Child Health Facts: National and State Profiles of Coverage

Nearly 10 million children in the United States lack health insurance coverage and over two-thirds of them or low-income. This databook provides baseline data on how many children are uninsured today and on the extent of Medicaid coverage. It provides astarting point to monitor and assess state efforts to reach and insure more children.

• Report
• Report