Questions

I find questions much more interesting than answers. Questioning is like opening a book. You don’t know what’s in store. Answers are like closing the book. There’s nothing left to say. Even if you have more to say, there’s nothing left to say. The question has been answered.

My friends Martha and Carrot started a dialog today. I’m not sure they knew they were talking to each other. Martha was talking about how the pandemic has freed us from the need for “normal” socializing and how one writer pathologized this as “social anxiety”, while to Martha it is “introversion”. While she didn’t belittle the very real mental health issue, she noted that there are some things you just don’t do in a group. She mentioned her first novel. “I’d had this incredible experience that was impossible to share with anyone. I’d written a novel. I’d brought my story, my vision, for Martin (the character) into real life. I’d done the work, the immense research, all of it, the library time (back then). Because of my book, I KNEW people who’d lived in the 13th century. The experience catapulted me into a different Martha, but I couldn’t share that, either.” I will mention her rediscovery of herself as a painter and drawer this year. First the blog began to feature oil paintings. Lately, pen and ink drawings have graced its pages. Even the title of her blog changed (twice!) during this pandemic. Is she another “different Martha”?

Carrot posited a restaurant in which “the phrase ‘can I get you started on something saucy’ is as much about the dialogue as it is about the appetizer.  The table clothes will be covered in questions and hypotheticals.  Each bill will come with the quote du jour.” The food you are served would correspond with the table talk:
Customer: Excuse me waiter, I ordered the gnocchi and pesto.

Waiter: Right, I’m sorry, it’s just that I heard you talking about your Instagram followers, so enjoy your Cream of Wheat.

How do we ask the right questions? Ask the wrong question (one that cries out to be answered) and we get nowhere. “What’s your favorite color?” “Blue.” Now what?

Ask without questioning, and you only get an answer. “Who am I?” “George.” Done. Or “the guy who writes this blog.” Who was I before I wrote this blog? Same me, or someone else? Am I the things I do? the roles I play? the thoughts and feelings I hold? the sum of all of my experiences? my beliefs and opinions? my body? Or am I someone else, who “has” all of these, rather than “being” any or all of them? Am I the point of view from which I see the world? If I didn’t see literally, would my “point of view” change? Would I be someone else? Is my “self” additive? (The sum of everything I hold as “me”?) Is it subtractive? (If I take away everything in the world that I identify as “other”, is what’s left over “me”?)

Dalton Trumbo looks at the relationship between body and identity, and between how we see ourselves and how others see us in the novel and subsequent film “Johnny Got His Gun”. It is the story of a badly injured WWI soldier and his post-war life in a VA hospital. There is little left of his body and he cannot see, speak, or hear. Who is “in there” and does that matter if no one “out here” acknowledges his humanity?

I used to ride with friends every week and talk and then drink some beer and eat some dinner and talk some more. Before that, I would go sit in a hot tub with some other friends and talk. Before that, I worked in a neighborhood store that was the center of a community. In all of these cases, it was a community of people interacting face-to-face. For the past year I have seen my coworkers and patients, and my family. I’ve had little contact with most of the people I identified as “my community”.

But I found this other community (hey, I’m old…it took me a long time – my daughter has been in a number of world-wide online communities for years) that has grown as organically in its own way as the physical community. When I started this blog I got some tips from a music blogger I know. I found and read a couple of bike blogs and they led me to this world of climbers, painters, writers, musicians (and writers about music)…It was Carrot and The Dihedral who introduced me to Martha.

What is community and what is necessary for our mental health? Is an online community any less real than a physical one? Can you go out for a virtual beer or cup of coffee? When I return to in-person friends, how will I balance that with these online friends?

Are other people essential, or something you have to deal with to get through your day? If the ones you “have to deal with” were gone, would you miss them?

P.S. The day after posting this, I read Ask Amy, with someone concerned about returning to face-to-face interactions. The writer related a recent interaction and made the distinction “interacting with people from a place of compassion, treating people as human beings — not human-doings.

Baiku

Bicycling magazine used to give away a bike each spring. Each year was a different contest. I never won. One year they wanted a picture of your bike to show why you needed a new one. I sent a photo of a bike I’d made from snow. I figured it would melt soon so I needed a new one. They disagreed.

Another year they wanted you to tell them why you should win a particular bike. I wrote a song called “My Serotta” to tell them why I should win the Serotta Ottrott. It was written to the tune of “My Sharona”. They were not convinced.

Then they asked for baikus – haikus about bikes. I sent a bunch. I didn’t win again. Here are rewritten versions of two of the losers – one about my daughter’s first ride, one about my imagined last ride.

First ride – age 5

Holding the saddle –
I let go as she rides off.
She doesn’t look back.

Last ride – age 95

Steep mountain descent.
Heart stops – dead before I land.
Body found smiling.

The Norway Maple in the yard of our old house (across the street from where we live now) succumbed last year. Counting growth rings is harder than it seems, so I don’t know how old it was. I’ll guess it was around 50 years old, having been mature when we moved in there 27 years ago. Our son (who was born that year) wanted a particular cutting board this year, so I was looking at cutting boards, and end grain maple boards (like butcher blocks) seemed like a top choice (though he chose edge grain walnut). Most are made by gluing a bunch of small pieces of wood together. I figured, what’s a stump but a big chunk of end-grain wood? Who needs glue?

So I took various saws across the street and started cutting. Once I got a slice free I had to get it relatively flat and smooth. “Relatively” is an important disclaimer there – cutting through 18 inches of wood and having two flat and parallel sides is easier said than done. But now I have a tree-shaped end-grain maple cutting board. I liked the shape of the tree rather than cutting it into a rectangle. I left a few scars intact – I’ll say it’s because I liked the way they looked, but I could also say I would have had to take off a lot of wood to get it totally smooth, and without a planer (and especially not one that can accept an 18 inch surface) to run it though. The colors are natural. It has been treated only with a food-grade mineral oil and wax mix.

It must be spring. The loons are passing through on their way to Canada. The robins are back. It is 75 degrees (24 Celsius) and sunny. The first warm Sunday of spring means it’s motorcycle crash day. Lots of people will be out for the first time, riding too fast, and not noticing the sand and gravel collected on curves. Wednesday Night Bike Rides start this week!

The path of least resistance?

Where I live we have three types of thoroughfares: roads, shared-use paths (commonly known as bike paths) and sidewalks.

Roads are for motor vehicles and bikes; pedestrians if there are no adjoining sidewalks. Sidewalks are for pedestrians and bikes (unless buildings abut the sidewalk, in which case bikes are prohibited). Bike paths (officially known as shared-use paths, even though some have “bike path” in their names) are for bikes, pedestrians, joggers, skaters, skiers, equestrians…

How do bikes fit into all of this? Some of the trails are toll roads if you’re on a bike but not if you’re walking. We have no toll roads for cars in this state. I have seen rants in the newspaper (or heard them from people) that bikes don’t belong on rural roads – they should stick to the paths. I’ve heard rants that bikes don’t belong on other roads because they go too slowly. I’ve seen rants (on a neighborhood app) about bikes that go too fast on the paths. And I’ve seen claims that bikes on sidewalks are illegal (as noted above, they are illegal in only a very limited downtown area where I live).

So where does that leave bikes? Not wanted on the roads, not wanted on the paths, not wanted on the sidewalks. Too slow for the roads, too fast for the paths, just plain dangerous on the sidewalks.

I have written before about John Forester‘s concept of vehicular cycling. Back in April of 2018 I wrote a series of posts about bike safety. This time, I’m here to talk about the conundrum. Our society has not yet decided whether to consider bikes toys or a mode of transportation; partly because there is no reason they can’t be both. How we are using a bike should be a determining factor in where we ride. Generally I prefer to ride lightly-traveled streets – both in town and in the country. Whether going fast or slow they seem to work best. (Jarjour, et al in Environmental Health, 2013, found lightly-traveled bike boulevards reduced cyclists’ exposure to environmental pollutants from vehicle exhaust – a result that should make you say “duh”, but should also make you rethink riding on busy streets.)

The purpose of traffic laws is to standardize and define relationships and expectations among users in order to increase safety. In grey areas, the most vulnerable user should have the right of way.We are responsible for each other’s safety and ultimately we are all responsible for our own safety. A law will not protect us from a multi-ton vehicle. Common sense should be our guiding principle.

Drivers are often advised that it is safest to drive at or near the prevailing speed of traffic rather than strictly at the speed limit; thus they may be going slower or faster than the posted speed at times. Going faster is always illegal, regardless of the “prevailing speed”.

Q. Isn’t slower always safer?
A. No, federal and state studies have consistently shown that the drivers most likely to get into accidents in traffic are those traveling significantly below the average speed. According to research, those driving 10 mph slower than the prevailing speed are more likely to be involved in an accident
.” https://www.motorists.org/issues/speed-limits/faq/

“It has been found that motorists are generally capable of determining the driving speed that is reasonable for prevailing road and traffic conditions unless there are some roadway conditions that they are unaware of or which are not readily apparent and that the majority will subsequently adjust their speed accordingly. The 85th percentile speed, the speed at or below which 85% of the vehicles travel a particular roadway, has been found to best represent this perceived ‘reasonable’ speed.https://wisconsindot.gov/dtsdManuals/traffic-ops/manuals-and-standards/teops/13-05.pdf

I would argue that 85% of motor vehicles exceed the speed limit on 25 mph residential and urban streets. Yokoo, et al (Traffic Injury Prevention, 2019) found that “speeding is widespread…” in Minneapolis/St Paul. Hu and Cicchino (Injury Prevention, 2020) and Jones and Brunt (Journal of Epidemiology and Community Health, 2017) argue for speed limit reductions in Boston and Wales, respectively. Apparently motorists can determine the safe speed but that doesn’t mean they/we adhere to it. The 85% rule appears to be most applicable for highway speeds.

 Urban shared-use paths require care and vigilance. Travel slowly enough not to spook other users and to be able to react to their sudden moves. Calling “On your left” frequently results in pedestrians looking over their left shoulders while unconsciously moving to the left into your path. That’s why I use a bell in the city (and most of my bike path use is at 6 AM when there are few people walking). People seem to do better at localizing the sound of the bell and moving appropriately. I have no evidence to support this beyond personal experience. (Lack of evidence is not the same as evidence against. It just means I can’t find that anyone has studied this.) The Next Door app in my neighborhood is currently exploding with a thread about e-bikes on shared-use paths.

The same standard that applies to motorists appears safest for bicyclists. If you are going to be traveling fast, stay on the street (or rural paths that are known to be used primarily by bikes). If your town has “bike boulevards”, they tend to be safer, with infrastructure designed (sort of) or retrofitted for bikes. (Walker et al. define bicycle boulevards as “low-volume and low-speed streets that have been optimized for bicycle travel through treatments such as traffic calming and traffic reduction, signage and pavement markings, and intersection crossing treatments.” [Fundamentals of bicycle boulevard planning & design. Prepared for the Portland State University Initiative for Bicycle and Pedestrian Innovation.2009])

Eric Minikel studied bike boulevards in Berkeley, CA, comparing them to adjacent streets and found:
“Using police-reported collision data and the city’s cyclist count data, this study finds that Berkeley’s bicycle boulevards do indeed have lower collision rates for cyclists than their parallel arterial routes. This is true for all six bicycle boulevard–arterial pairs for which data are available, with risk ratios ranging from 1.8 to 8.0. This is true whether only reported bicycle–motor vehicle collisions are examined or bicycle–bicycle, bicycle–pedestrian and single- cyclist incidents are included as well.” (Accident Analysis and Prevention, 2012)

If you are going to be traveling slowly, use urban paths. Personally, I see very few times that a sidewalk is safe. Motorists backing out of driveways (or turning into driveways) are not looking for bikes. They are not looking for anyone traveling faster than walking speed. Small children on bikes may be going at walking speed, but are so low as to be all but invisible to motorists. Learning to ride a bike on the sidewalk in front of your house may be fine, but traveling any distance on a sidewalk is probably not very safe for a young child.

Forester recommends riding like a vehicle – stay right except to pass, turn left from the left lane. He essentially argued that bikes should be integrated with motor vehicles and that separate bike lanes cause more dangerous situations at the inevitable intersections between bike and car – e.g. bikes turning left across multiple lanes of traffic from a bike lane on the right, cars turning right across bike lanes going straight. A completely separate bike path inevitably intersects roads, and motorists who have learned to be unaware of bikes (since they are not on the roads) will inevitably be more dangerous when they do have to meet. Apologies to Forester if I misrepresent him by merging my thoughts with his.

I would argue that bike paths have their place and that they require the same style of riding as do streets – with the understanding that the other “vehicles” with which you are sharing the road are roller bladers, kids, strollers, dogs, beginning riders; instead of cars and trucks. I think he is right that bike lanes create a false sense of security and result in greater danger (cars parked in the bike lane, parked cars opening doors into the bike lane, cars in right turn lanes turning right across the path of bike lanes that continue straight). I would argue that riding as close as practicable to the prevailing speed of traffic is safest – thus slower on shared-use paths and faster on roads.

While this column did not start as an argument for bike boulevards, they seem to deserve serious consideration. In many cities there are parallel roads. I would argue for using the less-traveled route while on a bicycle. Minikel shows that crashes are less-frequent on bicycle boulevards than on adjacent routes, but is this due to the boulevard infrastructure or just the relative dearth of traffic? Where one route is less-traveled than another, common sense would hint that the less-traveled route is safer for bikes. Is the infrastructure a major determinant? Mulvaney, et al (Cochrane Database Systematic Review, 2015) set out to determine whether infrastructure could be credited for increased safety. They concluded “Generally, there is a lack of high quality evidence to be able to draw firm conclusions as to the effect of cycling infrastructure on cycling collisions. There is a lack of rigorous evaluation of cycling infrastructure.” They judged the quality of most evidence as low and preliminarily hinted that 20 mph speed limits may help and that roundabouts may be dangerous for cyclists.

Personally I tend to avoid urban shared-use paths because I have to treat every intersection as a yield sign in order to protect myself from cars, and I have to ride more slowly than I’d like to when commuting during daytime hours when others are out. There are routes where the street alternative is worse, so I choose routes on a case-by-case basis. (And some are too pretty not to ride on.) My daily routes to and from work were chosen by trial-and-error and adapted over time.

As in almost everything I read for work, “further study is warranted” and “there is a dearth of quality evidence”. As always, common sense should be your guide, and common sense is less common than it ought to be.

As Rodney King (1992) asked, “Can we all get along?”

Helmet? Hell yes!

Bicycling magazine recently republished an article with the clickbait headline “It’s Okay If You Don’t Wear a Bike Helmet”. Clearly, the implication was that helmets are not really very useful.

The article went on to talk about safer bicycling infrastructure – but it doesn’t have to be an either/or situation. Should we stop designing crumple zones into cars because we shouldn’t crash them in the first place? Should we toss out airbags, seatbelts, and carseats for kids? None of those are useful when nothing goes wrong. We work for the best and plan for the worst.

What does the evidence say about helmets? And how good is that evidence? A quick review: when we look at evidence, we consider “levels of evidence”. Different authors define those differently but, generally speaking, the highest level of evidence is a systematic review of randomized controlled trials (Meaning, for the non-scientists among you: looking at not just one, but many studies of the same phenomenon; and not just observing what happens in retrospect, but planning a test, assigning people randomly to groups, and looking at what you are studying in relation to a control group. A few definitions: randomized – people are assigned to one of two or more groups randomly, so that the groups should look the same; double blind – neither the participant nor the observer knows which group the participant is in; placebo-controlled – the group that doesn’t get the test intervention gets something that looks the same but should have no direct effect on the condition studied.) Expert opinion is the other end of that scale.

Randomized controlled trials are not always possible. The article “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials” (Smith & Pell, British Medical Journal, 2003) points out the difficulty of testing some hypotheses. They concluded:

“As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.” (Smith & Pell 2003)

Further, Yeh, et al (BMJ,2018) in the PARACHUTE trial, conducted a randomized (but not blinded) study of parachute use in “Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial”. Their outcome measures were death and ISS (Injury Severity Score). Come to my workshop for an explanation of ISS. They concluded:

“Parachute use did not reduce death or major traumatic injury when jumping from aircraft in the first randomized evaluation of this intervention. However, the trial was only able to enroll participants on small stationary aircraft on the ground, suggesting cautious extrapolation to high altitude jumps. When beliefs regarding the effectiveness of an intervention exist in the community, randomized trials might selectively enroll individuals with a lower perceived likelihood of benefit, thus diminishing the applicability of the results to clinical practice.” (Yeh, et al, 2018)

We can extrapolate from the above studies that we cannot conduct an RCT (Randomized Controlled Trial) to truly test the efficacy of bike helmets. We can also conclude that careful reading is important, lest we draw the wrong conclusions, or accept the conclusions drawn in articles in the popular press about the study .

So what do we have? Olivier and Creighton, writing in the International Journal of Epidemiology (2016), reviewed thousands of studies. 40 met the inclusion criteria and were included in a meta-analysis, with data from >64,000 injured bicyclists. For those who only like to read abstracts, we’ll cut to the chase:

“Bicycle helmet use was associated with reduced odds of head injury, serious head injury, facial injury and fatal head injury. The reduction was greater for serious or fatal head injury. Neck injury was rare and not associated with helmet use. These re- sults support the use of strategies to increase the uptake of bicycle helmets as part of a comprehensive cycling safety plan.” (Olivier & Creighton, International journal of Epidemiology , 2016).

For a few nuggets from that study: “In a recent Australian study of linked police and hospital data for cyclists in motor vehicle collisions, 34% of hospital-admitted cyclists had a head injury and 15% had a serious head injury.2 In a coroner’s review of cycling fatalities in Canada, 55% of deaths were caused by head injuries.3” Also note that “neck injury was rare and not associated with helmet use.” One of the objections to helmets I have seen raised (by both bicyclists and motorcyclists) is that they think they increase the risk of neck injury. Olivier and Creighton found no such correlation.

Looking at individual studies cited, the risk reduction for head injury attributable to wearing a helmet was 85% in one study and about 30% in another (though 70% for severe injury as assessed by the AIS (Abbreviated Injury Scale). Come to my workshop for an explanation of the AIS.

The argument is often made (and is made in the Bicycling article) that wearing a helmet leads to riskier behavior. This is a phenomenon actually studied with all safety devices. Some studies assert “reduced cognitive control” while wearing a helmet. Several of these analyze the behaviors of subjects playing computer games, in which the “risk” is theoretical in the context of playing a game. One which did look at bicycling behaviors noted that male cyclists rode at a slightly higher speed when wearing a helmet. This was not true of female cyclists. It should be noted that the helmeted riders rode at 19.2 km/h (a whopping 11.9 mph) compared to 16.8 km/h (10.4 mph) and that anyone who had previously worn a bike helmet was excluded from the study.

Anecdotal evidence is at the bottom of most evidentiary scales, if included at all. Your author once crashed at about 1 mph (stopping at a stop sign, hitting a patch of ice with front wheel, and falling to the left side, striking the head). It happened so fast that I remember hearing my head bounce off the pavement at about the same time that I realized I was going down. The impact cracked the helmet but caused no ill effects. It was only after trying to get up (and slipping) that I was aware of the ice. The speed of travel did not appear to mitigate the effect. It might be noted that crashing at a higher speed could result in reducing the direct impact of head to pavement (as you could hit it sliding, rather than directly, and the head might not be the first body part to hit). Think about falling directly onto pavement on your head at zero speed. Does that sound harmless?

I grew up in the pre-helmet era. (Truth be told, I remember the first time we got a car with seat belts, and I also remember children’s car seats as being entertainment devices, not safety devices. Our car seats were made of aluminum, lightly padded and covered in vinyl. The belt was a ¾ inch wide vinyl strap. There was a steering wheel with a horn button.)

I moved to California as an adult in 1984. Some people wore helmets out there. Virtually no one did when I left Wisconsin, but they were widespread when I returned. (Let’s just agree to dispense with the “I didn’t have ‘x’ when I was a kid, and I survived…” argument. See paragraph two.)

The first helmets were essentially leather “hairnets” worn by some bike racers. The first consumer bike helmets were hot and heavy. They were worn only by nerds. The Bell V-1 Pro, introduced in the mid-80s, was the first helmet that offered protection and caught on widely (and note that it looks like a sturdier version of the leather hairnet – that was not an accident).

I was riding in the mountains when I came up on a downhill turn, sharper than it first appeared. My bike was in need of a headset at the time, so it chattered under hard braking. I scared myself on that turn and went straight to a bike shop. I dropped off the bike for a new headset and bought a Bell V-1 Pro. I have not ridden without a helmet since then.

Who am I to pontificate about helmet use? So far, I’d say there has been less pontificating and more reviewing evidence. That being said, it is probably clear by now that I come down in favor of helmets. (Especially if you read the title.) We have discussed infrastructure and safety here before. (And will again in a post very soon – written before this one but awaiting final revisions.) Not crashing is better than crashing. Prevention beats mitigation; but we will never prevent 100% of crashes and if you’re the one crashing, despite your best efforts, you might want that mitigation. Very few of us expect to crash. But that’s how I make my living.

I have spent the past 20+ years working in a large teaching hospital. I have spent most of those in a Level 1 Trauma Center. While some people plan to be in a hospital (for elective surgeries) or spend a lot of time in them (for management of chronic conditions), most of the people I work with had no intention of winding up under my care. I have learned, over the years, what injuries are likely to result with and without lap belts, shoulder belts, and airbags. And I learned why school bus drivers used to yell at you to keep your hands inside the bus. I have seen the arms that got trapped under cars and dragged along the pavement, and helped those folks with their rehab. (I no longer rest my arm on the windowsill when I drive, but that’s just me.) I know what you’re likely to break falling from a ladder, the difference in what young and old people tend to break in similar falls. I also have seen that people without helmets tend to have worse head injuries than those with helmets, that other injuries are pretty similar (mostly clavicle and rib fractures), and that those with head injuries tend to fare worse in both the short- and long-term.

We can also look at it from a business perspective – a risk/benefit analysis.
*Risk of not wearing a helmet – brain injury, death. Benefit of not wearing a helmet – better hair or the feeling of the breeze in your hair (probably not both).
*Risk of wearing a helmet – matted hair or not looking cool. (Some would argue that you have a greater chance of doing something stupid, but I’d say alcohol is the hands-down winner for that risk.) Benefit of wearing a helmet – reduced chance of head injury, bigger reduction in the risk of serious head injury or death.
You may consider other risks and benefits, but I think it would be hard to come to a different conclusion.

While we’re at it, how often do you see families out together; the kids are wearing helmets, the parents are not? What message does that send to the kids? The way I see it, you are telling your children “helmets are kids’ stuff.” We know most kids want to feel grown up and many want to be like their parents. You can bet that, as soon as possible, kids will ditch the helmet to feel grown up. I see many middle school kids using helmets as handlebar decorations. If you are a parent and ride a bike, think about helmets – are you putting helmets on your kids because other parents might yell at you if you don’t? Are you doing it because you think helmets will make them safer? If the latter, then why don’t helmets make you safer? If the former, why don’t you have the guts to stand up for your convictions? (And exactly what are those convictions? Do you think you are battling courageously the nanny state?)

So you can take my word for it as an expert, or as someone who has personally experienced crashing and hitting my head, or you can read the literature. In all cases, I think you’ll find that you’re better off with a helmet than without. (And maybe you’ll find one story of someone who was somehow injured by wearing a helmet. An early argument against seatbelts in cars was that you would get trapped in a burning car and die because you wore a seatbelt. Yes, that has happened; but less frequently than people have been thrown from cars – through the windshield, a window, the sunroof – and killed because they weren’t wearing a seatbelt; which is not to mention the multitude of injuries sustained by those flying around in a rolling car even if they don’t fly out through an opening.) Since most of you will not crash and hit your head, you can play the odds if you choose; but then we’d have to look at the public health consequences and the societal costs of your choice. That would be fodder for another post.

(Complete citations available on request – but you oughta be able to find the articles if you try, and have access to PubMed.)