Palo Alto Weekly

Cover Story - January 25, 2013

Palo Alto mom with a mission

At running races, in schools, defibrillators save lives, says Stephanie Martinson

by Chris Kenrick

When popular Monta Vista High School teacher and coach Ron Freeman collapsed and died of a heart attack at a school basketball game in 2011, the school community was galvanized into action.

Less than two years later, the Cupertino high school as well as each of the other four campuses in the Fremont Union High School District has at least seven automated external defibrillators (AEDs) on hand around campus, including units that are carried by school athletic trainers to practices and games.

During a sudden cardiac arrest, defibrillators deliver an electric shock to the heart to restore normal rhythm. After the shock is delivered, the typical AED will prompt the operator to perform CPR while the device continues to analyze the victim.

As the machines have become user-friendly and portable since the 1990s they have proliferated in offices, campuses, police cars, airports, golf courses and houses of worship.

Palo Alto resident Stephanie Martinson, a speech therapist and the mother of daughters at Palo Alto High and Ohlone Elementary schools, is on a mission to bring AEDs to schools and elsewhere.

"We are so far behind other states and other places in the adoption of these machines," Martinson said.

"Defibrillators are easy to use they talk the responder through and determine if the person needs a shock or not.

"We do a phenomenal job with asthma we have EpiPens everywhere and they're mandated in our schools but we also need the same standard of care for sudden cardiac arrest."

Martinson partners with organizers of local running events to lend the portable defibrillators in case a runner collapses and to promote awareness of their life-saving potential. She shows up on race days with friends and volunteers from Racing Hearts, a nonprofit she founded last year.

"I think what Stephanie is doing is really compelling," said John Carrington, a Menlo Park executive and survivor of sudden cardiac arrest.

Carrington, now CEO of the thin-film solar company MiaSole, credits his survival after a 2006 heart attack to an alert colleague and an AED.

"The more people that can become aware of this, the better," he said.

Martinson has secured AED endorsements from Olympic athletes, doctors, politicians, opinion leaders and survivors like Carrington.

She has research AED litigation records in an effort to talk people out of their fear of lawsuits.

She asks participants in running events to donate an extra $3 above the race fee to fund the spread of the defibrillators and training on their use.

There's just a 5 percent survival rate among the more than 300,000 Americans stricken with sudden cardiac arrest every year, Martinson said.

"People don't realize this could happen to anyone. Every three days it's a young athlete who dies.

"But we have a simple solution to improve the survival rate AEDs everywhere."

Martinson is not a heart-attack survivor herself. But her medical condition, hypertrophic cardiomyopathy, puts her at heightened risk.

For several years she lived with an internal defibrillator implanted in her chest, but it caused her "nothing but trouble."

The internal device was removed after it malfunctioned in 2007, mistakenly delivering 26 shocks to her heart.

"People say it's like being kicked by a horse but I say, 'No, it was like a 777 jet crashing in on me,'" she said of the experience. "All the electrical circuits were just exploding.

"I had to heal myself. There were so many parts of my brain I had to rework and study to try to heal myself.

"People who have gone through cancer or sudden cardiac arrest say, 'There's just a new me.'

"We all have a story, and this is my story, and I'm finally willing to share it."

Erik Walukiewicz, a former teacher and coach, used to play poker and golf with Freeman, the Monta Vista coach, who was 52 when he died on Jan. 21, 2011.

"It was at the end of a basketball game and he was out there and he said, 'OK guys, it's time to go home.' And then he collapsed and died right there on the site. It was really sad," Walukiewicz said.

"He was a great teacher and coach of kids."

Though nobody can say for sure whether an AED would have saved Freeman, the shock of his death was a catalyst for Monta Vista and its sister schools Homestead, Fremont, Cupertino and Lynbrook to get serious about a defibrillator program that already had been on the drawing boards, Walukiewicz said.

By that summer, trustees of the Fremont Union High School District had approved a defibrillator policy and by fall "we rolled out a program," said Walukiewicz, who is now the district's maintenance and operations coordinator and oversees 37 defibrillators in the five high schools.

"Fortunately we haven't had to use them, but the good thing is that if we ever had to, the units are there," Walukiewicz said, adding that the district so far has spent about $80,000 on the program.

"We have them all over the place because you want to be able to get one and be back in one and a half minutes. We typically have one on the pool deck, one in the gym, usually one in the theater, one in the main office and the athletic trainers have them to carry to athletic events.

"Anybody could have a sudden cardiac arrest at any time, but sometimes kids get struck by a ball or a blow to the chest, so that's why we place them where there are athletic events going on," he said.

Walukiewicz said he personally checks each unit monthly to make sure it is functional and that the batteries and adhesive electrode pads, which are to be placed on the victim, are up-to-date.

Maintenance and training are critical to sustaining a successful AED program, said Julianne Brawner, a founding partner of Menlo Park-based Health Education Services, a health training company that sells turnkey AED programs.

The Lodi Unified School District paid $400,000 in a 2009 legal settlement after an AED failed to resuscitate a Lodi High School student who collapsed in a physical education class. The student ultimately was resuscitated by paramedics using their own defibrillator and taken to the hospital, where it was determined he suffered a brain injury, according to the Lodi News.

The student's lawyer alleged that an expired battery had caused the school's machine to malfunction.

But if organizations observe state guidelines requiring that machines be maintained and that some staff be trained, even untrained users of AEDs are protected under California's Good Samaritan law, which offers legal protection to people who give reasonable assistance in an emergency, Brawner said.

AEDs "are very simple and intuitive to use," she said. "They've done studies where sixth-graders score just as well as paramedics. I haven't heard about the outcome, but I believe they were even testing third-graders to see how well they could follow the prompts."

It's estimated that 40,000 or 50,000 of the 330,000 who die after sudden cardiac arrest each year could be saved if AEDs were nearby, she said.

Brawner cited casinos in Las Vegas and Reno as "wonderful learning labs for the science of resuscitation because they have every inch of their properties under surveillance.

"When someone goes down, all their security forces are trained to do CPR and apply defibrillators, so the typical time from the time of collapse to defibrillation is one to three minutes, which is ideal.

"They report a 60 percent to 70 percent save rate, so we know that this works," Brawner said.

A victim's chances for surviving sudden cardiac arrest are "close to 90 percent" if defibrillation occurs within the first minute of collapse, according to the Sudden Cardiac Arrest Association.

"For every minute that defibrillation is delayed, survival decreases by 7 percent to 10 percent. If it is delayed by more than 10 minutes, the chance of survival in adults is less than 5 percent," the association says.

Brawner said organized AED programs are in place at schools in Menlo Park, Foothill and De Anza colleges, the San Mateo County Community College District, the University of California at Berkeley, Alameda County and Los Angeles.

"They're popping up all over," she said. "It's our mission to have defibrillators as available as fire extinguishers. The deterrent is cost, and in schools that is a huge issue."

Price of AEDs vary by make and model, but most cost between $1,500 and $2,000, according to the American Heart Association. Machines then must be monitored and maintained, with regular replacement of batteries and adhesive electrode pads.

The American Heart Association supports school-based AED programs as long as they are supported by"effective and efficient communication throughout the school campus; coordinated and practiced response plan; risk reduction; training and equipment for first aid and CPR and implementation of a lay rescuer AED program in schools with an established need."

"While getting AEDs placed is important, we want to assure it is done strategically and is supported by appropriate training and planning," Kate Lino, the heart association's communications manager for CPR & First Aid said.

At Stanford University, Assistant Fire Marshal Alison Pena oversees a database that tracks nearly 160 AEDs spread all around campus.

"This landed in my lap in 2003 and at that time we had just 15 units, but we knew this was going to take off," Pena said.

Stanford leaves it up to individual departments to purchase and manage their AEDs, but Pena tracks the machines and sends monthly maintenance reminders to every site coordinator, who must check their units and report on their condition. Pena also sends reminders, 60 days in advance, for scheduled replacements of batteries and pads.

"We've had a couple of uses three to be exact," Pena said. "They were all over in the athletic facilities."

Of the three victims, just one a Senior Games participant who was stricken while swimming at Avery Aquatic Center survived after use of an AED, Pena said.

The other two an athletic staff member in 2012 and a baseball spectator at the Sunken Diamond in 2004 succumbed, she said. She declined to disclose any additional information about the circumstances or victims.

"These machines are so easy to use really anyone can use them but they're used under very stressful situations," she said.

"We need to start getting comfortable with seeing these units and using them. Of course, we always encourage people to be trained in CPR and AEDs. I really believe in another decade AEDs are going to be as common as fire extinguishers and people should know how to use fire extinguishers as well."

Armed with a two-for-the-price-of-one coupon for AEDs, Stephanie Martinson in the fall of 2011 approached friends and the Palo Alto Council of PTAs for purchase of defibrillators for Palo Alto schools.

The PTA Council purchased the machines last June, with a plan to have three at Paly and three at Gunn, she said.

The machines currently sit in school district offices, but will be deployed on the campuses probably in February after athletic and office staff members on both campuses complete training, according to Associate Superintendent Charles Young.

"Stephanie is quite an amazing woman," Brawner said.

"It's a small community of people who have this same passion and mission, and she's coming up with some very innovative ways to fund the defibrillators.

"Her creativity is just unique. She's taken it upon herself to do outreach to these organizations to get funding, so my hat is off to her."

Martinson works days as a speech pathologist at the VA Palo Alto Health Care System, seeing many patients in the critical care unit.

After her own six surgeries between 2002 and 2008, and ultimate removal of her internal defibrillator, it took her some time to recover. It was only last August that she obtained nonprofit status for Racing Hearts from the Internal Revenue Service.

"People can overcome their life's difficulties," she said.

"I always knew I would advocate for AEDs in the schools; I just didn't start it until last fall," she said.

"I finally felt healed enough that I knew I could do it."

Staff Writer Chris Kenrick can be emailed at ckenrick@paweekly.com.

Comments

Posted by John Galt, a resident of Fairmeadow
on Jan 25, 2013 at 10:59 am

Excellent program, Congrats!
Please follow up by strictly following the maintenance program.
There have been far too many failures in AED use due to poor maintenance. You can't just hang them on the wall and "hope" they will work.
Research this issue to convince yourselves of the importance of maintenance.


Posted by KP, a resident of South of Midtown
on Jan 25, 2013 at 12:45 pm

I hope you can keep this program going - and, yes, make sure the maintenance is kept up.
My nephew died on the basketball court in Portland a few years ago - it was heartbreaking. His mother started a foundation and is trying to get every high school outfitted with these units.


Posted by Not-A-Good-Idea, a resident of Another Palo Alto neighborhood
on Jan 25, 2013 at 1:57 pm

Given that Palo Alto schools are all within one mile of a fire station, and that the response time for first responders is generally 4 minutes (plus or minus), it's a little difficult to believe that the school district would want to assume the liability of first response for anyone who happens to be on the school grounds.

There ought to be some reliable statistics available (for both California and the US) that would provide some sense of how often students/staff/guests suffer heart attacks while on a school campus. It's hard to believe that this happens very often--forcing school districts to be concerned about the need to provide this service. For school districts where first response is greater than four minutes--then this idea makes sense.

Hopefully the PAUSD will ask some hard questions of the people promoting this idea--such as producing the number of heart attacks on school sites over the past twenty years, or so. There also needs to be some information about the costs to the districts, in terms of outlays for hardware/training, and settlements that resulted from equipment failure. Keep in mind that law suits involving school districts result in settlements are often sealed, so that the public never knows why the equipment failed, or if there is any evidence that the school district was/is prepared to use this sort of equipment correctly during an emergency involving a cardiac event.

Along those lines, it would be interesting to see how many PAUSD teachers/staff have been certified in CPR—which does not require batteries.

All-in-all, this does not seem like a good idea.


Posted by Laila Craveiro, a resident of Midtown
on Jan 25, 2013 at 2:09 pm

Community involvement is part of a much needed jolt to the heart of almost all matters. Sudden cardiac arrest is a life-threatening problem that can be successfully addressed by non-medical responders and the use of AEDs. Racing Hearts is a great initiative. I hope to see this grass root movement taking new partners to grow strong.


Posted by a GREAT idea, a resident of Los Altos
on Jan 25, 2013 at 2:20 pm

@Not-A-Good-Idea -- "For school districts where first response is greater than four minutes--then this idea makes sense"

How have you arbitrarily chosen 4 minutes as the ideal?

Have you gone 4 minutes with a motionless heart? 1 minute?

"(plus or minus)"

Perhaps your heart-felt comment (not) indicates you do not have a child in schools at this time.

"Along those lines, it would be interesting to see how many PAUSD teachers/staff have been certified in CPR—which does not require batteries."

All-in-all, you comments do not seem like well thought out ideas.


Posted by Crescent Park Dad, a resident of Crescent Park
on Jan 25, 2013 at 3:03 pm

Fire Station proximity means nothing to a victim who's heart may have been stopped longer than the "4 minutes" distance. A primary example would be finding a victim on the bottom of the pool - not having any idea how long the victim has been under.

Believe it or not, none of the PAUSD pools have an AED available.


Posted by Not-A-Good-Idea, a resident of Another Palo Alto neighborhood
on Jan 25, 2013 at 3:31 pm

> How have you arbitrarily chosen 4 minutes as the ideal?

Arbitrarily chosen? Hardly.

Based on this comment, and the rest—this poster has probably not been exposed to any of the basics of "First Aid". Sigh .. let's go through the basics ..

Most people, without air, will die in about five minutes. Four minutes if pretty much the national standard (NFPA 1710):
Web Link

for first response with any hope of saving the victim. While this is almost impossible to meet at the national level, it is not so hard to meet in small towns—like Palo Alto—and in large cities near fire stations.

Having taken CPR in college, as well as the military, four minutes is the always given as the target for "biological death":

Web Link
BIOLOGICAL DEATH (4 minutes onwards) - brain damage may occur at this point.

During my time in the military, I had occasion to administer CPR to someone who had undergone what something later identified as an "alcoholic seizure". I was about twenty feet from this person, who was fine one minute, and keeled over the next. He was completely rigid, and not breathing.

Even though I was the ranking person in the room, and I had been through a rigorous CPR training course when I was in college—I found myself just staring at the man. As it turns out, he was not assigned to my unit, and no one knew who he was. At about two minutes, he started turning purple, and at/about four minutes, he started turning blue. It was at that time, I realized the was close to the "4-minute mark" and my CPR training kicked in. I order one of the GIs to start breathing into his mouth, and I started the "chest pump". To my great relief, he started breathing again—just before the medics showed up, and took over.

Even though I had saved this man's life—I felt awful because it took me almost four minutes to fully evaluate the situation, and get the CPR going. He did live, so my self-doubts were assuaged somewhat—but I realized that the training I had received in the military was not nearly as good as that I had received in college—in my SCUBA diving course.

My real life experiences with having been exposed to a life-and-death situation makes me wonder how many 1st and 2nd grade teachers that have trouble with PCs and other simple technologies would know anything about "clinical death", "biological death" and the colors that provide the internal "clock" ticking off the minutes of the victim's life.

I'm guessing that few teachers/staff in the PAUSD (or any school district) have ever been trained on "first aid basics"—which would necessarily include CPR.

> All-in-all, you comments do not seem like well thought out ideas.

Well, I've provided a fair amount of information as to why I believe that most teachers/staff would not be likely to jump into action and use this equipment effectively. I would be interested in your response. Will you call me a liar—claiming my experiences are made up? Or that I could not possibly have come to the conclusions that I did—because you have no such experiences—and therefore you must know what you are talking about and I do not?

Looking forward to your rebuttal.


Posted by Not-A-Good-Idea, a resident of Another Palo Alto neighborhood
on Jan 25, 2013 at 3:36 pm

> Fire Station proximity means nothing to a victim who's
> heart may have been stopped longer than the "4 minutes" distance

Check the definition of "Biological Death".


Posted by a GREAT idea, a resident of Los Altos
on Jan 25, 2013 at 3:38 pm

I'm sorry that you are projecting your proven inability, through your claim not to help a dying man for 4 minutes, onto others.

AEDs save lives. Period. You're using a lot of words to defend being too cheap to put them in schools.


Posted by Not-A-Good-Idea, a resident of Another Palo Alto neighborhood
on Jan 25, 2013 at 3:54 pm

> I'm sorry that you are projecting your proven inability,
> through your claim not to help a dying man for 4 minutes,
> onto others


I never said I knew he was dying and that I purposefully withheld aid. I simply said that it took that long ( a very short amount of time in reality) to recognize that he was in fatal duress. It is astounding that you would post this, while apparently not even knowing the difference between "clinical" and "biological" death!


I'm guess by your snide, and almost hateful responses, that you have no idea what I am talking about. I'm guess you are not the sort of person who ever served in the military, or ever had to make flash decisions that affected other people's lives.

I did learn from the experience. But I see that it would not pay to provide you any more information as to how this experience affected other situations in which I found myself.

You claim at these devices save lives. Well, in the right hands, I have not doubt. But school teachers/staff are generally not the right hands. And as I pointed out, CPR would be the first step—because these devices are simply a tool, not a solution.

By the way, how many lives do these devices save on school campuses, every year, in the US?


Posted by a GREAT idea, a resident of Los Altos
on Jan 25, 2013 at 4:02 pm

"I simply said that it took that long ( a very short amount of time in reality) to recognize that he was in fatal duress." Yes, you told us you delayed action for 4 minutes, even though you claimed to be trained to do otherwise. Hence the comment: your proven inability to help a dying man for 4 minutes.

"You claim at these devices save lives." Did you even read the linked article?


Posted by Sara Armstrong, a resident of Charleston Meadows
on Jan 25, 2013 at 4:24 pm

There is a good graphic on the Racing Hearts' website that shows chance of survival based on minutes to defibrillation: Web Link. Each minute delayed results in 7-10% decrease in survival.


Posted by local gurl, a resident of Greenmeadow
on Jan 25, 2013 at 4:41 pm

My best friend's life was saved by a colleague who thought quickly enough to reach for the AED. Yes, they MUST MUST MUST be well maintained!!


Posted by anne, a resident of Green Acres
on Jan 25, 2013 at 7:08 pm

I think this is great, and I commend this mom, knowing how many barriers she probably faced even to implement a good idea like this.

However, if she reads this, I would ask her to learn a bit more about allergies and asthma. The article says: "We do a phenomenal job with asthma -- we have EpiPens everywhere and they're mandated in our schools -- but we also need the same standard of care for sudden cardiac arrest."

EpiPens deliver epinephrine, which is an emergency treatment for anaphylactic allergy, not for asthma.

The California Department of Education says asthma is the leading cause of school absenteeism. It's difficult to get accurate statistics, but from what I gather from the county, we have a rate of asthma in Palo Alto middle schools that exceeds what it should be given the demographic. Prevention goes a long way with asthma, and PAUSD isn't yet dealing with this issue. We are doing much better about letting kids carry their inhalers in school, but we're doing badly at making those inhalers unnecessary for a good percentage of them as we could be doing.

I can't speak for parents of kids with anaphylactic allergies, for which EpiPens are required if they have an attack. Prevention is possible here, too, though in the case of asthma prevention means mostly good maintenance and indoor air quality measures, in the case of anaphylactic allergies, the steps are different and politically more difficult for parents depending on the school.

So, as someone who wants to bring good indoor air quality practices to PAUSD, I would say -- thank you for what you are doing, but please don't use that example!


Posted by Anne, a resident of Green Acres
on Jan 25, 2013 at 7:41 pm

Well, my hubby who had asthma as a child informs me that epipens are sometimes used in asthma when all else fails. But even so, to say we are doing a phenomenal job with asthma because we have epipens available is kind of like saying we do a phenomenal job with traffic safety because we have fast ambulances to haul the kids getting hit by cars everyday to the hospital. We can do things to reduce asthma attacks by half in our district, and we aren't yet making the effort.




Posted by Bravo, a resident of Professorville
on Jan 26, 2013 at 9:05 am

Thank you. This should have been done decades ago, as in Seattle!


Posted by Cara, a resident of Midtown
on Jan 26, 2013 at 3:43 pm

It's great to see Stephanie Martinson recognized for the wonderful work she is doing for this community and others. She started with an idea and grew it into an effective program.


Posted by Laura, a resident of another community
on Jan 27, 2013 at 6:59 am

It is great to see AED's being placed in more schools and available for sports activities. Keep up the great work. I'd like to mention a couple important points that many people might not be aware of... Sudden Cardiac Arrest(SCA) is not a Heart Attack. There are times that a heart attack can lead to a SCA, but SCA is due to "electrical" issue and heart attack is usually due to a blockage. Many of the "electrical" issues are hereditary, such as Long QT, CPVT, etc. They are caused by rare genetic mutations that get passed down. In my family, a genetic mutation (CPVT - Catecholimenergic Polymorphic Ventricular Tachycardia) has been passed down. I have it and both of my boys have it. We didn't know about it until our 17 yr old son had sudden cardiac arrest. Thanks to the quick action of his 4 friends, he not only survived, but did not have any brain damage. Although they did not have an AED available, they did call 911 and immediately start CPR. 2 of the boys had great CPR training at the YMCA for their lifeguard jobs. Our family has gone through genetic testing and the mutation was confirmed. In our case, a beta blocker is working really well at controlling the irregular heartbeats. I've always had a theory about allergies - lots of people think that fatal allergies are on the rise because of environmental changes, but I think that it is more because they are so hereditary and we've gotten so good at saving someone from an allergic reaction. In the past, they would have died and not passed on the genes, but now they live (thankfully) and pass the genes related to the fatal allergy (like peanuts) on to the next generation. I think it could end up being the same with the hereditary arrythmias. More people are surviving and passing on the genes. I think they will become less rare. I think that the current stats are 1 in 5000 for Long QT and 1 in 10,000 for CPVT. For CPVT, there is a 50% chance of passing it down to your child. It is not recessive, so only 1 parent has to have it to pass it. I've done quite a bit of research on arrythmias over the past couple years, and have seen mention arrythmias might be a contributing factor in many SIDS (sudden infant death syndrome) cases. I think that there will be an increase in reported deaths due to SCA because now that they are learning more about arrythmias, and genetic testing is becoming more available & affordable, many of the "death by unknown cause", will be attributed to a genetic arrythmia. Sorry to ramble, but I really believe that AED's are going to be even more needed than they are right now. And another point I wanted to mention is that people used to think that CPR wasn't helpful past a certain number of minutes, but research now shows that proper CPR (chest compressions only) can keep oxygenated blood flowing past the brain for a very long time. Think about some of those divers that can stay down for 20 - 30 minutes without air. That is because the blood still has oxygen in it. When someone suffers SCA, their heart isn't pumping any blood. The doctors/nurses that treated our son, said it is very unusual for someone to do CPR correctly (even with good training). To do it right, you've got to do it hard and fast and without stopping. As in, "breaking bones hard". I belong to an online support community (Inspire), and several people mention on there that they got so tired doing CPR, that they had to switch to "stomping" on the person's chest with their foot. (and it worked) People need to know that the "new" CPR doesn't require any real training. You can easily google the videos by typing in CPR and Stayin Alive. CPR standards were recently updated and I am pretty sure that mouth to mouth is now only recommended in drowning victim cases. Most local fire departments offer free Saturday classes on CPR. Everyone should take advantage of this. Sorry to go on and on, obviously this is near & dear to me.


Posted by Gunn Parent, a resident of Midtown
on Jan 27, 2013 at 2:08 pm

Thank you Stephanie and others for all your hard work on this. If placing AEDs in our schools only ever saved the life of one child (or adult) wouldn't it be worthwhile? Let's not get so paranoid about liability or second-guessing how people may or may not react in an emergency that we choose to not do things that may save people's lives. We are talking about dollars versus lives. I vote for saving lives. I like the approach by Stanford's Pena of sending out regular maintenance reminders.


Posted by put em everywhere, a resident of Meadow Park
on Jan 27, 2013 at 3:26 pm

Thank you, Stephanie!

and thanks to the poster who shot down the not-a-good-idea poster. Lame, lame, lame! Argue about biological death times all you want... when your kid is at that school, you'll get it!


Posted by RH Supporter, a resident of Los Altos
on Jan 28, 2013 at 10:13 am

Hats off to Stephanie Martinson for her tremendous work in helping to place AEDs throughout our communities. It is especially awe-inspiring to see her take such a personal issue and put her experience to good use by helping to protect others who face many of her same health problems. I expect this initiative to grow tremendously in the coming years. Congratulations, Stephanie and Racing Hearts!


Posted by parent, a resident of Old Palo Alto
on Mar 15, 2013 at 2:49 pm

What is the status of this program for PAUSD?

My brother-in-law is an athletic trainer at a big high school on the east coast. Just this last week, he was called to a PE class where a student had collapsed and had no heartbeat. With CPR and the AED, he was able to resuscitate the student after an excruciating amount of time. It took another 30 minutes after the medical team arrived to get him stable enough just for transport back to the Children's Hospital. (The student is now stable and undergoing care.)

We really should have these sprinkled around the middle/high school campuses. Our campuses are so broken up and sprawling that getting care when and where it's needed is not trivial.


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