Evolution of Jewish victimhood 1947-2022

“Trump hosted Holocaust denier at Mar-a-Lago estate during visit with Kanye West, a week after announcing 2024 run” (CNN, today):

Former President Donald Trump hosted White nationalist and Holocaust denier Nick Fuentes and rapper Kanye West at his Mar-a-Lago estate this week, demonstrating his continued willingness to associate with figures who have well-publicized antisemitic views as he embarks on another White House run.

West, who has legally changed his name to Ye, posted a video Thursday on Twitter in which he claimed that Trump “is really impressed with Fuentes,” who has repeatedly made antisemitic and racist comments as chronicled by the Anti-Defamation League.

(Why isn’t it forbidden deadnaming to refer to Ye as “Kanye West”?)

I had to visit Wikipedia to figure out who Nick Fuentes was, i.e., a young Mexican-American who has already been unpersoned by nearly all (Jewish-controlled?) media. Readers: Had you heard about Nick Fuentes before this week?

Here are some typical tweets on the subject of Trump’s dinner table:

I’m not sure that I love the evolution of Jewish victimhood over the past 75 years. In 1948, we fought against the regular militaries of Egypt, Syria, Jordan, Iraq, Lebanon, Saudi Arabia, and Yemen. Today our enemy is an individual 24-year-old incel. If we extrapolate out another 10 years, is it reasonable to predict that all Jews worldwide can be taken out by a pet rabbit and we need all of the goyim to rally around us and protect us from that rabbit?

Separately, if indeed it is true that Nick Fuentes is a Holocaust skeptic, why isn’t it reasonable for a 24-year-old to question the Holocaust? Much of what he has been exposed to in U.S. media during his lifetime has proved to be lies. Why is it obvious that on this one subject the New York Times happens to be telling the truth? (Note that the Holocaust was not considered an important subject by the NYT in the 1940s.)

Finally, what is the evidence that Fuentes hates Jews for being Jewish. Maybe he hates the Democrat political program and knows that the majority of secular American Jews have adopted this program as their replacement religion. Is Fuentes on record as saying that he hates Jewish conservatives?

Related:

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Long COVID and California Worker’s Compensation

I was chatting with a guy who works at a Los Angeles-based manufacturer about the challenge of building back up to full production. “One issue is that if you got COVID at any time during the past two and a half years,” he said, “California assumes that you got it at work. Then if you say that you have Long COVID you will get years of Worker’s Compensation payments. Especially older workers were prone to making Long COVID Worker’s Comp claims. and, if you add up their Social Security, Worker’s Comp, and 401k, it wouldn’t make any sense for them to return to the factory.”

Fact check: this law firm says “with COVID-19, there is a rebuttable presumption of a workplace connection. An employer has the burden of proving that a claimant was not exposed to COVID-19 in the relation to their employment.”

Let’s look at the California labor force participation rate. California has one of the nation’s youngest populations (one reason the COVID-tagged death rate was lower than in some other states) and we’d therefore expect the labor force participation rate to be higher than the U.S. average. Yet it isn’t:

We see participation rising as women entered the labor market (70s and 80s) and then falling as women were offered the opportunity to earn cash via divorce litigation or simply having sex with a married dentist (state child support formulas guaranteeing profits were introduced around 1990; history and also “Divorce laws and the economic behavior of married couples” (Voena 2016)). Then we see the downward trend from all of the enhancements to the welfare state that started in 2009 (see Book Review: The Redistribution Recession for how Americans could find themselves in a higher-than-100-percent tax bracket as a consequence of means-tested programs, including mortgage relief). And right now we are bumping along at 62 percent in one of the best labor markets for workers in history. That’s the same as the national rate despite California being 1.5 years younger (median) than the U.S. overall.

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If student loan forgiveness is illegal, can it still be accomplished via an infinite payment pause?

Continuing with our Thanksgiving theme, we can give thanks to the most generous members of our society. The most praiseworthy generosity is, of course, giving away money that other people earned. If we accept that stealing a neighbor’s car and donating it to charity makes me a more charitable person, Washington, D.C., is home to the world’s most generous humans. As we try to chew our dried leftover turkey, let’s look at a notable example of generosity from the central planners… “Biden extends student loan payment pause as debt relief plan remains on hold” (NBC):

The Biden administration announced Tuesday that it would extend the payment pause on federal student loans, as President Joe Biden’s debt cancellation plan remains blocked in court.

The payment pause, which was previously set to expire in January, will be extended until June 30 or until the litigation is resolved — whichever comes first. If the litigation has not been resolved by June 30, payments will resume 60 days after that.

“I’m completely confident that my plan is legal,” Biden said in a video announcement. “But it isn’t fair to ask tens of millions of borrowers eligible for relief to resume their student debt payments while the courts consider the lawsuit.”

Federal student loan holders have not been required to make payments since March 2020, when President Donald Trump signed the CARES Act, which paused payments through September 2020 and stopped interest from accruing to alleviate the economic impact of the coronavirus pandemic.

In theory it is Congress that sets the budget. So it might be illegal for a president to forgive loans, such that the borrowers don’t have to pay for their gender studies degrees and the cost can instead be shifted onto the working class. And, since Congress can spend money and transfer costs from the working class to the laptop class, the original payment/interest pause in 2020 was definitely legal. But maybe it is also legal for a charitable president with a big heart to keep extending the pauses via executive order. The loan isn’t “forgiven” (illegal unless Congress does it and more accurately described as “transferred to the working class”), but it never has to be paid so long as a great humanitarian/philanthropist is in the White House. The original value of the loan eventually becomes insignificant due to inflation.

Related:

  • “Student Loan Pause Could Cost $275 Billion” (CRB): The pause costs over $5 billion per month and extending it through the end of 2024 would cost at least $120 billion. This would bring the total cost since Spring of 2020 to $275 billion. This represents about 70 percent of the cost of the President’s announced debt cancellation plan and is higher than the ten-year cost of President Biden’s proposal to double the maximum Pell Grant by 2029.
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Ice Cube evaluates the Science

Back in the 20th century, a Ph.D. physicist in our lab at MIT introduced all of us to his favorite musical artists. Ice Cube was high on the list, especially for Death Certificate.

We can give thanks today for Ice Cube’s thoughtful analysis of the Covid vaccine Science. From the New York Post:

Last year, it was reported that Cube left the cast of Sony’s ”Oh Hell No“ after refusing the COVID-19 vaccine shot.

“I turned down a movie because I didn’t want to get the motherf–king jab,” Cube said on the podcast. “I turned down $9 million. I didn’t want get the jab. F–k that jab. F–k y’all for trying to make me get it. I don’t know how Hollywood feels about me right now.”

“Those motherf—ers didn’t give it to me because I wouldn’t get the shot. I didn’t turn it down. They just wouldn’t give it to me,” his expletive-filled rant continued. “The covid shot, the jab … I didn’t need it. I didn’t catch that shit at all. Nothing. F–k them. I didn’t need that s–t.”

Happy Thanksgiving Day to everyone! I trust and hope that all of you are following this MSNBC physician’s advice to refrain from gathering and instead sit alone watching Netflix (especially House of Cards featuring Kevin Spacey?):

Related:

  • Rammstein, another physics favorite (but they’re German so they can’t be included in our celebration of stealing a continent from the Native Americans)
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If rich countries pay poor countries for climate change victimization, must poor countries pay rich countries for science and engineering?

Poor countries are the victims of rich countries, according to the Newspaper of the Righteous, and should get paid for their victimization. “Calls for Climate Reparations Reach Boiling Point in Glasgow Talks” (NYT, November 11):

For decades, vulnerable countries and activist groups have demanded that rich polluter countries pay for irreparable damage from climate change. This year, there may be a breakthrough.

What is owed to countries least responsible for the problem of global warming but most harmed by its effects — and by whom?

Year after year, calls have steadily grown louder for industrialized nations responsible for the greenhouse gas emissions already heating up the planet to own up to the problem — and pay for the damage.

This year, demands for redress have sharpened as climate justice has become a rallying cry, not just from countries in the global south, like Mr. Huq’s, but from a broad range of activists, especially young people, in the United States and Europe.

How much are we talking?

Estimates of the amount of money required to address loss and damage varies widely, from roughly $300 to $600 billion a year by 2030.

Less than the elites steal from the American working class every year via low-skill immigration! (Harvard study: $500 billion/year from the working class to the elites in pre-Biden money)

There’s additional scrutiny on the United States, in part because of its outsized role as history’s biggest polluter, but also because of the stated commitments of the Biden administration to climate justice.

The journalist and editors at the New York Times do not quote anyone who has an argument against paying. Is that because no argument can be made?

It’s Thanksgiving week. What about the fact that non-Western countries have gotten Western science (not Science in the form of cloth masks and vaccines that don’t prevent infection or transmission, but science as taught prior to 2020) for free? Shouldn’t these non-Western countries give thanks for Western science and engineering and maybe even give money (as an offset) for Western science and engineering?

How much are Michelle Faraday‘s descriptions of electrical phenomena worth? For a poor country that wishes to set up a power grid, what are Katherine Clerk Maxwell’s Equations worth? For people in poor countries who don’t want to die from infection, how much value did they receive from being handed the work of Louise Pasteur? If they want to get from place to place without having to build roads, aren’t they getting a lot of value from Katharine Wright‘s invention of the first practical flying machine? (assembled and piloted by her brothers) If they enjoy communicating and being entertained, they’re getting value from Wilma Shockley‘s invention of the transistor, no? If they don’t want to starve to death, they need the fertilizers that are made via the process that chemists Frida Haber and Carla Bosch developed.

It doesn’t make sense to start money flowing until both credits and debits have been tallied, does it? If we did that accounting, wouldn’t we likely find that poor countries were getting a lot more than $600 billion in value from Western science and engineering? World GDP is roughly $100 trillion.

Here are some October 2022 photos from Westminster Abbey. Important English and Scottish scientists, including Isabelle Newton, either get a tomb or a memorial or both.

Let’s not forget the monuments to British colonialism and an author whose low opinion of Jews is amply confirmed by Sam Bankman-Fried:

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Is Sam Bankman-Fried the Zillow of Crypto?

Zillow managed to lose nearly $1 billion buying and flipping houses during the most dramatic real estate inflation in the history of the United States. They could have bought houses at random and made money, at least in nominal dollars, yet they managed to lose.

MIT alum and major Joe Biden donor Sam Bankman-Fried managed to lose his own money and also money that he stole from depositors in the crypto marketplace. But how? His trading operation, Alameda Research, was started in November 2017. Bitcoin was about $7,000 back then. Today, however, Bitcoin is quoted at over 16,000 Bidies. Adjusted for inflation, perhaps this is not a great return but it looks good in nominal dollars at least.

How did a guy celebrated as a genius by Sequoia Capital and the rest of the Silicon Valley smart set manage to lose money while operating in a strong tailwind? Is it like the Florida real estate boom of the mid-1920s in which people who’d been successful kept doubling down and, therefore, the recent dip in crypto prices caused losses far greater than what had been earned on the way up?

Let’s look at what was motivating this rare genius. “How the newest megadonor wants to change Washington” (Politico, August 4, 2022):

… part of life as Sam Bankman-Fried is about embracing paradoxes. The 30-year-old, who has amassed an estimated $20 billion fortune over the last four years through cryptocurrency, drives a hybrid Toyota Corolla.

He was also one of just a handful of donors who spent $10 million-plus backing President Joe Biden in 2020, and in the last year, he’s hired a network of political operatives and spent tens of millions more shaping Democratic House primaries. It was a shocking wave of spending that looked like it could remake the Democratic Party bench in Washington, candidate by candidate. Looking ahead to the 2024 election, he has said he could spend anywhere from $100 million to $1 billion.

… Bankman-Fried has what it takes to be the biggest donor in politics — an eleven-figure bank account he’s committed to giving away before he dies…

Looks like he followed through on that last commitment. What was his main political objective? More and better coronapanic:

In politics, that’s led Sam Bankman-Fried to dual objectives. There’s the one he has talked about most: preventing the next pandemic, which he fears could be more lethal than Covid-19 and would pose a huge threat to humanity, an obsession for effective altruists.

But if he needed only $1 billion to deliver a Democrat-ruled paradise to Americans and that was his main objective, why did he keep placing risky bets? He already passed the $1 billion mark a long time ago, right?

Maybe it was his parents who were motivating him to bet big and steal big? His dad is a Trump-hating Stanford Law professor, Joe Bankman. Mom is Barbara Fried, another Stanford Law professor, who was a leader of a Silicon Valley PAC funneling money to Democrats (Vox). Perhaps the parents said that they needed $10 billion to prevent Republicans from exercising any political power in the U.S. going forward? (plus another $300 million for vacation houses in the Bahamas to be owned by mom and dad that would also be nice enough to host Bill and Hillary Clinton)

Maybe it was about J.K. Rowling and the 2SLGBTQQIA+ community? “Sam Bankman-Fried shifts blame for FTX collapse to ex-girlfriend’s crypto firm” (New York Post, 11/17/2022):

Disgraced crypto mogul Sam Bankman-Fried unleashed a wild, wide-ranging interview in which he appeared to shift blame for the collapse of his company FTX to the trading firm run by his ex-girlfriend, Caroline Ellison.

Bankman-Fried is under intense pressure to address his decision to funnel $10 billion in FTX client funds to prop up Alameda Research, where Ellison — a 28-year-old, professed “Harry Potter” enthusiast who has tweeted about taking amphetamines — served as CEO.

Of that money, at least $1 billion in customer funds is still missing.

The company ran its own cryptocurrency, i.e., Ponzi scheme, in which the bits that they pulled out of their servers’ butts were worth more than $2 billion (CNBC). So we need to try to understand how Sam Bankman-Fried and Caroline Ellison managed to lose at least $2 billion.

How did these two lose so much money? The modern equivalent of CDOs?

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Will David DePape be deported to Canada?

Happy Thanksgiving week everyone! Except for Canadians, who celebrated on October 10. Speaking of Canadians, what’s the plan for David DePape, the undocumented immigrant who attacked Paul Pelosi? Will he be deported to Canada after completing a prison sentence?

From https://www.speaker.gov/issues/immigration-reform, November 5, 2022:

Our nation’s immigrants are the constant reinvigoration of America. Each wave of newcomers brings their patriotism, bravery and determination to succeed to our shores – and in doing so, makes America more American. As students and servicemembers, entrepreneurs and public servants, parents and neighbors, these new Americans affirm our country’s fundamental, founding truth: that in diversity, lies strength.

Yet President Trump and Congressional Republicans continue to push a hateful, harmful anti-immigrant agenda that instills fear in our communities and weakens our country. Instead of respecting the hard-working men and women who want to contribute to our nation, Republicans are trying to make American taxpayers pay for an immoral, ineffective and expensive border wall. At the same time, the Trump Administration is unleashing a cruel deportation force that is tearing apart families across America.

It’s interesting that Trump was still president, as far as Pelosi’s official web site was concerned, nearly two years after leaving office. Separately, since Nancy Pelosi assures us that immigrants are superior overall to native-born Americans, what did David DePape do prior to the unfortunate incident of October 28, 2022 to exhibit “patriotism, bravery and determination to succeed”?

What are we thankful for this year? I’m thankful that I don’t live in San Francisco where even the elite are not safe in their homes and where children of the non-elite are always one Scientist’s email away from having their schools closed.

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Did Twitter manage to fill its diversity quotas via the recent mass layoffs?

In a document written, I think, well before the Elon Musk takeover, Twitter wanted to hit the following quotas:

(Grammar police: Not “WHOM you work with?”)

They already had 46 percent “women”.

So they just needed to fire men and non-binary workers in order to achieve the 2025 dream in 2022. (Note that the quota of 50% for “women” necessarily meant that “men” would be less than half of the workforce because at least some of the workers would identify with the other 72 gender IDs recognized by Science.)

I wonder what Twitter meant for “At least a quarter of our US Tweepforce will be under-represented populations”. Would “over 60” be “under-represented”? How about 2SLGBTQQIA+? Members of the LGBTQIA+ were 13.5 percent of the workers before Black Friday:

If LGBTQIA+ qualifies as “under-represented”, Twitter could have filled its 25% quota simply by firing only workers who admitted to cisgender heterosexuality.

Who wants to guess what the diversity stats will look like the next time they’re released? (Or maybe part of Dark Elon’s plan was to fire the people who prepare these stats?)

Speaking of quotas, the United Nations is working toward a quota of 0% for the killing of journalists identifying as “women” (alternatively, a quota of 100% for the killing of journalists identifying with gender IDs other than “women”).

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Medical School 2020, Year 4, Week 11 (Nephrology Week 2)

Nephrology is all about vascular access. How do you get a device that can draw out enough blood flow for the dialysis machine? A patient who has a temporary need for dialysis, e.g., from septic shock leading to poor kidney perfusion, will get a “VasCath”, a large bore central venous catheter in the internal jugular vein. This will get patients through a few weeks, but if they need longer term dialysis they will need to get a tunneled catheter. The tunneled dialysis catheter (TDC) has fewer infection complications than a free-standing Vascath. If a patient will be on long-term dialysis, a discussion about an AV fistula versus graft (synthetic tube) is made with a vascular surgeon or interventional nephrologist.

I head to the outpatient center and start with vascular access procedures. I watch as the interventional nephrologist performs balloon angioplasty and stenting for narrowed fistulas. For the third one, is my turn to do the procedure: I cannulate the graft with the needle, I insert the guidewire, dilator, and finally the balloon gadget. We then take fluoroscopy images (contrast injected dye with live X-ray video) to identify where the stenotic regions are. There are two narrowings, one near the graft insertion into the vein and a “central” stenosis on the left subclavian vein. The attending explains he had a central line, and that is a common cause of central stenosis. We balloon up both of them and take post contrast. Immediately it looks better, and you can even feel the “thrill” (vibration from the flow) increase. Very satisfying!

After three cases, I join an older Iranian nephrologist and head to the dialysis unit. There are about ten quiet patients with glazed eyes in chairs. They’re not watching TV or reading books. The only sound is white noise from the dialysis machine’s spinning roller pump. “Welcome to Purgatory,” my attending whispers. “We keep these patients alive, but a vast majority live a miserable life with amputations, heart failure, on oxygen, wheelchair-bound or, worse, SNF [skilled nursing facility; pronounced “Sniff”] dependent. This is Hell on Heart.” 

We interview a 68-year-old black wheelchair-bound male with a right-sided above-knee amputation. He has been on dialysis for 3 years and was recently hospitalized for COPD and CHF exacerbation. He was discharged from a 3-week stay in a nursing facility back to his home. The nephrologist asks, “What do you notice about everyone here?” I respond, “This looks and smells like death.”

We then relax in his office for two hours. “Nephrology is one of the least competitive fields, with fewer applicants than slots. I always tell my [internal medicine] residents to apply for a nephrology fellowship,” he says. “We’re some of the higher paid specialists, right up there with cardiology and gastroenterology because we do procedures. Nephrology is the gatekeeper to dialysis. ESRD requiring dialysis is the only condition that I know of that will get you a one-way ticket, no questions asked, to disability.”

[Editor: Medicare spent $51 billion on ESRD in 2019, which does not include SSDI payments.]

Nephrologists make most of their money by managing dialysis patients, even though this takes less time compared to hospital consults and clinic visits with atypical kidney failure patients (e.g., Lupus, rare auto-immune diseases, obstruction from BPH).

“Dialysis costs Medicare about $60,000 per year, but the government spends more on covering inpatient hospitalizations,” said the nephrologist. “The average is roughly $120,000 per patient per year. In the pre-Medicare age, these patients would have died years earlier, but now Medicare pays for all the cardiovascular complications [heart attacks, leg ischemia, strokes] in these sick patients in addition to the vascular access complications [infections and stenosis]. Over the years they have bundled the payments so we get a fixed monthly fee for dialysis patients and take a hit if they get hospitalized for a vascular access complication. We perform outpatient procedures [e.g., stents and balloon angioplasty] to ensure they don’t wind up in the hospital. Two interventions per year is typical.”

My attending explains the economic landscape for nephrologists. Each dialysis patient yields roughly $250 per month to the physician and requires weekly face-to-face evaluations, normally done during a dialysis session, either by the doctor or a nurse-practitioner. The maximum practical roster is 500 patients, yielding gross income of $1.5 million per year, but this requires quitting the hospital job and sharing some of the money with the ACP. “Ninety percent of our time is spent with consults at the hospital, procedures, or office visits, but all our money is from dialysis patients.” The nurse-practitioner or physician’s assistant is critical to hitting the 500-patient goal. The NP handles three out of every four required dialysis patient evaluations. Quite a few nephrology groups also get revenue via owning the dialysis center itself and therefore obtain profits from the separate Medicare reimbursements for machine operation.

[Editor: Davita is an example of a corporate dialysis center owner. The company enjoyed a market capitalization of roughly $6 billion in January 2020.]

As we are packing up to head home, the nephrologist is paged for a STAT consult. We head to the hospital surgical ICU. The 57-year-old female with breast cancer on chemotherapy presented to the ED for acute onset abdominal pain. She was found to have Acute Diverticulitis – an uncontained hole in the sigmoid colon. She lives in a rural area without surgical capabilities. Due to weather conditions, they had to transport her via a 1.5-hour ambulance ride. When she arrived at our hospital, she was in extremis. She underwent emergent exploratory laparotomy with suctioning of 3 liters of liquid stool in her peritoneal cavity and resection of the perforated colon segment. She is too unstable so the surgeons performed “Damage Control” and left the bowel in discontinuity and placed a temporary abdominal closure device. She is in septic shock, intubated on high ventilation support (34 breaths per minute), and getting multiple vasopressors to keep her brain perfused and heart pumping. Her kidneys have failed. She will die without immediate dialysis. We get consent from the devastated family for renal replacement therapy. This is not the three-hour sessions three times per week (intermittent hemodialysis or “iHD”). Continuous renal replacement therapy (CRRT) is the life-prolonging intervention that continuously filters toxins in patients who are too unstable to handle the high flow rates required for iHD. We place the CRRT orders and the critical care nurse begins to hook up the machine as the critical care team places a VasCath. As we walk out of the hospital, my attending comments, “If her sepsis response does not peak in the next 12 hours, this is futile.” (The family decides to withdraw care after 72 hours of ICU care. Her small bowel became necrotic from the high doses of vasopressors. I am there when we turn off the CRRT machine and return her blood, pull the endotracheal tube, and stop the vasopressors medications. Her family is at the bedside when her heart stops 10 minutes later.”)

Friday: the attending walks me through a full fistula exam. There are a lot of techniques to evaluate the fistula. This has become a lost art due to widespread access to ultrasound. First, I listen with my stethoscope. “A good fistula should have a continuous rumbling sound that does not vary with the heart beat. If you begin to have a high pitch blowing whoosh of the fistula with systole, it means it is beginning to narrow,” he explains. “Remember these AV fistulas are massive blood vessels right next to the skin. The most common reason for stenosis [narrowing] is from poor cannulation by the dialysis nurse. If you traumatize the vessel too much, it will lead to aneurysm formation. This will form a clot and over time cause narrowing of the vessel. The most feared complication is ulceration. Just last week I had a consult from a patient (not ours) whose fistula ruptured from an ulceration while she was showering. EMS described a murder scene as she was bleeding out. Her husband was smart and put a finger on the clot proximal to the bleeding. She lived and made it to the hospital but these can be scary things.”

My attending points out that close to 90 percent of the dialysis patients are black, despite the fact that we serve a region that is only about 20 percent African American. This is due to higher rates of uncontrolled diabetes and hypertension. NIH says “African Americans are almost four times as likely as Whites to develop kidney failure.” A black American who lives to age 75 is a likely candidate for kidney problems.

We also talk about his perspective on cardiovascular disease. “Let me ask you something. Why has no study shown stenting a patient with coronary artery disease has any benefit, either mortality or quality of life after six months?” the attending asks. “Because although you can open up the artery, the stent will narrow almost immediately. In a coronary stent, it’s hard to access to blow it back up. That’s why AV fistulas work. We can go in every few months and blow it back up.”

Statistics for the week… Study: 3 hours. Sleep: 8 hours/night; Fun: 1 night. Med School Prom. Students and faculty dress up for a night of hors d’oeuvres and 2-drink tickets at a local restaurant venue.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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Medical School 2020, Year 4 Week 10 (Nephrology elective)

Picking up with our medical school diary, authored by our anonymous mole inside the system… It’s the fall of 2019.

I meet at 9:00 am in the hospital dialysis unit with nurse practitioner (NP) Nora. She’s 34 and has worked at the nephrology practice for four years, progressively taking on more responsibility. She is my contact during the two-week nephrology rotation. The attending, a 42-year-old interventional nephrologist, is on call at the hospital and performs procedures at the nearby clinic. NP Nora and I hold down the fort.

We run the list of patients in the hospital who will need dialysis today, and go over the consults from overnight and this morning. Consults come in three flavors: 

  1. The most common consult is for patients with end-stage renal disease (ESRD) who are admitted to the hospital for an unrelated reason, such as a GI bleed, myocardial infarction, or pneumonia, and need their dialysis while in the hospital. We try to continue their standard schedule, e.g., “TTS” for Tuesday, Thursday, and Saturday, about two hours on the machine per session at an outpatient dialysis center. Five clicks in Epic and the dialysis nurses will know what to do. 
  2. Acute renal failure. These patients are typically unstable, e.g., from septic or cardiogenic shock that resulted in such poor perfusion to the kidneys that they shut down. These patients have electrolyte derangements and toxin buildup that is not being filtered by the kidneys. They need either intermittent hemodialysis (IHD) or CRRT (continuous renal replacement therapy; “slow” dialysis). 
  3. The last type of consult is for electrolyte abnormalities, frequently low or high sodium. These are usually “tea and cracker” old ladies who do not eat enough, alcoholics, and the occasional ultra distance runner. If the sodium is corrected too fast, the osmolarity change can result in brain damage. (A University of Virginia fraternity contributed the highest recorded sodium to the medical literature: “Survival of acute hypernatremia due to massive soy sauce ingestion” (Carlberg, et al. 2013).)

We get six consults throughout the day, four of which are for ESRD admits. I watch Nora’s exam on the first ESRD consult. She examines the patient’s vascular access, an arteriovenous (AV) fistula, and determines his schedule and typical net volume change from the outside records. We get these on paper because the patient’s dialysis center’s electronic medical record does not interface with our Epic system. It takes 20 minutes to find the needles we’re looking for in the haystack of paper. We evaluate his volume status by listening to the lungs and checking for peripheral edema in the legs. I do everything on the next ESRD admit, with NP Nora watching and helping.

An AV fistula is a surgically-created connection between a large vein and artery in the arm that is brought close to the skin for cannulation with a needle. This fistula is allowed to mature until there is adequate blood flow for dialysis, while ensuring adequate perfusion to the distal limb. 

In the afternoon, we get a consult for acute renal failure in a 42-year-old uncontrolled type 2 diabetic patient who presented yesterday evening in septic shock from a necrotizing soft tissue infection of the leg. He probably stepped on a sharp object and did not notice the wound for a few days. He underwent a below the knee (BTK) amputation of the right leg, and was sent to the ICU. His kidneys have not recovered, and they are starting him on CRRT because his blood pressure drops too much with the two-hour iHD.

The most interesting consult during the week is on a 58-year-old patient with metastatic bladder cancer. The prognosis is that he is likely to live only one or two additional months. The cancer has obstructed both ureters, resulting in progressively worsening kidney failure. The tumor responded to first-line therapy, but recurred three months later, and did not respond to second-line therapy. The patient presented to the emergency room with left flank pain from hydronephrosis, a kidney ballooning from distal obstruction. He underwent placement of a nephrostomy tube (a catheter that the interventional radiologist pokes into the kidney to drain urine) to drain the kidney and prevent further deterioration of his last remaining functional kidney. We explain that we could start dialysis on him, but would need to coordinate with the oncologist given a palliative approach may be a better path for him. He will likely have end stage renal disease within a few weeks.

The oncologist agrees that palliative is the best option given that the patient has only about a 10 percent chance of some response from rescue or “salvage” chemotherapy. This will entail three months of debilitating pain (at a cost of over $100,000 to Medicaid). The oncologist did not sugar coat matters for the patient: “This is probably the worst case of bladder cancer I have ever seen. If you don’t go on dialysis, the way you will die is you’ll become very tired. You’ll have periods where you are lucid, and then you will go back to sleep. This will happen over a few days, until you fall asleep. Your body will begin to realize it is dying, and release its natural endorphins to help with the pain. We’ll give you pain medications until that kicks in.” As we walk down the hall, he explains to me, “Kidney failure is a good way to die. It’s quite peaceful.”

By the end of the week I am appreciating the teamwork of the NP and attending. She gets things done around the dialysis unit, puts in orders, and helps organize the nephrologist. When a consult comes in for something atypical, the consult is sent to the nephrologist. During rounds she will ask about the management of these patients, and seems to learn something new every week.

After work, Sarcastic Samantha, Lanky Luke and I grab drinks with the nephrology NP at our favorite burgers and beer joint. Samantha comments how she does not see many PAs and NPs that are happy in their job, including herself. The nephrology NP responds, “I’ve gone through so many mundane ACP [Advanced Care Partner] jobs in which I was miserable. It’s all about finding a partner in a doctor. I think that’s the beauty of the ACP is that you can mold into the role – find your niche. You need to find a physician that will build you up so you are a smooth team.” She adds, “We are trying to hire another ACP to work under me. The problem we have is that new ACPs switch jobs so frequently it’s hard to justify investing time in them.”

Statistics for the week… Study: 2 hours. Sleep: 8 hours/night; Fun: 1 night. Jane and I went on a weekend Airbnb cabin getaway.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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