Month: September 2017

Mom and I finished our cruise trip with a TAP Portugal flight from Lisbon to Boston. In every other country that I can remember visiting the people who check passports are unarmed. If there is a perceived likelihood of armed conflict with deplaning passengers there might be one or two specialist soldiers or police officers walking around. At Logan Airport, however, every immigration or customs official was armed with a pistol. Thus there were roughly 100 people with guns confronting the arriving passengers. If this situation is replicated all across the U.S., I wonder why there aren’t more shootings. Presumably it is unlikely that an arriving passengers will actually have a gun, but why wouldn’t there be at least occasional shootings of unarmed passengers by officials saying “I thought he was pulling out a gun”?

[Separately, if you ever do fly TAP Portugal, make sure that you sign up for specific seats towards the front of the aircraft. It seems that TAP operates a three-class service, but the middle class (where you probably want to be) was apparently unknown to our travel agent (Frosch). TAP sells Business for crazy $$. They have a regular Economy for which you pay the Economy fare and then go to their site and pay an extra 25 euro or so to get a seat with a normal amount of legroom (maybe like JetBlue’s worst seats). Then they have a Steerage class in the back for people who are 5′ tall and/or desperately poor and unable to afford the 25 euro. We let Frosch handle everything and of course ended up in Steerage.]

Related:

• Why aren’t there a lot more police shootings in the U.S.?

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Last year Mom and I were cruising on Royal Caribbean, whose slogan could reasonably be “cheaper than staying home and a lot more organized.” This year it was Crystal from Lisbon to the Azores, Madeira, Canary Islands, Morocco, and back to Lisbon. Crystal Cruises is a higher-end operation, about $1,000 per day for two people in a balcony room, and therefore attracts a wealthier demographic.

Median age of a passenger was probably close to 70 years and median wealth was “sufficient to blow $20k+ for a little over two weeks, including airfare and maybe some hotel stays on either end.”

A common concern and source of disappointment for many of these financially successful 70-year-olds was the comparatively unsuccessful trajectories of now-adult children. The Son Also Rises: economics history with everyday applications says that we should expect a lot of correlation in success through multiple generations of a family, but the statistical phenomenon of regression to the mean is not revoked. So if the Crystal passenger had been the most successful member of his or her family, Gregory Clark’s research suggests a significant probability that the children of that passenger would achieve at closer to the mean level for the extended family. The still-married-to-their-original-sweethearts parents also fretted about how their children hadn’t been able to replicate that stability. The explanation for the divorce lawsuits and children raised by just one parent was generally a change in character quality. Young people had inferior characters compared to old people. Nobody mentioned the updates to U.S. family law as a possible reason why a 50-year-old American’s domestic life might have unfolded very differently from that of the 80-year-old parents. The mother of a physician, for example, talked about how a young woman had lied about being on birth control and was now harvesting child support from her son. She never looked at the question of whether or not the 1990 child support guidelines made this a rational economic strategy. Although both she and her son live in a state that provides for potentially infinite child support revenue, the choice of becoming a child support profiteer was seen as a sign of bad character, not evidence of economic rationality.

Most of the passengers were organized into apparently heterosexual cisgender couples. There was a bimodal distribution in age gap among the couples. The first marriages typically involved a gap of less than 5 years. For those men against whom a divorce lawsuit had been filed, the second marriage seemed to be to a woman roughly 10 years younger. “The wives are a lot better looking than the husbands,” said one first-time Crystal passenger.

The ship advertised an LGBT gathering one afternoon and it turned out to be 7 men with an average age of about 55 and all but one traveling in a couple. Our host was the cruise director, a former onboard dancer who had worked his way up in the Crystal career ladder. Readers will be proud of me, I hope, for refraining from pointing out the cruise line’s failure to welcome the transgendered with “all gender restroom” signs” (the public restrooms on the ship were divided simply into “men” and “women”).

[Are you skeptical that I would fit in at an LGBT event? Keep in mind that I was traveling with my mother, listening to Broadway show tunes every night, and looking forward to an Elton John tribute concert on the last night of the cruise.]

I also attended a semi-official “singles” gathering. Nine people showed up, all women. How did they get to be “single”? Most had been successful divorce plaintiffs 10-15 years earlier, which led one passenger to quip “That’s how they’re able to afford Crystal.” This was only partially correct. These plaintiffs had obtained alimony and/or child support orders sufficient to provide them with a luxury lifestyle at the time of their original lawsuit. However, their revenue from the discarded husband had not been adjusted to compensate for inflation in the price of comfortable downtown hotel rooms, three-star restaurants, etc. Therefore their alimony checks were not sufficient to fund a truly luxurious lifestyle by today’s standard. They had thus sought to supplement their alimony and/or child support profits by tapping into the spending power of rich boyfriends. Unfortunately, the guys who met their minimum income and wealth requirements were apparently falling short in terms of personality and age. Thus the singles gathering ended up being a round-table discussion of the shortcomings of these men and why the most recent romance had fizzled.

Not all of the single females on the ship had gained wealth through divorce. One lady of about 60 had been the higher-earning spouse. She got sued by her husband and had been paying him alimony. She was not looking for a new mate. Another had earned her fortune by founding and managing a couple of matchmaking services. The latest has men as the only paying clients because “women are too emotional; they complain that ‘I didn’t pay you to get rejected’ after unsuccessful dates.”

One of the more amusing conversations was between the expert matchmaker and a 40-something career woman who asked “Aren’t men looking for their intellectual equals?” and “Wouldn’t these successful men rather have a somewhat older woman with an education and a successful career than a younger woman with nothing but looks?” The answer was that her clients were essentially indifferent to a woman’s educational and career attainment; they wanted beauty and an agreeable personality. “The more successful the woman the harder it is to find a match for her,” said the expert. “There must be some guys out there who aren’t that shallow,” said the career gal. Of course that was my chance to interject “I haven’t met one.”

[I asked how it was possible to operate a matchmaking operation for truly affluent men. Instead of incurring the risk of not getting picked for a marriage and walking away with nothing, why wouldn’t some women try to get pregnant on the first date and then harvest child support? The matchmaker was intimately familiar with California family law, its unlimited child support guidelines, and the challenge of reaching the 10-year marriage bar in order to collect alimony: “That’s why all of the women dating or married to Hollywood stars try to get pregnant as soon as possible.” Her staff tries to screen out women with mercenary motives via interviews and research into the family background. The goal is to find women who want to get married and stay married, but certainly some of the women labeled “family-oriented” by the professionals have turned out to be more cash- and litigation-oriented. The service guarantees introductions, not a litigation-free long run.]

The worlds of business and real estate have so much volatility that they generate a lot of rich old guys and there were a handful of three-generation groups on the ship, each one funded by a patriarch. The adult children couldn’t imagine being richer than their parents and a few of them, after seeing me and my 83-year-old mother together, said “it is so nice of your mom to take you on this trip” (i.e., they assumed that mom was funding our adventure).

[Separately, you might ask if the extra cost for Crystal is worth it compared to Royal Caribbean. The Indonesian-owned and LA-managed (through this month by CEO Edie Rodriguez; going forward by Tom Wolber) Crystal is an impressive operation, but so is Royal Caribbean. For me the main difference is that Royal Caribbean is like a floating city while Crystal is a small town. On the 2,500-passenger Serenade of the Seas we would run into people we knew a few times per day, but we were typically surrounded by strangers. On the 900-passenger Crystal Symphony we were almost always in a room with someone we’d met before.]

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“Billionaires, Bruised Egos and the Death of a Grand Project” (nytimes):

For Barry Diller, the turning point came at a Sept. 5 settlement meeting with the small band of opponents who had tied up his plans for a $250 million park and cultural center in the Hudson River for more than two years.

Instead, Mr. Diller said, after all the questions, “I ended the meeting so depressed.” He had grown “disillusioned” about the project in the spring, when a federal judge revoked the permit for the pier, stopping preliminary work. When settlement talks began in July, he was “uncomfortable” sitting down with the people who had used the courts to wage a war of attrition against the project.

With that phone call, Mr. Diller ended a six-year saga that had cost $40 million before construction had started in earnest.

Whatever the merits of this project might have been, it should be inspiring to young people that $40 million in revenue was generated for lawyers and bureaucrats.

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“Dear Mrs. Trump” is a letter from a Cambridge Public School librarian to Melania Trump, who sent some Dr. Seuss titles to our fair city:

Our beautiful and diverse student body is made up of children from all over the world; from different socioeconomic statuses; with a spectrum of gender expressions and identities; with a range of abilities; and of varied racial, ethnic, and religious backgrounds.

Yearly per-pupil spending in Cambridge is well over $20,000 [the statistic is correct, but most of the money is spent on administration and pensions; actual in-classroom spending is a small fraction of the total]

we still struggle to close the achievement gap, retain teachers of color, and dismantle the systemic white supremacy in our institution. [but if white students achieve more than students of color in the Cambridge Public Schools, isn’t the system actually working to increase “systematic white supremacy”?]

You may not be aware of this, but Dr. Seuss is a bit of a cliché, a tired and worn ambassador for children’s literature. … Another fact that many people are unaware of is that Dr. Seuss’s illustrations are steeped in racist propaganda, caricatures, and harmful stereotypes. … Scholar Philip Nel’s new book, Was the Cat in the Hat Black? The Hidden Racism of Children’s Literature, and the Need for Diverse Books, further explores and shines a spotlight on the systemic racism and oppression in education and literature.

The librarian offers a list of ten books in return, e.g., “In this gentle story, Haitian American Saya’s mother is incarcerated because she has no papers. … doesn’t shy away from the realities … the trauma of saying goodbye at the detention facility.” and Separate Is Never Equal: Sylvia Mendez & Her Family’s Fight for Desegregation. Transgender issues are represented by The Boy & the Bindi. (She left off Yo Soy Muslim: A Father’s Letter to His Daughter, prominently featured at the Harvard Bookstore last night.)

[Separately, the librarian complains that “many of us can’t afford to live in the city in which we teach,” but of course if she didn’t have a job she would be entitled to free apartment from the Cambridge Housing Authority. Alternatively, any school employee who studied Massachusetts family law should have been able to figure out a way to live anywhere in Massachusetts without working.]

Readers: Was the Cat in the Hat black? What about Thing 1 and Thing 2? Also, how did the Cat get hold of the alien robot technology that he used to clean up the house after his visit?

Related:

• Cambridge Public Schools: perspective from a new teacher
• Teacher explains why public schools are so bad

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I’ve been getting a lot of emails from friends who have friends or relatives trapped in Puerto Rico. With food and water supplies questionable, they’re looking for ideas on how to get out. Unfortunately there are only a handful of flights operating daily from the main San Juan airport. I checked the JetBlue web site and it seems that there is ample capacity on flights out of nearby places such as the Dominican Republic and the Turks and Caicos. This leads me to wonder why, as part of the relief efforts, the government hasn’t rented a Boeing 767 or similar-sized plane (300-400 passengers in single-class configuration) to run a $100/person shuttle service to get people to Punta Cana, D.R., Provo, etc.

If the argument is “Those other countries don’t want a lot of refugees camped in their airports” then we can send Obama and Hillary to explain to them how accepting refugees boosts a country’s economic growth. If our brightest political minds are unpersuasive, seats on the shuttle could be limited to those who have a confirmed prepaid reservation for an onward flight.

There are charter companies operating privately in Puerto Rico right now that can do this, but they operate small planes and therefore can’t make a real dent in the queue of people who want to leave and are willing to pay to leave. Tradewind is a reputable example. They currently have two PC-12s flying out of San Juan. Each plane can hold a maximum of 9 passengers, depending on seating configuration. It is roughly $4,500 to get a full planeload from SJU to Punta Cana, including all of the fees on both ends (approximately $1,000 in fees; a good preview of what the U.S. system might look like after the airlines take over Air Traffic Control). I contacted Tradewind and their schedule is getting tight, but they had availability for next-day flights.

In the old days when something bad happened in a remote location, a government would send a big ship to pick up its citizens who wanted to get out. Why not do the same thing this week in Puerto Rico, but updated to “big plane”? (Though I guess if the airports are maxed out, it would also work to load people onto cruise ships for the short trip to a nearby island with good airport capacity.)

“Puerto Rico’s main airport is barely functioning” (CNN, 9/26) says “On Monday there were only 10 commercial flights between San Juan and the mainland United States, with 10 more scheduled for Tuesday,” and “At the same time, many more military, charter and relief operation jets are also flying in and out of the airport, according to the FAA.” It seems as though the main obstacle to getting people out is a refusal to relax bureaucratic requirements: “Airlines are having difficulty printing out boarding passes that fliers need to go through TSA checkpoints and board flights.” But what is the likelihood of terrorists making their way to Puerto Rico in order to blow up a shuttle flight to Punta Cana? Why not collect $100, make sure that nobody is bringing an actual gun on the plane, and lift off? Load up with food and water from Club Med Punta Cana and come back. Repeat. We were able to do this for the Berlin Airlift with vastly more primitive equipment. Despite passengers often being armed, nobody hijacked an aircraft that was taking them out during the Fall (Liberation?) of Saigon.

Related:

• Canadian welcome for Syrian refugees (using a daily Airbus A380 or Trump’s idle Boeing 757 to deliver to Canadians what they say they want)
• “Hate Taxes? Move To Tax-Free Puerto Rico, Stay American, Avoid IRS” (Forbes)… it seemed like a good idea back in 2014.

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Here’s a NYT Op-Ed that typifies the point of view of Americans who supported Hillary Clinton: “Tyranny of the Minority”.

Since Donald Trump’s cataclysmic election, the unthinkable has become ordinary. We’ve grown used to naked profiteering off the presidency, an administration that calls for the firing of private citizens for political dissent and nuclear diplomacy conducted via Twitter taunts.

See also “Billboard calling for Trump’s impeachment goes up in California” (CBS):

“There’s this pattern that seems to repeat: Trump does something absolutely unacceptable, unethical, just the thing you could never imagine even the worst of our previous presidents doing,” Kurtz said. “There’s this wave of outrage — it happened after Charlottesville, it happened even before he was elected when he admitted to sexually assaulting women — and then it settles down and his base is still with him.”

Is there an artistic medium for dealing with cataclysmic and unthinkable events? Where naked profiteering can be just another character trait? Where sexual assault is part of an ordinary day at the office? Let’s consider Tosca. Scarpia, the Chief of Police, uses torture to root out a political dissenter. He uses his position of power and privilege to get sex out of Tosca.

Conclusion: only opera is big enough to handle the character of Donald Trump. I think that I will need readers’ help in fleshing out the action, but I am going to start…

Act I, Scene 1: United Chorus comes on stage singing “America the Beautiful.” Sixty percent wear blue shirts and forty percent wear red. Trump and Hillary enter stage right and stage left. Hillary and Trump sing over and in between the verses of “America the Beautiful,” gradually ruining the song. The chorus is pulled apart into two groups, sorted by shirt color, each one behind a candidate.

Act 1, Scene 2: Bill and Hillary at home. Hillary sings about her Christian faith and how an omnipotent and benevolent God has selected her to lead the American people. Bill quietly sings “A redhead at breakfast, a blonde at lunch, a brunette before dinner.” (will become known as “The Intern Song”; tune from Don Giovanni’s Madamina, il catalogo è questo). Every 2 minutes, a foreigner arrives to empty a wheelbarrow full of cash for the Clinton Foundation.

Act 1, Scene 3: Debate. Trump repeatedly chants “Build the Wall.” Hillary sings a complex and hard-to-hear ballad about gender equality, foreign policy, fair government-determined pay rates, and higher taxes for the rich.

Act 1, Scene 4: Election Night. Stage divided by a wall in the middle. Right side depicts inside the Trump campaign headquarters; left side shows Hillary’s HQ. Hillary sings “New Drapes,” about her redecoration plans for the White House. Trump sings “It’s all Rigged.” Towards the end of the scene, Hillary, drawing on the profound Christian faith expressed in Scene 2, laments that God has forsaken her: “Oh why does Donald Trump have a friend in Jesus?”

Act 2, Scene 1: A derelict warehouse. Used syringes and trash litter the floor. Warm humid mold-containing air piped into the opera house to stifle the audience. Signage reading “JFK International Arrivals.” Trump tries to push passengers with headgear back into the jet bridges while singing “Your goats and camels are lonely at home” (tune lifted from Di Provenza il mar, il suol chi dal cor ti cancellò, Germont’s sentimental song about “the sea and soil of Provence” in La Traviata). Stage left: Tropical courthouse in Hawaii. Judge in the courthouse, with Hillary silently standing behind him, pulls the arriving passengers past Trump via long strings. Back of the stage: Canadian flag and Justin Trudeau standing next to it singing “You’re all welcome in Canada.”

Act 2, Scene 2: Chorus back on stage, a mixture of red and blue, once again united, singing “River of cash, keep flowing.” Chorus members cycle through the Social Security office to pick up SSDI checks, the physician’s office to get OxyContin prescriptions, and the pharmacy to pick up their Oxy, handing over their $3 Medicaid co-pay. Trump and Congress at the front of the stage. Trump sings “Repeal Obamacare” and Congress responds with “We will, we will!” This is repeated for a couple of hours, Robert Wilson-style, while the river of cash keeps flowing (enters at top left of stage and disappears into a pit marked “hospital” in the center) and the chorus keeps getting their OxyContin bottles. Just before the curtain comes down, a lone figure in a purple shirt labeled “Libertarian” comes on stage, the cash river falters, and the lone figure sings “Why would you vote to spend one day out of every five working to pay for your health care?”

Act 2, Scene 3: Stage split up into thirds: San Francisco Bay Area, Harvard University, New York Times editorial board. All singers unite in a chorus of “We’re so smart; why doesn’t he listen to us?” Hillary scolds from the balcony.

Act 2, Scene 4: Synagogue. Trump wears a kippah and, accompanied by Jewish family members, attempts to walk into Rosh Hashanah services while singing “Oh what a friend we have in Yahweh”. The family is blocked by chorus holding up signs condemning Trump’s anti-Semitism. Standoff until clock chimes 12 and protesters rush to the other side of the stage for an anti-Israel rally (signs flipped around to condemn Israeli apartheid system).

Act 2, Scene 5: White House. Stage left: Beautiful Melania sings sweet soprano lullaby to angelic Barron. Center: Aides attack each other with knives. Stage right: Trump sits on solid gold toilet holding Android phone and singing out a succession of Tweets.

Act 3: *** this is where I need reader help ***

Grand Finale: House lights down. Orchestra pit, previously completely hidden from audience, is raised by hydraulics until it is higher than the stage. In the darkness, the conductor turns around to face the audience. Spotlights on the raised orchestra pit. Audience sees that all musicians and the conductor are wearing Vladimir Putin masks. The curtain falls and the hall is plunged into darkness.

Readers: What did I miss? What goes into Act 3?

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Boring but potentially important: http://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2017/09/state-retiree-health-care-liabilities-an-update shows that folks in New Jersey will need to work a second job during the summer of 2018 and give all of their wages to the state government to pay the hoped-for cost of health insurance for retired state government workers.

Figure 2 of this report calculates, as a percentage of personal income, the amount that state and local governments have failed to set aside for likely health insurance costs. (Of course the actual amount could be much less or much more depending on future health care costs, longevity of retired workers, etc.)

Note that the states depicted are not directly comparable. For Massachusetts, for example, the percentage shown covers only state workers and not local government workers or teachers. For New Jersey and Alaska (workers there will need to work a second job for another year and pay state taxes on that second job at a 100% rate), on the other hand, the percentage shown covers all categories of retirees.

I remain curious why voters don’t rebel and, via referendums, forbid politicians from promising to pay unknowable amounts to retired workers, as opposed to having 401k-style retirement provisions in which the taxpayer contribution could be calculated without input from God (regarding human longevity 50 years from now, health care costs 50 years from now, interest rates 50 years from now, etc.).

Related:

• Real World Divorce on New Jersey (some ways to make money in that state without working)

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From our anonymous insider…

This week will cover mycology (study of fungi) and parasitology.

Our professor, a 60-year-old ID doctor with thick grey hair, used to go overseas six months of every year to treat rare disease outbreaks, including the 2014’s Ebola outbreak in Sierra Leone. He is celebrating his forty-fifth year of teaching medical students! When he went to medical school, Latin was an admission requirement. This would have been quite helpful in memorizing the 70+ pathogens covered during the previous three weeks as well as in pronouncing medical terminology. Instead of using textbook images for these diseases, he uses pictures of his own patients. During an investigation, he goes to the patient’s house and workplace to investigate potential exposures. One student’s summary: “He’s basically Dr. House!”

Dr. House likes to look at the big picture. “We think history is all about human actions. False. Two-thirds of the cells in our body are bacteria. We are the Uber for bacteria. Genghis Khan was about to conquer all of Europe. His army caught Yersinia pestis in Turkey. The Russians did not stop Napoleon’s army. Napoleon caught dysentery from Shigella outbreaks.” Several students are planning to read Guns, Germs and Steel on his recommendation.

Fungi are dimorphic organisms. At colder temperatures, fungi grow as the familiar mold, creating small inhalable spores. At body temperature, these spores convert into a circular yeast structure. Lectures detailed the three categories of fungi: dermatophytes (fungi that love keratinized tissue such as skin, nails and hair), systemic (fungi that can result in body-wide infections), and opportunistic (fungi that do not cause infections unless the patient is immunocompromised). Only dermatophytes are transmitted from person to person.

This block tends to evoke exotic diagnoses from students. “I’m going to get histoplasmosis [systemic fungal infection]!” exclaimed Straight-Shooter Sally after she removed an unwanted bird’s nest from her potted plants. “As I was throwing it in the trash, the nest broke in half. I inhaled all the bird poop and dust!” After class it is not uncommon to hear, “Do I have a rash on my hand? Do I have syphilis?” One student after class asked Dr. House to inspect his foot. Dr. House had commented, “People who get athlete’s foot just on the nail, not the foot, are more likely to have diabetes.” The student asked, “Do I have diabetes?” Dr. House replied, “You’ll be fine. Remember to never treat your own children. I was convinced my kids had meningitis when their first 103 degree fever occurred.” He ended with a joke: “If athletes get athlete’s foot, what do astronauts get…? Missile toe!”

Parasites are divided into protozoa (microscopic eukaryotic single-celled organisms) and helminths (macroscopic eukaryotic multicellular organisms). With only two days of lecture, we focused on the most common parasites, especially malaria. A common theme of this block is that many symptoms of disease are not caused by the pathogen-killing cells. For example, the watery diarrhea of Clostridium Difficile and Cholera are caused through a toxin-mediated mechanism releasing water into the lumen of the gut. The nonspecific flu-like symptoms of most viruses are not caused by cells dying but the systemic host immune interferon response. Malaria, caused by the protozoa Plasmodium, is an exception to this rule. Plasmodium infects and lyses (ruptures) red blood cells after replicating inside them. Different plasmodium species have different lysing rates giving a classical cyclical fever/anemia pattern ranging from 48 hours to months. Dr. House recounted how as late as the 1920s, syphilis was treated by giving the patient malaria (P. vivax)! The malaria would cause such a high fever it would kill Treponema pallidum. After the syphilis was cured, they would give chloroquinolone to cure the malaria.

We also learned about how the Rockefeller Foundation was founded to address the epidemic of Necator americanus (Hookworm) in the South (see http://www.pbs.org/wgbh/nova/next/nature/how-a-worm-gave-the-south-a-bad-name/). Hookworm is a helminth that latches onto the gut lumen where it produces eggs that pass out in the feces. When a human walks barefoot through a field of fecal-contaminated soil, larvae penetrate into the foot. “Farmers would use human feces to fertilize the field where children would play barefoot.” Once inside, the worm travels through the blood to the lungs, travels up the trachea to the pharynx, and finally is swallowed into the gut. Each hookworm drinks 0.3 mL of blood per day. “The problem is you are not infected with just one hookworm, but thousands. Losing 30 mL of blood per day will cause severe iron-deficiency microcytic anemia.” Over time, this produces lethargy and mental retardation. It is estimated that 40 percent of school-aged children were infected with hookworm in the early 1900s. The Rockefeller Foundation led a massive public campaign that focused on schools to eradicate hookworm from the South.

Dr. House described the waterborne parasite called Cryptosporidium . “Crypto is all through the DC water system. It is resistant to chlorine treatment.” The immune system is normally able to contain the infection. However, some of my AIDS patients before HIV antivirals would have 60 bowel movements a day due to cryptosporidium. These people would live on the toilet, and die from dehydration and malnutrition.” Dr. House couldn’t end lecture without showing us live video, captured during a colonoscopy, of Ascaris (“Giant Roundworm”), which can grow up to a length of more than a foot in the human gut (https://youtu.be/HOaZCkA8Zvk).

Classmates were particularly interested in another waterborne parasite Naegleria fowleri, the “brain-eating amoeba.” Naegleria is found in warm lakes, including in the U.S. It is thought to gain access to the brain through the cribriform plate (thin bone separating the brain from nasal cavities) under barotrauma or a pressurized injection of infected water, e.g., falling during water skiing. I was conversing with a female hematologist in the hallway later than afternoon. She commented, “I will never swim in a lake out of fear of getting Naegleria.”

Our patient case: Grandma Martha, a 68-year-old female accountant with degenerative disk disease in her lower back. Her daughter brought her to the ED for worsening back pain, neck stiffness, and headache over the course of weeks. On physical exam, she showed diminished lower extremity reflexes. Dr. House explained, “Before you can order a lumbar puncture (“LP” or “spinal tap”), you have to rule out increased intracranial pressure which could cause herniation of the brain.” An MRI revealed several inflamed lesions of the meninges without evidence of increased intracranial pressure. LP results showed decreased protein, decreased glucose, and the presence of neutrophils in the CSF. Gram stain on the cerebrospinal fluid was negative (no bacteria observed). “The LP results were suggestive of a bacterial meningitis. However, her presentation did not fit. Bacterial meningitis is typically a very rapid onset of symptoms.” She was started on empiric antibiotics until culture results could be obtained. “I was driving home that evening listening to the news on the radio. They were reporting about an outbreak of contaminated steroids. I turned the car around. Not everything on the news is Fake News.” Several chuckles were heard in the audience.

Back in 2012, Martha had been getting regular epidural steroid injections for back pain. At least one was supplied by the New England Compounding Center (NECC) and, due to a profit-motivated sloppy approach to sterility, had been infected with the fungus Exserohilum rostratum. “We didn’t know how to treat it. No one had ever seen this before.” Dr. House added, “It is extraordinary how quickly the local health departments and the CDC responded. Within 48 hours of the first diagnosis, the CDC was calling patients.” (753 patients were injected with contaminated steroid; 234 developed fungal meningitis and 64 died. See https://www.cdc.gov/hai/outbreaks/meningitis.html.)

Martha was started on an aggressive antifungal regimen including amphotericin (known as “amphoterrible” due to its severe side effects including kidney failure) and voriconazole. “The challenge with fungi and parasites is that our immune system does not do a good job of killing it. Instead, they typically wall off the lesion to contain it. We did not know if our drugs could reach these lesions. We also did not know about the risk of recurrence. How long should we treat the patient?” Martha was in the hospital for 70 days, and continued treatment for another two months. She has fully recovered from the ordeal.

“I was fortunate compared to several other people who live with long term complications from the meningitis. Or who died. I know several people who have dealt with recurrent meningitis episodes,” explained Martha. A student asked about the recent 9-year prison sentence for the NECC co-owner and pharmacist Barry Cadden. “What would you say to him?” “Well, I wouldn’t say anything to him. I would punch him the face,” chuckled Martha. Her daughter jumped in, “I would punch him too.”

I had lunch outside with six classmates. One commented that “Medicine was really the Wild West a few decades ago. Could you imagine discovering these unknown disorders like hookworm?” Straight-Shooter Sally added, “The best part would be getting to name all these symptoms! How badass would it be to name Toxic Megacolon [severe, potentially lethal, distension of the colon that can occur when an antidiarrheal agent is administered during an active C diff infection.]”

Luke got in a heated discussion with Type-A Anita about her two years as an intern at the American Federation of Teachers. She was describing her work “empowering teachers in local communities across the globe.” Luke asked if these teachers were American. Anita responded that they were foreign teachers. Luke asked, “Why should American teachers be forced to pay dues to a union spending money on issues that are not relevant to them?”

Our group then walked over to the hospital’s SimLab, which is led by a retired nurse and EM (emergency medicine) resident. We practiced running a Code Blue where a patient was in cardiac arrest. The main purpose of the simulation was to introduce us to standard communication skills such as “call-backs” (acknowledging an order with a clear read-back) and SBAR (situation, background, assessment, recommendation) hands off. Lanky Luke had run EMS for all of his undergraduate career. The rest of us had no idea what we were doing. The first simulation round we were sent without any guidance to resuscitate a dummy. Over time we got the rhythm of running a code. Two people focus on chest compressions, one person performs breaths, one person runs the monitor and defibrillator, and one person records events. I learned that if you are performing chest compressions correctly you can actually feel a pulse from the compression in the femoral (leg) artery.

What do people who don’t go to medical school do with $300,000 of college education and $300,000 of taxpayer-funded K-12? One of my undergraduate classmates on Facebook this week:

if you’ve been paying attention, you probably know I haven’t been the same since November 9, 2016. things changed not only in this country but also in how I view myself within that context. i joked that if Trump won I would leave the country…

well, now it’s time to follow-through on my promise. after weeks and weeks of trying to figure out what was next, I finally realized that I had no idea and couldn’t figure it out while remaining in my last job and in my last city. so as many of you know, I left DC and my job [social media analyst for advertising agency] …

but now the time has come for me to say goodbye to what used to be my home and is now just the place I try to avoid claiming. i hope to find myself in the coming weeks and months and find what makes me truly happy, in both work and in my personal life.

to that end, I am saying goodbye to the US of A and hello to everywhere else! i do not know where I will end up and although it’s a bit scary, I know I’ll

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A few weeks back, I wondered When can a church take down a Black Lives Matter flag?

The NFL players protesting the “Star-Spangled Banner” raise the same question, I think. If we assume that their protest is only about police treatment of African-Americans, what are the criteria for declaring victory and ceasing the protest? I hope that everyone can agree that even one citizen mistreated by the police is one too many. Does that mean the protest must continue until there are zero incidents of alleged mistreatment of any citizen with dark skin? Over what period of time?

Or has this morphed into a protest about Donald Trump? So it can stop once the hated Trumpenfuhrer leaves the Reich Chancellery?

Or has it been expanded into a protest against social injustice? Then it has to continue until our society is deemed just?

Related:

• Why do they play the national anthem at football games? Do other countries do this?

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After two weeks on a cruise ship I’m catching up on the news. A reasonable high-level summary seems to be that Earth is trying to shake off 325 million human parasites by trashing the U.S. with hurricanes, flooding, tornadoes, and other severe weather.

Back in January I wrote Why accept any refugees to the U.S. if they are welcome in Canada? after Canada offered to accept an unlimited number of refugees conditioned only on their being rejected by the U.S. I’m wondering if the idea makes more sense in light of recent weather events.

What is the value of obtaining refugee status in the U.S. only to be wiped out by a hurricane, monster thunderstorm, rising sea level, or tornado? Canada is too cold for tornadoes, big thunderstorms, and hurricanes. It is well inland and elevated from the rising seas. Most Canadian provinces should be net beneficiaries from global warming, e.g., through a longer and more productive farming season.

Not only does Canada have a far lower crime rate than the U.S., but at least central Canada seems like a far safer place from a weather risk point of view.

Readers: What do you think? If we sincerely have the best interests of refugees in mind, is it time to print up “You will be a lot safer in central Canada” signs for our borders?

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