Month: September 2018

We were at a friend’s house for dinner the other night. The hosts are both medical doctors and were hugely enriched by the Federal government’s expansion of funding for the health care industry during the Obama Administration. Lately they’ve been hugely enriched by the booming economy (at least here in pharma- and health-care-heavy Massachusetts) and stock market.

As per usual for Massachusetts, however, they are forecasting imminent doom for both the country and the planet due to Donald Trump’s existence. When I asked “What have you personally suffered as a result of Donald Trump being in the White House?” the answer is that it is not legitimate to think of one’s own welfare. They are especially virtuous because they are thinking on a planetary scale and are virtuously concerned with all of humanity, not merely their thriving personal finances and situation. Two particular knocks against Trump is that he is relaxing environmental regulations so that our local atmosphere will be polluted and that he will be responsible for a planetary-scale meltdown of climate change, e.g., due to withdrawing from the Paris Agreement.

Yet Wikipedia says that the entire machinery of the Paris agreement was hoping to “mobilize $100 billion per year … by 2020” (and in terms of reality, about $10 billion total was actually contributed over a period of years). The economic boom from Donald Trump’s corporate tax rate cut has expanded the U.S. economy by more than $10 billion a week. Perhaps the hated Trump won’t work with the hated Republicans in Congress to spend this new wealth on combatting climate change, but the next President (a virtuous Democrat?) will have that opportunity.

If fighting the increase in atmospheric CO2 is a long-term problem, having been built up for the past few hundred years, what’s wrong with accumulating wealth now and spending it once Donald Trump has hopped on his personal Boeing 757 for the trip out of D.C. and back to private citizenship? Since Trump has been much more successful in generating economic growth than previous presidents (Obama did have a dead cat bounce off the Collapse of 2008), if we assume that a wealthier country has more flexibility in terms of what it can do to combat climate change, should Donald Trump actually considered be the hero of the environmentalist hour?

[Analogy: Lyndon Johnson was able to pursue both the Great Society and the Vietnam War only because of 200 years of accumulated wealth. Medicare and Medicaid were created by Johnson and have become the government’s largest spending area. The Great Society also made food stamps permanent and expanded taxpayer-funded housing for Americans on welfare. So the Trump economic boom could in theory pave the way for a future Great CO2 Vacuum. Congress is currently indulging in deficit spending, but the additions to the national debt seem likely to be smaller than the growth (i.e., we’re still paying off debt that Congress accumulated during the Reagan years (they said “yes” to his tax cut proposal, but “no” to his proposed spending cuts), but we’re doing it as a richer country).]

Related:

• “Litigation, Alimony, and Child Support in the U.S. Economy” (we’d be roughly $500 billion/year wealthier if we switched to a German-style family law system, enough to fund the Paris Agreement’s wildest hopes 5X over)

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From our anonymous insider…

Neurology week is shortened by two days of snow cancellations (the hospital and rotations for M3 and M4 students are on a normal schedule).

A 45-year-old neurologist with a British accent lectures on neuromuscular disorders such as Parkinson’s disease, Huntington’s disease, Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease), and Multiple Sclerosis. Gigolo Giorgio asked about why deep brain stimulation (DBS) works for certain conditions? Neurologist response: “All of DBS is voodoo. There is not real science behind it, but it works. We just do not know why.”

He teaches us about tardive dyskinesia, a permanent movement disorder after exposure to antipsychotics. In a healthy person, dopamine from the substantia nigra (black pigmented neurons in the midbrain) acts to facilitate muscle movement via stimulation of the basal ganglia, a network of neurons located deep in the brain (“deep nuclei”). Antipsychotics block dopamine signaling, an attempt at reducing the symptoms of bipolar disorder and schizophrenia. This can have the same effect as damaging the substantia nigra, as happens in Parkinson’s disease. “Tardive dyskinesia happens after long-term use of the drug. We believe it is the brain trying to rewire around the drug. There are lawyers filling courtrooms around the nation suing doctors and pharmaceutical companies for this. There are more lawyers focusing on it than neurologists!”

He concluded: “The history and physical exam are are a dying artform. Some conditions, such as Guillain-Barré, you see nothing on imaging. Surgical residents, if they even have a stethoscope, put the diaphragm on the “Surgeon’s triangle” — where they can hear the abdomen, heart and lungs in one place. I ask what they got out of it and they respond, ‘Umm, they are alive.’ The answer is in the patient. You should know what is wrong with 95 percent of patients after taking the history. If you leave the room without knowing, DO NOT order tests. Go back in and take a good history, then do a good physical, and then order those unnecessary $5,000 imaging studies.

A 55-year-old neurologist reads through slides on seizure disorders. Several students doze off or check social media. She went five minutes over the 10:50 am official end time. The next lecturer, a 75-year-old neurologist, had snuck into the room five minutes early for the 11:00 am block and blurted out, “Are you done? I’ll just do this another day.” She then storms out. We have found a reason to have a PhD block facilitator in our lectures. She ran out of the third floor classroom and managed to corral the senior citizen on the first floor.

Despite a late start time due to the chase scene, the older neurologist did not disappoint. She lectured on myelopathies (disorders of the spinal cord). She ignored her uploaded powerpoint and used the chalkboard. We started with basic anatomy of the spinal cord and its blood supply. She asked, “Does anyone surf?” Buff Brad raises his hand. “How do you surf?” He slowly responds, “I wade out on my stomach, then pop up.” She responds: “You are clearly a novice. First time surfers lay on their stomach and extend their back as they surf out to catch the next wave. This prolonged hyperextension of the spine causes compression of the anterior spinal artery in what is termed Surfer’s myelopathy, potentially causing permanent paralysis.” The class laughs. [Correct technique is a yoga-style pose on one’s knees.] She concludes: “My husband died, so I have no one to not listen to me except medical students. It is such a pleasant surprise you are all listening to me.” In the Age of Universal Offense, students were divided over her lecture. Everyone agreed they learned a great deal, but some were turned off by her sense of humor.

Wednesday morning, our chief of neurosurgery, a man in his 50s (see Year 1, Week 15), lectures for two hours on traumatic brain injury (TBI). The IT staff as usual comes in before the lecture to to ensure that the required-by-regulation PowerPoint slides were ready and that the video is recording. The Chief: “I don’t think I will be using it at all. PowerPoint is a way to present material you do not know.” He made chalk drawings on the blackboard.

Any patient presenting for TBI will be scored using the Glasgow Coma Scale (GCS), which evaluates the patient’s eye, verbal and motor responses to stimulus. “Glascow Coma Scale is like the SAT. You get a score for just showing up. Glascow Coma Scale starts at 3. Don’t say 2 to an attending. You’ll sound like an idiot.” Pinterest Penelope wrote this advice down. The Chief: “What are you doing? Pens down and listen.” [Editor: Research shows that students who take notes learn more, even if they later discard those notes. See “The Pen Is Mightier Than the Keyboard: Advantages of Longhand Over Laptop Note Taking” (Mueller and Oppenheimer 2014, Psychological Science) and its references.]

Gigolo Giorgio was startled by the Kernohan’s notch phenomenon. Kernohan’s notch phenomenon typically occurs due to a hematoma (extravascular blood in the brain) causing the uncus, an inferior lobe of the brain, to herniate through the connective tissue floor of the brain into the brainstem canal. Nerves exiting the brainstem, namely CN III that innervates muscles of the eye, are compressed and lose function. “If the pupil is dilated on the left side, I go in on the left side, right?” However, occasionally the uncus can push the midbrain to constrict the contralateral CN III instead of the ipsilateral CN III. “I can operate on the wrong side of the brain because of this false localizing sign,” he continued. “This was not unheard of before we had stat CTs commonplace in hospitals.”

The Chief: “Medicine is a language. Isn’t medical school so easy compared to crazy particle physics you did in undergrad. If you approach it just like a language it is not that difficult. Medicine is learning to convey complex data in succinct phrases. If a resident calls me and says there is 4mm midline shift after trauma I am going to run out of bed. If a resident says there is a 1mm midline shift with a small hematoma, I am going to say, ‘Yep that’s a old alcoholic brain that is compensating for a subdural swell. We can deal with it tomorrow.’ I just downloaded a lot of information quickly. Practice presenting patients, that is what we will be evaluating you on in rotations.”

Straight-Shooter Sally: “I don’t think I learned much for Step 1 [the exam we’re taking this summer]. He did not get past his 2nd PowerPoint slide, but who cares.”

[The neurosurgeon’s life was also educational for us. His wife loyally managed the home front, including two kids, through a 7-year residency. As soon as the surgeon began earning a surgeon’s wage, she went down to the courthouse and shed the husband while keeping the kids and his income.]

Our patient case: Jimmy, a 69-year-old recently retired internist, was celebrating his 50th wedding anniversary with a trip to Scotland. “We were traveling with a group tour. I started to feel terrible. I was vomiting and felt weak. I was getting on the next train when I fainted. I initially attributed it to dehydration.” He continued, “When we were walking on the cobblestone paths in one of the beautiful small towns, I started to see double. I did not know which of the two people in front of me was real. As physicians we know double vision under the context of systemic symptoms is a serious concern, but denial is powerful. Because I did not want to ruin our wedding anniversary, I tried to hide the symptoms from my wife. We had been waiting so long for this trip and my retirement.”

His wife interjected, “I made us fly home early. He just looked weak. He was barely eating.” Once back, their son, also an internist, realized something was amiss, and interrogated Jimmy. GI symptoms are rare for Lyme disease, but the presence of diplopia, malaise, and hiking in endemic areas prior to the overseas trip caused the son to immediately suspect disseminated Lyme disease. The family took him to the ED.

Lyme disease is a tick borne illness caused by the Borrelia burgdorferi that is easily treated with antibiotics. Lyme disease is divided into three phases: early localized, early disseminated, and late disseminated. Jimmy never had the classic early localized symptoms of the “bull’s-eye” rash (erythema migrans), present in 80 percent of patients. Early disseminated Lyme disease occurs weeks to months after the initial tick bite. Jimmy’s double vision was caused by inflammation of peripheral nerves (peripheral neuropathy). He was also diagnosed with myocarditis (heart muscle inflammation) and atrioventricular (“AV”) heart block, under-diagnosed complications of early disseminated Lyme disease.

Jimmy arrived at the ED and was worked up for Lyme disease only due to the persistence of the internist son. “They were trying to work him up for a MI [myocardial infarction] and PE [pulmonary embolism]. I kept saying, ‘no, no get Lyme serology’.” Once the test came back positive, he was started on doxycycline (antibiotic). His EKG showed mild AV block, and he was placed on cardiac monitoring. Over the course of five days, his symptoms improved remarkably, and he was discharged on day seven.”

Gigolo Giorgio: “Why is there not a Lyme vaccine?” The internist son: “There was a Lyme vaccine. [FDA approved in 1998] GSK withdrew it after the early 2000s vogue for class action lawsuits against vaccine manufacturers. There is a new product in development using injected antibodies against burgdorferi bacterium that would protect for one season and then wear off. Has anyone gotten IVIGs [intravenous immunoglobulins] before traveling? They hurt! Great business model though. Europe is further in testing the vaccine now even though the US had it first.” Another physician in the audience jumped in: “All my horses and dogs have the vaccine!”

[Editor: Mindy the Crippler, our Golden Retriever, got Lyme vaccines in 2014, 2015, and 2016. In 2017, less than a year after the most recent shot, she got… Lyme disease. This is in the tick-plagued hell of the western Boston suburbs (“woodsy”).]

During lunch, we split into small groups in small groups to talk with M4s about Step 1 and the match process. My group was led by two women who are both applying to Ob/Gyn. Step 1 exam is an 8-hour exam with seven 1-hour, 40-question blocks and a 1 hour optional break split between each block. It costs $610 to register for the exam. “Do not study First Aid or any textbook,” said the Florida native “Just do questions on UWorld, and go over each answer.” She explained that she cried in the middle of Step I. “I had to call our school counselor for support.” The Bostonian, engaged to a recent graduate of the school visiting for support, described her Step 1 experience: “I had to get my fiancé to hold me [fortunately, he’s one year ahead of her in his medical training]. I threw up the breakfast he made me. Fortunately, he packed me sandwiches and granola bars so I did not take the exam on an empty stomach.”

After the M4s left, we stayed to consume the catered sandwiches and chat. Anita led the discussion: “Now no one can deny that our president is a racist pig.” [Donald Trump had recently characterized Haiti as a “Shithole”] Anita explained that she preferred immigrants from unsuccessful countries: “We want immigrants who understand hardship. They will be grateful, educate us, and create jobs.” Why not a merit-based system? Anita did not want immigrants taking the high-paying jobs. [Editor: like hers!]

Jane and I attend a late afternoon reception for applicants to our medical school who have come for final interviews. Most were fresh out of college and wanted to know about research opportunities at our school as well as nightlife (they don’t seem to have an accurate estimate

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“The Plot to Subvert an Election” (nytimes) shows that the Russian plot against Hillary (and therefore all of us) is so obvious that it takes 30 browser pages to explain.

One thing that the newspaper does not explain is whether the Russians are still engaging in mind control.

“As Critics Assail Trump, His Supporters Dig In Deeper” (nytimes, June 23, 2018) says that “Mr. Trump’s approval rating among Republicans is now about 90 percent.” It was written nearly 2 years following the election. If the idea that Donald Trump would make a better president than Hillary Clinton exists only because of Russian actions during 2016, how is it that tens of millions of people continue to hold this view in 2018?

Readers: Who has the patience to wade through this New York Times exposé? Does it say whom the Russians will pick to be our next president?

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The Brett Kavanaugh situation is not especially interesting from a forensic point of view, since there is no practical way of anyone knowing what might have transpired in a private bedroom 35+ years ago (if indeed these two people ever met at all) . But it is kind of interesting from a human cognition point of view. It shows the worthless nature of denials in this kind of situation.

Christine Blasey Ford says Kavanaugh did X, Y, and Z. Kavanaugh denies X, Y, and Z. The average person can’t help thinking “the truth must lie somewhere in the middle, so I’m pretty sure that he did X and Y.” (Look at your Facebook friends’ statements and comments on media articles about this. People express their knowledge of what might have happened with the same certainty that they use describing what they personally had for lunch.)

I think he would actually have been better off by saying “Why don’t you ask her some more questions to see if her story makes sense to you?” or “Does it seem like an odd coincidence that she started telling folks this story, including her therapist, in 2012 when my name was put forward as a likely Mitt Romney Supreme Court nominee.” or “Gee, have you read ‘Factitious sexual harassment’ by Feldman-Schorrig where she talks about ‘the motives that most commonly underlie the wish for victim designation’?” or “Did you find out where the party was and go have a look in the bedroom of that house for yourself?”? If Kavanaugh had asked people to accept or reject the entire Christine Blasey Ford story, he would at least have a lot more people saying “I don’t think he did anything at all.”

[The same thing happens in Family Court in the winner-take-all states. A plaintiff says “the defendant is having sex with the 4-year-old, which is why I need to be the only parent” (this request will later be modified to “well, the child should be with the defendant only every other weekend”, but nobody will notice the apparent logical inconsistency in wanting one’s child to be abused 3 or 4 nights out of 14). The defendant says, Kavanaugh-style, “I didn’t do it.” The judge splits the difference in his or her mind: “Well, the defendant probably isn’t having sex with the 4-year-old, but something perverted is going on, so I’m going to make the plaintiff the primary parent and limit the perversion to every other weekend.” The primary parent gets a free house, a 15-19-year (depending on state) shower of tax-free cash, the pleasure of the child’s company, and free babysitting 3-4 nights out of 14. The defendant might have been better off pointing out that the accusations of sexual abuse didn’t start until the quest for cash was on and simply asking the judge “Is it plausible that every wealthy defendant in your courtroom also happens to be a child molester?”]

Readers: Do you agree that Kavanaugh’s denial didn’t convince anyone? If so, what should he have said?

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New Englanders:

I’m repeating our MIT Flying Club presentation on “Oshkosh as a Safe Space” (based on our 2018 camping trip out of an SR20). Possible times are Friday 12:30 and 6:30, Saturday 12:30 and 6:30, and Sunday at 12:30. Email me, philg@mit.edu, if interested and I can slot you in. There will be food! The venue is the incredibly luxurious and hospitable Rectrix at KBED (Hanscom Field).

(Oh yes, if you’re an aircraft or boat owner, you can come early to participate in a focus group regarding light sport amphibians and get a $300 Amazon gift card!)

[Separately, in asking a friend at the airport whether to invite someone to the focus group, the response was “Well, he used to own two airplanes. But then his wife divorced him and now he’s kind of poor.”]

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“How Puerto Rico Became the Newest Tax Haven for the Super Rich” (GQ) is kind of fun. While Americans elsewhere are outraged by inequality, the Puerto Rican government is seeking to maximize it (by importing as many high-income citizens as possible and giving them a 4 percent tax rate).

[Actually, the rest of America is also working hard to increase inequality, but by bringing in low-skill immigrants to expand the bottom of the distribution. The Puerto Ricans have a policy to increase inequality by bringing in more people to occupy the top. So there are Americans everywhere decrying inequality while working to increase it!]

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How is everyone enjoying the school year so far? Here’s the first communication I received from the elementary school…

This letter is to inform you that a student in your child’s classroom has a severe allergy to peanuts and tree nuts. Strict avoidance of all peanut/tree nut products is the only way to prevent a life-threatening allergic reaction. … [bold in the original]

Our town’s school system also runs a preschool. Here’s the first email from the teacher.

Subject: IMPORTANT

Welcome to preschool! I am so excited to spend this school year with all of your children and I can tell we are going to build a strong, positive classroom community.

** I wanted to be sure that everyone is aware that we have a strict “no peanut/tree nut” policy at the preschool. This includes items that were manufactured or processed in a facility that also processes peanuts or tree nuts, so please be sure to check labels carefully. Tomorrow (or on your child’s first day) I will be sending home a notice from the nurse explaining the policy.

…

Related:

• web site regarding the debate in our town about whether to tear down the current school, move the children into trailers for three years, and spend $100 million on rebuilding the school in-place (maybe proponents could win this debate simply by saying “we found a nut in a classroom so now we are forced to demolish the old building”?)

 

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