Tip from a self-driving car engineer: don’t choose black

A friend is shopping for a new car. He happens to have been working for the past five years on various Silicon Valley self-driving car efforts. What’s he looking at for a new car for himself? A C8 Corvette! (Why not the product of the finest minds of Silicon Valley? “Can any expensive car have a worse interior than Tesla? Seems impossible. They shaved every possible penny there.”)

What color? “Anything but black,” he replied. “The Zeus Bronze Metallic also might be too close to black.” What’s wrong with black? “It will be invisible to Lidar. The cameras might see it during the daytime, but it will be dangerous to drive at night because self-driving cars won’t see it.”

Readers: What do you think of the C8 in Zeus Bronze?

Compare to the Red Mist Metallic, which is the most popular color:

Some additional thoughts from our deeply embedded source…

When can we expect the promised age of self-driving cars?

Hard to answer as depends on legislation and business. Let’s go backwards and try to guess. What is the long-term future? Is it (a) autonomous cars try to mix into traffic with humans, or (b) human driving is illegal?

To get to (a), are the steps (1) start selling autonomous to fleet operators, (2) start selling autonomous to citizens, (3) stop making new human-driven cars, hence no wheel, and grandfather some human driven cars

For (1) to happen the cars have to get good enough, for (2) to happen the cars have to get cheap enough, for (3) to happen Biden/Harris will need the power to repurpose the roads for the greatest public good/safety (also nice because now the government will know where all of the citizens are going and when)

My guess is that the industry wants (a) for now but the government will want (b), which makes more efficient use of roads, simplifies the software, and also facilitates tracking everyone.

Right now (2021) self-driving car is expensive and dangerous. Reducing expense is possible once more money goes into the ecosystem, but it remains to be seen how safely they operate. Horse/car analogy does not make sense: man-driven flesh vehicle to man-driven ICE vehicle. Self driving is from man-driven vehicle to software-driven.

Why is this challenge so tough for software?

The problem with mixing software-driven and human-driven vehicles is exemplified by “is that guy watching Netflix while driving going to yield to my left turn?” Hard to get that right.

When will a family be able to buy a self-driving car, then, without a steering wheel and mix it up with human-driven contraptions?

Pure guess 25 years

A Tesla 3-owning friend:

Tesla owners think by 2017. Then by 2019. Then by 2020. Now by 2021. They pay $10,000 for “full self driving” software. Tucker Auto was shut down for less of a scam.

An immigrant from Eastern Europe participating in this discussion:

My father had a self-driving car for a decade in the 80s. It was called a company chauffeur. He couldn’t do much in the car because it is still less convenient. If it is a short drive, you won’t accomplish much. Read the news perhaps, or write a few emails. Phone calls you can make now.

The self-driving software engineer saw the biggest competition as coming from Uber and similar human-driven services. As long as low-skill labor in the U.S. remains cheap due to mass immigration, self-driving tech would have to be both inexpensive and nearly perfect to be competitive.

Shifting gears, so to speak, for a moment… what about the fact that cameras are being driven around 24/7 in vehicles that can stream footage up to the cloud? The government can already get footage from doorbell and house-attached cameras (see “Amazon Ring is creating the surveillance complex” by Mark Hurst). Will a police officer in 10 years be able to say “I want to see what was happening at the intersection of 8th and Main at 10:32 pm” and get footage from all of the self-driving cars that happened to be passing that location at the time?

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Fund burning of existing copies of harmful Dr. Seuss books?

Books containing harmful ideas will no longer be sold new, says “Dr. Seuss Enterprises Will Shelve 6 Books, Citing ‘Hurtful’ Portrayals” (NPR):

“In And to Think That I Saw It on Mulberry Street, for example, a character described as Chinese has two lines for eyes, carries chopsticks and a bowl of rice, and wears traditional Japanese-style shoes. In If I Ran the Zoo, two men said to be from Africa are shown shirtless, shoeless and wearing grass skirts as they carry an exotic animal. Outside of his books, the author’s personal legacy has come into question, too — Seuss wrote an entire minstrel show in college and performed as the main character in full blackface.”

Let’s look at If I Ran the Zoo. The used (“collectible”) book is still available at Amazon, however, for $1,700:

and it may be available in a lot of public libraries where young minds could fall into error.

Would it make sense for a billionaire Silicon Valley progressive to fund the purchase of all extant copies of these harmful works and then burn them? A typical public library would presumably be happy to receive $1,700 for a worn book that had originally cost them $10. Like the Pfizer vaccine that is not banned in India (“mostly false” and a “conspiracy theory” according to Newsweek; it is just that the vaccine is not approved and therefore illegal to use), the libraries wouldn’t be banning If I Ran the Zoo. It would just be deaccessioned to make room for better/newer books.

(If your budget is smaller and you’re looking for bedtime stories that don’t offend modern merchants, Amazon will sell you a new copy of Mein Kampf for $22.49 ($10.99 Kindle):

“I am convinced that we cannot possibly dispense with the trade unions. On the contrary, they are among the most important institutions in the economic life of the nation. Not only are they important in the sphere of social policy but also, and even more so, in the national political sphere. For when the great masses of a nation see their vital needs satisfied through a just trade unionist movement the stamina of the whole nation in its struggle for existence will be enormously reinforced thereby.” and “For this, to be sure, from the child’s primer down to the last newspaper, every theater and every movie house, every advertising pillar and every billboard, must be pressed into the service of this one great mission”)

The Russians and Dutch rebels behind Library Genesis have preserved a PDF of the not-banned Dr. Seuss work. The world of 1950 contains some all-white neighborhoods:

But one can travel to find Asians (“who all wear their eyes at a slant”):

He goes to Nantucket without a Gulfstream? My rating: #MostlyFalse

The remote African island of “Yerka,” not as realistically depicted as in National Geographic:

As with the 2016 election, it all comes down to the Russians:

Update, evening of 3/3: at least some sellers are hoping to get $5,000 per copy.

Related:

  • the Cobra effect (if a billionaire offers $1,700 per copy, maybe more copies will magically appear?)
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Medical School 2020, Year 3, Week 16 (Inpatient Gyn)

Gynecology rotation starts at 7:30 am in the outpatient surgery center. The chief texted the previous night to skip hospital rounds and just meet the team at the outpatient surgery center for the first 8:00 am case (this is an inpatient week, but if there are no scheduled surgeries at the hospital we go with an attending to the outpatient center). I appreciate the extra sleep! Our first patient is a 27-year-old who had an unfortunate uterine perforation after IUD placement by a Planned Parenthood Nurse Practitioner. “I think it was her first IUD placement. Looking back, she was so nervous.” After a brief physical, we have about 30 minutes before the OR is ready.

Did it hurt getting the IUD placed? “It hurt so bad, but they told me that’s expected. Over the next week, the intense pain got better, but I just kept having these sharp lightning bolts of pain once or twice a day.” She saw an Ob/Gyn for a regular check up three months later who ordered an abdominal x-ray that showed a “T”-shaped device in the right upper quadrant. 

The 70-year-old attending arrives. She meets the patient and confirms the consent is signed. I grab gloves for the attending, intern and myself. We perform a laparoscopic removal of the IUD. It was lodged in the omentum requiring three port placements (three holes in the belly). Throughout the entire procedure, the 60-year-old anesthesiologist, a former dentist, tried to convince me that anesthesia is the best route. “Hospitalists are miserable,” he began. “They have 80 patients, they work 12-hour shifts. It’s not good for the patient, but it’s the way medicine has gone. In anesthesia, we have only one patient at a time, and we are done after you leave the office. And the physiology is just awesome.”

As the OR is prepared by the nurse, surgical tech, and OR tech,s for the next case, we head to post-op to talk to our recovering patient. After a brief conversation with the patient and her mother, we head to the nurse’s station where the intern is instructed to prescribe 10 OxyContin 5 mg. “It’s crazy how much opioid pills we still give out. Epic defaults to 30 pills for a prescription,” says the attending. “I still have dozens of narco left over from my breast cancer surgery. Everyone is talking about the opioid problem and how doctors created this monster, perhaps, but I still blame the government. They started to adjust reimbursement rates based on patient-reported pain scales. No wonder the ED gave out Oxy like candy.”

Before our next procedure (hysteroscopy, camera through the cervix into the uterus to look for, and possibly biopsy, cancerous polyps), I chat with the attending about the future of Ob/Gyn: “Ob/Gyn was a beautiful field because it combines surgery with long-term patient relationships. I am the primary care provider for a lot of my patients. We’re succumbing to the specialization tsunami. I’ve been grandfathered in, but most hospitals require you to choose a track: gynecology or obstetrics.” She continued, “The days of having clinic in the morning with two afternoons of gyn surgeries alternating with a week of obstetrics are ending. Administration is chipping away at the scope of practice for every field.”

After a total of three procedures, I leave the outpatient OR at noon to attend lectures at the hospital on urinary incontinence by a “UroGyn” (Urogynecologist, 4-year OB/Gyn residency followed by 3-year fellowship). 

The next day starts with hospital rounds before surgery at 6:30 am in the main hospital OR. We have two laparoscopic fibroid removals and a hysterectomy scheduled. Dr. McSteamy is the attending. He is a 37-year-old whose recent marriage occasioned despair among the residents (all female, except for one gay guy, a junior resident, who shared their grief). The chief, now four years out of medical school, struggles with basic laparoscopic techniques, incorrectly locating the ureters, a critical item given the risk of damage during the procedure. She also has a six-month-old at home, which might explain some of her deficiencies, but her parents have moved here to assist the software engineer husband in taking care of the baby. She is trying to find a job next year as a general practitioner in a smaller hospital setting. 

During the second hysterectomy, the junior resident gets a page for two ED admits. He and I step out to evaluate a 24-year-old bartender with a three-day history of excruciating labial pain. She had a similar episode several years ago. Her right labia majora is swollen, erythematous (reddened), and extremely painful when she walks or moves. As I prepare to present the findings to Dr. McSteamy, I look up management of Bartholin abscess in my trusted Comprehensive Handbook of Obstetrics and Gynecology by Zheng, a $30 book that fits into a scrubs pocket. The bartholin glands, located at 4 and 8 o’clock in the vaginal introitus, secrete lubricating fluid through a small duct. Some women develop a blockage in the duct leading to an enlarging cyst that becomes infected. Once McSteamy is out of surgery, we head down as a team to examine the patient. We then gather supplies (numbing medication, Wort catheter, scalpel, iodine prep) to drain the abscess. Before we go in, the ED attending asks if the resident has performed one of these. No. Dr. McSteamy then describes the procedure. The ED attending also wants to watch as she has never seen one performed. We transfer the patient into an ED procedure room with stirrups. The resident injects lidocaine in the 3 cm labial abscess and she cries out in pain. After 5 minutes, the resident makes a small incision in the labia, which results in screams and “sorry, sorry.” He then slips a 3 mm-diameter drainage catheter into the abscess. She is supposed to leave this in for 2-4 weeks, but the attending admits that most will fall out within a week. If this happens again she might consider getting a bartholin gland excision or marsupialization surgery (turns the gland inside-out) to maintain duct patency

Friday morning: round on two post-op patients and then am sent off to study before a mandatory class meeting at 1:00 pm. Nervous Nancy is in the student lounge watching Grey’s Anatomy on her phone. She is on outpatient Ob/Gyn week and was told not to bother driving to the clinic today. “Whenever I get nervous before exams, I instinctively watch Grey’s Anatomy. My excuse is I might learn something from it while calming my nerves by binge-watching.” We talk about her experience on Obstetrics. “I sometimes think, screw I am going to have a baby even though I am vastly irresponsible and underprepared. Look at these moms. Then I remember that they are terrible people.” I recount my experience with the G9P8 having the ninth baby. When asked why she keeps having babies, she responds: “Well all my children are in foster care so I need to have another one to actually keep one.” Nervous Nancy laughs, and says, “I’ve seen those too. Maybe your children are in foster care because you are a crack addict.”

We head over to the school for confessions of a medical student. We were instructed to prepare by writing a two-paragraph anonymous confession from this year. We are divided into 10-person groups, each led by a physician who shuffles them and hands them out for presentation: 

  1. Dear patient, I know everything about you. I know your STD history, I know you have had more children than reported to your husband, and I know your mother died from colon cancer. But as I walk through the door I realized I forgot your name. Unnamed patient, I am sorry.
  2. We were so rushed one day on rounding that we didn’t not explain to a patient why we were performing a digital rectal exam. I felt we violated his dignity. We were trying to rule out colon cancer.
  3. I resent when doctors say “we have it so much easier than you did”. They don’t understand the stresses we are under from residency competitiveness and financial costs.
  4. It is such a relief to see bad doctors practicing. The imperfection reminds me that I don’t have to be perfect to become a doctor. Being a doctor is human, and humans are imperfect. Some are even bad at their job.
  5. I learn more from watching bad doctors make mistakes than from good doctors.
  6. We had a patient whose biopsy was delayed because of another patient requiring a more urgent read. We joked how annoying he was. He started to yell that he was going to sue the hospital so the team disliked him even more for him being so difficult. He started to have delirium. When I went in alone to check on him in the morning he was clam and present. He confided in me: “I don’t care about myself, my wife is not strong enough to handle another day of not knowing.” The wife broke down in the room. He then got delirious and started asking philosophical questions, “Where are you going?”, “Are you content?”, “What happens next?” It gave me chills.
  7. I can never do pediatrics. An anti-vaxxer mom and her three kids came to the pediatric clinic for a first visit after getting thrown by of their prior pediciatrian. The kids asked me why they can’t go to normal school instead of being homeschooled. It was terrifying seeing a crazy woman make decisions that will impact these kids’ lives with no one to stop her.
  8. We don’t do much good in the hospital or in medicine. So much waste, discharging patients for them to come back in a week. We just use all this expensive technology that prolongs a miserable life. The best care I’ve seen so far was when a surgeon decided to not operate and recommended comfort care.
  9. I kept telling my team that a patient had a certain diagnosis, albeit atypical presentation. They kept saying how it could never be that, and made fun of me. After a few days and it turned out I was right, but they never acknowledged what I had told them. In my evaluation they mentioned only trivial stuff: on time, attentive, knows patients.
  10. I feel disillusioned. Despite all this training I feel worthless and unable to manage any real problems my friends and family ask me about. Barbara Freiderson helped me: “The negative screams at you, but the positive only whispers.”

Nervous Nancy: “I just feel like I am always in the way. That no one is grateful for us, and the people that actually care for the patient would have it easier without us present.” The physician leader asks, “Do any of you wish you were invisible?” Every student grinned, and nodded. Gigolo Giorgio, who sports a beer belly after gaining several pounds on psychiatry comments: “I think you mean we all want to be flatter against the wall.” 

Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 1 night. Halloween celebration. Gigolo Giorgio hosts a pregame before the class Halloween party downtown. We reminisce about our rotation experiences. Buff Brad and his girlfriend dress up as Gamora and Warlock from Guardians of the Galaxy, Adrenaline Andrew and his girlfriend win first prize with homemade jellyfish costumes out of christmas lights and clear umbrellas. Classmates are downing shots and beer. Once we arrive at the rented out bar’s upstairs room, students dance Top 25 Pop hits while a line grows at the private bar for $5 mixed drinks. Gigolo Giorgio jokes: “[Put-Together Pete] is on his 24-hour night shift for surgery, we should all get blackout and visit him in the ED.”

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

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Proof that you can make money using my blog as an investment guide…

… just do the opposite of whatever I’m bullish about.

Me: Two-thirds full airline idea (12/23/2019)

Me: Coronavirus will breathe life into my two-thirds-full airline idea? (3/23/2020)

“What Delta’s Big Bet on Blocking Middle Seats Means for Flying” (Wall Street Journal, 2/10/2021):

The last U.S. airline with this policy has lost fliers to carriers with looser rules—here’s why Delta is holding out for now

The grand experiment of blocking the middle seat on airplanes has proved what we have known all along about air travel: More people care about a cheap fare than comfort, or even pandemic safety.

The bottom line for Delta during the pandemic has been bigger losses than rival airlines selling all their seats. Delta was the most profitable U.S. airline in the final six months of 2019. That flipped during the pandemic. In the last six months of 2020, Delta had the biggest losses, with a net loss of more than $6 billion, greater than United and Southwest combined.

Even with state governors telling people that coronavirus was so dangerous that we should close schools and have children stay home to get fat and stupid, close society and have adults stay home to get fat, drunk, opioid-addicted, and stupid, and imprison/fine people for breaking a variety of rules that were apparently in conflict with the First Amendment right to assemble, consumers decided that coronavirus was not dangerous enough to be avoided by paying a little more for an airline ticket (and getting a much more luxurious experience as well).

One of the harbors in Hilton Head, South Carolina where you can keep the yacht that you buy after acting (after reversing the sign) on my advice:

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Medical School 2020, Year 3, Week 15 (Gyn Onc)

As part of our OB/Gyn rotation, we selected a week-long surgical subspeciality, either urologic oncology (“UroGyn”) or gynecologic oncology (“GynOnc”). GynOnc is known to be an intense rotation featuring surgery hours with operations that frequently last more than four hours and extend well into the night. Lanky Luke responds to hearing that I chose GynOnc: “I loved UroGyn last week. It’s all old ladies with urinary incontinence, but the surgeries are really neat.”

GynOnc begins at 6:30 am on the oncology floor. My Chief, Marvelous Martha, is a big and tall 34-year-old who loves talking about her adventures on the Bumble dating application. The residents and my classmates adore her. Nervous Nancy: “All her patients are taken care of, even the small details about nausea, ambulation, pain. I don’t know how she stays so on top of all the patients on the floor.” The intern is a short, 45-year-old mother of two college-age kids. She worked as a project manager for GE before going to medical school. Nervous Nancy was shocked to hear about the two kids in college: “She looks so young!”

[Editor: How long would a 34-year-old guy talking about his Tinder adventures last at this hospital?]

The case load is light so I go to the medical student lounge and meet Lanky Luke and Particular Patrick. Particular Patrick says that he misses the “intensity of surgery” and is “bored out of [his] mind on Family Medicine.” Lanky Luke is not enjoying L&D nights. “I have to watch what I say around my team. They were complaining that Medicaid would pay for the Mirena IUD, but would not pay to remove the IUD unless medically indicated. I wanted to say, ‘Maybe we shouldn’t be taking it out. If you can’t pay the $100 fee to have it removed, maybe you’re not able to afford a child. Taxpayers paid for five years of contraception. They’ll pay for 18 years of housing, health care, and food if a baby is pushed out. Why can’t the Medicaid customer scratch up $100 in the middle?'”

Luke’s team was not entirely humorless. “This hippie couple brought in an eight page labor plan document. The [male] resident showed me a cartoon in his locker in which a sheet of paper labeled ‘labor plan’ was being shoved up someone’s butthole.” Proving the old adage “no plan survives contact with the enemy,” labor was prolonged and the fetal heart rate was “nonreassuring.” They got a C-section. The father took his shirt off in the middle of the OR and had the newborn placed on his chest (“kangaroo care”) while the mother was getting sewn back up. A nurse joked: “It’ll latch onto you if you’re not careful.” The father was excited. “Really!?” Should I let him?” Luke fought the urge to add “No, no you should not. You want that baby to suck on your hairy nipple? He’ll never latch onto another one after that traumatizing experience.”

Our weekly afternoon lecture begins at 1:30 pm and is on contraception and miscarriages. The generalist OB/Gyn describes the different techniques for an abortion (medical versus surgical). “Most states limit abortions beyond 24 or 26 weeks and some as early as 22 weeks. Most women do not get results for their fetal anatomy ultrasound until 22 weeks. Whether or not you support abortion, it’s important for everyone to understand the harrowing choice some women have to make, sometimes in a matter of days to get an appointment.” We also go over the various types of birth control and the uses of OCPs [oral contraceptive pills] beyond contraception per se. For example, patients with BRCA1 mutations have a 60 percent chance of getting breast cancer by age of 70, and a 50 percent chance of getting ovarian cancer by the age of 70. Every year that a patient takes COCs (combined oral contraceptive) decreases the risk of ovarian cancer by 5 percent.” We get out at 4:45 pm and are done for the day.

Tuesday is more typical. I get to the hospital at 5:45 am to pre-round on two patients. Both  were admitted for intractable nausea and vomiting. The first was admitted two days after getting her first cycle of carboplatin/paclitaxol chemotherapy for stage IV endometrial cancer. She’s about 55. My other patient is a 57-year-old with ascites (fluid in her belly, in this case over 20 liters) that has led to the classic protuberant “beer belly” that suggests ovarian cancer (stage IV in her case).

We have four cases today: two “majors”, both TLH/BSO (total laparoscopic hysterectomy with bilateral salpingo-oophorectomy); two “minors”, a laser ablation and a cervical stenosis repair. The attending is a 55-year-old gyn onc surgeon. She’s sarcastic, but quite patient. 

I run to meet the first two patients in pre-op before heading to the OR for gown and gloves. Our first case is a robot-assisted TLH/BSO with lymph node removal and an omentectomy (removal of a fatty lining) for ovarian cancer staging. The 53-year-old patient underwent neoadjuvant chemotherapy before this surgery. “Ovarian cancer responds well to chemotherapy,” says the attending. “Sixty percent of ovarian cancer will go into remission. That’s why we need to be thorough and not leave any protected spaces of tumor that the chemo can’t access. Unfortunately, 90 percent of our patients will have recurrence and over time the cancer develops resistance. The big ticket item in ovarian cancer research is finding a maintenance therapy that prolongs remission.”

Two of the OR technicians have been on staff for only a couple of months. It takes 90 minutes before we get the robot docked, and the arms attached to the laparoscopic port sites. The attending and Martha head to the robot control panels, about 15 feet away. They’re still in the OR, but they’ve scrubbed out for comfort. I hold the uterine manipulator and the mid-level resident uses a grasper under direction from the attending. The attending sounds frustrated as she coaches Martha: “Never buzz with the scissors open.”; “Angle the scissors. Use your point of strength!”

We begin to remove the omentum from its connections to the gut tube. “This is the biggest omentum ever!” says the attending. “I just don’t know.” After more came out: “This is unreal how big this omentum is.”; “This is a really fucking big omentum.” After 3.5 hours with the robot, we give up and perform a laparotomy (conventional opening of the belly with a large incision; the opposite of laparoscopic) to finish the removal. The da Vinci Xi robot ($2 million base price; accessories additional; $10,000 in disposables for each operation) turned out to be useless.

It is nearly time for a UroGyn lecture covering content easily found with UpToDate or OnlineMedEd.com.

I tell Martha that I will skip the lecture because the surgery is far more interesting. “Sorry we can’t let you do that,” she responds. “We’ve gotten in so much trouble for students being late to lecture. Appreciate the enthusiasm.”

The next case is a laser ablation of the cervix to prevent cervical cancer. The OR staff lug in a giant CO2 laser. The attending commands, “Arm the laser beam”. Just as in Austin Powers, the nurse responds, “Laser armed and ready.” The attending lets each of us have a quick experience looking through the microscope and aiming the laser. The nurses made the surgeon insert a wet 4×4 gauze into the anus to prevent the release of any methane gas that might be ignited by the laser.

Thursday features two hysterectomies and a fibroid removal. We use the robot (da Vinci) for the first two cases, and opt against it for the more challenging third case. Our attending is relatively new and extremely cautious, so each case takes at least three hours (one hour would be normal). The residents are not afraid to express their frustration in the OB lounge. “I hate working with him. Everything takes three times as long as it should.” The second case is removal of a two-centimeter fibroid at a patient’s insistence. The 40-year-old Eastern European is convinced that all of her problems stem from this benign tumor. The intern ungratefully complains about the attending to another OB/Gyn team: “No one should ever remove a fibroid that small.” The Gyn Chief adds: “I cannot believe [the attending] went ahead with that surgery. Either do a hysterectomy or tell her we’re not removing it.”

The third case, removal of a uterus with a 10 cm fibroid, starts at 3:30 pm, right when we would ordinarily be heading home. The chief is driving with the laparoscopic graspers while I wield the uterine manipulator. By the time we get the fibroid dislodged, it is 8:30 pm. Then the fibroid won’t fit through the vagina. We then have to do a laparotomy (open the belly with a knife, thus rendering all of the laparoscopic work and extra time pointless). On the bright side, the attending allows me to make the incision with the scalpel. It feels heavy. The attending sends us home at 10:15 pm while he closes up. He felt bad for keeping the chief from her 14-month-old. 

We sit in the OR lounge and chat with another OB/Gyn attending. He explained to the young team members that our medical education and experience would transform us into superior beings with respect to uncovering microaggressions and revealing implicit bias: “Doctors are more in tune with bias than other people in society because we deal with the consequences of bias all the time. A patient comes in for the 10th time in two months for the same nonsense problem, we are prone to blow it off and send them out. The patient comes back to the ED in crisis because of what we missed. Every doctor in practice for more than twenty years has had this experience.”

[Editor: “Your Surgeon Is Probably a Republican, Your Psychiatrist Probably a Democrat” (nytimes, October 6, 2016) lends some credence to this theory. Surgeons, notorious for not doing any long-term follow-up with their patients (so they would never learn about the consequence of holding a bias), are much more likely to be Republican than Internal Medicine docs.]

I leave early for lecture on Friday. I chat with Nervous Nancy in our medical student lounge. Nervous Nancy, age 31, confided: “After going through L&D, I sometimes think to myself, screw it I am going to have a baby. I am vastly irresponsible, and underprepared. But look at some of these mothers. Then I remember that they are terrible people. They’ll have a child without batting an eye when the kid is going to the NICU because of the mother’s unrepentant cocaine use.”

[Editor: In the 1990s, a social worker friend in her mid-30s said that she had been agonizing over whether she was sufficiently prepared to take on the responsibility of caring for a child. She then reflected that one of her clients was 15 years old, pregnant with her second child, and living, without apparent health impacts to mother or child, almost exclusively on a diet of Coca Cola and Doritos.]

Statistics for the week… Study: 2 hours. Sleep: 5 hours/night; Fun: 0 nights. I leave the hospital early on Friday afternoon to catch a flight to a college classmate’s wedding. We chatted with the groom’s cousin the morning after the wedding. My best friend, also a third year medical student at a different school, asked, “Did you notice something about him?” I quickly responded, “Yep, pinpoint pupils.” He grins back, “Yep, must have been partying all night with some opioids.”

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

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Revisiting my COVID-19 death estimate

In the comments to “Why do we care about COVID-19 deaths more than driving-related deaths?” (March 26, 2020), a reader asked a great question:

How good of an estimate today can you make of traffic-related deaths in the US in the next year? This estimate is quite uncertain given that miles driven will likely plummet and depend on the duration of various shutdowns. You can still probably guesstimate the total miles driven will be some fraction of the previous year and be within 0.25X to 4X. You won’t be wrong by 100X.

Now predict today the number of coronavirus deaths in the next year in the US. Your estimate could very easily be off by 100X or more.

This was just a few days after New York went into shutdown (March 22) and before the typical U.S. hospital had seen even one Covid-19 patient. Here was my prediction:

why can’t we extrapolate from Lombardy to get a reasonable estimate? Out of 10 million people, COVID-19 has killed 5,000 to date. Assume that becomes 10,000 by the end of the year. That’s 1 in 1,000 people. Applying that to the U.S. we get 330,000. Horrific, of course, but about the same as the driving deaths expected for next 10 years (which didn’t seriously concern the nation). I don’t think this can be off by 100X. 33 million is too much. 3300 is, sadly, likely to be exceeded (1,301 as of right now). Maybe we can do 4X better than Italy due to advances in knowledge and drug therapies that are available. That brings us down to 82,500 deaths, not too different from what the Imperial College folks are predicting per capita for the UK. We’re not as competent as other countries when it comes to health care, so estimate 150,000 COVID-caused deaths through February 2021? Let’s come back to this post on March 1, 2021 and see if the mortality was, in fact, within 0.25X to 4X of 150,000.

Our heroic anonymous reader gave me some wide error bars (0.25-4X), there, but not nearly as wide as what the IHME prophets gave themselves regarding Sweden (“They’re fairly confident that on May 23, Sweden will have between 11 deaths and… 2,789 deaths”).

So… my proposed method back in March was to extrapolate from Lombardy to the entire U.S., reduce for the worldwide effort to develop treatments and add back in for American incompetence at organizing health care. This boiled down to 45 percent of whatever the Lombardy death rate was. And then there was an additional guess that, as of March 26, Lombardy was halfway through its total COVID-19 deaths.

So… let’s put two questions to the readers.

How did my guess that Lombardy was halfway through its total COVID-19 suffering hold up? As of February 27, the Google said that 28,275 people in Lombardy had died with a COVID-19 tag (Italy had a big second wave of deaths tagged to COVID-19 starting in the fall of 2020). I’m having a bit of trouble finding the death rate through December 31, 2020 (maybe a reader can help out). My guess that 10,000 would be the death toll in Lombardy “by the end of the year [2020]” seems to have been a little over 0.5X of the actual.

How did my guess that the U.S. toll would be “45 percent of Lombardy” hold up? As of February 27, 2020, the Google said that 510,000 Americans had suffered “COVID-19 death” (keep in mind that, with a median age of 80-82 for “COVID-19 death”, we are saying that a 92-year-old with cancer, diabetes, and COPD “died of COVID-19” so long as a positive PCR test can be obtained).

Through February 27, 2020, Lombardy has had a COVID-tagged death rate of 0.28 percent (28,275 divided by 10 million). The U.S. has had a death rate of 0.155 percent (510,000 divided by 330 million, but perhaps the divisor should be 350 million?).

The guess was 45 percent and, as of February 27, the statistic was 55 percent (0.155 divided by 0.28).

What about the 150,000 number that I tossed out? That is 0.29X of the 510,000 number that we’re being fed. So, unlike our heroes at IMHE and other epidemiology institutions, the reality was within the error bars that I set up.

(One reason that my estimate came out on the low side, I think, is that I underestimated the extent to which Americans would want to wallow in coronasadness and maximize the count of very old, very frail people who purportedly died “of COVID-19”. This can be seen on Facebook as people claim that the impact of coronavirus has been worse than all of the wars that the U.S. has ever fought, except maybe the War of Northern Aggression. At least some subset of Americans wants to equate a healthy 18-year-old marching off and never returning with an 82-year-old who was expected to die within 1-2 years meeting his/her/zir/their final end within a few weeks of a positive PCR test. Admittedly this method of counting is not unique to the U.S. For example, the Swedes have a computer system automatically tag “COVID-19” to anyone who dies within 30 days of a positive test, even if the person dies in a traffic accident.)

From my Italy photos, a square in Burano, 1996:

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Medical School 2020, Year 3, Week 14 (L&D Days)

I arrive for L&D days at 7:00 am and meet the all-female team before our 7:30 am handoff. Nervous Nancy is leaving from the night shift: “I’m loving OB/Gyn. All the good parts of surgery, with none of the soul crushing.”

The Chief resident is a wide-shouldered fit new mother who periodically attaches her $480 wearable Willow breast pump. The Chief explains to me: “You’ll find that days are full of admissions from clinic and triage. You will have some elective C-sections, but nights are where all the deliveries happen.”

The intern is an Indian-American only half the size of the Chief. Though specializing in OB/Gyn, she’s still struggling to perform a cervical exam and gushes when talking to the Chief. She asks how to rotate a baby from OT to OA [Occiput Transverse to Occiput Anterior, positions of the baby’s head during delivery]. “Wow, that is so amazing.” 

My first patient: a 39-year-old G9P8 (9 pregnancies; 8 births) admitted the previous day for induction of labor at 37 weeks for “PreE” (preeclampsia; high blood pressure with proteinuria). The night team resident, Teacher Tom: “I asked her why she keeps having kids. She explained that all her previous kids were taken away from her so she needs to have another one. Does she think she’s taking this one home? CPS took her kids away because of her meth habit.” Nervous Nancy: “I had a G13P11, with no twins. At first I read it as G1, but then realized we were in double digits. Just how?”

I follow the mid-level resident who is in charge of all OB consultations in the hospital outside of L&D. For example, there is an “antepartum” unit for pregnant patients who are not expected to give birth. We check on a 26-year-old African-American G3P2 patient with a BMI of 62. She stopped taking her birth control while breastfeeding the second child. The resident attributes this to a “lactation consultant who told her not to keep taking her Micronor because it’ll decrease milk production. This is what happens, when people go outside their expertise. Do they realize how dangerous short interval pregnancies are on the mother and baby? The only studies show that estrogen might have an impact on breast production. No study has shown any change in breast production with progesterone. It’s online voodoo and look what’s happened.”

Our 350 lb. patient is 29 weeks pregnant and on tocolytics (medications that prevent labor) and BMZ (betamethasone steroid). “The purpose of the tocolytics is not to prevent preterm labor,” explains the resident, “but to give the steroid enough time to improve fetal lung development.” The patient was taken to the OR for a classical C-Section (vertical incision rather than low transverse incision of the uterus) due to non reassuring neonatal stress test (NST) and a malpositioned baby (transverse). A classical C-section has a much greater risk of uterine rupture in future vaginal births and therefore all future deliveries will require a C-section.

Our next consult is in the ED. A tearful 26-year-old mother, PPD #5 (postpartum day 5) from LTCS (low transverse C-section), is panicking. In between tears, she sobs, “I need to be at home taking care of my baby, but my belly hurts so much.” The resident, in a calm voice: “Breath in, Breath out. Slow your breathing.” A CT scan shows a small hematoma in the abdominal wall, which is why we were consulted. The resident explains: “She is totally fine. Everyone is going to have that size hematoma after a CS. This is simply a panic attack from being a new mother. She needs to get evaluated for postpartum depression, but doesn’t need to be in the hospital for this.” The resident applies pressure with her thumb on the patient’s forehead at a “trigger point” to calm her down. As we walk back to the elevator, she explains, “A lot of what you do as the mid-level [resident], is finesse and coddling patients.”

Thursday afternoon I deliver a 22-year-old “self-pay” (did not fill out the Medicaid paperwork) G1 African-American mother. Unlike with any of the previous deliveries at which I had been present, the father had accompanied the mother to the hospital. He was a 21-year-old Caucasian pacing and asking questions every few minutes.

She appeared to be progressing slowly, typical for nullips. She started to feel the urge to push at 8 cm dilated, but the resident said to wait until completely dilation (10 cm) so as to avoid cervix damage. The team steps out to see other patients, leaving me and the 45-year-old highly experienced nurse in the room. Having heard the word push, I eagerly gown up. Five minutes after the team left, she starts pushing and the baby pops out. The nurse and I rush with outstretched hands toward the newborn boy, but I am closer and catch him. I put the baby on mom’s chest, as the nurse and I scream for the BRT (Birth Respond Team). The nurse and I clamp the cord while the team rushes through the door and gowns up. With supervision from the attending, I instruct the father to cut the cord, and then I deliver the placenta. I earn a “good catch” comment from the nurse.

While shadowing the intern the next morning, we see the mother again. She complains of belly/breast pain. The intern is anxious to get back upstairs and deliver babies. She listens, but doesn’t touch the patient’s abdomen. During the intern’s presentation to the attending, a 60-year-old who had his own practice for many years, she explains that the first-time mother is ready for discharge. The attending says “Something doesn’t add up. Why is she still in pain after a vaginal delivery?” We return to the patient’s room together. When the attending presses on the patient, she jumps off the bed: rebound pain (inflammation of abdominal cavity). We get an ultrasound and CT of the abdomen showing appendicitis. I chalk this one up as an example of specialists having a tough time seeing the big picture.

The attending debriefs us in the resident room afterwards. He comments: “My favorite quote from teaching was by an intern. ‘I don’t know what’s wrong with the patient, but I don’t think we need to do anything.'” The Chief replies: “Dr. P, you told me intern year that I didn’t have even the competence of a second-year medical student.” Dr. P: “That sounds like something I would say.”

Also Friday morning, I ask my favorite family medicine intern, Tangled Tiffany, if she’s examined the postpartum patient we are both following. She responds, “No, let’s go in together. You do the talking.” I ask the 28-year-old PPD #1 after SVD (spontaneous vaginal delivery) basic questions: “Are you walking, eating, stooling, passing gas, peeing. How are you breastfeeding? Any pain? Has lactation come?” She reports a mild cold. I then conduct my physical exam. After just one week on OB, I had become accustomed to performing a half-hearted physical examination. I use the stethoscope through her robe and report, “Everything sounds good, maybe a few occasional wheezes, on her right lung base.” We have only a few minutes before I have to get my note in and head to the 7:30 am handoff. Tiffany replies, “Are you sure, look again. I came in before and found a few things. Maybe take her gown off.” I take her gown off, and hear inspiratory wheezes, likely from a cold. She also has a Grade III/VI diastolic (heart) murmur.

Tangled Tiffany smirks at my shame: “This was a test. I came in before and examined her. She was nice enough to play along, and [to the patient], might I add, you did it perfectly! She’s had this murmur since childhood, but has never gotten it checked out. She promised me she would follow up this time.” When we leave the room, she comments: “Not a single OB/Gyn mentioned this in a note at any time during this pregnancy. Just remember, don’t skimp on the physical exam. It takes two seconds, but I see this all the time. A doctor listening through clothing is not doing a full exam. Unless the patient has a Grade VI murmur, you’re not going to hear anything.” We arrive for handoff at 7:35 am, but people are still strolling in.

This was the first week where I did not feel welcome and had to chase after team members who seemed anxious to see patients without me. One time I ended up following the intern on the way to the women’s bathroom. I confided this to Nervous Nancy the next day. “Oh, yeah, that happens all the time with me. I just play it off that I was also going to the bathroom.” When I offered to stay late on Tuesday for a C-section, they responded with, “You can go home now. We don’t want to violate your Duty Hours.” When I offer to stay for handoff to present my patients: “You can go home. It’ll be too crowded in the resident room. Go home.”

It is small consolation, but they don’t seem to like the patients any better. There is a lot of trash talk in the lounge, and sometimes just outside patient rooms, about obese patients. Example: 

“I still have to do cervical checks. I’m elbow deep struggling to keep the legs out of my way.” (our intern)

The team is only slightly more impressed with family medicine colleagues, one of whom notes “It’s family medicine not family practice. I wouldn’t mind when they call us family practice, but it’s in context of everything else. It’s just the icing on the cake — they have no respect for us. They look down on us as if we don’t know how to correctly deliver a baby. We do C-sections. I do them just as well as the interns. We know how to handle intrapartum complications. They think that because we are not as specialized as they are, we don’t need to know how to practice these skills.”

Classmates are active on Facebook regarding the Brett Kavanagh nomination hearings. Type-A Anita and Pinterest Penelope get one-day excused absences to attend a protest. There is a picture of them holding signs of “KavaNope”. After the confirmation:

well this is horse shit, but what else would I expect from white men in power? welcome to the bench Kavanaugh, I look forward to losing the rights I’ve won in the past 5 decades.

One hour later, she admonishes “Ladies, make sure there are video cameras and eye witnesses the next time a man violates you” and brackets a quote from President Trump:

Absolutely. Fucking. Disgusting. 

“I do stand with women, but we need to show the evidence. You cannot just say to somebody, ‘I was sexually assaulted,’ or, ‘You did that to me,’ because sometimes the media goes too far, and the way they portray some stories it’s, it’s not correct, it’s not right,” said Trump

Absolutely. Fucking. Disgusting.

She also shares her boyfriend’s Facebook post:

I stand with all the survivors currently reliving their traumatic experiences and seeing their legal and justice systems fail them. I cannot apologize on behalf of all men, but I can say that I’m a proud feminist 100 percent and you have an ally in me.

Pinterest Penelope:

Male friends: how many of you called senators? How many of you made the time to protest? How many of you had hard conversations with your other male friends? Don’t talk to me about much “this sucks”. Goes double for @white people for issues on police brutality and gerrymandering

[Editor: The construction of bizarrely shaped districts to make certain that one party wins (gerrymandering) may be required by the Supreme Court’s 1986 decision in Thornburg v. Gingles to protect the rights of minority voters from having their votes “diluted”.]

Statistics for the week… Study: 8 hours. Sleep: 7 hours/night; Fun: 1 night. Christopher Robin movie night with Jane.

The

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Windfall Profits Tax on Bitcoin?

Whenever other people are smarter and more successful than I am, I like to propose a massive tax applicable only to them. Since I neglected to buy Bitcoin…. it is time for a Jimmy Carter style Windfall Profits Tax on cryptoprofiteers! (spoiler: the Tax Foundation says that this is a bad idea)

One challenge with this is that it might be hard to hunt down folks who have a seed phrase and a passphrase written down on a Post-It note. Some Bitcoin success stories invested in ETFs and public equities that are somehow tied to Bitcoin and they’ll be easy to hit with Philip’s 95 percent windfall profits tax. But the richest/biggest fish may get away (renounce U.S. citizenship, pay the exit tax, move to a tax-free country, and then start cashing in the Bitcoin).

Is Bitcoin a bubble? Physicist and general smart guy Brian Keating points out that the “bubble” has lasted for ten years, much longer than tulip mania (six months) and other historical bubbles. Peter Schiff, smart enough to move to Puerto Rico in 2015 and skip on Federal taxes, points out that the Feds began inflating the stock market and housing market in the mid-1990s and the collapse didn’t come until 2008. Schiff: “If people are dumb enough to pay $50,000 for Bitcoin, maybe they’ll be dumb enough to pay $100,000.” Isn’t it a good hedge against governments printing money and inflation? “Maybe Bitcoin is a hedge against stupidity because if people are still stupid they will still buy it. If you’re worried about the dollar going down, don’t hedge it with something riskier than the dollar. Buy Swiss francs.” (watch Keating and Schiff talk)

A bad guy lair (for a Bitcoin early adopter?) under construction in Sarasota:

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Medical School 2020, Year 3, Week 13 (L&D Nights)

Wildflower Willow after our pediatrics exam. “I loved my OB/Gyn rotation–actually doing something instead of just talking for hours about a patient on internal medicine. We would be relaxing in the resident lounge area and then hear a yell for BRT — that’s the Birth Response Team — and we would run.” She continued, “I am pretty bummed that I didn’t get to deliver a baby. I wasn’t proactive my first week. My second week I had four perfect multips [multiparous mothers, i.e., those who have previously delivered a baby] but each of them had a complication requiring either a CS or an operative vaginal delivery [vacuum delivery assistance].”

OB/Gyn orientation starts at 8:00 am Monday morning. The clerkship director, an attending obstetrician, provides a well-organized pamphlet with details about each component of the block, one week each: Labor and Delivery (“L&D”) days, L&D nights, outpatient gynecology, outpatient obstetrics, surgical oncology, and either Maternal Fetal Medicine (MFM) or Reproductive Endocrinology and Infertility (REI). She picks Device Denise, a short, cheerful 27-year-old who worked for two years in medical device engineering, as a schedule example. Denise comments, half sucking up (she wants to go into Ob/Gyn), half truthful: “This is by far the most organized clerkship we’ve had.” The clerkship director responds: “Well, it is the most complicated schedule. A lot of students complain about moving around among locations and specialties. You run around because we do so many different things in OB/Gyn.” My individually printed schedule shows that I will start with L&D nights.

At 9:00, we head over for a 30-minute tour of the hospital and end at the simulation center to practice suture technique and delivery of a baby on a $60,000 model. The simulation technician: “This isn’t even one of the more expensive ones. We have a $110,000 model of a kid the EM residents practice on.” Half of us have already done surgery so we are quite proficient in scrubbing in and sutring. The simulation model is a plastic female with her legs spread. Southern Steve comments: “Her feet look quite manly. Are they interchangeable with some other models?” Technician: “No that’s just the way she’s built.” She then presses start on a computer and a motor pushes a rubber doll out of the model’s vagina. This is followed by a rubber pancake connected to rubber tubing, representing the placenta and umbilical cord. The attending goes through correct technique to deliver a baby. When the technician and attendings leave the room, I ask, “Do you think this was a worthwhile investment?” Device Denise: “It’s better than not knowing what is going on with a real patient.” Lanky Luke: “It was helpful but it could have just as easily be done by observing a real patient.” 

Orientation ends at 11:00 am, and I head home to take a quick nap. I come back in to meet the night team at 5:00 pm for the handoff from the day team. The team consists of an attending, the senior PGY4 High-Horse Haley, a mid-level (PGY2 or PGY3), a OB/Gyn intern Teacher Tom, a Family Medicine intern Tangled Tiffany, and myself. Despite having been an intern for only a couple of months, Teacher Tom has already been recognized with a teaching award due to great medical student evaluations in the preceding two blocks. Tangled Tiffany has long tangled red hair and an open personality. She is a great teacher, her patients love her, but she clashes with High-Horse Haley. If she were a man, Tiffany might not survive in a #MeToo world. When I ask her the brand of neck heating pad she recommended, she responds, “Well, I could look through the texts with my ex-boyfriend, but no… I shouldn’t. Nobody wants to see those.”

Tiffany asks if I want to interview her patient in Triage. I lead the interview by asking questions (how frequent are your contractions, any bleeding, prenatal care history, etc.), while Tiffany fills in the numerous gaps. She then performs a cervical exam to measure cervical dilation, effacement, and station (position of baby relative to hips). We then report to our mid-level and senior resident in the resident computer area. After 10 minutes, High-Horse Haley scolds Tiffany  for performing a cervical exam without supervision. Apparently, a family medicine intern was not supposed to do this without either an upper level or the OB intern. She explains: “I was worried she was about to push the baby out any second.”

I scrub into a Cesarean section. The patient is a 26-year-old inmate at a nearby prison and suffers from Hepatitis B and C. She had been arrested for shoplifting and was then convicted of being a meth dealer. There are two armed guards looking through the OR door. (I asked them later how frequently they’re at the hospital. One responds “I’m here almost every day. I think I might have learned enough to work as a nurse.”)

It is unnerving that the patient is awake throughout the entire procedure talking to her sister behind the drape as the PGY2 makes the initial midline transverse incision. They bluntly dissect down to the abdominal fascial layer. The attending pimps me on the layers of the abdomen. Attending: “You speak like internal medicine doc — I would know, I’m married to one. Not a bad thing. You’ll find most OB/Gyn give short answers but we do have a few deep divers.” The resident makes a small cut with scissors into the fascia, then the attending and resident yank laterally ripping the fascia — it’s pretty violent. They then pull the uterus through the fascial opening — it looks like a turkey! The resident makes a small inferior transverse incision into the uterus. Membranes rupture with a gush of amniotic fluid and then the resident pulls the baby out. Whole process takes about 10 minutes. We suction the baby, clamp the cord after 1 minute, and then hand the baby to the neonatologist in the room. We don’t know what’s happening with the baby after that. 

Haley then proceeds to suture the uterus as the attending guides through. They talk about different suture technique among attendings. After they place the uterus back into position, the PGY2 closes the fascia with help from the attending. The attending allows me to do a running subcuticular to close the initial incision. They were impressed because most of the students this year have not done their surgical rotation yet. 

I ask the attending if she operates on patients with Hep C frequently? “Yes all the time. Also HIV. Some of my partners get tested every six months and I probably should start too.” 

Around 10:00 pm, everything slows down. No triage patients, no one close to delivery. I go with the OB resident to watch him do two cervical checks for actively laboring. No one is past 5 cm dilation. Botht the FM and OB resident know how to speak Spanish fairly well and could get theri interpreter license. The FM resident asked the OB resident: “What do you think about the Spanish license and phone interpreters?” “The phone interpreters are terrible. I asked a patient if they were soaking more than three pads per day. They asked do you need three pads? I do not get certified because of the liability. If something happened to a Spanish-speaking patient, they will grill me on my Spanish. Even if you did nothing wrong, they’ll blame the language barrier due to not using an interpreter and cross examine you to see how well you speak Spanish. You will be made to look like an idiot on the stand.” 

Tiffany: “My patient is 29 years old with six kids, soon to be seven, who doesn’t speak a word of English after living in the US for over 10 years.  I have nothing against refugees or old people who are not going to be able to learn a new language. But she has been here for over 10 years and doesn’t work. I did my training in Miami and I use Spanish here more than there. Everyone speaks English [in our city]. How does she take care of her kids?” She added: “Geez, I’m sounding Republican now that I make money. Mom always said I would become one. But I’m not, I am a hardcore Democrat. Weird. I just can’t stand lazy people.” Teacher Tom: “Better get used to it.”

[Editor: She doesn’t like lazy people, but votes to give anyone who doesn’t work a free house, free health care, free food, and a free smartphone?]

Our team has very little patience for non-laboring patients. The surgery service “made us take care” of a multip at 24 weeks who underwent hemorrhoid surgery. The surgery service threw the patient on our service because of an unequivocal fetal heart rate test (Non Stress test) requiring a more expensive rule-out test (BPP). Surgery is consult, OB is primary even though the only reason she is in the hospital is for recovery from the hemorrhoid surgery.  She was told this is an excruciatingly painful surgery that will take two days to be bearable. The surgery resident went into the wolfden. “She is a weiner, very low pain tolerance.”  The resident came to us afterwards to say nothing is wrong with postoperative course, and no more pain meds can be given. “This is a direct quote from the surgeon, ‘I don’t see them for two weeks because they will chew me out.” 

We read the operative note for the surgery. High-Horse Haley comments: “You see everyone says OB is disgusting. Look at this. During the surgery they dilated anus to get access. Babies are meant to come out of the vagina. Anuses not meant to be dilated.”

The mid-level explains that there is no medical necessity to be in the hospital and we are just giving you meds that can be given at home. You’ll recover better at home. The husband responded that they won’t leave because it would be difficult to get into the car and get her up the stairs to their bedroom. “Sleep on the damn floor. We’re not keeping them because he doesn’t want to deal with her at home.” Are they private or Medicaid? Private. “There is no way that Anthem is going to pay for this hospital stay. It’ll be out of pocket. Most expensive hotel stay ever. $4,000 just for the night, not including outpatient med costs.”

After they are informed about cost, they leave within 30 minutes.

Around 2:00 am, Tiffany delivers her patient’s baby with the attending and Haley and myself in the room. I get to deliver the placenta and perform a uterine massage. Haley: “Tomorrow we’ll try to get you a baby to deliver. Good job.”

Things become dead at 4:00 am. We don’t have any patients to report to the morning team so we make up names to put on the sign out sheet. We come up with: Bree, Frank; Rea, Gunner. Tom: “Let’s see how long until they notice they’re all fake.”

Wednesday night starts off with a few rule-out ROM (rupture of membrane) ferning tests. Tangled Tiffany swabs the vagina and wipes the swab on a glass slide. If the amniotic fluid has ruptured, the salts will crystalize into snowflakes at 40x magnification.

My patient for the night is a 24-year-old pregnant with her first child. I walk into her room at 6:30 pm to introduce myself. The similar-age father is snuggling on the pull-out bed with the patient’s sister. The expectant mother is concerned about pain. “I was promised I wouldn’t feel anything. Is this true?” There were enough similar questions that her day nurse requested reassignment. The epidural is in and we know that it’s working because she can’t move her legs, but the new mom continues to complain about pain. Haley joins five minutes later: “You are going to feel some pain. Delivering a baby is painful. Pressure is okay.” As delivery gets closer we finally acquiesce

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Okay to deliberately infect the young with coronavirus…

“Up to 90 volunteers in UK to take part in pioneering Covid infection trial” (Guardian):

Approval has been given for an initial trial that will involve up to 90 carefully screened, healthy, adult volunteers aged between 18 and 30. They will be exposed to the coronavirus in a safe, controlled environment. It is hoped further trials will follow.

“These are quite unique studies, able to accelerate not only understanding of diseases caused by infection, but also to accelerate the discovery of new treatments and of vaccines,” said Peter Openshaw, a professor of experimental medicine at Imperial College London.

Young, healthy, volunteers are being recruited as they are known to be at low risk of complications from the virus. Openshaw said the safety of volunteers was paramount: “None of us want to do this if there is any appreciable risk”

So… there is no “appreciable risk” for someone under 30 to experience a 100-percent chance of becoming infected with coronavirus.

What about opening a public school with healthy children and slender healthy teachers under age 30 (recruit some new teachers as needed)? I hope that we can all agree that this would be way too risky!

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