Immigrants can get U.S. passports in one day

For native-born U.S. citizens, it takes about three months, including mailing time, to get a passport if you pay extra for “expedited” service. From the State Department web page (retrieved end of October 2023):

As of October, they were saying that it would take 2 weeks to mail, then 5-7 weeks to “process”, then 2 more weeks to mail.

Friends who are immigrants have been reporting U.S. passport renewals in just a day or two. How do they do it? The U.S. government offers an emergency service. The immigrant uses Adobe Acrobat to create the required PDFs regarding the “life-threatening illness or injury” from which an immediate family member back in the old country is suffering. The American bureaucrats have no means of verifying these documents so entirely fictitious physician names and addresses work fine. The immigrant buys a fully refundable plane ticket back to the old country, makes an appointment, walks into a U.S. government passport agency.

Why can’t State Department clear the backlog, especially for simple renewals? What stops them from paying overtime to the existing staff to work nights and weekends until the processing time is back to something more reasonable? (or hiring Venezuelan asylees to assist? We are informed that 500,000+ Venezuelans who’ve joined us are eager to work and highly qualified) What’s “reasonable”? In 1971, when the U.S. population was 200 million, it typically took between 5 and 21 days to get a passport (New York Times) and when the backlog increased the government would add night shifts to clear it. In 1961 (US population 180 million), it took 3 days:

A native-born American might be able to work a similar process via the “urgent travel” channel. Buy a refundable ticket for travel within 14 days and then begin to work the phones and try to get an appointment and travel to a major city (a customer in Tallahassee, Florida would have to drive perhaps 6 hours to Miami or Atlanta or New Orleans).

Finally, why do we need to show passports when returning to the U.S.? The passport was already checked twice by airline personnel on the departure side. If the southern border is open to millions of new Americans who choose to walk in, why must we stand in line for a third check after an exhausting international flight?


  • “Airport travel delays after U.S. Customs computer outage” (NBC, 2019): International travelers were waiting in long entry lines at some of the nation’s busiest airports Friday … The outage affected New York’s John F. Kennedy Airport, Los Angeles International Airport and Chicago’s O’Hare International Airport, among others. Images on social media showed travelers jammed into terminals at JFK and O’Hare as they awaited admittance to the United States.
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Elon Musk at war in Ukraine

Can a private citizen change the outcome of a foreign war? The answer is “Yes” for Citizen Musk. From Elon Musk, the book:

An hour before Russia launched its invasion of Ukraine on February 24, 2022, it used a massive malware attack to disable the routers of the American satellite company Viasat that provided communications and internet to the country. The command system of the Ukrainian military was crippled, making it almost impossible to mount a defense. Top Ukrainian officials frantically appealed to Musk for help, and the vice prime minister, Mykhailo Fedorov, used Twitter to urge him to provide connectivity. “We ask you to provide Ukraine with Starlink stations,” he pleaded. Musk agreed. Two days later, five hundred terminals arrived in Ukraine. “We have the US military looking to help us with transport, State has offered humanitarian flights and some compensation,” Gwynne Shotwell emailed Musk. “Folks are rallying for sure!” “Cool,” Musk responded. “Sounds good.” He got on a Zoom call with President Volodymyr Zelenskyy, discussed the logistics of a larger rollout, and promised to visit Ukraine when the war was over.

Every day that week, Musk held regular meetings with the Starlink engineers. Unlike every other company and even parts of the U.S. military, they were able to find ways to defeat Russian jamming. By Sunday, the company was providing voice connections for a Ukrainian special operations brigade. Starlink kits were also used to connect the Ukrainian military to the U.S. Joint Special Operations Command and to get Ukrainian television broadcasts back up. Within days, six thousand more terminals and dishes were shipped, and by July there were fifteen thousand Starlink terminals operating in Ukraine.

How much of a difference did this make?

“Without Starlink, we would have been losing the war,” one Ukrainian platoon commander told the [Wall Street Journal].

Musk is lucky that the Russians don’t currently have a space machine like Bird One (from You Only Live Twice) that can vacuum up the Starlink satellites!

Elon Musk ended up making decisions at least as consequential as any made in Kyiv, according to Isaacson:

“This could be a giant disaster,” Musk texted me. It was a Friday evening in September 2022, and Musk had gone into crisis-drama mode, this time with reason. A dangerous and knotty issue had arisen, and he believed that there was “a non-trivial possibility,” as he put it, that it could lead to a nuclear war, with Starlink partly responsible. The Ukrainian military was attempting a sneak attack on the Russian naval fleet based at Sevastopol in Crimea by sending six small drone submarines packed with explosives, and they were using Starlink to guide them to the target. Although he had readily supported Ukraine, his foreign policy instincts were those of a realist and student of European military history. He believed that it was reckless for Ukraine to launch an attack on Crimea, which Russia had annexed in 2014. The Russian ambassador had warned him, in a conversation a few weeks earlier, that attacking Crimea would be a red line and could lead to a nuclear response. Musk explained to me the details of Russian law and doctrine that decreed such a response. Throughout the evening and into the night, he personally took charge of the situation. Allowing the use of Starlink for the attack, he concluded, could be a disaster for the world. So he reaffirmed a secret policy that he had implemented, which the Ukrainians did not know about, to disable coverage within a hundred kilometers of the Crimean coast. As a result, when the Ukrainian drone subs got near the Russian fleet in Sevastopol, they lost connectivity and washed ashore harmlessly.

He also called the Russian ambassador to assure him that Starlink was being used for defensive purposes only. “I think if the Ukrainian attacks had succeeded in sinking the Russian fleet, it would have been like a mini Pearl Harbor and led to a major escalation,” Musk says. “We did not want to be a part of that.”

Isn’t this a bit like the United Nations in Gaza? For 75 years, they’ve been providing nearly everything that the Palestinians to raise the next generations of soldiers/martyrs and simultaneously claiming to be involved only in peace/defense. Musk strengthened Ukraine’s defensive capability, which gave them more resources to put into offense.

Like the UN, Musk tried his hand at diplomacy:

He took it upon himself to help find an end to the Ukrainian war, proposing a peace plan that included new referenda in the Donbas and other Russian-controlled regions, accepting that Crimea was a part of Russia, and assuring that Ukraine remained a “neutral” nation rather than becoming part of NATO. It provoked an uproar. “Fuck off is my very diplomatic reply to you,” tweeted Ukraine’s ambassador to Germany. President Zelenskyy was a bit more cautious. He posted a poll on Twitter asking, “Which Elon Musk do you like more?: One who supports Ukraine, or One who supports Russia.” Musk backed down a bit in subsequent tweets. “SpaceX’s out of pocket cost to enable and support Starlink in Ukraine is ~$80M so far,” he wrote in response to Zelenskyy’s question. “Our support for Russia is $0. Obviously, we are pro Ukraine.” But then he added, “Trying to retake Crimea will cause massive death, probably fail and risk nuclear war. This would be terrible for Ukraine and Earth.”

Eventually he ended up in a text message exchange with Ukraine’s Vice Prime Minister Fedorov:

Musk: “Russia will stop at nothing, nothing, to hold Crimea. This poses catastrophic risk to the world…. Seek peace while you have the upper hand….”

After his exchange with Fedorov, Musk felt frustrated. “How am I in this war?” he asked me during a late-night phone conversation. “Starlink was not meant to be involved in wars. It was so people can watch Netflix and chill and get online for school and do good peaceful things, not drone strikes.”

In a world of war profiteers, Starlink seems to have been the only involved company that didn’t get rich off the conflict:

[SpaceX President/COO Gwynne] Shotwell also felt strongly that SpaceX should stop subsidizing the Ukrainian military operation. Providing humanitarian help was fine, but private companies should not be financing a foreign country’s war. That should be left to the government, which is why the U.S. has a Foreign Military Sales program that puts a layer of protection between private companies and foreign governments. Other companies, including big and profitable defense contractors, were charging billions to supply weapons to Ukraine, so it seemed unfair that Starlink, which was not yet profitable, should do it for free. “We initially gave the Ukrainians free service for humanitarian and defense purposes, such as keeping up their hospitals and banking systems,” she says. “But then they started putting them on fucking drones trying to blow up Russian ships. I’m happy to donate services for ambulances and hospitals and mothers. That’s what companies and people should do. But it’s wrong to pay for military drone strikes.”


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Randomized controlled trial of therapy for teenagers

“These Teens Got Therapy. Then They Got Worse.” (Atlantic, by Olga Khazan; paywalled, but readable in the Google cache):

Researchers in Australia assigned more than 1,000 young teenagers to one of two classes: either a typical middle-school health class or one that taught a version of a mental-health treatment called dialectical behavior therapy, or DBT. After eight weeks, the researchers planned to measure whether the DBT teens’ mental health had improved.

The therapy was based on strong science: DBT incorporates some classic techniques from therapy, such as cognitive reappraisal, or reframing negative events in a more positive way, and it also includes more avant-garde techniques such as mindfulness, the practice of being in the present moment. Both techniques have been proven to alleviate psychological struggles.

The author and editors forgot to capitalize “Science”!

This special DBT-for-teens program also covered a range of both mental-health coping strategies and life skills—which are, again, correlated with health and happiness. One week, students were instructed to pay attention to things they wouldn’t typically notice, such as a sunset. Another, they were told to sleep more, eat right, and exercise. They were taught to accept unpleasant things they couldn’t change, and also how to distract themselves from negative emotions and ask for things they need. “We really tried to put the focus on, how can you apply some of this stuff to things that are happening in your everyday lives already?” Lauren Harvey, a psychologist at the University of Sydney and the lead author of the study, told me.

But what happened was not what Harvey and her co-authors predicted. The therapy seemed to make the kids worse. Immediately after the intervention, the therapy group had worse relationships with their parents and increases in depression and anxiety. They were also less emotionally regulated and had less awareness of their emotions, and they reported a lower quality of life, compared with the control group.

Most of these negative effects dissipated after a few months, but six months later, the therapy group was still reporting poorer relationships with their parents.

Last year, a study of thousands of British kids who were put through a mindfulness program found that, in the end, they had the same depression and well-being outcomes as the control group. A cognitive-behavioral-therapy program for teens had similarly disappointing results—it proved no better than regular classwork.


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Elon Musk and videogames

When not working, does the world’s greatest innovator sit in a cardigan reading books, à la Jimmy Carter or Bill Gates? Elon Musk by Walter Isaacson:

One key to understanding Musk—his intensity, focus, competitiveness, die-hard attitudes, and love of strategy—is through his passion for video games. Hours of immersion became the way he let off (or built up) steam and honed his tactical skills and strategic thinking for business.

Musk had enjoyed all types of video games as a teenager in South Africa, including first-person shooters and adventure quests, but at college he became more focused on the genre known as strategy games, ones that involve two or more players competing to build an empire using high-level strategy, resource management, supply-chain logistics, and tactical thinking.

His only indulgence was allowing breaks for intense video-game binges. The Zip2 team won second place in a national Quake competition.

In 2021, he became obsessed with a new multiplayer strategy game on his iPhone, Polytopia. In it, players choose to be one of sixteen characters, known as tribes, and compete to develop technologies, corner resources, and wage battles in order to build an empire. He became so good he was able to beat the game’s Swedish developer, Felix Ekenstam. What did his passion for the game say about him? “I am just wired for war, basically,” he answers.

This seems like a good time to drag out a TED talk by a neuroscientist, Daphne Bavelier. This was sent to me by a neuroscientist who hates video games and has spent years trying to prevent his son from playing them. He admits that there is no scientific basis for his hatred and cites Prof. Bavelier.

What is the rationale for telling kids to get off their Xboxes if Elon Musk thrived on shooter games and #Science says that games are beneficial?


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What’s the military situation in Gaza right now?

There have been active battles since October 7, 2023 in and near Gaza (I wouldn’t call this a new “war” because these battles are still part of the war that Arabs declared on Israel in 1948). The Israeli counterattack seems to have started in earnest on October 28 (Wikipedia), though that was preceded by some bombing. So Israel’s campaign is about a month old.

If this were a battle between two conventional armies, that might be long enough for one side to win a decisive victory (see the 6-week Battle of France during World War II, for example). The continued existence of the Islamic Resistance Movement (“Hamas”), complete with plenty of rockets, ammo, and tunnel ventilation, and Palestinian Islamic Jihad, could, in that case, be evidence of failure by the Israel Defense Forces.

Israel, however, seems to be treating these battles as a fight against insurgents. That description seems to fit Hamas to some extent. Hamas mostly attacks civilians, e.g., via launching rockets into cities or the October 7 attack. On the other hand, Hamas also exhibits many of the characteristics of a standard national government with army. Hamas won a free and fair election and should be the legitimate government of all Palestinians in the West Bank and Gaza. The West Bank was stolen from Hamas, but the majority of Palestinians in both the West Bank and Gaza continue to support Hamas. See a 2021 poll, for example, and a poll taken earlier this month:

A larger percentage of Palestinians support the October 7 attacks, in which civilians were raped, maimed, and killed, than strongly support Hamas. This might be accounted for by the fact that Palestinians overwhelmingly expect their side to “emerge victorious”:

Israel seems to have constructed a fictional world in which only 10 percent of Palestinians are in favor of eradicating Israel, via violent means if necessary. Thus, the IDF has been tasked with going into Gaza and sorting through the 2 million residents to find the 100,000 who either carry guns on behalf of Hamas, Palestinian Jihad, or a similar group, or who provide substantial administrative and logistical support for those who carry the guns. (And maybe it is more like 10,000 people that Israel is seeking, on the assumption that the ordinary soldiers won’t cause trouble once officers are captured and imprisoned.)

A few weeks ago, I asked how this project could possible work. From How can Israel’s encirclement of Gaza City work if Hamas fighters can simply head south via tunnel?:

What stops the Hamas fighters [encircled in the north] from simply evading the IDF by proceeding south via tunnel? Once in the southern zone, the fighters can melt into the population that elected Hamas and continues to support Hamas according to opinion polls

How long has it taken other militaries to accomplish similar goals? I.e., sift through a population to find the 1 in 20 or 1 in 100 who are insurgents when the general population supports the insurgency. We can look at Russia’s Second Chechen War, a decade-long operation. There was the 25-year civil war in Sri Lanka. There is the Syrian civil war, now in its 12th year.

“Military briefing: has Israel achieved its war aims in Gaza?” (Financial Times, November 23):

For all Israel’s military gains in northern Gaza, Israeli officials admit that if they are to achieve the aim of defeating Hamas, the next phase of the fighting will have to involve an advance into the south of the strip.

Israeli forces have already begun to prepare for such a move, and officials have begun warning residents of Khan Younis to flee towards what they have said will be a “safe zone” in Muwasi, a 14 sq km area in the south-west of the territory.

Aid groups have dismissed the idea of cramming hundreds of thousands of people, many of whom have already been displaced from the north of the strip, into such a tiny space as unworkable. But Israeli officials insist there is no other way to defeat Hamas, as its top leaders in Gaza, such as Yahya Sinwar and Mohammed Deif, are thought to be hiding there, and because Hamas has also redeployed numerous fighters from the north to the south.

“I’m quite sure that hundreds, if not thousands, of Hamas members who are originally from the northern part of Gaza are right now in the south,” said Michael Milstein, a former IDF intelligence official. “And of course, they also transferred their weapons and rockets to the south with them.”

What about the tunnels? I’m hesitant to quote either side in any war as an authoritative source, but here’s what Israel says:

Israel’s military said on Wednesday that its combat engineers had destroyed the shafts of some 400 tunnels. But officials concede this is only a limited dent in a system that is thought to be more than 500km in length.

“Once we [take all of Gaza] it will probably take almost a year to clear the whole Gaza Strip, and to explore all their underground infrastructures, and find all their rockets and missiles . . . The strip is one big bunker,” said [Amir Avivi, former deputy commander of the Gaza Division of Israel’s military]. “It’s full of booby traps, full of IEDs everywhere, bombs, munitions — it’s unbelievable what they built. So there’s going to be a lot of work.”

Is Israel actually on track to succeed in accomplishing what it has promised to accomplish, from a purely military point of view, in Gaza? (Obviously, Israel has already lost in the court of world popular opinion. This post is about the purely military aspects of the conflict, not whether progressives and/or Muslims are right to accuse Israel of war crimes, genocide, etc.)

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Medical School 2020, Year 4, Week 33 (Residency Prep, week 1)

Six weeks until graduation. Before the last two-week elective, we have four weeks of Residency Prep (“RP”). It is March 16, 2020, and the deans are changing policies every few days, trying to stay ahead of COVID-19. M1 and M2 classes have been on Zoom for a week. Lanky Luke was facilitating an 8-student “Medical Education” elective. “Life is pretty normal for them,” Luke said. “Less than 10 percent of the class even went to lecture pre-COVID-19 so they are used to it.” He adds, “It’s odd to see people in pajamas. I don’t complain! I am too!” 

M3s are the most affected. Initially, their rotations continued, with instructions to stay out of rooms that require PPE (gowns, gloves, masks, etc.). Students are forbidden to take care of any COVID-19 patient, although our hospital has only one, a 91-year-old woman in the ICU transferred from an outside county.

This policy existed for three days.

On Tuesday, we get an email canceling all clinical rotations until further notice. Students are reassigned into non-clinical rotations. Our options: Medical Spanish via Zoom, Pathology via Zoom, Medical Education, and Advanced Anatomy (cadaver dissections; 2-3 students and one teacher in a large lab). We also have the option to take another two weeks of research or study time (a.k.a. “vacation”). Mischievous Mary is quite annoyed as she has to complete a “medical” elective before graduation so she doesn’t have the vacation option. She would have done in-person cardiology consults, but instead must do remote pathology. “FML!” she texts.

After communicating to us the critical importance of these social distancing guidelines, the administration summons us all into an auditorium to sit side-by-side and learn about a new policy for Match Day (Friday, March 20). While we breathe whatever viruses everyone else has acquired during various rotations, two deans explain that Match Day will be restricted to class members and essential staff (e.g., Deans and Chairs of Departments). University-sponsored events are now limited to 100 people.

Before the coronavirus, this would be a two-day party starting at 10:00 am with a ceremony in the auditorium. Friends and family would fly in from around the nation, with tickets capped at 10 per student. After speeches by various dignitaries, each student individually goes into a private room to open a printout of a letter  that the school would have received the night before. Students emerge to go up to the microphone and give an Oscars-style talk about how grateful they are to have matched at whatever institution. All of this is recorded on video for posterity. Everyone in the audience toasts with Champagne, followed by a catered reception. Groups of friends, accompanied by their out-of-town visiting family members, go to local restaurants for lunch. The gatherings continue into the evening in restaurant and bar private rooms and patios. There would be brunches and barbecues on Saturday and continuing into Sunday for the hardcore.

We will get none of this.

Chaos ensues as already-anxious students absorb the fact that they will not be able to open their Match letters with family and friends. Students talk over each other trying to negotiate with the deans for 2-ticket or 1-ticket allotments. Nervous Nancy quiets the room. “Some of us have loved ones that are old and vulnerable. This is serious. Let’s just have a small ceremony and leave.” Father Fred, a 30-year-old whose children are now 3 and 6-months old, asks, “Could we can pick up our letters and leave the premise to open with family instead of staying around?” The decision is that we will stay for one hour to hear shortened speeches, and then leave after we are handed our Match letters at noon to open them with loved ones outside. We’ll communicate our Match results to classmates via a group spreadsheet.

GroupMe erupts before Jane and I get to the car. 

Gigolo Giorgio: “PSA: you will get an email from NRMP at 1:00 pm, so you could just wait in bed.” 

Pinterest Penelope: “Another hour of my life wasted.”

Lanky Luke: Question- what if only significant others (perhaps fiancé and spouses or something) are allowed? It would probably be only a few individuals who are mostly local. This option would allow them to enjoy the experience with individuals who are equally impacted by this decision, while minimizing exposure. (likes and “I agree” responses accumulate)

Buff Bri: They really should cut nonessential faculty and staff. We might be able to squeeze a few more in there.

Pinterest Penelope is the camel nose under the tent: Would [Jeffrey] count? He’s not my fiancé, but we’ve been together over four years and he lives here.

Gigolo Giorgio: not opposed to the +1 idea, but still think it needs to be that everyone gets the invite or nothing. just not fair for some people to have their person there and not everyone 

Class president: The other thing we could do, which I have heard students from other schools are doing, is to take our envelopes and have our own [enormous] ceremony and opening party somewhere away from school. we could hold it in [local venue] and rent the space for longer and do everything as planned there.

Nervous Nancy: I’m not sure how great this visual would be if it got out to the public that the esteemed medical graduates are partying it up downtown while pandemic is ensuing. I wasn’t gonna ask my SO to attend cause I really really don’t like ceremonies and I’m immunocompromised [from treatment of Crohns disease]. Basically I totally get that my POV might not be the majority.

Straight-Shooter Sally: Y’all hiding behind your computers and phones acting like we didn’t meet in majority with the deans, talked it through, and decided to play our part in social distancing. We already have it better than so many people. (attaches Excel sheet from reddit with canceled Match days by medical school.)

Fashionable Fiona: If the +1 option is pitched to [the deans] and then shut down, I’m amenable to our leadership then pitching the just SO option for the 30 or so people that have one. I get it’s not ideal or fair for everyone, but I recognize that SOs are as heavily invested in our med school experience and equally impacted by Match day. Just because I can’t have someone there, I don’t want all of you to be robbed of your SO being there. Although if they’re shooting down the +1 option, they’ll likely shoot down to the SO option for similar reasons. But still, maybe worth a shot? Desperate times. 

Gigolo Giorgio: So one student’s SO is more important than another student’s mom or dad? I don’t have any family coming either way, but it sounds like it would be unfair to do just SOs

Gigolo Giorgio: With so many other schools canceling Match day, undergrad campuses closing the campus and having online classes across the nation, and Virginia being in a state of emergency- what makes us the exception? What if the 100 limit is changed to 75 tomorrow? Or 50? I understand we’ve worked for this moment over 4 years and its a once in a lifetime opportunity to celebrate with our loved ones, but we also need to do our part to address this pandemic. Again, my family doesn’t love me enough to come so idc either way

Nervous Nancy:  Tbh y’all I’m embarrassed. The Match is supposed to demonstrate that we are almost doctors, we shouldn’t need the admin to tell us that we should respect social distancing, limit travel, etc. Come on we’re better at epidemiology than this. This a global pandemic out there y’all, people are dying. (And we bitching about our special day being less special for those with [left-home] SOs). Ton of people are not having the special moments that they worked years to earn, for be those moments Athletic or academic, we are doing it to keep people safe. Let’s not be petty, foolish. While probably having a 1+ would most likely be totally OK, imaging how dumb we’re gonna look if something does spread, and it went public that [our school] looked for a loophole with the magic # of 100…. so please pretty please, we are better than this 

Gigolo Giorgio:  “Super spreader event at local medical school: [School] overrules decision to keep Match day private and decide to invite guests! ‘F*ck the virus, I wanna be with my SO if I’m gonna die anyways,’ says a group of students. What a headline.

Ambitious Al: @Georgio you forgot the #YOLO in there 

Buff Bri: Hey everyone! Love you guys and can’t wait for us to all celebrate this next great step 😍 I spoke with [fancy restaurant with fantastic cocktails] and they said that they were ok with having 40-60 of us going to the courtyard at 1PM on March 20th. I know things are constantly changing but I think this will be an awesome chance for us to celebrate over drinks. I will keep you all updated if anything changes, but [restaurant’s] management is aware of Match Day and is very excited to host us

He follows up: Seems like we have almost the whole class who has RSVPed Yes but if anyone else wants to come, let me know!

Fashionable Fiona:: Hi all ~ Now that we *tentatively* have some plans for Match Day, we wanted to let you guys know that we have booked the basement of [local bar/club] (same place we have Halloween!) for our official match night celebration. Given that the yearly school reception has been cancelled (and with it the lovely rice krispie treats) we wanted to have an opportunity to enjoy and celebrate together with good food and drink. Things are definitely fluid right now in [our city], but I have confirmation from [the bar] that they are still allowing events to happen. Guests are also invited but obviously, please do not come/invite your guests to come if any of you are currently sick or are traveling from a high risk area. – We will have a cash bar for food and drinks and rockin’ dance floor! Hope to see you guys there! – Your Match Day Committee 

This week turns into a vacation for me. Residency Prep classes have been rescheduled for next week to allow the IT department to figure out logistics. I go in on Wednesday for individual meetings with two administrators to prepare graduation paperwork, such as NPI and documents that will be needed for state medical license applications.

GroupMe updates from classmates allow us to identify recently stocked stores for hard-to-find goods. Bri: “I found paper towels and toilet paper, but not hand sanitizer.” Jane and I grill with Luke and Sarcastic Samantha almost every evening because the weather is so nice. Samantha is still working as a hospitalist PA: “The hospital is so empty that department heads are asking physicians to take voluntary leave. This is what a hospital should look like. Finally just the actual people who should be in the hospital are here.”

Statistics for the week… Study: 0 hours. Sleep: 8 hours/night; Fun: 7 days. Example fun: Jane and I attend a Thursday party at Buff Bri’s apartment. We set up tables outside for beer pong and spike ball while drinking White Claws and cheap beer basking in the beautiful 70-degree sunshine. Jane and I left around 4:30 pm. We learned that several students went downtown to “support the bars”. Nervous Nancy scolds them over the GroupMe: “I want to thank everyone who is socially distancing and did not go downtown after [Buff Bri’s] party. We are going to be seeing a lot of each other over the next few weeks until graduation, and some of us have loved ones that are vulnerable.”

[Editor: For reference regarding the evolving thinking about social distancing and coronavirus, Li Wenliang warned colleagues about what he believed to be an outbreak of 7 SARS cases on December 30, 2019. China isolated Wuhan on

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This year, I’m especially grateful that there is no war on U.S. soil. Regardless of which side in the Hamas-Israel fight one supports, nearly everyone will agree that war is hell and those who are insulated from war are fortunate. Since 1865, Americans have enjoyed better insulation than almost any other group of people, though, of course, quite a few Americans who identified as men have been sent off to fight.

Zooming all the way to the other end of the spectrum… I’m grateful that we can eat outdoors in nice weather in Florida without being besieged by yellowjackets, the wasps that ruin what would otherwise be great experiences in the Northeast U.S. I’ve enjoyed outdoor meals on both coasts and in Orlando and never been bothered. Florida is supposedly part of this insect’s range, so I have no explanation for why yellowjackets don’t swarm around restaurants and backyard barbecues.

For something in the middle… ChatGPT, which will be one year old on November 30, especially its ability to liberate programmers from the tedium of having to search for libraries and API calls (admittedly a tedium created by other programmers, drunk on the near-infinite memory capacity of modern computer systems). ChatGPT and similar have the potential to make programming an interesting job once again (see Is “data scientist” the new “programmer”?).

Readers: What are you grateful for this year?

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Medical School 2020, Year 4, Week 32 (Anesthesia, week 2)

The calm before the storm (March 9-13, 2020). All the talk in the hospital is about coronavirus. Small talk has become easier with physicians able to recycle the same opinions for multiple hall conversations. 

The first patient is getting a surgery for pes planus or “flat foot”. After I place the laryngeal mask airway (LMA; less invasive alternative to intubation, less protective airway that sits above the epiglottis), the anesthesiologist tells me I can do whatever I want today.  “You can stay and hang out with me, or you can try to get some other airways.” I stay for the first 30 minutes and watch as they cut the fibularis longus tendon and then hammer out the joints of the talus with the tarsal bones and then fuse it. It seems medieval, but that’s orthopaedics/podiatry. With another hour still to go, I head to the anesthesia ready room to snag some more intubations.

The admin anesthesiologist for the week is reviewing the OR assignments and a 26-year-old medic in training is sitting on the couch on his phone. “I just need 15 intubations for the month and then I’m done,” he said. “They told me to show up here, but I’ve just been sitting here for 30 minutes.” (By contrast, we medical students are assigned an anesthesiologist via an evening text from the anesthesia coordinator.) We wait for 1.5 hours as anesthesiologists periodically stop by. I ask if they have any intubations, but they are all LMAs.

The senior partner, who is more than 65 years old, is wiping down the keyboards, mice, and handles with disinfectant to cleanse fomites containing the coronavirus (fomite comes from the Latin fomes meaning “tinder,” a term for something that can start an infection first used in 1546 by Girolamo Fracastoro). A 37-year-old anesthesiologist with a thick Eastern European accent tries to warn him. She asks, “What are you doing? We’re all going to get COVID-19 from the Tunnel of Death and elevators.” (The “Tunnel of Death” or “OR tunnel” is the doorway and initial hallway through which patients and staff get to the ORs.)

More anesthesiologists funnel in to join the conversation. There is clear frustration among the anesthesia private practice group that staffs the entire hospital with the hospital’s administration regarding preparation for coronavirus. Several talk about the three anesthesiologists who died during the 2003 Toronto SARS outbreak. The senior partner: “Admins are in charge of the preparation, which invariably means we are screwed, though I am even more concerned about our hospital’s preparation after the meeting yesterday. There is no PPE. We have 8 respirators with only enough parts for 10 uses! I’m not coming in if they don’t get their act together. The administration is already working from home.” A younger new graduate responds, “I’ve lost $30,000 in the market. I’ll take your shifts!” He adds, “I’m still confused whether this is airborne versus requiring respiratory droplet precautions. Unless this is like TB, a surgical mask should suffice.”

The Eastern European: “I am not coming in if we don’t have the right equipment. I’d kill my father in five minutes.” The senior partner continues: “I wasn’t worried about this until I talked to my Italian doctor friend. If over 65 years old, no vent[ilator] for you.” The Eastern European: “It’s the same as dialysis. You don’t get dialysis in Europe if you’re over 65 years of age. And you know what, I can’t judge them when we put 91-year-old grandmas from the nursing home on dialysis.” The young graduate: “This whole discussion was the problem with ACA and the death squad panel. ” The senior partner: “But how much is age predictive of functional status? We see lots of 40-year-olds that look 80. There is just no good way to ration care.” The Eastern European anesthesiologist retorts, “I’m okay being in the death panel!” The young graduate walking to his next case: “Look look, the answer is a chronic disease severity score.”

The senior partner summarizes:  “The administration is useless. If they really wanted to help, get APRV (Airway pressure release ventilation, a mode of ventilation that gives a longer inspiratory time to help fluid filled lungs maintain oxygenation) on the new ventilator machines. It’s just a software update.” Anesthesiologists leave the room for the next case (no intubations…) as one spreads the rumor of a technologist stealing 2 cases of masks last month and selling them for $100 a box (of 20) on Amazon. “The hospital fired him and is pressing charges.”

The consensus opinion is that the hospital will be overwhelmed by COVID-19 demand. We have more than 1,000 beds, but just over 75 ICU beds, and a limited number of ventilators (though possibly a big stockpile of older models in a warehouse). The young guy who was enthusiastic about picking up extra work was the outlier: “It’s mostly going to kill old people.” The senior partner responded, “A lot of us are in that category.”

[One week later, we got our first confirmed case, transferred from a small community hospital in a remote area.]

At 9:00 am, I walk to the endoscopy suite, having heard this is the best place to get high frequency intubations with quick turnover between “scopes” (Esophagogastroduodenoscopy or “EGDs” and colonoscopies) that require ETTs due to position changes. The anesthesiologist in the endoscopy suite runs 4 rooms with the help of 3 CRNAs (certified registered nurse anesthetist). “Fine with me,” he replies when asked if I could join. “What’s your goal?” He quickly grins and says, “Go to room 2 and ask Todd. They do ERCPs [endoscopic retrograde cholangiopancreaticograms or an EGD with cannulation of the bile ducts] in there so a lot of intubations.” Todd, a CRNA, waves me in. I watch the interventional gastroenterologist biopsying a common bile duct stricture caused by a mass. The cases last about 45 minutes and the next patient is wheeled in quickly. I’m able to attempt five intubations before noon. Four go well, but, having failed to visualize the cords well, I mistakenly insert an endotracheal tube into the esophagus of a 40-year-old male with a recurrence of rectal cancer. Todd picked it up quickly before we delivered more than 3 bag breaths, and corrected it without issue. I placed an NG tube to decompress any air in the stomach. I am disappointed in myself, but an important lesson is given by the practical CRNA. “If something doesn’t go smooth, speak up. Never lie.” He continues, “I am amazed how when something doesnt go right, newer crna’s are defensive and withhold information from the anesthesiologist. I think it comes from insecurity. And they weren’t spanked for lying as a kid.”

Our last patient was a 65-year-old with an MI three weeks ago undergoing EGD for cirrhosis. “I don’t know if this patient should be getting an elective procedure right now so soon after a heart attack, but what do I know? I’m just a CRNA. My boss and the interventional gastroenterologist both signed off on it.” I check back in with the podiatry room, then leave at 12:30 pm. 

My intubations improve throughout the week with a clear technique developed and learn how to estimate the correct size of an oral airway by measuring the distance from the patient’s mouth to the tragus of the ear. My last day I got to use the GlideScope, a video laryngoscope. I was able to see the vastly improved relaxation using propofol as the induction agent compared to etomidate (used in shock and heart failure patients). Propofol drops the blood pressure a lot more than etomidate. The attending summarizes: “The most dangerous part of anesthesia is between induction and the operation beginning. Remember sometimes we want the blood pressure to drop during the extremely stimulating intubation.”

The last day of the rotation is at the outpatient surgery center. The pre-op nurse checks in the first patient, a 71-year-old male with COPD undergoing knee arthroscopy, asking if he brought his personal CPAP machine for the post-op recovery nap. The patient’s wife points to a duffel bag on the table. “I’ve never seen a Marlboro CPAP bag!” says the nurse. The patient’s wife responds, “We were such loyal customers that they sent us a bag. And it fits his CPAP machine perfectly!”

The anesthesiologist lets me lead the show. I hook the patient up to the monitor, preoxygenate for several minutes, push the meds that I drew up from the vials, and successfully intubate the patient. The anesthesiologist explains the importance of managing postoperative nausea. Post op nausea increases aspiration risk, impacts patient satisfaction, but most importantly money. He explains, “The post-op area is a high resource area, almost as high as ICU.” Every nurse can have at most two patients. He continues, “A patient with post-op nausea will hold the bed for longer. It’s not uncommon that after the patient is done in the OR, you are twiddling your thumbs in the OR on PACU hold.”

How to assess the risk for post-op nausea? If the patient has the four most important risk factors, there is an 80 percent chance of post-op nausea: (1) history of prior post-op nausea or motion sickness, (2) female, (3) lengthy surgery, and (4) inhalation anesthetic.

How to treat it? There are four treatments for post-op nausea, the most successful being Zofran, glucocorticosteroid, and an extremely low dose of droperidol. (Smoking cigarettes is helpful and supported by research, but no U.S. hospital has thus far set up a designated post-op smoking area.) Droperidol is an antipsychotic (a “typical” antipsychotic, and therefore a strong dopamine antagonist). This is less commonly used even though it has great results because of the antipsychotic term. Everyone is scared of the black box warning for QT interval prolongation (repolarization segment on the electrocardiogram that, if prolonged, can lead to serious arrhythmias). “Funny how the drug got the black box from FDA even though Zofran has the exact same QT prolongation risk. Somehow Zofran as a new drug slipped through it…”

The anesthesia rotation was highly instructive and it seems like a great lifestyle, especially for those who like to shop online from their phones for several hours per day. However, I would never be able to handle the waiting.

Statistics for the week… Study: 0 hours. Sleep: 8 hours/night; Fun: 2 nights. Example fun: Samantha purchased a smoker for Luke’s birthday. We smoked ribs and “beer” chicken (whole chicken stuffed with a cracked beer to keep it moist) for five hours while drinking beer and the new fad White Claws.  Lanky Luke, having completed anesthesia last month, jokes, “Let’s just say Samantha was not happy seeing our credit card bill after that rotation. I bought so much stuff on my phone during those two weeks.” Their bank account having survived, Sarcastic Samantha is excited to get a new job when Luke matches in a new town. She recounts a typical week at her job as a hospitalist PA rounding on psychiatry inpatients for medical consultations. The 50-year-old female told her, “Doc I need a disimpaction!” Why? “‘I haven’t pooped!” “Let’s start with some laxatives and a suppository first.” The next day, she asked how the suppository went. The patient  responds,”I don’t know.” “What do you mean you don’t know?” “I think I heard two things drop in the toilet.” “Good, good, that means you pooped. Let me know if you need more help.”

She tells us another story from the psych unit: “The next day, my 32-year-old just started screaming on the floor. You could hear her through the double closed door in each room. She wouldn’t shut up. We rolled her onto a sheet, and plopped her on her bed. Wouldn’t stop for an hour.” Since we were outdoors, Samantha gave a demonstration of the screaming volume. “A nurse overheard her whisper to another patient that she was going to pretend to fall and sue the hospital. She doesn’t realize we have everything under video surveillance so we

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Elon Musk and coronapanic

From Elon Musk by Walter Isaacson…

“The coronavirus panic is dumb,” Musk tweeted. It was March 6, 2020, and COVID had just shut down his new factory in Shanghai and begun to spread in the U.S. That was decimating Tesla’s stock price, but it was not just the financial hit that upset Musk. The government-imposed mandates, in China and then California, inflamed his anti-authority streak.

It was not being pro-Science that prevented Musk from embracing measures that proved ineffective against SARS-CoV-2, but a mindless anti-authority attitude. (Keep in mind that the author is a huge hater of Donald Trump, a passionate supporter of Democrats, and a believer in cloth masks against an aerosol virus)

When California issued a stay-at-home order later in March, just when the Fremont factory was starting to produce the Model Y, he became defiant. The factory would remain open. He wrote in a company-wide email, “I’d like to be super clear that if you feel the slightest bit ill or even uncomfortable, please do not feel obligated to come to work,” but then he added, “I will personally be at work. My frank opinion remains that the harm from the coronavirus panic far exceeds that of the virus itself.” After county officials threatened to force the plant to shut down, Musk filed suit against the orders. “If somebody wants to stay in their house, that’s great,” Musk said. “But to say that they cannot leave their house, and they will be arrested if they do, this is fascist. This is not democratic. This is not freedom. Give people back their goddamn freedom.” He kept the plant open and challenged the county sheriff to make arrests. “I will be on the line with everyone else,” he tweeted. “If anyone is arrested, I ask that it only be me.” Musk prevailed. The local authorities reached an agreement with Tesla to let the Fremont factory stay open so long as certain mask-wearing and other safety protocols were followed. These were honored mainly in the breach, but the dispute died down, the assembly line churned out cars, and the factory experienced no serious COVID outbreak.

The controversy became a factor in his political evolution. He went from being a fanboy and fundraiser for Barack Obama to railing against progressive Democrats.

(It cannot be that Democrats evolved, e.g., from being against same-sex marriage to being in favor of gender affirming surgery for teenagers. It is Musk who changed.)

Musk does not love our nation’s second most famous warrior against COVID-19:

… he wasn’t impressed by Joe Biden. “When he was vice president, I went to a lunch with him in San Francisco where he droned on for an hour and was boring as hell, like one of those dolls where you pull the string and it just says the same mindless phrases over and over.”

“Biden is a damp sock puppet in human form,” Musk responded [regarding Biden’s celebration of GM as the most important company in EVs at a time when GM was shipping 26 cars per calendar quarter]

Nor did Musk appreciate the evolution of California progressivism:

“I came there when it was the land of opportunity,” he says. “Now it’s the land of litigation, regulation, and taxation.”

Isaacson, much as he hates Republicans, attributes Musk’s mind-poisoning to libertarianism. But for this poison, Isaacson suggests, Musk might still be among the righteous. How stupid are libertarians? Isaacson describes Peter Thiel not wearing a seatbelt while Musk drives and crashes a McLaren:

Thiel got a ride with Musk in his McLaren. “So, what can this car do?” Thiel asked. “Watch this,” Musk replied, pulling into the fast lane and flooring the accelerator. The rear axle broke and the car spun around, hit an embankment, and flew in the air like a flying saucer. Parts of the body shredded. Thiel, a practicing libertarian, was not wearing a seatbelt, but he emerged unscathed.

Isaacson doesn’t explain why John Stuart Mill and Milton Friedman are against seatbelts in supercars. (I would like an explanation of why the rear axle broke! A pothole on Sand Hill Road?!? Quelle horreur! Acceleration per se doesn’t seem like a plausible cause. In the video below, Musk says “the rear end broke free”; Isaacson, the Harvard graduate, may not have understood that this describes wheelspin, not the rear axle and wheels coming off the car.)

Speaking of coronapanic, Musk and Bill Gates meet in March 2022. They had to agree to disagree on Mars colonization (Gates thinks lacks practical value, as do I, though planning to get to Mars means that if you fail your engineering work makes getting to orbit dirt cheap.)

At the end of the tour, the conversation turned to philanthropy. Musk expressed his view that most of it was “bullshit.” There was only a twenty-cent impact for every dollar put in, he estimated. He could do more good for climate change by investing in Tesla. “Hey, I’m going to show you five projects of a hundred million each,” Gates responded. He listed money for refugees, American schools, an AIDS cure, eradicating some mosquito types through gene drives, and genetically modified seeds that will resist the effects of climate change. Gates is very diligent about philanthropy, and he promised to write for Musk a “super-long description of the ideas.”

Money for refugees? I haven’t heard of Bill Gates doing anything for the 1.7 million Afghans recently expelled from Pakistan nor for the nearly 400,000 Palestinians expelled by Kuwait. Gates wants to fight climate change and also make some money betting that nobody wants electric cars:

Gates had shorted Tesla stock, placing a big bet that it would go down in value. He turned out to be wrong. By the time he arrived in Austin, he had lost $1.5 billion. Musk had heard about it and was seething. Short-sellers occupied his innermost circle of hell. Gates said he was sorry, but that did not placate Musk. “I apologized to him,” Gates says. “Once he heard I’d shorted the stock, he was super mean to me, but he’s super mean to so many people, so you can’t take it too personally.” The dispute reflected different mindsets. When I asked Gates why he had shorted Tesla, he explained that he had calculated that the supply of electric cars would get ahead of demand, causing prices to fall.

[after Gates keeps hitting Musk up for cash] “Sorry,” Musk shot back instantly. “I cannot take your philanthropy on climate seriously when you have a massive short position against Tesla, the company doing the most to solve climate change.”

“At this point, I am convinced that he is categorically insane (and an asshole to the core),” Musk texted me right after his exchange with Gates. “I did actually want to like him (sigh).”

Musk’s investments in Neuralink should be considered nonprofit donations in my opinion. This is blue sky research of the type that governments typically fund because there is no reasonable expectation of a return on investment.

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Nine minutes of Formula 1 glory at the Las Vegas Grand Prix

This is a report on the spectator experience at the Thursday evening Formula 1 practice session in Las Vegas 2023.

My friends had $1,500 three-day tickets in the West Harmon bleachers (the cheapest seats; the average price paid was, supposedly, $7,000). One week prior, I bought a Thursday night resale ticket for $180 plus $35 in Ticketmaster fees, managing to get into the same row as my friends.

The obvious hotels were Planet Hollywood, Paris, and Horseshoe, which are walking distance from the West Harmon entrance. These were available in the $100/night range (plus fees!). However, I was concerned that my flight from Burbank, California might be late and didn’t think that it would be possible to get from the airport to a hotel inside the track after 7 pm. (In fact, we saw cars and taxis going in and out continuously. There is at least one temporary bridge that was built over the track to allow access to hotel-casinos inside the track.) I booked a Hilton near the convention center for a slightly higher price and took the monorail with my friends.

How could hotel rooms during this event have become so cheap? Las Vegas has roughly 150,000 hotel rooms. “F1 claims a healthy 315,000 fans attended the grand prix over four days” (ESPN). That’s only about 100,000 people on any given day. If the predicted traffic and hassles scared off non-F1 tourists, the inevitable result was a lot of empty rooms.

The F1 hype began at the airport:

Our ticket enabled us to go in at 6 pm and begin eating the included Wolfgang Puck food and drinking the included non-alcoholic beverages. We arrived just after 7 pm to poke around the fan environment. A big screen displayed a pre-race TV show. There were a few fun activities for fans, but most had long lines. The food options included a weak hot dog, too-far-from-the-grill grilled cheese, a strange dry ramen box, chicken and waffles (cultural appropriation? they were good in any case), a purportedly Chinese-style chicken salad (more cultural appropriation), cider donuts (terrible), and churros (did not try). Lines for food were reasonable to non-existent. There were huge lines at the store until quite late:

Our bleacher seats had a good view, but the legroom was tight for anyone over 5’6″. The temperature was about 55 degrees. Here is what it looks like (1) walking up the stairs (note portapotties in the background; they really needed people to perform hourly cleanings on what became disgusting environments), (2) the (distant) environment for the rich and famous, and (3) the view of the track from near the top of our bleachers (we were actually sitting quite a bit closer).

When the cars began zooming by at 8:30 pm, it was impressive to see the showers of sparks from cars scraping minor bumps in the road in front of us. At around 8:39, however, the race was halted because, we were told, a manhole cover’s concrete frame had failed. I was deeply confused by this because the course is on a public street. If trucks drive over the manhole daily and don’t break it, how could an 1,800 lb. F1 car, even with a downforce multiplier, break it? I haven’t figured out the full story. The F1 folks say that a concrete frame failed, but not whether it was a new concrete frame installed for the race or the standard frame put in some years ago by the city. I think that the answer to the “why didn’t it fail when a truck drove over it a week ago?” question might be that the F1 car broke the cover/frame with force in the opposite direction. I.e., the cover was sucked up rather than pushed down. This is a force direction for which manhole covers aren’t normally engineered.

The second practice was scheduled for midnight. Quite a few people stayed to drink $12 beers and $39 LED-lit trophy-style glasses of booze:

We walked out to the nearby Horseshoe casino (formerly Bally’s) and relaxed. Even with the track being hot, people were getting in/out via taxi:

My friends went back to their apartment around 11 pm. They were unconvinced that the midnight practice would happen on schedule and were planning to return for Friday and Saturday. I decided to reenter the fan zone. The monitors displayed messages saying that there would be an update soon. There was no longer a line for podium photos, so I got a picture to take credit for winning the race on the damaged track via rugged Honda Odyssey:

At 12:30 am, the monitors promised that the next practice session would start at 2:00 am. I bailed out because I needed to get on an 11:20 am flight from LAS. What happened to the diehard fans who stayed? The organizers kicked them out of their seats at 1:30 am, then ran the practice beginning at 2:30 am with no spectators. It was like a CIA torture scheme in which the enemy is kept awake for hours and then denied what was promised.

I’m glad that I didn’t buy anything at the store because everyone received a follow-up apology email from the F1 folks with a $200 coupon for merchandise as compensation for the missed hours of racing action. Which two hats will I be able to get with this $200 coupon plus $50 for tax and shipping?

The next day I went past the Greenspun College for Urban Affairs and very nearly found the DEI gates:

Inside the terminal, I found Sainz’s car after the manhole cover encounter:

Would I go back? Even with the monitors provided, it was much more confusing to try to follow the race live compared to watching on TV and having things explained. For Jho Low types who don’t mind spending $10,000+ on a three-day ticket, I’m sure that the luxury zone with pit tours is fun and comfortable. It’s a permanent building so probably they have some decent bathrooms at least. I guess it would be worth it if you’re plugged into the international set of other people to whom $10,000 is pocket change and the event would be a chance to see a lot of your friends.

For everyone else, perhaps a last-minute ticket to the Friday evening event would make sense followed by watching the main race on TV in order to (a) save money, and (b) learn what was happening. It is straightforward to go in and out by monorail. If there is a long gap between races, it is easy to go out of the event, find a relaxing place to sit at a restaurant or in a casino bar, and then return.

Readers: Who understands the mechanism via which the manhole cover failed? Also, who enjoyed watching the race on TV?

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