Category: Uncategorized

Unlike from New York, there are no nonstop flights from Boston to Moscow. An unusual option in terms of timing is departing Logan Airport at 7:50 am, having dinner during a three-hour layover at LHR, and then proceeding onward to Moscow on a flight 10:35 pm that arrives around 4:30 am Moscow time (that’s 9:30 pm in Boston). Hop in an Uber and you can be at your hotel at 6:00 am, the perfect time to go to sleep if your body still thinks it is 11:00 pm, which it is in Boston.

British Airways quotes some pretty low prices. One way that they accomplish this miracle is that seat selection in advance is not included. Add about $250 and some hassle because, at least if you’re in the Economy or Premium Economy (a.k.a. what they used to call “Coach”) ghetto, you need to go to a separate post-booking web site to see if any decent seats are still left. Then pay.

The flight over was awesome. Boston Terminal E was deserted. I had checked in a bag and was through security about 10 minutes after arriving at the curb. The flight over was pretty nice, though it seems that BA is getting out of the Economy business. Fully half of the 777 was given over to First and Business. I am ashamed to admit this, but I watched (and enjoyed!) a documentary on synchronized swimming: Perfect.

LHR is kind of hassle, involving two train rides, another security check, and Terminal 5 shops that seem geared mostly to luxury fashion. There are no quiet restaurants that I could find and, as with American airports, there are loud TVs going at most gates, so it was a long three hours. Business and First passengers can enjoy what are presumably some fairly plush lounges.

It is about 4 hours on a packed A321 to Moscow. They have a strange business class seating arrangement in the front, but it might well be worth paying for. Unlike U.S. airlines, BA doesn’t seem to have any way when checking in to pay for an upgrade on one or more legs.

Although Russia tries to hassle Americans with a visa requirement somewhat reciprocal to what we impose on them, actual immigration and customs is much more efficient than in the U.S. Unlike at U.S. airports, if your luggage is delayed they do have bathrooms in the baggage claim area!

It is a one-hour ride into central Moscow and it costs about $17.50 via Uber. Airport WiFi in Russia requires authentication via a Russia cell phone number or bank card, I think, so make sure that you have a strategy for getting data service once you’re there (see Verizon Wireless in Russia). Although technically my room reservation didn’t start until 2 pm, the Marriott Royal Aurora hotel (highly recommended) offered me an immediate check-in.

The trip back started at 4:05 pm from DME. There was a 20-minute line to get through departure immigration, so I would advise not cutting it too close (though sometimes they called for specific flights and took people out of sequence). This was a comfortable 777 with Premium Economy seating. On the final leg from LHR to Boston, about 7.5 hours, the seat that I’d paid for and gone through the hassle of signing up for via the Web was actually broken (would not recline). The flight attendants could not fix. BA did not offer any kind of refund for the seat selection or other fees. It was a smooth ride down the glideslope, but the 777 pounded Runway 27 at Logan so hard that passengers gasped. (Can we sign up to be the landing gear supplier to BA?) Wind was a steady 16 knots so it is unclear why the landing was so hard. In any event, the gear remarkably did not come off the plane and we arrived at the gate early. Clearing immigration was quick due to my global entry status.

If you’re one of the Business or First travelers that BA actually wants to deal with, and you want to avoid flying overnight, I think these are good options in terms of timing. It might also work if you’re completely indifferent as to where you sit in the airplanes. I’m not sure that Premium Economy makes sense given the hassle of booking specific seats on a separate web site (coupled with the airline’s lack of any procedure for dealing with the consequences of their failure to maintain working seats).

Full post, including comments

Brookline police log, May 23, excerpts:

At 8:25 p.m., a party came to the front desk and spoke to police officer about an orange gummy bear left on a rear bumper behind a Beacon Street business. The caller was advised that it was not a police matter.

At 12:42 p.m., a custodian reported aggressive turkeys at 1 Rene Playground during recess time.

At 1:28 p.m., a caller reported a gaggle of geese in her yard on Fenwood Road, and said they went after her dog.

At 7:00 p.m. a caller reported turkeys in the middle of Beacon Street.

At 12:37 p.m. a caller reported that there was a group of eight people vomiting and filming outside of 111 Cypress St.

Full post, including comments

In Moscow a UK citizen told me “I’d love to live in London, but a decent apartment is at least 1 million pounds [$1.3 million] and I don’t have those kinds of savings.”

Then I flew to London and learned about a shortcut to the savings process…

I talked to a guy who’d been a divorce lawsuit defendant after a two-year marriage. He explained that courts split a married couple’s property 50/50 and that, unlike in California, premarital property is included. So he lost a London house that he’d purchased prior to the marriage. He agreed to a 50/50 shared parenting arrangement with his plaintiff, which meant that she had a “need” for a house in addition to her baseline entitlement to 50 percent of the combined property. She had enhanced her claim by refraining from work during the marriage.

Note that being married for just a day or two may not be sufficient in order to get a full 50 percent share. Courts can deviate from this policy if the marriage is “short-term”. There is no set definition of “short-term,” but the idea seems to be “a few months.” A two-year marriage is not obviously “short-term.”

It is difficult to contract out of this regime because English courts don’t typically recognize prenuptial agreements (see the International chapter of Real World Divorce for litigation regarding a German prenuptial agreement that Nicolas Granatino wanted set aside so that he could get more of his wife’s assets).

English courts are increasingly gender-neutral and therefore the above strategy could be employed by a man targeting a higher-wealth and/or higher-income woman. It is definitely helpful to have a child, though.

[Separately, I wonder if this contributes to the income inequality that the British complain about. A UK citizen who didn’t want to risk losing half of his or her assets after a year or two would have to avoid marriage or marry someone with at least as much in premarital savings.]

Full post, including comments

My standing bet with Trumpenfuhrer-hating pilots is that I will buy them dinner if the target of their hatred is able to get even a single FAA regulation changed in 8 years.

All kinds of friends have been asking me about “President Donald J. Trump’s Principles for Reforming the U.S. Air Traffic Control System”:

the FAA’s ATC operations are currently mired within a Federal bureaucracy that hinders innovative operations and the timely introduction of new technology. In order to modernize our ATC system, the Administration supports moving the FAA’s ATC operations into a new non-governmental entity. This will enable ATC to keep pace with the accelerating rate of change in the aviation industry, including the integration of new entrants such as Unmanned Aircraft Systems and Commercial Space Transports. A more nimble ATC entity will also be able to more quickly and securely implement Next Generation (NextGen) technology, which will reduce aircraft delays and expand the availability of the National Airspace System (NAS) for all users.

The new ATC entity would grant FAA-certified users access to the NAS, subject to their participation in the system’s user fees,

America’s growing aviation system demands a new, independent, non-government organization to operate our Nation’s airspace. The new entity should have access to capital markets in order to spur capital investment, technology adoption, and innovation faster, more effectively, and securely. Over the last 20 years, more than 50 countries have already successfully transitioned their ATC operations.

Here’s where the proposal begins to go off into the realm of fantasy, in my opinion. It can cost the U.S. 5-10X as much to do anything involving the government, whether run by the government itself or run by a crony (“privatized”), compared to what other countries spend (see New Yorker, for example). We would be bankrupt if we tried to operate a huge subway system that runs every minute like they do in Moscow, for example. We spend 4X as much, as a percentage of GDP, as Singapore on health care. Any argument of the form “people in Country X can do Y” is irrelevant, in my opinion, unless the plan is to import people from Country X to run Y here in the U.S.

Two members [of the Board] should be selected from the airline list, two members should be selected from the union list, one member should be selected from the general aviation list, one member should be selected from the airport list, and two members should be selected from the Department of Transportation list. Those eight initial Board members would then select a Chief Executive Officer. Those nine Board members would then select four independent Board members.

Why does the union for air traffic controllers support this proposal? Under the current system, controllers are civil servants so it is tough for them to get paid more than $400,000 per year (the President’s salary). Under a privatized system in which they have a monopoly on labor and board seats on the monopoly entity that pays for labor, there is no limit to what controllers might get paid. It could be the $500,000 per year that stage hands can get in New York (Forbes). It could be the $1.2 million per year that controllers in Spain are able to get (previous post).

Harrison Ford spoke in Boston on Sunday (People). Regarding ATC privatization, he said “What is the problem that we’re trying to solve?” Considering all of the things that the government does, running a 1950s-style ATC system is probably one of the best. Controllers are competent, energetic, helpful, and reliable. They get a lot more than private-sector workers (as with others in the federal government), but not so much that taxes on aviation fuel and airline tickets have to be cranked up to insane levels. The 1950s-style radars are up and running most of the time.

The Trump proposal is to hand over to a government crony a monopoly on running a 1950s-style ATC system and let the crony charge whatever fees it wants. There is a hint regarding new technology, but the U.S. track record in this area is terrible. The contracts regarding the fancy new ADS-B system ($20 billion?) have completely stifled innovation according to the FAA employees with whom I’ve spoken. The contract specifies a minimum level of performance and therefore the performance is fixed at that level indefinitely (e.g., this brand-new system won’t give you weather information for airports that are farther than about 500 miles away, so the people who paid for this new system still have to keep installing and paying subscription fees for XM satellite weather).

It would be interesting to see a rethinking of ATC that used modern technology and clean-sheet engineering. One small example: Americans have paid and are paying billions of dollars for ADS-B, which streams digital information into aircraft avionics systems. Why are aircraft operators having to swap out SD cards with updated databases every 28 days? The databases contain information on airports, navigation beacons, and intersections (lat/longs) that changes at a geological pace. For airline and charter operators, the FAA and DoT requires that the work of swapping out SD cards be done by maintenance (not pilot) employees who are on random drug testing. If an aircraft is based remotely from the maintenance facility, therefore, mechanics or avionics technicians must drive out to where the aircraft lives. It might cost $5,000 per year to keep the database in a GPS (functionally the same as the GPS in your smartphone) current. Why aren’t the handful of bits that are updated streamed to aircraft either in flight via ADS-B or on the ground via LTE?

It would be interesting to see a proposal for a system that starting from the following goals:

• separation of human-occupied aircraft from drones, including drones sold to consumers for $500
• zero humans in the loop for en-route operations by Date X
• zero humans in the loop for approach control by Date Y
• zero humans in the loop for airport (tower/ground) operations by Date Z
• only a single communications method required for in-flight operations (not VHF voice radio plus transponder plus ADS-B)

How challenging is this? There are only about 7,000 aircraft in the sky at once spread across 5 million square miles of U.S. airspace (FAA). Admittedly these tend to be clustered in certain areas, especially around the busiest airports. Nonetheless, we are not discouraged from working on self-driving cars despite the fact that a single Interstate highway might carry 7,000 cars in one hour in one direction.

So… the Trump Administration proposal doesn’t seem to address the real safety hazard that has developed over the past 10 years, i.e., drones. In fact, the proposal probably makes it worse. The organization that has the power to regulate what equipment is included in a drone sold to consumer (federal government) will become disconnected from the organization that has to deal with the potential for mid-air collisions.

[What has the FAA been busy with instead of managing the drone hazard? One example is the FAA’s huge staff devoted to hassling aircraft manufacturers and owners regarding extremely unlikely problems, e.g., forcing Bell to put an $18,000 backup attitude indicator into a VFR-only 505 helicopter, which already has two huge G1000 screens that offer attitude information. These themselves are unnecessary because under VFR the pilot looks out the window to see if the helicopter is pitched up or down. It is not legal to fly the 505 into the clouds and it would only be in exceptional situations when a pilot would refer to the extremely reliable G1000 for basic aircraft control. The old Bell Jet Ranger, which the 505 replaces, was legal to operate without any attitude indicator (“artificial horizon”). If an operator stuck a mechanical gyro in the panel the FAA required no backup to the unreliable mechanical instrument. Now that the new 505 Jet Ranger comes with a bulletproof electronic attitude indicator, a backup is required, and it can’t be the $500 backup that is available in the world of kit aircraft or portable electronics that Cessna pilots might use. (Thus does an ever-larger fraction of GDP get devoted to stuff that has no value to Americans, making GDP an even less reliable indicator of economic progress.)]

The Trump Administration proposal locks Americans into paying for a unionized labor force of 24,500 people (BLS) to do a job that, in a clean-sheet design, likely wouldn’t be done by humans at all. If the controllers are able to use privatization to boost their salaries to $300,000 per year and total comp (including pension and health care benefits) to $500,000 per year, this will be a $12 billion cost to the U.S. economy (some comparison numbers).

The Trump Administration proposal contains no metrics for how we would know whether or not the implemented privatized/cronyized system was actually better. The people will be able to declare “success” and “mission accomplished” as soon as this is spun out. Currently there is no metric for FAA success or failure, but at least they are subject to Congressional oversight if the lack of accomplishment becomes too obvious.

If the government can’t resist privatizing something related to aircraft this year, I suggest starting with aircraft certification. Due to our comparatively ponderous bureaucracy, the U.S. is at a competitive disadvantage to countries such as Switzerland and Austria where new aircraft designs can be tested and approved quickly. The FAA can turn over aircraft certification to a competing group of UL-style companies, maybe with some involvement by the insurance industry. Unlike with ATC there is no need for a “big bang” change due to the fact that the team certifying a new Boeing 787 variant need not talk to the team certifying a new helicopter.

If Congress can’t resist privatizing ATC, I suggest starting with Alaska, Hawaii, and Puerto Rico and giving those three disconnected airspaces to different organizations. There is no reason that multiple private ATC operators can’t cooperate with existing government ATC and/or each other. The FAA controllers already cooperate with privatized Canadian and governmental Mexican, Cuban, and Bahamian controllers (for example). If this goes well, let these three competing vendors start bidding for one center (out of 20) at a time within the continental U.S.

Whatever we do, it needs to be done with some high-level goals (such as the elimination of in-the-loop humans and redundant legacy communications systems) and metrics so that we can evaluate our progress against those goals. We also should be humble with respect to our repeated failures at executing projects like this and consider that government-run ATC is one of our government’s few success stories. If the goal is, as it seems, to continue running a 1950s-style system (humans primary, augmented by radar and computers), I don’t see how it can be worthwhile. If the goal is to run a system that takes advantage of modern technology, the proposal should start with “let’s redesign this from a clean sheet.”

[Comment from a friend: “Think of the last time the ATC system went down? Vs private airline scheduling and reservation systems? (Two weeks ago)?”]

Related:

• The potential train wreck of privatized air traffic control (2016 posting showing that this terrible idea is not original to the Trumpenfuhrer)
• Atlantic article on Trump’s proposal

Full post, including comments

One of the things that I’ve been spending money on for the last 25 years or so is heroin. Recently I discovered that heroin is not part of a healthy lifestyle. My dealer has been getting pretty rich from all of the money that I and other customers have been handing over. So I’m planning to sue him for selling me the heroin that I didn’t realize was bad for me.

One other tidbit: One of my part-time activities is educating children about how they shouldn’t use heroin and other narcotics.

Ladies and gentlemen of the jury: How do you like my lawsuit?

Okay… now how is the above-described hypothetical different from the real lawsuit by the state of Ohio against five vendors of heroin pills:

The state of Ohio sued five pharmaceutical manufacturers Wednesday, arguing the companies fraudulently marketed addictive prescription painkillers and seeking hundreds of millions of dollars to address Ohio’s opioid crisis.

Attorney General Mike DeWine said the drug manufacturers knowingly misled physicians and patients into thinking OxyContin, Percocet and other opioids were nonaddictive and safe in large quantities. Although the state has cracked down on prescribing the drugs, DeWine said, they were and are a gateway to more dangerous heroin and fentanyl, street drugs now responsible for most opioid overdoses.

So… the state regulates doctors, deciding which can and cannot practice within Ohio. The state also runs anti-opiate classes in its schools. The state decides what pills can and can’t be purchased with Medicaid (see Who funded America’s opiate epidemic? You did.). But the drug manufacturers are responsible?

Related:

• “Generations, disabled” (Washington Post), about the government paying Americans to stay home and take pills: “They were the fourth generation in this family to receive federal disability checks…”

 

Full post, including comments

Antonio Garcia Martinez (of Chaos Monkeys fame) recently made a Facebook posting from Havana:

The detailed how-to on how to bring home prostitutes from my Airbnb hostess is worth recording.

I should call her once I know I’m coming home with a ‘chica’, so she can be there to officially register her as ‘visitante nocturno’, which implies taking her identification details and sending them to the state. Once the girl robs me in my sleep, which she’ll inevitably do, the señora will report her to the police, and the full machinery of Cuban state suppression will be engaged to hunt her down. And hunt her they will: the señora reported that a guest of hers had a bottle of expensive cologne stolen, and the police found the girl and returned the cologne. Totalitarianism has certain advantages.

Lastly, Cuban sexual mores are evidently rather less than evangelical. ‘Las chicas…es lo normal,’ she intoned (‘the girls…it’s normal’), punctuated with that resigned shrug common among Habaneros. Note, this is a stately and briskly competent older lady well into her 50s.

I see a five-star Airbnb review in your future, Margarita.

This is consistent with a 2013 Miami Herald story:

easy access to young women willing to ignore age differences — in exchange for as little as $30 for the night.

Today, prostitution may well be the most profitable job in an island where the average monthly salary officially stands at less than $20 and a bottle of cooking oil costs $3.

What if the embargo collapses and it is straightforward to JetBlue to my home town of Boston, for example? Under the Massachusetts child support guidelines, the Cuban tourist who has sex with a local earning $50,180 will get $30 per day ($210 per week; $10,920 per year) for 23 years. If the Cuban tourist can find a partner who earns $250,000 per year, revenue per the guidelines is $40,000 per year ($920,000 over 23 years). (See “American Child Support Profits Without an American Child” within “Child Support Litigation without a Marriage” for how U.S. taxpayers will fund the administrative and legal costs of getting the cash flowing over the border.)

[Nearby Florida has similar laws, but child support ends at age 18 or 19 and the revenue is only about half of what can be obtained in Massachusetts or New York, so the return on investment in a few extra hours of air travel is substantial.]

It seems that some of this already goes on with respect to Canada, though if the biological parents had sex in Cuba rather than in Canada, the Canadian child support formula would not necessarily apply. From Havana Times:

a prostitute in Bayamo who gives birth to a Canadian client’s baby and receives just $100 per month from Canada will live better than the OB/Gyn who delivers the baby.

Readers: What happens when/if Cuba-U.S. travel is completely open?

Related:

• Cuban divorcee moves from Cuba to Florida and seeks modification of child support from $1.50/month to $8,000/month (2001) [but if the pregnancy had occurred in Florida she would have been able to collect at Florida rates even while remaining in Cuba]
• Where New York Times readers don’t want to follow Europe: Legalized prostitution

Full post, including comments

Exam week and most of us are feeling burned out. “I just want to get this over with,” lamented one classmate. “Studying another few hours won’t change anything.”

We had four exams, three hours each, one per day, from Monday through Thursday, starting at 8:00 am or 9:00 am. All were computer-based.

The main NBME exam was challenging and surprisingly clinically-focused. Example: “Where is the lesion for someone who has right-sided intention tremor?” (Answer: right cerebellum; not everything in the brain is cross-wired.) Type-A Anita complained, “I thought it would be much more detailed and less big picture. I studied all the wrong things.” There were numerous questions on peripheral nerve deficits as a result of disk herniation. Students complained that this subject was not covered in “significant detail” during lectures.

The anatomy exam, developed locally by Doctor J, was a blend of challenging second-order questions and basic identification questions, with both multiple-choice and short-answer styles. Students complained that the second-order questions as not testing only “anatomy material”. For example, three students complained about questions asking to locate the lesion site for various visual field deficients. Several memorable questions started with a group of stroke symptoms and asked the student to identify the blood vessel most likely affected. Students were outraged at these applied questions. “I cannot believe Doctor J put that question in. He put that in just to screw us over.”

Students were also frustrated by the locally-developed clinical exam covering the HEENT (head, ear, eye, nose, and throat) exam, the neurological exam, and child development. We looked at computer images of different retinas. Given a description of a patient’s reflexes, we had to name the peripheral nerve or spinal nerve roots that might be damaged. We looked at a computer screen image of an ear canal that we would have seen through an otoscope. We were asked to identify the age of kids based on certain observable skills and behaviors. Type-A Anita complained to several classmates, “I don’t need to know this for Step 1” (the board exam we will take at the end of our second year). The classmates echoed back, “I don’t need to know this because I don’t want to be a pediatrician.” Students complained about the image quality of the ear canal, even though a higher quality image would not have helped them answer the question. Students complained, “This material overlapped with our other exams.”

The patient case exam asked to propose hypotheses for various clinical scenarios. What tests would you order? What diseases should be on your differential for this given test result? What other information would you want to know? How would you manage this patient with Parkinson’s? What other symptoms and test results would you expect from this patient? Most students do not study for this exam. Students complained about the drugs that were covered.

After our last exam, Jane and I went to a brewery. Students trickled in as people finished. “Cheers to another step to becoming a doctor!” Dorothy Disinterested responded, “I have lost so much faith in our medical system. It scares me to think that we are one-quarter of the way to doing stuff to patients.”

Statistics for the week… Study: 15 hours. Sleep: 5 hours/night; Fun: 1 night. Example fun: We met at a classmate’s apartment for pool and darts around 8:00 pm before heading downtown for an “End of M1” celebration. My classmate and I went to a less crowded part of the bar to get another beer. We were listening to a bartender’s conversation with some of her friends. A friend asked the bartender, “What have you been up to since you graduated college?” She responded, “Working here pretty much.” My friend commented afterwards, “That’s too bad she went to college with all that debt. She could have been the manager by now if she started after high school.”

More: http://fifthchance.com/MedicalSchool2020

Full post, including comments

A friend sent me “Who is Reality Winner? Accused leaker wanted to ‘resist’ Trump” (Fox News, so should I de-friend this guy for being Deplorable?). The substance of the case doesn’t interest me too much. I have to assume that “a [U.S. government] classified intelligence document” is mostly speculation and misunderstandings. What I am curious to know is whether the National Security Agency hired an employee (even through a contractor) named “Reality” and expected things to work out.

Readers: Was this spirited gal actually working in an NSA facility?

Related:

• Code Warriors (book about the NSA): “On an Army sergeant’s salary of $100 a week, [the NSA employee who turned out to be selling secrets to the Soviets] owned two Cadillacs, a baby-blue Jaguar sports car, a thirty-foot cabin cruiser, and a world-class racing hydroplane; he told coworkers a series of contradictory and patently fantastic stories to account for his sudden wealth, including that his father owned a large plantation in Louisiana, that he had made a successful investment in filling stations, that he owned land containing a valuable mineral used to make cosmetics, and that he had won the money as prizes in boat races.”
• article about tracing source of this document via laser printer dots

Full post, including comments

Apple, Facebook, and Google have soaked up a huge percentage of humanity’s wealth. Why aren’t they enriching our lives more?

Since I’m a Gmail user, let’s take Google as an example. Google knew that I was going to Moscow (itinerary emailed to my Gmail address). Google knew my schedule (Calendar). Google should know my various interests by now, from reading my Gmail messages and Docs content. Due to me being of such an advanced age that I still use email rather than text, Google definitely knows my real social network (the people with whom I correspond via email).

Why didn’t Google suggest to me a whole bunch of cultural events? People to meet? Groups to join? The stuff that Google tries to help with is stuff that was already pretty easy to do in the pre-Internet days, e.g., book a hotel or airline ticket. Even in those areas, Google is simply following the mid-1990s leaders such as Expedia.

I don’t think that one can argue that enriching lives is unprofitable and therefore these profit-seeking companies aren’t interested. Selling tickets to events should lead to commissions. Connecting people to meet in public places, such as restaurants or bars, should also lead to commissions. These could be a lot more lucrative than what Google gets from selling mouse clicks.

Readers: if we assume that human boredom leads to a lot of purchases, e.g., of movies and games, why aren’t companies such as Apple, Facebook, and Google chasing this market through actual social connections?

Full post, including comments

Three hour-long lectures on child development. A student commented, “Who knew that children are blind as a bat when they are born. 20/300 vision!” Afterwards, several instructors brought in children aged one month to five years for a workshop. Each pediatrician noted specific tasks, behaviors and skills. Dorothy Disinterested was reprimanded for “not being interested in the subject material and being on her cellphone”. Dorothy explained afterwards, “I am just not interested in children.”

Also three hour-long lectures on cerebrospinal fluid (CSF) circulation. The brain is surrounded by an outer connective tissue called the meninges (meningitis is the inflammation of this connective tissue) composed of three layers (outer to inner): dura, arachnoid, and pia. The dura, a fibrous white sheet, is strongly adhered to the inside of the skull and, via dura folds, divides the cranial cavity into quadrants. The falx cerebri divides the brain into left and right hemispheres. The tentorium cerebelli is a horizontal sheet that separates the cerebrum (above) from the cerebellum (below). These dural folds are tightly adhered to the arachnoid, named for its resemblance to a spider web, a clear membrane that wraps around the exterior surface of the brain. The innermost layer is the pia, another thin membrane, follows the contours of the brain into its crevices (sulci and fissures). The subarachnoid space, the space between the arachnoid covering and the tightly adhered pia, is filled with CSF.

CSF is produced in four connected brain cavities called ventricles. The left and right lateral ventricles connect to the third ventricle through a thin constriction called the interventricular foramen of Monro. The third ventricle drains through a narrow constriction called the Aqueduct of Sylvius into the fourth ventricle of the brainstem. CSF exits the fourth ventricle into the subarachnoid space through three foramina (the two lateral Foramina of Luschka and the medial foramen of Magendie). Students appreciated that the early 19th-century anatomists who discovered these respective structures have last names whose first letters correspond to the structures’ anatomical positions: Francois Magendie for medial; Hubert von Luschka for lateral.

The CSF suspends the brain in fluid, thereby protecting the delicate tissue structure from small shocks and providing a buoyancy effect, which turns a 1500-gram brain into 25 grams. Without the buoyancy effect, the weight of the brain would crush itself. Each ventricle contains a choroid plexus where 500mL CSF, enough for four complete daily changes, is produced by ependymal cells. CSF circulates through the ventricles, draining metabolic waste products of neurological activity, such as glutamate (excitatory neurotransmitter) and potassium, into the subarachnoid space.

My favorite trauma surgeon explained the different types of hemorrhages. Blunt trauma can fracture the skull causing an epidural hemorrhage, rupture of the meningeal arteries that travel along the inside surface skull. After a car crash, the patient will go unconscious. They will then wake up for a “lucid interval” of roughly 30 minutes, then suddenly go unconscious again as the ruptured meningeal artery leaks into the brain. A subdural hemorrhage typically occurs in old age. The brain shrinks, which stretches the small veins that drain blood from the brain to the large venous sinuses in the dura. Slight trauma can then cause the veins to rupture, starting a slow bleed that brings the patient into the ED days or weeks later with headache and confusion. Both types of hemorrhages can result in sufficient elevation of pressure to cause herniation of the brain, in which parts of the cortex protrude through holes in the skull.

Our patient case: Greg, a 23-year-old male with Mike, his cardiologist father and Jennifer, his nurse mother. Jennifer’s pregnancy was completely normal until a 30-week ultrasound. The obstetrician noted an enlarged skull with a protrusion on the right side. The mother explained, “My OB told me, ‘Something came up on the ultrasound that we need to take another look at.’ I knew something was wrong. Whenever a physician sees something bad that they have to refer you out to a specialist, they refuse to tell you a definitive answer..” Jennifer waited several hours in the waiting room until the specialist could see her. “I did not want to call Mike because he was dealing with a tough heart case.”

Further ultrasound examination confirmed that Greg’s Aqueduct of Sylvius had narrowed, causing hydrocephalus (abnormal accumulation of CSF). The choroid plexus continues to produce CSF despite the increasing ventricular pressure in his lateral and third ventricles. The increased ventricular pressure and size was damaging developing brain tissue and preventing the skull from closing. The physicians told Mike and Jennifer that Greg would unlikely be able to survive and that, if he did, he would have severe cognitive deficits.

“We knew this was bad,” continued Jennifer. “We both have medical backgrounds so we were imagining the worse. Mike immediately became an expert on this condition. Keep in mind in those days Google was not around. Mike went to medical libraries to scour the limited literature on this condition and its outcomes. Our doctors recommended we terminate the pregnancy. But when I saw the ultrasound, I could not terminate. He was my boy.” Jennifer was immediately scheduled for a cesarean section. Greg was whisked away to the NICU for intensive treatment. He had a ventriculoperitoneal shunt (tube inserted through brain tissue into a ventricle to drain CSF into the peritoneal cavity) and several cranial skull surgeries to release the increased intracranial pressure.

Greg is 5’5 with a cheerful smile. He speaks slowly but carefully. “More articulate than some of our classmates,” commented one student afterwards. He chuckles after his jokes. He has terrible vision as a consequence of visual cortex damage.

Most of Greg’s medical care occurred in his infancy. He had two additional surgeries to restructure his skull at age 8 and 14. He lives with his parents and works part-time as a clerk at a local grocery store. His mother said that Greg’s social life is more active than their own: “There are all these support groups for disabled people. I feel like every week I am ferrying him to an event downtown.” He is intellectually disabled but has an encyclopedic knowledge of the Harry Potter books. Several female classmates tested his knowledge after the session.

One week before exams and Pinterest Penelope, our class social chair, released the results of “class superlatives”, one per student. One student complained about the distraction from studying: “She is just trying to sabotage us.” I received, “Most likely to ask Low Yield Questions in Lecture”. Type-A Anita got, “Most Likely to Complain About Said Low Yield Question Asker”. Our lone Canadian (we have no other foreign students) got “Most likely to curse in front of a patient.” Our class president received, “Most likely to use ‘I’m a Doctor’ line at the bar”. The shy Asian received, “Most likely to ruin his/her white coat and need to order another”. Dorothy Disinterested apparently does have at least some interests. She received “Most likely to hook-up with a patient” (as the social chair is also female, this did not generate any complaints to the deans).

Statistics for the week… Study: 20 hours. Sleep: 7 hours/night; Fun: 1 day. Example fun: a “finisher prize” for the last day of class, beer and burgers with four classmates.

More: http://fifthchance.com/MedicalSchool2020

Full post, including comments