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Today’s the last full of day of Barack Obama’s job in the White House. My Facebook friends are falling over themselves talking about how Americans (especially those who voted for the Trumpenfuhrer) have been unworthy of this great man.

If you’re looking for inspiration on how to praise Barack Obama appropriately, I suggest the Good Morning America scene in the movie What About Bob?

Bob: What I’d really like to do, is put the greatness of this man in perspective. I think that there ‘s only 3 names…Dr. Albert Schweitzer, ah, Mother Teresa of Calcutta, probably, and…Leo Marvin

— this YouTube clip at about 3:25

Also at 2:10: “It’s this man. It’s the compassion. It’s the dignity. It’s the wisdom. It’s the horse sense of the guy that gets you…” and then “What do I say to someone who has turned my whole life around? Who has given up so of their time and their vacation to make me better?”

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My sojourn in the world of 8th grade math continues. As pointless and repetitive as the exercises are, the feeble attempts by the textbook authors to make the problems relevant are worse. Here’s a “real world” example of linear equations:

1. You and your friend together sell 58 tickets to a raffle.
2. You sold 14 more tickets than your friend.
3. How many did you and your friend each sell?

Even if an 8th grader were willing to consider a world in which this kind of partial information were available (maybe Enron did accounting like this?) and someone cared about the answer, why would it matter?

Readers: What’s an example of a system of linear equations that has obvious practical value, as perceived by an 8th grader?

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Victoria: The Queen: An Intimate Biography of the Woman Who Ruled an Empire (Julia Baird 2016) contains some interesting miscellaneous facts.

We might have avoided World War I if Kaiser Wilhelm‘s dad hadn’t died of cancer at 56. Wilhelm was Victoria’s grandson. His mom was Princess Victoria, referred to as “Pussy” in her youth.

Wilhelm was a proud, often cruel, and talentless man who harbored a particular kind of hatred for his mother. The painful breech birth Vicky had suffered meant he had to be wrenched from her womb, causing partial paralysis of his left arm due to nerve damage (this is now known as Erb’s palsy). This made his left arm fifteen centimeters shorter than his right, something he tried to disguise for years by resting it on swords or other props. The medical establishment was ill equipped to deal with such a disability, which was considered shameful at the time. The treatments used to try to repair his arm were horrific. One such treatment, first applied when he was a few months old, was “animal baths.” Twice a week, a hare was killed and sliced open; Wilhelm’s limp arm was slid inside the still-warm body in the hope that some of its life force would magically transfer to the baby boy. Willy was also jolted with electric shocks and strapped into a metal contraption that forced his head upright. He blamed his mother for his shame, and for his years of unsuccessful, painful treatments: he would never forgive her.

As a militaristic conservative who favored state rule, Wilhelm believed he was the true patriot in his family. He “fancied himself of enormous importance,” Vicky told her mother. He thought he was more Prussian than his progressive father, Fritz, and was a great admirer of Bismarck and all things associated with “despotism and Police State.” Victoria was so irritated by her twenty-eight-year-old grandson’s haughtiness that she did not want to invite him to her Golden Jubilee.

From England, Victoria regarded his scheming with irritation. Even Chancellor Bismarck recognized Willy was too immature to rule, that he was impetuous, “susceptible to flattery and could plunge Germany into war without foreseeing or wishing it.” It turned out to be a matter of character, though, not maturity, for this was precisely what happened years later, when Wilhelm’s eagerness for war would far outstrip his competence at waging it.

What would have happened if Fritz’s cancerous throat had not prematurely ended his life? Germany would have been under the rule of a liberal, compassionate emperor, a leader who wanted to improve the lives of the working class and who especially despised the anti-Semitic movement. “As a modern civilized man, as a Christian and a gentleman, he found it abhorrent,” wrote Vicky; he tried to counter it where he could. His son Wilhelm was the opposite, stirring up and championing anti-Semitism, writing in 1927 while in exile in the Netherlands that “press, Jews & mosquitos…are a nuisance that humanity must get rid of in some way or another. I believe the best would be gas?

Christians and Muslims couldn’t agree on what was legitimate in war:

The Turkish atrocities were gruesome. The skulls of Bulgarians were carried on spikes or piled on carts, pregnant women were ripped open and rows of fetuses brandished on bayonets, children sold into slavery and harems, women savagely raped, people locked inside churches and burned alive. “Christian heads,” wrote one correspondent, were “tossed about the market place, like balls from one Turk to another.”

People argued about the relative legal power between men and women:

As the queen jostled for power and demanded to be heard, British women were also growing more restless and began arguing for the right to their own incomes, to divorce on the same terms as men, to protection from violence, and to shared custody of their children. (For most of the century, men were given full custody of children if they divorced or separated from their wives.)

Until 1870 all of the money women earned belonged to their husbands, and until 1882 their property did too, even after a divorce or separation. According to the centuries-old principle of coverture, English law saw a wife not as a separate entity but a “femme covert,” who was under the “protection and influence of her husband, her baron or lord.

The Second Married Women’s Property Act of 1882 established wives as distinct entities—“femme sole”—who could own, inherit, and rent property and represent themselves in a court of law. Gradually women won more rights to care for their children after divorce; from 1886 the welfare of the children could be taken into account when determining if women could have some (limited) custody over their children.

(See the History of Divorce chapter for an interviewee’s explanation that “Originally fathers got custody because they remained responsible for the child’s support.”)

Excited by CES 2017? A lot changed in the 19th century and during Victoria’s reign (1837-1901):

The world took on a new fascination for Victoria now that she was part of it. In the year she became queen, Charles Dickens began the serialization of Oliver Twist; Caroline Norton published her radical pamphlet arguing that mothers should have some custody of their young children after divorce; and a national antislavery convention was held in America, in which British women were thanked for their support. Inventors patented the electric telegraph, the first daguerreotype was successfully exposed, and the Grand Junction Railway, which ran between Manchester and Birmingham, was completed. The momentum for massive change had begun to gather pace.

Readers: What do you think? Should we date the modern world to 1901, the year Victoria died? We have aviation now, but with a bit of patience it was possible to travel comfortably by train and ship. We have Internet, but they had the telegraph for important messages (and why do we need the unimportant ones?). Is it fair to say that the pace of change has slowed?

More: read Victoria: The Queen: An Intimate Biography of the Woman Who Ruled an Empire.

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“Higher Minimum Wage May Have Losers” (nytimes) is kind of fun. Economists and the New York Times editors have figured out that when workers are expensive, employers try to hire only the most energetic and productive. (SSDI for everyone else!)

• MIT professor studies high-wage retailers (2015 post on how higher wage retailers actually spend less on labor overall)
• Caveman Economics: Will the next rounds of higher minimum wages cause massive unemployment? (an earlier-in-2015 posting where I conjectured that if minimum wages are high only the most productive Americans would have jobs and said “We will also need a word to describe what happens when a business goes from a large group of low-paid workers to a small group of gung-ho moderately paid workers. My vote: ‘The business has been Costcoed’.”)
• “Child Support Litigation without a Marriage” (having a child can pay a lot more per hour than any of the proposed minimum wages)

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Victoria: The Queen: An Intimate Biography of the Woman Who Ruled an Empire (Julia Baird 2016) takes the position that it was mostly Prince Albert, Victoria’s husband, who made us associate the word “Victorian” with attempts to control sexual behavior.

Baird provides the reader with context:

In the late eighteenth century, when Melbourne grew up, marital faithfulness was not a prized virtue. Marriages were seen as companionable contracts within which one should produce a male heir. Melbourne’s own mother was, as he said himself, “a remarkable woman, a devoted mother, an excellent wife,—but not chaste, not chaste.” She had many lovers, with whom she had several children. It was widely known that Melbourne’s father was not his mother’s husband, from whom he took his name, but one of his mother’s lovers, Lord Egremont. What was surprising was that Melbourne stayed faithful to his own cuckolding wife. According to his biographer David Cecil, a married man was then thought peculiar if he did not have a “sprightly, full-bosomed” mistress. As for married women, “the practice was too common to stir comment.”

[regarding a man that today we might describe as “gay”] No one seriously gossiped about it while he was alive, at a time when homosexuality was not considered an identity but something people occasionally dabbled in, often as teenagers and young men and women. According to Michel Foucault, the beginning of the categorization of homosexuality as an identity did not come until 1870.

Albert laid down the law within the palace:

Punishment was given for “dishonest and sexually loose behavior.” A strict new code of conduct was carefully framed and hung in the bedrooms of maids of honor. Victoria’s name has long been associated with the puritanism Albert championed in her court, but he, not she, was the true advocate of these standards. Melbourne quickly realized that while Victoria “did not much care about such niceties of moral choice,” Albert was “extremely strait-laced.” The prince insisted on “spotless character,” while the queen did not care “a straw about it.” No one was exempt from Albert’s standards. Even his own brother had been a cause of fury due to his sexual licentiousness that had resulted in severe “visitations” of venereal disease. Yet Victoria would do little to stem her husband’s fervor; the Albert era, at least inside the palace, had begun.

One of their sons was fond of an actress:

Prince Albert first heard the rumors of his son’s thespian liaison with Nellie Clifden from Baron Stockmar, then in Germany, who had stumbled upon the story in European papers. The gossip had been swirling about the London clubs for weeks. … Sexual looseness was Albert’s psychological Achilles’ heel: his own family had been destroyed by infidelity, and his only brother had contracted syphilis. Albert was incapable of viewing trysts as casual, inevitable, or meaningless; for him, they could only contain the seeds of ruin. In the nineteenth century, this kind of affair could mean not just scandal, but disease, pregnancy, court cases, and financial ruin.

On November 16, four days after he heard the rumors about the affair from Stockmar, Albert sat down to write to his son. It was a strikingly harsh letter, especially as it was not unusual for aristocratic men to dabble with women before marriage. It began: “I write to you with a heavy heart upon a subject which has caused me the greatest pain I have yet felt in this life,” the discovery that his son, a prince, had “sunk into vice and debauchery.” Bertie had always seemed ignorant and weak, he wrote, but “depraved” was a new low. His father warned him of nightmarish scenarios: this “woman of the town” could have a child—and take him to court if he denied it. She could offer “disgusting details of your profligacy” and Bertie himself could be cross-examined, mobbed, and humiliated. Bertie, shamed and guilty, begged his forgiveness. Albert told him nothing could restore his innocence. Victoria shared her husband’s disgust: “Oh! that boy—much as I pity him I never can or shall look at him without a shudder.”

Sex and cash were, um, intimately linked:

“Fast” women were blamed for many things in Victorian England: a loosening of moral codes, the masculinization of ladies, and an epidemic of venereal disease that had crippled the British defense forces in the Crimea, in India, and in England. By 1864, almost a third of all British troops were admitted to the hospital for syphilis or gonorrhea. Because it was not the soldiers who were blamed but the women they slept with, the solution decided upon was simple: the army and navy needed clean prostitutes. In 1864, the first of the Contagious Diseases Acts introduced official brothels for the military.

the Victorian double standard under which women were punished for sexual behavior while men escaped scrutiny and condemnation. Still, many men regarded prostitutes as essential to the social fabric. Tolstoy, for example, could not imagine London without its “Magdalenes.” “What would become of families?” he wrote in 1870. “How many wives or daughters would remain chaste? What would become of the laws of morality which people so love to observe? It seems to me that this class of woman is essential to the family under the present complex forms of life.” Divorces were still rare, and men were supposed to delay marriage until they were financially solvent. Unemployment created a swath of single men. Prostitution was the subject of much speculation but little rigorous research in England at the time. Estimates of the number of female sex workers in London at midcentury ranged between 80,000 and 120,000, out of a total population of 2.3 million men and women.

The 1871 Royal Commission on the Contagious Diseases Acts, for example, declared there was no comparison to be made between prostitutes and their clients: “With the one sex the offence is committed as a matter of gain, with the other it is an irregular indulgence of a natural impulse.” Yet, as one sex worker said after being imprisoned, “It did seem hard, ma’am, that the Magistrate on the bench who gave the casting vote for my imprisonment had paid me several shillings a day or two before, in the street, to go with him.”

Have you heard about a politician and women willing to have sex if the price is right?

It is not clear when Gladstone’s fetish for “fallen women” began, though it is clear that the period of greatest activity was around 1850, when he had been in Parliament for eighteen years. … He spent hours talking to sex workers he met in the streets, trying to persuade them to choose another life. He read them Tennyson and Thomas Malory, arranged for them to have their portraits painted, and grew deeply attached to them. The tall, somber politician was particularly drawn to beautiful prostitutes, something that did not escape comment. In 1852, he described one of his great interests as “half a most lovely statue, beautiful beyond measure.” … Concerned colleagues tried to warn Gladstone about possible ramifications of his behavior, but he refused to stop. Sex workers called him “Old Glad-eye.” He tried to rescue somewhere between eighty and ninety prostitutes over the five years following 1849, but he had little success. He admitted, “There is but one of whom I know that the miserable life has been abandoned and that I can fairly join that fact with influence of mine.”

After Albert’s death things lightened up a bit:

[Victoria] allowed women thought to be innocent parties in divorce cases to join the Jubilee; she even contemplated extending this privilege to such women from other countries, although Lord Salisbury counseled her against it “on account of the risk of admitting American women of light character”). It was a time for leniency—across the empire, prisoners were set free, except those who were cruel to animals, a sin Victoria considered unforgivable.

More: read Victoria: The Queen: An Intimate Biography of the Woman Who Ruled an Empire.

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“Big Sugar’s Secret Ally? Nutritionists” (nytimes):

When it comes to weight gain, the sugar industry and purveyors of sugary beverages still insist, a calorie is a calorie, regardless of its source, so guidelines that single out sugar as a dietary evil are not evidence-based.

Surprisingly, the scientific consensus is technically in agreement. It holds that obesity is caused “by a lack of energy balance,” as the National Institutes of Health website explains — in other words, by our taking in more calories than we expend. Hence, the primary, if not the only, way that foods can influence our body weight is through their caloric content.

When scientists agree on climate change, science is good and the process of inquiry is one of pure intellect. When scientists agree on calorie consumption and weight, science is bad and the process of inquiry is tainted by “dogmatic belief.”

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Victoria: The Queen: An Intimate Biography of the Woman Who Ruled an Empire (Julia Baird 2016) writes about the lifestyles of the rich and royal back in the old days:

King George IV [Victoria’s predecessor] was not a popular ruler. The Duke of Wellington considered him the worst man he had ever met, without a single redeeming quality. A reactionary Tory, the king fought the ongoing reform movement and had to be forced to assent to a bill allowing Catholics to stand for Parliament in 1829. William Makepeace Thackeray dismissed him as “nothing but a coat, and a wig, and a mask smiling below it.” The extravagant king had also become a symbol of the gross excess of Britain’s rich, as he drained public funds when the country was crippled by the cost of a war with France that had ended in 1815. When he became king at age fifty-eight, he weighed 245 pounds, had a fifty-inch waist, and was addicted to opium. His belly hung to his knees.

Bertie, the future King Edward VII, was fond of gambling, horseracing, and brothels. Even as she grew old, Victoria was loath to hand over any official duties to her oldest son.

It was hard to get good help back then:

Up to two-thirds of palace servants were unsupervised at any given time, so they did much as they pleased, disappearing at will. The staff was known for rudeness. Rarely was anyone available to show guests to their rooms; many got lost in the labyrinthine corridors. Albert identified a series of scams and perks that servants had abused for decades: people outside the palace often forged the signatures of the queen’s ladies when ordering carriages, charging the cost of their ride to the royal household; fresh candles were put out each day while the footmen pocketed the previous day’s, many unlit; and expensive staff dinners were offered to those with only tenuous connections to the royal court. Albert slashed salaries, sometimes by as much as two-thirds, to account for the fact that many servants worked in the palace for only half the year. Last on Albert’s agenda was what he called the “moral dignity of the Court.” The gambling tables disappeared from Windsor. No one was allowed to sit down in the queen’s presence—or in Albert’s. (The wife of Lord John Russell—who was later prime minister—was allowed to rest in a chair after she had just given birth, “but the Queen took care when the Prince joined the company to have a very fat lady standing in front of [her].”) Ministers had to back out of the room when visiting the queen, as it was considered poor etiquette to show a monarch your backside. Court dress was obligatory. (If a woman did not want to wear the appropriate styles she needed to get a doctor’s certificate explaining how it would be injurious to her health, and then seek permission from the Lord Chamberlain’s department.)

One had to remember that the throne was not secure:

Friedrich Engels were producing The Communist Manifesto, urging the working class to “arise ye starvelings from your slumbers.” As Buckingham Palace was being enlarged and beautified, European royalty were pushed off their thrones. While Albert was surveying with pleasure his own tranquil abodes, angry hordes swarmed through palaces in Paris, Berlin, Vienna, Prague, and Budapest.

There were live threats:

One of the greatest threats to public safety came from the Fenian Brotherhood, which was founded in America in 1858 with the aim of overthrowing British control of Ireland and establishing an Irish republic. In 1866, the Brotherhood unsuccessfully tried to invade Canada from America. In 1867, they began a campaign of terror in Britain, blowing up a prison wall and killing a policeman.

Three months later, on a trip to Australia, a Fenian shot Victoria’s twenty-three-year-old son Prince Alfred in Sydney. He was on his way to Cabbage Tree Beach to “see the aboriginals, as they were then ready for some sports,” when he was shot in the back and fell on his hands and knees. The bullet lodged in his abdomen. For three days, he later told his mother, he could not breathe. The Irish assailant, who was about thirty-five, fair, and well dressed, was later executed.

Victoria had nothing like the modern-day Secret Service to protect her. Baird describes multiple assassination attempts that failed due to good luck.

Maybe we should be more grateful to Richard Nixon for signing the Environmental Protection Agency into law. Even the royals were not isolated:

A century earlier, the river named Tamesis by Caesar was clean. But when the water closet replaced the cesspool in the mid-1800s, channeling the city’s sewage to the river in large murky pipes, the water turned to black in less than half a century. At the same time, the capital’s population ballooned. In 1801, there were 136,000 houses in London. By 1851, there were 306,000. Those living near the river noticed an increasing acidity and murkiness in the water. By the mid-1850s, eighty million gallons of human waste from more than three million Londoners was draining down the Thames each year. The problem seemed insurmountable. In 1852, the chief engineer of the Metropolitan Sewers Commission, Frank Forster, died, and his death was attributed to “harassing fatigues and anxieties of official duties.” The next year, a cholera epidemic raged through the city, killing almost twelve thousand. This finally convinced scientists that disease was not borne by foul air, but by water. Yet the government, crippled by inertia and lack of will and urgency, failed to act. The royal family was insulated, but not exempt. Buckingham Palace often reeked of leaking excrement and crawled with rodents. Victoria watched her dogs chasing rats around her bedroom at Windsor, praising one for “valiantly” triumphing; “the rat made an awful noise, though he was killed right out pretty quickly.

By June 1858, the smell was so bad that lime was scattered in the river beneath the Houses of Parliament, and sheets soaked in bleach hung from ceilings inside so the gentlemen could speak without having to hold handkerchiefs over their noses. In the early summer, a long dry spell had dwindled the supply of fresh water coming from upland areas, and the water temperature was at a record high. A thick mass of black sewage stretched for eighteen miles. The resulting crisis became known as the Great Stink. Much of the city business ground to a halt; the courts rushed through cases to avoid prolonged exposure to the fumes.

(The above may explain Victoria’s fondness for Scotland!)

War concentrated a monarch’s mind:

Gladstone preached a gentler colonialism, supporting the principles of local autonomy and self-government—the same position he favored for Ireland. Gladstone even vowed to give independence to the South African Transvaal, which had been annexed by Britain in 1877. He was wary of further expansion in Africa and the Pacific, and called brutally obtained new swaths of land “false phantoms of glory.” Victoria was furious: she saw wars as a necessary means of protecting her empire.

On October 11, 1899, the Second Anglo-Boer War broke out. Few things concentrated Victoria’s mind as much as military conflict. She bade many of the troops farewell in person, and recorded details of the battles in her journal with a palpable anxiety. She was now eighty years old, but she maintained a keen interest in her army and continued to argue for more resources and men. While she did not see herself as a natural imperialist—writing of China, for example, that the world at large should not have the impression that we will not let anyone but ourselves have anything—she was eventually persuaded of the case for war in Africa. She believed that Britain should protect its subjects and territory. Her caveats were that the poor not be disproportionately burdened by a war tax and that the horses sent to fight be well treated.

Throughout the book, Baird’s main criticism of Victoria is that she did not advocate for a modern American- or European-style Welfare state. Examples:

At a time when most working-class people lived in misery, Victoria was more readily stirred by compassion for individuals she met than by reform movements. She worried about whether widowed women had enough money to live on and whether dwarves who performed for her were well treated. She worried about the well-being of orphans, wounded military veterans, and victims of sexual assault. When she saw how “lonely” child offenders jailed on the Isle of Wight spent months in solitary confinement, she was troubled by their sad existence.

The English had a deep, enduring belief in the importance of laissez-faire. The government was loath to intervene, ostensibly on the grounds that those suffering should be able to hoist themselves out of their misery and poverty without requiring aid. Kindness, it was feared, would corrupt them.

As Victoria grew older, she gradually leaned more toward conservatism. In her youth, she had taken a keen interest in the life of the poor as described by Charles Dickens, but she had not gone on to take an interest in the causes of poverty and frequently blamed those protesting against it.

For the rest of her life, she would fail to concertedly champion attempts to alleviate poverty or improve basic living and working conditions. Victoria’s problem was not lack of concern about social ills but lack of exposure to them

More: read Victoria: The Queen: An Intimate Biography of the Woman Who Ruled an Empire

 

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Regarding an XPS 13 2-in-1:

• Philip Greenspun: “and [the power adaptor] plugs into one of the USB-C ports then?”
• Agent (k_swathi_m): “The system comes with a charging port and this machine also has USB-C port.”
• Philip Greenspun: [referring to a low-res image of the machine] “”4. USB C 3.1 with Powershare / AC Power and Display Port” is the full description of what I think is one physical connector”
• Agent (k_swathi_m): “It means that you can use this USB C 3.1 to Powershare”
• Agent (k_swathi_m): “or you can use to AC Power”
• Agent (k_swathi_m): “and Display Port”
• Agent (k_swathi_m): “You can use that port for either of the options.”
• Philip Greenspun: “So the “charging port” you mentioned above is in fact a USB C port?”
• Agent (k_swathi_m): “Yes, that is correct.”

Readers: Post your best please!

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I scanned the headlines in the New York Times and found “‘All Talk,’ Trump Says in Attack on Civil Rights Icon”. It worked as clickbait since the only civil rights icon that came to mind was Martin Luther King, Jr. This was a lot more shocking to me than anything Trump was accused of during the election!

It turned out that the civil rights “icon” being attacked was not, in fact, the person whose birthday we celebrate today, but rather a Democrat from Georgia who was publicly boycotting the coronation of King Donald I.

I recently finished a biography of Ulysses S. Grant (some blog entries about this book to follow), which describes the ineffectiveness of Northern/central efforts to dictate to Southerners how to think in the decades following the Civil War. This gave me even a little more respect for MLK and the challenge he faced. The framework of desegregation had been created during the Eisenhower Administration but dictating something from D.C. and what happens locally can be different. Like Grant, Eisenhower changed people’s behavior at gunpoint; MLK changed people’s minds (not everyone, of course, but even Jesus Christ and the Buddha weren’t able to convince everyone!).

Readers: share your MLK Day thoughts!

Related:

• What would Martin Luther King, Jr. do for us today?
• “A pattern of deeming Republican presidents ‘illegitimate'” (Washington Post; it seems that this Democrat from Georgia, who was attacked by Democrats in the South in the 1960s, is happy only when a Democrat occupies the White House)

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From our anonymous insider…

“We live every second on the edge between bleeding to death and death by heart attack,” exclaimed the young hematologist attending. She introduced us to the coagulation pathway and the lucrative and life-sustaining hematological drugs. Numerous clotting factors (proteins) are produced in the liver and released into the bloodstream. My favorites were the actions of fibrin and plasmin. Vascular damage initiates a cascade of clotting factors to cleave the precursor fibrinogen into fibrin. Fibrin acts as a sticky filament that forms an intricate spider web, binding platelets together, creating a thrombus (blood clot). This nanoscopic mesh traps everything from red and white blood cells to the numerous clotting factors such as plasmin to plug the vessel breach. Vascular remodeling and wound repair signals activate the entrapped plasmin which degrade the fibrin web through fibrinolysis.

Simply resting one’s arm on a table creates cuts in the microcirculation. Our finely-tuned coagulation system is able to plug these cuts to prevent severe bleeding, while not creating too many blood clots that would obstruct flow to tissues. The hematologist explained that mutations in clotting proteins lead to uncontrolled bleeding disorders such as hemophilia (factor VI, IX or XI) and von Willibrand Disease or uncontrolled thrombosis formation such as in Leiden Factor V. She finished by explaining that vitamin K is essential for the activity of a liver enzyme that is used in the production of several important clotting factors (Factors II, VII, IX, X, numbers that become ingrained into any medical student’s mind for Step I). Drugs such as warfarin target the enzyme that catalyzes the reduction of oxidized vitamin K. Without this reduction process, fewer functioning clotting factors are synthesized. This results in decreased clotting function for a given signal, the costs and benefits of which were presented in this week’s patient case.

“Gerry” is an eighty year old black male who suffers from congestive heart failure after three heart attacks. “I did not treat my body well for many years.” Gerry became an alcoholic in his twenties, and smoked two packs a day from his late teens through his 60s. Vodka was his drink of choice.

Gerry grew up fatherless in a crime-ridden neighborhood. “Ma did her best to raise my two brothers and me. She would whip us if we did anything wrong. She’d grab us by a leg, hold us upside down and smack away. If none of my brothers would turn the culprit in, she would whip us all to ensure the guilty got punished,” Gerry reflected. “Much of my neighborhood’s problem was from the destruction of the family. No one has respect for authority. When I grew up, the cops were the good guys, Ma the bad one. We grew up wanting to be cops.”

Gerry described the low point in his life as returning home to see his wife and children conducting an alcohol search. “They missed the bottle that I hid in the toilet cover.” He claimed that he was able to “drink a bottle of vodka before work and no one would notice.” His wife divorced him after catching him driving drunk with their two girls and then his unmanaged health conditions continued to deteriorate.

Gerry began to have congestive heart failure from combined systemic hypertension (high blood pressure everywhere) and pulmonary hypertension (high blood pressure in the lungs). His second heart attack in his sixties was a wake-up call. “My doctor said, ‘If you do not make drastic changes, I do not expect you will live another year.’ I went completely cold turkey. I moved back home at sixty and quit cigarettes and alcohol.” Gerry now lives in a retirement home. “I was very anxious about death, so much so I would be afraid to sleep in my bed. I would try to stay awake in my recliner. Eventually I realized when I go, going in my sleep is the best way. Now I sleep like an angel.”

Gerry’s cardiologist explained that Gerry owes his life to advances in pacemakers and fibrinolytic pharmaceutical drugs. His weakened heart, after three separate heart attacks, has less contractility. Certain areas of the his heart, such as the atrial appendages and ventricular apexes, do not fully contract. This causes “pooling” of blood or hemostasis. Still blood is more likely to form a thrombus (or blood clot). These clots, unless broken down, can travel and obstruct vessels to vital organs causing a thromboembolism. A thromboembolism lodging in a coronary artery is the most common type of heart attack; a thromboembolism lodging in a vessel supplying the brain is called a stroke. Gerry is also at increased risk of Deep Vein Thrombosis, or DVT, due to sedentary lifestyle in advanced age and poor circulation from decreased cardiac output . If a DVT in a femoral vein gets dislodged it can lead to rapid death from a pulmonary embolism, blocking blood flow to the lungs (the cause of death in at least one of our cadaver).

“Even ten years ago, the general consensus was to avoid excess bleeding,” explained the cardiologist. “This has shifted to prevention of clots. You can recover from excess bleeding by getting a transfusion or IV fluids. You will not recover from brain damage from a stroke, sudden death from a PE or heart damage from a MI.” Gerry and the cardiologist discussed how warfarin and coumadin are difficult to take and to prescribe because their effect varies with vitamin K input. “If my patient eats a lot of spinach one meal, it could throw the whole clotting system out of whack with drastic consequences.” A new age of fibrinolytic drugs are coming that are vitamin K-independent (see eliquis ads on TV). However, this new age would not alleviate a common concern for Gerry and other elderly people: “I sometimes have trouble remembering if I took my medications in the morning if I do not put them in the pillbox. If I took my meds again at night, could this kill me? This is something that gives me so much anxiety.” The cardiologist added that one occasional double dose would not kill him, but emphasized these are powerful drugs.

Jane recounted a “Women in Surgery” interest meeting she attended with other interested female medical students. A young trauma surgeon who has been an attending for three years led the discussion on the life of surgery. “Go into something else if you could be happy there. Surgery is only for people for whom nothing else would satisfy.” Jane recounted the surgeon’s main point: “There is no such thing as work-life balance. Anything not work becomes a distraction against surgery… Getting married, distraction. Having children, distraction. I was in surgery on my son’s birthday. He waited until 10:00 pm to give me a slice of his birthday cake. His birthday was a distraction.” The surgeon recounted a story of informing the parents their 17-year old child is dead. “Women cry a lot more than men. Men are usually silent. I woke up at 3:00 am for weeks thinking about that case, of what I could have done differently. Surgery never leaves you.” The trauma surgeon said to wait for the surgery rotation (third or fourth year) before seeking to go into her specialty: “Most of you will be pulling your hair out on the first 24-hour shift, but a few of you will become captivated. Don’t force it.”

Our medical school requires students to do community service projects in six-person groups. My group chose to work with opioid addicts. The program was started by the local police department to try to fight the rise in opioid overdoses in the area. As long as there is no outstanding warrant, opioid users can bring in drugs and paraphernalia to the local police station, or a recently added clinic, and receive counseling and access to rehab programs. We met with the director, a middle-aged woman whose college son overdosed on heroin laced with fentanyl, and a nurse.

I asked how many addicts would willingly give up their drugs? The answer turned out to be three or four individuals per day. The nurse explained that based on an interview, a “program ambassador” customizes a recovery plan tapping into local, state, and federal programs: “The resources are there, just it is impossible for a non-expert to navigate them. One common complication is addicts having children. They are afraid of losing custody if they ask for help from healthcare professionals.” Our group will able to serve as ambassadors once we complete an 8-hour training program.

Tuition is due this week. I have a Graduate Plus loan at 6.31 percent. There is no federal subsidy for this loan and the interest begins accruing immediately, but payments are deferred until after graduation. If I work in a non-profit health care system, i.e., most American hospitals, monthly payments are capped at a percentage of my salary. After ten years, the principal will be forgiven (paid by taxpayers!) if it hasn’t been paid off. The program was designed for people who joined the Peace Corps, not for radiologists earning $350,000 per year, so there is some talk about the new Congress closing “the Doctor’s Loophole.”.

Statistics for the week… Study: 25 hours. With exams next week, I wish I was at this stage two weeks ago. Sleep: 7 hours/night; Fun: 1 night. Example fun: Evening watching Netflix’s The Crown followed by Sunday brunch.

The Whole Book: http://tinyurl.com/MedicalSchool2020

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