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Medical School 2020, Year 1, Week 13

by philg

From our anonymous insider..

We finished respiratory physiology with a lecture on arterial blood gases. Breathing allows the infusion of oxygen into the bloodstream and the removal of carbon dioxide produced by cellular metabolism. The respiratory rate is normally regulated by the amount of carbon dioxide in the blood, not by the amount of oxygen. CO2 is tightly regulated because carbon dioxide determines the pH of the blood. Remember that soda contains carbonic acid. When the can is cracked, carbonic acid is converted into CO2 and water, i.e., fizzy water. The reverse process, of CO2 in the blood turning into carbonic acid, results in acidic blood. The body tries to maintain a slightly basic blood pH of 7.4.

My favorite trauma surgeon used some of her patient experiences as case studies to describe the different permutations of arterial blood gas states. In one example, a drunk 18-year old falls three-stories. He is found unconscious, not breathing, with O2 saturation (sat) levels severely depressed at 60%, and CO2 levels severely elevated. The patient is suffering from respiratory acidosis. As the patient is transported to the hospital in an ambulance, his O2 sat rises to 80%, but CO2 has dropped below normal. The high-school-age EMT raised the patient’s oxygen saturation levels with the breathing bag, but was squeezing it too quickly, causing increased expiration of CO2 and respiratory alkalosis.

The patient case was “John,” a 40-year old male suffering from life-threatening asthma since the age of four. Growing up, his condition was successfully managed by the family pediatrician. John’s father was a teacher and John emphasized how this doctor had tailored the treatment and medications to his family’s modest budget, e.g., by finding low-cost alternative medications and free samples. In college, the asthma spiraled out of control. “I saw a PCP [primary care provider] at college once. The guy immediately insulted my pediatrician saying the way I was managing my asthma was terrible.” The PCP scoffed when John said the treatments were working well for him. John never went back and lost touch with the medical system. As his uncontrolled asthma began to worsen (John now admits the college PCP might have been right), he used home remedies. When he was having an asthma attack at night, he would brew a large pot of coffee and sit outside on the porch in the middle of the freezing night drinking cups of coffee with his plump pug (caffeine would relax his bronchioles). “I probably should have gone to the ED many times,” John said, “but I would push the limits. Also, I knew how much it would cost me so I gulped that coffee.”

John’s asthma said that his asthma improved after he “moved and started a new job,” enabling him to see the pulmonologist sitting next to him. It turned out that the “new job” was a cardiology fellowship and the pulmonologist was his attending. She joked that her fellow/patient was non-compliant and John admitted that it was difficult to find time to take care of himself. He sees patients as part of the fellowship, has two toddlers at home, and moonlights at the VA to support his family (a fellow earns about $60,000 per year). John noted some additional financial pressure from a recent regulation requiring eliminating Ozone-depleting chlorofluorocarbons from the inhalers’ ejection mechanism. Although the drug itself was the same, this slight tweak to the mechanism allowed pharmaceutical companies to re-patent medications that formerly had generic competition. Prices soared from single digits to hundreds of dollars per inhaler. John said his insurance now covers most of it, but many patients have to pay out-of-pocket due to high deductibles. John noted that for some patients the inhalers can cost more than their mortgage payment, leading to abandonment of the optimal medications. John emphasized the need to listen to patients: “If they say something is working, don’t brush it aside like the college PCP.”

Anatomy lab was incredible, by far the most fascinating day thus far in medical school. After an early morning excursion with Jane to pick up pastries at our favorite breakfast place, we entered the cadaver lab where a fresh pig’s heart from the local butcher awaited each student. The human hearts we removed last week were preserved for a later date once we can appreciate pathological conditions. We were quite timid at first. The surgeons and cardiologists went over and gave us a little instruction about where to make the first scalpel stroke, then said “just enjoy exploring wherever your heart desires.” As soon as we opened the hearts, which we’re told are almost identical to a human’s, we saw an unfamiliar environment. Tendinous fibers, also known as heart strings, criss-crossed in the ventricular chambers connecting the atrioventricular valves to papillary muscles on the heart chamber wall. We rubbed the translucent leaflets of the heart valves in between our fingers. I saw and felt the beautiful tree-like muscular protrusions of the ventricular wall that help guide the flow to their destination, shattering my vision of the interior heart as a smooth surface.

Afterwards my favorite trauma surgeon gave a lecture on the aging heart. She described how the current generation of physicians were all trained on a younger population. Now, when physicians apply this standard of “normal” to older patients, many normal aging processes are diagnosed as pathological. For example, during aging the whole long axis of the heart begins to shorten. This is often misconstrued and overdiagnosed as a pathological state. She cautioned, “Get used to this. You are going to be dealing with an older population.”

Last week’s ear infection patient and I now share something: fleas. I have decamped to Jane’s house until the fumigators can come. The physician with whom I saw the toddler calmly said, “It happens sometimes. Downside of seeing kids.”

Statistics for the week… Study: 12 hours. Sleep: 7 hours/night, fleas kept me up one night; Fun: no downtown outings. Example fun: movie night with Jane bedtime 9:00 pm.

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

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Who has tried out the new Herman Miller Aeron Chair?

by philg

Folks:

Herman Miller says that they’ve improved the design of their Aeron chair so that it now looks exactly the same but works better (presumably there is at least a higher price that works better for Herman Miller shareholders?).

Has anyone tried the “Aeron Remastered” for an extended period of time? (e.g., a whole day of typing)

Thanks in advance for any feedback.

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What did the people in the book Hidden Figures do?

by philg

The movie Hidden Figures is out in theaters. We’re planning on going to the theater as soon as our presence is not required in the house every single evening, i.e., in 2033. I looked at the book on which the movie is based last night. This title is Hidden Figures: The American Dream and the Untold Story of the Black Women Mathematicians Who Helped Win the Space Race. I.e., it contains the word “mathematicians.”

I majored in math in college due to a mistaken belief that I was intelligent. So I was eager to see some equations. Yet the book is solid prose. The only numbers are page numbers, basically. Certainly there are no equations. Instead of the festival of LaTeX that I expected, the book could have been authored via text message.

So… what did the NASA employees chronicled in this book actually do?

[Note that I was myself a NASA employee in 1978(!), developing a database management system for Pioneer Venus Orbiter data to support physicists writing analysis code. The PDP-11/70 that I used has disappeared because hardware engineers have made so many advances since the mid-1970s. The computer language that we used, however, which was developed by John Backus in 1957, is alive and well today. What does the survival of Fortran tell us about progress in computer software and computer science?]

Related:

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Tail of procedures, litigation, and reportage following encounter between two Stanford students

by philg

This New York Times article covers what happened after

The case involved a woman, a sophomore, who had met a player on Stanford’s powerhouse football team at a fraternity party one Saturday night. They went back to her room where, she said, he raped her. He said they had consensual sex.

There was a hearing in front of the university’s kangaroo court in 2015. Then there was some litigation in a government-run courthouse: “After the case ended, she sought a temporary restraining order in state court against the man.” Now there is this epic-length New York Times story with more than 1400 comments (here’s mine:

This is a good argument for colleges to stop running sports teams, dormitories, etc. If they were to focus on teaching they could probably do a better job at it. With all students living in private housing, an alleged rape (unless it occurred in a lecture hall during a lecture) would be purely a matter for government law enforcement personnel.

Even before we add rape adjudication into the mix, how can managers who are trying to run a Four Seasons-grade hotel and restaurant complex and also NFL/NBA/MLB-grade sports teams also have attention left over to try to improve the way that education is delivered?

).

[I wonder if my comment is correct, though. The Obama Administration in 2011 ordered colleges standing under the shower of federal cash (e.g., loan subsidies) to set up kangaroo courts. Might that order apply even to a college with no dorms or sports? So the college with no way to monitor what students are doing after class has to set up a court to hear about stuff that happened off campus?]

How much administrative and legal process and media attention can a society afford to invest in after late-night private encounters between 20-year-olds before it becomes a serious drag on GDP growth?

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How can investors make money on higher minimum wage laws?

by philg

Massachusetts has raised its minimum wage for 2017 to $11/hour, up from $8/hour. This won’t have much effect in the Boston area but it should cut down on employment in the already-blighted central and western portions of the state. With benefits and taxes a full-time minimum wage worker will cost $30,000/year or more, right? Plainly there are plenty of American workers who don’t generate an extra $30,000 per year in additional revenue for a business and there are plenty of businesses for which it would be tough to find any workers that can generate $30,000 per year in additional revenue.

We can cry about America’s declining labor force participation rate or we can optimize our portfolio to adjust to reality.

With more people excluded by law from the labor force there will be more entitlement to public housing, so cities and states will have to build more. Is there a public company that builds free houses for lower-income Americans? How about buying stock in cable TV companies? Fewer people in the workforce means more are watching TV, right? People who don’t have jobs can drink more beer, right? What are the publicly traded companies that sell the most beer to low-income or no-income Americans?

Fast food chains and big retailers have lower labor costs, as a percentage of sales, than quaint local businesses (one source). If we assume that two local coffee shops die and are replaced by one Dunkin Donuts, that should be good for Dunkin’s, right? The company will have lower real estate costs due to less competition from independent shops and higher sales. Local retail is already under pressure and higher minimum wage laws should further tip the scales in favor of Walmart, Costco, and Amazon. Buy these stocks?

What about betting against commercial real estate? If businesses that can’t afford higher labor costs shut down there will be less demand for space and rents won’t grow as rapidly as previously planned. This seems risky due to immigration-driven population growth. With a forecast population of 441 million in 2065 and the same amount of land it is tough to see how owners of land zoned for retail are going to suffer.

Readers: any better ideas for investors in this new labor market landscape?

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New Jet Ranger certified

by philg

A couple of weeks ago, Bell got its new 5-seat Jet Ranger 505 certified (press release; product page). The machine will be built in Quebec, rather than the originally planned factory in Louisiana. Otherwise the development seems to have gone as scheduled, a remarkable achievement.

With air conditioning and other non-optional options, the out-the-door price seems to be roughly $1.3 million. Presumably due to the collapse of the worldwide helicopter market, occasioned by the stagnation in oil prices that limits offshore production, Bell has not raised the price from what it was offering back in 2014 at Heli-Expo. That means a used steam-gauge Bell 407, which can seat 7, is now available for less than the cost of a new Jet Ranger.

Aviation-oriented readers: What do you think? When a used old-style Jet Ranger can be had for $400,000 (example), is there going to be a strong market for this new design? The new design has many improvements, but are they sufficient to justify the extra cost? (the old Jet Ranger will need more maintenance, of course, but perhaps the extra cost will be roughly the same as the difference in cost of capital and insurance)

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How did we behave in our Occupied Territories?

by philg

Israel’s behavior is an evergreen source of interest to the United Nations and lately the two organizations have been in the news. My Hillary-supporting Facebook friends have been out in front of this, praising Obama and criticizing Israel for building houses on land won during the 68-year war that has followed the Arab rejection of the UN’s proposed 1947 borders. I respond with “Let me know to which Indian tribe you’re going to be giving your house, and please do send me your new address in Manhattan, which I understand was legally purchased.”

How did we actually behave in our own Occupied Territories when the occupation was fresh? The Pulitzer Prize-winning Encounters at the Heart of the World: A History of the Mandan People answers this question to some extent:

Ancestral Mandans appeared in what is now South Dakota around 1000 C.E.17 Their arrival in the Missouri River valley coincided with a major climatic shift: a trend toward warmer, wetter conditions in the years from 900 to 1250. The trend extended far beyond the grasslands of North America. In Europe, these centuries coincide with the Medieval Warm Period, an era in which painters depicted bountiful harvest feasts, Norse settlers built colonies in Greenland and America, and peasants expanded their fields onto lands formerly too cold, high, or dry to plant crops.

CROW CREEK VILLAGE, SOUTH DAKOTA, MID-1400s The site of this ancient village overlooks the Missouri River in south-central South Dakota, eleven miles north of the modern town of Chamberlain. The land today belongs to the Crow Creek Sioux, but during much of the 1300s and 1400s its occupants were Caddoan-speaking newcomers—refugees or descendants of refugees from the drought on the central plains. And at some point in the mid-fifteenth century, something terrible happened here.* The community was fortified by location and design. Naturally protected by the river and two smaller waterways, the town also had defenses constructed by its residents. Keen eyes still can discern the low-lying trace of two dry moats the townspeople dug for protection. The inner moat was bastioned and backed up with a palisade. The outer moat may not have had a palisade, but its ten bastions are still visible if you follow its course across the ground. At one time, this trench was six feet deep and twelve or more feet wide.27 These concentric fortifications indicate that the community went through a period of growth. Archaeologists think the settlers created the inner ditch and its palisade first. But twelve house sites in the gap between the two trenches suggest that the population eventually became too big to fit inside the first ditch. When this happened, residents dug the second one beyond it, enlarging the fortified area of their village. One calculation puts the town’s population at 831. The defense system clearly indicates that Crow Creek’s residents felt threatened from outside. And indeed they must have been, because at some point their town came under attack. The identity of the assailants is not known, but their actions were ferocious. In 1978, archaeologists unearthed at least 486 jumbled sets of human remains from the northwest end of the outer fortification ditch. If the ancient town’s population was 831, those bones represented the remains of nearly 60 percent of its residents. The end has to have been gruesome. Mutilated craniums indicate that the attackers scalped 90 percent of their victims and dealt skull-fracturing blows to 40 percent. They decapitated nearly one-quarter. A number of townspeople had limbs hacked off. Cut marks on jawbones indicate that some had their tongues cut from their mouths.

… warfare and hunting took a toll on Mandan men. When the anthropologist Alfred Bowers polled the Mandans in 1870–72, he found that women outnumbered men nearly two to one. The painter-ethnographer George Catlin estimated “two and sometimes three women to a man” when he visited the upper Missouri in 1832.

Life was kind of tough before the White Man showed up, but we brought rats to eat their corn supplies and smallpox:

The rats multiplied at a rate hard for human beings to comprehend. Some wild rats live as long as three years, but one year is average. Brief though it may be, that twelve-month life span is sufficient for a female brown rat to accomplish impressive reproductive feats. She reaches sexual maturity at three to four months and then is virtually sure to conceive each time she is fertile, for during a single six-hour fertile period she might mate as many as five hundred times. After she has mated successfully, pregnancy lasts about twenty-three days, and she can breed again less than twenty-four hours after delivering. A normal litter yields six to eight pups, and a typical female has seven litters a year, or roughly fifty offspring.

For the Mandans, the proportion of losses [from smallpox] was highest of all. Chardon estimated seven-eighths of them were dead. Joshua Pilcher reported that just 31 of 1,600 survived. The Jesuit father Pierre-Jean de Smet, who traveled to Council Bluffs in 1838 and then to the Rockies in 1840, heard that the scourge had reduced the Mandans “to thirty-two, others say to nineteen only!”

Lack of recent exposure [to smallpox] was not the only reason that Mandans were so vulnerable. When Catlin had taken the Yellow Stone upriver to the Mandans five years earlier, two physicians—participants in a new federal effort to vaccinate Native Americans against smallpox—had joined the passengers at Fort Leavenworth. With the help of military personnel, they immunized many of the nations below the Arikaras. Some individuals chose not to submit to the strange procedure, developed in England by Edward Jenner in 1796. But those who were vaccinated included 2,081 Omahas, Otoes, Sioux, and Pawnees. By February 1833, more than seventeen thousand had been vaccinated nationwide. The Mandans and Hidatsas were not among them, nor were the Crows, Blackfeet, Crees, or Assiniboines. Why? The immunization effort had gotten off to a late start in 1832, with winter closing in while the vaccinators were still in South Dakota. “Many individuals were not vaccinated owing to lack of time,” writes the historian Michael Trimble. The physicians asked to continue their work among the more northerly nations the next year, but the commissioner of Indian affairs turned them down. In fact, federal authorities intentionally excluded the northern tribes from the vaccination campaign. They deemed the villagers peripheral, and expendable as well. “Under any circumstances, no effort will be made to send a Surgeon higher up the Missouri than the Mandans, and I think not higher than the Arikaras,” wrote Secretary of War Lewis Cass to the Indian agent John Dougherty on May 9, 1832. The Mandans had lost their economic clout. The fur trade was fading, and their association with the Arikaras had tainted the Mandans as hostile. In an observation shaped by these changes in circumstance and perception, Cass proclaimed that the Indians of the upper Missouri were now “far beyond the operation of any causes, primary or secondary, which can be traced to civilised man.”

The Mandans do survive today (Wikipedia), with roughly 365 “full-blood” members.

More: read Encounters at the Heart of the World: A History of the Mandan People.

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