Medical School 2020, Year 4, Week 11 (Nephrology Week 2)

by philg

Nephrology is all about vascular access. How do you get a device that can draw out enough blood flow for the dialysis machine? A patient who has a temporary need for dialysis, e.g., from septic shock leading to poor kidney perfusion, will get a “VasCath”, a large bore central venous catheter in the internal jugular vein. This will get patients through a few weeks, but if they need longer term dialysis they will need to get a tunneled catheter. The tunneled dialysis catheter (TDC) has fewer infection complications than a free-standing Vascath. If a patient will be on long-term dialysis, a discussion about an AV fistula versus graft (synthetic tube) is made with a vascular surgeon or interventional nephrologist.

I head to the outpatient center and start with vascular access procedures. I watch as the interventional nephrologist performs balloon angioplasty and stenting for narrowed fistulas. For the third one, is my turn to do the procedure: I cannulate the graft with the needle, I insert the guidewire, dilator, and finally the balloon gadget. We then take fluoroscopy images (contrast injected dye with live X-ray video) to identify where the stenotic regions are. There are two narrowings, one near the graft insertion into the vein and a “central” stenosis on the left subclavian vein. The attending explains he had a central line, and that is a common cause of central stenosis. We balloon up both of them and take post contrast. Immediately it looks better, and you can even feel the “thrill” (vibration from the flow) increase. Very satisfying!

After three cases, I join an older Iranian nephrologist and head to the dialysis unit. There are about ten quiet patients with glazed eyes in chairs. They’re not watching TV or reading books. The only sound is white noise from the dialysis machine’s spinning roller pump. “Welcome to Purgatory,” my attending whispers. “We keep these patients alive, but a vast majority live a miserable life with amputations, heart failure, on oxygen, wheelchair-bound or, worse, SNF [skilled nursing facility; pronounced “Sniff”] dependent. This is Hell on Heart.” 

We interview a 68-year-old black wheelchair-bound male with a right-sided above-knee amputation. He has been on dialysis for 3 years and was recently hospitalized for COPD and CHF exacerbation. He was discharged from a 3-week stay in a nursing facility back to his home. The nephrologist asks, “What do you notice about everyone here?” I respond, “This looks and smells like death.”

We then relax in his office for two hours. “Nephrology is one of the least competitive fields, with fewer applicants than slots. I always tell my [internal medicine] residents to apply for a nephrology fellowship,” he says. “We’re some of the higher paid specialists, right up there with cardiology and gastroenterology because we do procedures. Nephrology is the gatekeeper to dialysis. ESRD requiring dialysis is the only condition that I know of that will get you a one-way ticket, no questions asked, to disability.”

[Editor: Medicare spent $51 billion on ESRD in 2019, which does not include SSDI payments.]

Nephrologists make most of their money by managing dialysis patients, even though this takes less time compared to hospital consults and clinic visits with atypical kidney failure patients (e.g., Lupus, rare auto-immune diseases, obstruction from BPH).

“Dialysis costs Medicare about $60,000 per year, but the government spends more on covering inpatient hospitalizations,” said the nephrologist. “The average is roughly $120,000 per patient per year. In the pre-Medicare age, these patients would have died years earlier, but now Medicare pays for all the cardiovascular complications [heart attacks, leg ischemia, strokes] in these sick patients in addition to the vascular access complications [infections and stenosis]. Over the years they have bundled the payments so we get a fixed monthly fee for dialysis patients and take a hit if they get hospitalized for a vascular access complication. We perform outpatient procedures [e.g., stents and balloon angioplasty] to ensure they don’t wind up in the hospital. Two interventions per year is typical.”

My attending explains the economic landscape for nephrologists. Each dialysis patient yields roughly $250 per month to the physician and requires weekly face-to-face evaluations, normally done during a dialysis session, either by the doctor or a nurse-practitioner. The maximum practical roster is 500 patients, yielding gross income of $1.5 million per year, but this requires quitting the hospital job and sharing some of the money with the ACP. “Ninety percent of our time is spent with consults at the hospital, procedures, or office visits, but all our money is from dialysis patients.” The nurse-practitioner or physician’s assistant is critical to hitting the 500-patient goal. The NP handles three out of every four required dialysis patient evaluations. Quite a few nephrology groups also get revenue via owning the dialysis center itself and therefore obtain profits from the separate Medicare reimbursements for machine operation.

[Editor: Davita is an example of a corporate dialysis center owner. The company enjoyed a market capitalization of roughly $6 billion in January 2020.]

As we are packing up to head home, the nephrologist is paged for a STAT consult. We head to the hospital surgical ICU. The 57-year-old female with breast cancer on chemotherapy presented to the ED for acute onset abdominal pain. She was found to have Acute Diverticulitis – an uncontained hole in the sigmoid colon. She lives in a rural area without surgical capabilities. Due to weather conditions, they had to transport her via a 1.5-hour ambulance ride. When she arrived at our hospital, she was in extremis. She underwent emergent exploratory laparotomy with suctioning of 3 liters of liquid stool in her peritoneal cavity and resection of the perforated colon segment. She is too unstable so the surgeons performed “Damage Control” and left the bowel in discontinuity and placed a temporary abdominal closure device. She is in septic shock, intubated on high ventilation support (34 breaths per minute), and getting multiple vasopressors to keep her brain perfused and heart pumping. Her kidneys have failed. She will die without immediate dialysis. We get consent from the devastated family for renal replacement therapy. This is not the three-hour sessions three times per week (intermittent hemodialysis or “iHD”). Continuous renal replacement therapy (CRRT) is the life-prolonging intervention that continuously filters toxins in patients who are too unstable to handle the high flow rates required for iHD. We place the CRRT orders and the critical care nurse begins to hook up the machine as the critical care team places a VasCath. As we walk out of the hospital, my attending comments, “If her sepsis response does not peak in the next 12 hours, this is futile.” (The family decides to withdraw care after 72 hours of ICU care. Her small bowel became necrotic from the high doses of vasopressors. I am there when we turn off the CRRT machine and return her blood, pull the endotracheal tube, and stop the vasopressors medications. Her family is at the bedside when her heart stops 10 minutes later.”)

Friday: the attending walks me through a full fistula exam. There are a lot of techniques to evaluate the fistula. This has become a lost art due to widespread access to ultrasound. First, I listen with my stethoscope. “A good fistula should have a continuous rumbling sound that does not vary with the heart beat. If you begin to have a high pitch blowing whoosh of the fistula with systole, it means it is beginning to narrow,” he explains. “Remember these AV fistulas are massive blood vessels right next to the skin. The most common reason for stenosis [narrowing] is from poor cannulation by the dialysis nurse. If you traumatize the vessel too much, it will lead to aneurysm formation. This will form a clot and over time cause narrowing of the vessel. The most feared complication is ulceration. Just last week I had a consult from a patient (not ours) whose fistula ruptured from an ulceration while she was showering. EMS described a murder scene as she was bleeding out. Her husband was smart and put a finger on the clot proximal to the bleeding. She lived and made it to the hospital but these can be scary things.”

My attending points out that close to 90 percent of the dialysis patients are black, despite the fact that we serve a region that is only about 20 percent African American. This is due to higher rates of uncontrolled diabetes and hypertension. NIH says “African Americans are almost four times as likely as Whites to develop kidney failure.” A black American who lives to age 75 is a likely candidate for kidney problems.

We also talk about his perspective on cardiovascular disease. “Let me ask you something. Why has no study shown stenting a patient with coronary artery disease has any benefit, either mortality or quality of life after six months?” the attending asks. “Because although you can open up the artery, the stent will narrow almost immediately. In a coronary stent, it’s hard to access to blow it back up. That’s why AV fistulas work. We can go in every few months and blow it back up.”

Statistics for the week… Study: 3 hours. Sleep: 8 hours/night; Fun: 1 night. Med School Prom. Students and faculty dress up for a night of hors d’oeuvres and 2-drink tickets at a local restaurant venue.

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

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Medical School 2020, Year 4 Week 10 (Nephrology elective)

by philg

Picking up with our medical school diary, authored by our anonymous mole inside the system… It’s the fall of 2019.

I meet at 9:00 am in the hospital dialysis unit with nurse practitioner (NP) Nora. She’s 34 and has worked at the nephrology practice for four years, progressively taking on more responsibility. She is my contact during the two-week nephrology rotation. The attending, a 42-year-old interventional nephrologist, is on call at the hospital and performs procedures at the nearby clinic. NP Nora and I hold down the fort.

We run the list of patients in the hospital who will need dialysis today, and go over the consults from overnight and this morning. Consults come in three flavors: 

  1. The most common consult is for patients with end-stage renal disease (ESRD) who are admitted to the hospital for an unrelated reason, such as a GI bleed, myocardial infarction, or pneumonia, and need their dialysis while in the hospital. We try to continue their standard schedule, e.g., “TTS” for Tuesday, Thursday, and Saturday, about two hours on the machine per session at an outpatient dialysis center. Five clicks in Epic and the dialysis nurses will know what to do. 
  2. Acute renal failure. These patients are typically unstable, e.g., from septic or cardiogenic shock that resulted in such poor perfusion to the kidneys that they shut down. These patients have electrolyte derangements and toxin buildup that is not being filtered by the kidneys. They need either intermittent hemodialysis (IHD) or CRRT (continuous renal replacement therapy; “slow” dialysis). 
  3. The last type of consult is for electrolyte abnormalities, frequently low or high sodium. These are usually “tea and cracker” old ladies who do not eat enough, alcoholics, and the occasional ultra distance runner. If the sodium is corrected too fast, the osmolarity change can result in brain damage. (A University of Virginia fraternity contributed the highest recorded sodium to the medical literature: “Survival of acute hypernatremia due to massive soy sauce ingestion” (Carlberg, et al. 2013).)

We get six consults throughout the day, four of which are for ESRD admits. I watch Nora’s exam on the first ESRD consult. She examines the patient’s vascular access, an arteriovenous (AV) fistula, and determines his schedule and typical net volume change from the outside records. We get these on paper because the patient’s dialysis center’s electronic medical record does not interface with our Epic system. It takes 20 minutes to find the needles we’re looking for in the haystack of paper. We evaluate his volume status by listening to the lungs and checking for peripheral edema in the legs. I do everything on the next ESRD admit, with NP Nora watching and helping.

An AV fistula is a surgically-created connection between a large vein and artery in the arm that is brought close to the skin for cannulation with a needle. This fistula is allowed to mature until there is adequate blood flow for dialysis, while ensuring adequate perfusion to the distal limb. 

In the afternoon, we get a consult for acute renal failure in a 42-year-old uncontrolled type 2 diabetic patient who presented yesterday evening in septic shock from a necrotizing soft tissue infection of the leg. He probably stepped on a sharp object and did not notice the wound for a few days. He underwent a below the knee (BTK) amputation of the right leg, and was sent to the ICU. His kidneys have not recovered, and they are starting him on CRRT because his blood pressure drops too much with the two-hour iHD.

The most interesting consult during the week is on a 58-year-old patient with metastatic bladder cancer. The prognosis is that he is likely to live only one or two additional months. The cancer has obstructed both ureters, resulting in progressively worsening kidney failure. The tumor responded to first-line therapy, but recurred three months later, and did not respond to second-line therapy. The patient presented to the emergency room with left flank pain from hydronephrosis, a kidney ballooning from distal obstruction. He underwent placement of a nephrostomy tube (a catheter that the interventional radiologist pokes into the kidney to drain urine) to drain the kidney and prevent further deterioration of his last remaining functional kidney. We explain that we could start dialysis on him, but would need to coordinate with the oncologist given a palliative approach may be a better path for him. He will likely have end stage renal disease within a few weeks.

The oncologist agrees that palliative is the best option given that the patient has only about a 10 percent chance of some response from rescue or “salvage” chemotherapy. This will entail three months of debilitating pain (at a cost of over $100,000 to Medicaid). The oncologist did not sugar coat matters for the patient: “This is probably the worst case of bladder cancer I have ever seen. If you don’t go on dialysis, the way you will die is you’ll become very tired. You’ll have periods where you are lucid, and then you will go back to sleep. This will happen over a few days, until you fall asleep. Your body will begin to realize it is dying, and release its natural endorphins to help with the pain. We’ll give you pain medications until that kicks in.” As we walk down the hall, he explains to me, “Kidney failure is a good way to die. It’s quite peaceful.”

By the end of the week I am appreciating the teamwork of the NP and attending. She gets things done around the dialysis unit, puts in orders, and helps organize the nephrologist. When a consult comes in for something atypical, the consult is sent to the nephrologist. During rounds she will ask about the management of these patients, and seems to learn something new every week.

After work, Sarcastic Samantha, Lanky Luke and I grab drinks with the nephrology NP at our favorite burgers and beer joint. Samantha comments how she does not see many PAs and NPs that are happy in their job, including herself. The nephrology NP responds, “I’ve gone through so many mundane ACP [Advanced Care Partner] jobs in which I was miserable. It’s all about finding a partner in a doctor. I think that’s the beauty of the ACP is that you can mold into the role – find your niche. You need to find a physician that will build you up so you are a smooth team.” She adds, “We are trying to hire another ACP to work under me. The problem we have is that new ACPs switch jobs so frequently it’s hard to justify investing time in them.”

Statistics for the week… Study: 2 hours. Sleep: 8 hours/night; Fun: 1 night. Jane and I went on a weekend Airbnb cabin getaway.

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

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Aerial Underground Railroad

by philg

“The pilots flying passengers across US state lines for abortions” (Guardian, October 30):

All Steven knew was what time and where. A part-time pilot from the Chicago area, he was picking up a total stranger in his single-engine plane, a passenger who needed to fly more than a thousand miles, across state lines, from the midwest to the east coast.

The passenger was seeking reproductive health services and needed to travel to a state where they could access them. Steven is just one of hundreds of pilots across the US, who have been volunteering the use of their small planes to fly people seeking abortions and other services from states that have outlawed it to states that haven’t.

The effort to connect volunteer pilots with patients is led by Elevated Access, a non-profit organization based out of Illinois. It was founded in April in response to a growing number of women being forced to embark on expensive and time-consuming journeys in attempts to obtain abortions.

What about pregnant men? They will have to Ride the Dog (Greyhound)? A photo on the organization’s web site shows what appears to be a pregnant man in the passenger seat (front right; the pilot sits front left in most fixed-wing aircraft):

How many owner- and renter-pilots are passionate about these issues?

Indeed, since the supreme court formally stripped away federal abortion protection rights in June, Elevated Access has seen a giant uptick in volunteer pilots, with 870 pilots offering to transport patients across state lines for abortions and gender-affirming care.

How many have a valuable gender ID?

Elevated Access was set up to ease those difficulties, using the 3,000 general aviation airports scattered across the country. It recently marked a milestone by completing its first all-female pilot mission, involving seven states and two solo female pilots flying a 1,400-mile relay to transport a client. Only 6% of pilots in the US are women, it noted.

The partners?

As a referral-only organization, Elevated Access connects passengers to pilots through referrals by its partner organizations such as Planned Parenthood and the National Abortion Federation.

Here’s an interesting analogy:

“I think as pilots, we’re very proud of the freedom we have and so it seems appropriate for me to use the freedom I have to help out people whose much more fundamental freedoms – [such as] rights to medical care or decisions about how they want to control their own body – are being jeopardized right now.”

What if the better analogy is the pregnant person is the pilot and the baby is the passenger? Let’s consider EgyptAir 990.

The cockpit voice recorder (CVR) recorded the captain excusing himself to go to the lavatory, followed 30 seconds later by the first officer saying in Egyptian Arabic “Tawkalt ala Allah,” which can be translated as “I put my trust in God.” A minute later, the autopilot was disengaged, immediately followed by the first officer again repeating the same Arabic phrase which can be also translated as, “I rely on God.” Three seconds later, the throttles for both engines were reduced to idle, and both elevators were moved 3° nose down. The first officer repeated “I rely on God” seven more times…

(The very first time I flew a turbojet, the Cessna CJ3 demo pilot deadpanned “You’ve disconnected the autopilot. Do you want to declare an emergency?”)

Gameel Al-Batouti was certainly controlling his own body, as the quoted pilot above says is the correct situation, and he got what he wanted. But the passengers did not get what they wanted, i.e., to emerge alive at the end of the journey.

(The article contains some misinformation, implying that pilots must file flight plans in order to travel by air. In fact, unless one wishes to fly via reference to instruments (in the clouds), no flight plan is typically required.)

Ph.D. and Ivy League grad Deplorables in a chat group reacted to this:

  • Does this mean that I can fly for free as a pregnant man ?
  • Can I get preggers every month? Oh, I might fly for abortion and change my mind and fly back and fly there again and…
  • aborting takeoff is not an option
  • They think they are Underground Railroad heroes.
  • Are planes that belong to Abortion Air are stored in coat hangars?
  • Also after each baby killed one can paint a little baby skull 💀 on the side of the plane

The organization’s mission:

Elevated Access recognizes that not all people have access to the healthcare they need due to stigma in their community. Because we believe everyone deserves access to healthcare such as abortion and gender-affirming care, our volunteer pilots provide free transportation to get people where they can get the care they need to live their best life.

What about a healthy baby subjected to abortion care at 24 weeks, as is legal “on-demand” in Maskachusetts (abortion care after 24 weeks is legal if one doctor thinks it is a good idea)? Is he/she/ze/they living his/her/zir/their best life?

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Should Ron DeSantis buy some empathy if he wants to be president?

by philg

Due to the death of democracy and the success of fascism, the Tyrant of Tallahassee continues to govern Florida. What if Ron DeSantis wants to be El Presidente? I’m not sure that he can do it unless he changes some of his harsh ways. The majority of Americans are indifferent to whether a politician is senile and incompetent so long as he/she/ze/they appears to possess “empathy.” The peasantry thinks that a politician who feigns concern for the peasants will implement policies that help the peasants (central planning always favored over the market, therefore, because only central plans carry explicit intentions).

Ron DeSantis has been highly competent, e.g., supervising the response to Hurricane Ian so that the barrier island bridges were restored within weeks and electric power, which he’d been working on for years, bounced back even sooner. But he can also be kind of mean, which is the opposite of empathy. I cringed when he talked about looters being shot. “Florida Gov. Ron DeSantis’ focus on ‘looting’ causes outrage” (Orlando Weekly):

We go through this with every storm. Nobody wants your waterlogged electronics and soggy couch.

“We want to make sure we maintain law and order,” said DeSantis, before floating the idea that thieves are taking boats into damaged areas to steal from flooded homes. “You can have people bringing boats into some of these islands… I would not want to chance that if I were you, given we’re a Second Amendment state.”

Wouldn’t it have been sufficient for him to say, only if asked, “Florida has a lot of great police departments and a tradition of public order. Also, there are plenty of armed citizens.”? As the article cited above notes, there aren’t a lot of great looting opportunities in flooded neighborhoods.

We also have the debacle of a government that can’t figure out who is eligible to vote and therefore must rely on what potentially confused residents say. Ron DeSantis could express empathy for those who couldn’t figure out whether they were entitled to vote instead of prosecuting them. See “Florida voter has election fraud charges touted by DeSantis dismissed” (ABC):

A Florida man had his election fraud charges dismissed on Friday, making him the first of 20 people who Gov. Ron DeSantis announced had been charged with voter fraud in August, to beat his case.

Robert Lee Wood, who faced one count of making a false affirmation on a voter application, and one count of voting as an unqualified elector, had his charges dismissed on the grounds that the prosecutor lacked appropriate jurisdiction.

Wood was facing up to five years in prison and $5,000 in fines and fees, for allegedly illegally voting in the 2020 election.

When the charges were announced on Aug. 18, DeSantis said at a press conference that local prosecutors had been “loath” to take up election fraud cases.

“Now we have the ability with the attorney general and statewide prosecutor to bring those [cases] on behalf of the state of Florida,” he said.

But a judge found on Friday that the statewide prosecutor did not have jurisdiction over one case in Miami. Statewide prosecutors, which are an extension of the Attorney General’s office, are prosecuting all of the election fraud cases that were brought in August.

That includes Wood, who was charged with second-degree murder in 1991. Wood registered to vote in 2020 after being approached by a voter rights advocate at a grocery store. Wood claimed he did not fill out the form, rather he just signed it, according to the affidavit of arrest filled out by an FDLE agent.

The form includes a section which asks the applicant to either verify that they are not a felon, or if so, to declare that their right to vote had been restored.

Voter rights advocates say that provision is especially confusing because of the passage of Amendment 4 to the Florida Constitution in 2018, which restored all felons their rights to vote except for those convicted of sex felonies or murder charges.

Later, another condition was added requiring voters with felonies to pay off their fines and fees before having their rights restored.

In a state of 22 million people, prosecuting 20 people for improperly voting is unlikely to change any election outcome, even if hundreds more are motivated to read the fine print. So, in my view, all that the prosecutions do is make DeSantis appear to lack empathy. Convicted murderers might not be “the best people” as Donald Trump would put it and maybe we don’t want them voting (though I would rather exclude those who’ve had their student loans forgiven and haven’t yet worked for at least 8 years and let convicted felons vote! Convicted felons at least know a lot about prison and criminal justice system) but we can still express empathy towards them.

I don’t think that DeSantis can become president if he continues on this track. The migrant flights to sanctuary states and cities can work because they show true empathy for the migrants (wanting to see them loved and cared for by “In this house we believe…” signers in Maskachusetts, for example). But some of the stuff that DeSantis says and does seems gratuitously mean and/or could be improved hugely by a change in tone.

Maybe DeSantis can just buy some empathy with his $300,000 in net worth?

From NBAA, Empathia, Inc.:

Readers: What do you think? Who is a fan of what Ron DeSantis does, but thinks he is losing potential votes by the way he expresses himself?

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Should new houses and apartments be designed with an alcove for a robot vacuum cleaner?

by philg

Everyone I know who tried the first robot vacuum cleaners eventually gave up. They held so little debris that it was just as much work to empty them as it would have been to vacuum the room with an $80 Hoover. Walls got banged up from the robot’s clumsy attempts to map rooms and avoid furniture. Delicacy prevents me from going into details, but a family dog with a stomach bug and a robot vacuum cleaner turned out to be a toxic combination in many households. (Do a web search and you will find many stories!)

Friends in Maskachusetts have been been on a renewed buying spree lately driven by, I think, the following beliefs:

  • the original electric home vacuum cleaners were not marvelous labor-saving devices and their descendants (up to 114 Bidies for a decent Hoover?) are, in fact, extremely tedious to push around in a McMansion
  • a battery-powered machine is always more effective at cleaning than a 114-Bidie plug-in Hoover with a 1440-watt motor
  • the latest and greatest robots have better sensors and software
  • their children have weak immune systems from 1.5 years of school closure and activity lockdowns and shutdowns and therefore the house must be cleaner than ever before

Although the market segment was pioneered by iRobot, an MIT spinoff, these guys have come to the consensus (“a Scientific consensus”) that the Chinese-engineered Roborock S7 MaxV Ultra is the best machine and has the best software.

They’ve sent me pictures of this dock and robot in their $2-3 million COVID-safe suburban bunkers. They take up a lot of floor space and look completely out of place. Here’s what the naked machine looks like:

(Across the top you have dirty water (post-mopping), clean water (pre-mopping), and a wastebasket for the self-emptying dust bin within the robot. The company claims this allows 3-4 days of usage before the robot’s human servant must be summoned to change out the water or empty the bin. They base this on a small footprint of 1,070 square feet.)

You wouldn’t leave a regular vacuum cleaner out where family members, guests, etc. could see it, right? The vacuum cleaner is ugly and used intermittently so it lives in a closet. These robots aren’t smart enough to open doors, so my friends are putting them where they are often visible to people trying to enjoy the house. It’s New England and the robots can’t climb stairs so a house with three living levels will have three of these cluttering the space.

I’m wondering if houses and apartments should now be designed so that a robot vacuum with dock will stay mostly out of sight. Maybe it lives in an alcove under the stairs. Perhaps there is a curtain that it can drive under (it is mostly the dock that needs to be hidden). The companies that make these devices should get together and agree on a standard for the shape and size of the alcove. Obviously the alcove needs electricity. Maybe for rich people there should also be a fresh water supply plumbed in and a drain and perhaps robots could be made that tapped into these so that the only thing that the human servant of the robot ever had to do was empty the dust bin.

I know there’s a fine line between brilliant and stupid. Which side of the line is this idea on?

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Crypto friends weigh in on the FTX meltdown

by philg

Friends who bought private jets and luxury waterfront property with their crypto profits were discussing the FTX meltdown and Sam Bankman-Fried‘s return to financial Earth.

One cited the Sequoia Capital investment memo regarding the vegan MIT graduate founder:

The FTX competitive advantage? Ethical behavior. SBF is a Peter Singer–inspired utilitarian in a sea of Robert Nozick–inspired libertarians. He’s an ethical maximalist in an industry that’s overwhelmingly populated with ethical minimalists. I’m a Nozick man myself, but I know who I’d rather trust my money with: SBF, hands-down. And if he does end up saving the world as a side effect of being my banker, all the better.

This is a purportedly hard-nosed Silicon Valley venture capital firm. Another chat participant cited a mixture of truth and fiction:

A comment from one of the participants:

Makes Madoff look like an amateur. He Played everyone. And I mean everyone. Absolutely insane. He was clearly insolvent in June and knew it. Then the real fraud began.

Good old fashioned segregation of funds issue.

Some tweets these guys liked:

Related:

  • “Andreessen Horowitz Went All In on Crypto at the Worst Possible Time” (WSJ, October 26, 2022): “a 50-year-old partner named Chris Dixon who was one of the earliest evangelists for how the blockchain technology powering cryptocurrencies could change business. His unit was one of the most-active crypto investors last year, and in May announced a $4.5 billion crypto fund, the largest ever for such investments.”
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What percentage of workers at your company aren’t worth having even at $0/year?

by philg

A friend is a mid-level manager at one of the FAANG companies that enforces religious orthodoxy here in the U.S., e.g., by deplatforming those who fail to respect the rainbow flag. She expressed dismay that her division was being trimmed by 20 percent in order to shore up profits. I asked “What percentage of the people you work with aren’t worth having around even at a $0 salary because they’re either unproductive, annoying, or both?” She thought for a few moments and then answered “About 20 percent.”

So maybe the slim-down in the tech industry won’t change much.

Readers: What percentage of folks would you get rid of at your company even if these people were available at no cost to the company?

Related:

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How did the 2022 elections work out for Florida?

by philg

Americans generally affirmed the idea that the country will be better with bigger government and higher taxes. Whether this is true or false, Florida’s prosperity primarily depends on the differential between Florida and other states, not the absolute quality of life in Florida. It is a bit like the ancient story of two non-binary campers:

Kendall and Arden are camping when a thin-looking brown bear approaches they/them and them/they, growling.

Kendall starts putting on their running shoes.

Arden says, “What are you doing? We don’t need to bring in Ketanji’s panel of biologists to know that, regardless of your pronouns, you can’t outrun a bear!”

Kendall says, “I don’t have to outrun the bear—I just have to outrun you!”

“The Flight of New York City’s Wealthy Was a Once-in-a-Century Shock” (NYT) did not happen because Florida v2020 and v2021 was better than Florida v2019, but because NYC v2020/2021 was so much worse than NYC v2019.

State governments became vastly more powerful in 2020, e.g., deciding whether residents of a state would be able to leave their homes, send children to school, work for a living, avoid the injection of their children with an experimental medicine designed to help 80-year-olds. An interstate move to switch overlords is therefore much more likely than when the state-to-state difference was a few dollars in tax.

Democrats kept control of New York State. Kathy Hochul would need to order a lockdown or two in order match what Florida Realtor of the Year 2020 Andrew Cuomo achieved, but her victory is an important precondition in keeping people who value liberty pointed south on Interstate 95 to their new homes in the Florida Free State (TM). I also appreciate her teaching young Puerto Ricans that rules established by elites may not apply to elites…

Massachusetts elected a Lockdown Democrat governor and passed a new higher tax rate on those who are rich enough to afford Florida waterfront (see Why did 1 million poor people vote against a higher tax rate for rich people in Massachusetts?). That should be great for residents of Palm Beach County. Even a handful of families moving into $20-100 million houses down here provide a big boost in revenue.

Colorado moved away from its flat tax by limiting deductions for those earning more than $300,000 per year. That’s not a huge nudge toward Florida, but it is a nudge. San Francisco added a tax on condos owned by rich people who leave them vacant for 183 days per year or more (53/47 vote; a mystery that it could have been that close given that hardly any voters own a condo that would be subject to this tax).

The governor’s race in Texas was the biggest disappointment for realtors in Florida. A Beto victory carried with it the prospect of rich Californians choosing Florida rather than Texas as their escape-from-Newsom destination. The silver living is that Greg Abbott’s victory was only 55/44 (compare to 56/42 in 2018 and 59/39 in 2014). Given the propensity of today’s young people to support progressive politics and the overall national trend towards bigger government, it seems likely that Texas will eventually be governed by Democrats, a huge boost to Florida’s chances of capturing fleeing successful Californians. Maybe Texas is safe from California-style government today, but people who go to the effort of moving are also interested in what a state will be like in 10-20 years.

An exchange on Facebook with one of those successful Californias who praised a college that doesn’t discriminate on the basis of skin color:

I wish my own kids were brave, and principled, and original thinking enough to consider applying instead of conforming to conventional wisdom and stupid rankings. I’ll keep trying to teach them.

But your kids have watched you conform. California politicians took away your liberties one by one starting in March 2020 and you simply stayed in California, right? And, in fact, your kids watch you pay taxes to fund all of it.

I have 2 kids I can’t move away from [California family law gave his wife millions of reason to sue him…]. But in 2 years when #2 goes to college I’ll have a lot more altitude to go elsewhere. FL is too far away and TX is too close to purple. UT is the current front runner.

The guy believes that Texas is just a few young voters away from Following the Science into lockdowns, mask orders, vaccine papers checks, etc., and maybe a new personal income tax to pay for it all! (Beto promised to use Science to protect Texans from viral threats. In fairness, so did Abbott, but he interpreted Science’s whispers differently.)

There was great news in Michigan. Lockdown Democrat Gretchen Whitmer was reelected 54/44, a clear indication that nothing is going to change in Michigan. People who don’t love the government there should move away. Wisconsin (a paradise for child support profiteers) similar reelected a Democrat governor. Pennsylvania is a great source of new residents with money for Florida. A Democrat won there by a large margin (56/42). Again, people who don’t want to be ruled by Democrats have only one realistic option: move. And once the decision to move is made, Florida is there and ready with jobs, low taxes, all-year outdoor recreation, etc.

Maine and Kansas also reelected Democrats as governors.

A Democrat victory at the Federal level should drive additional moves to Florida. A person who wants his/her/zir/their state to resist new takeovers of power by Washington, D.C. will find that in Florida, the state in which Joe Biden’s order that travelers wear masks on airplanes was found unconstitutional. A person who wants to maintain his/her/zir/their spending power in the face of Federal income tax rate increases can probably do so by moving from a medium-to-high-tax state to a state with no personal income tax and some reasonable assurance that the electorate won’t amend the constitution to impose one. That’s Florida, Wyoming, South Dakota, and Tennessee? New Hampshire actually does have an income tax (not on wages, but on dividends and interest). Texas is at risk over time of having everything that California has (see above).

What about politics here in Florida? First, the election results were available on the timeline that taxpayers expected:

(Hurricane Nicole arrived on the SE coast roughly 24 hours after the polls closed.)

The stealth scheme to raise pay for the Praetorian Guard (see Florida comes up with a scheme for increasing taxes on private workers via a property tax exemption for government workers) was approved by a majority of voters, but not above the 60 percent threshold necessary to amend the Florida constitution. Voters here in majority-Democrat Palm Beach County approved $200 million in borrowing to fund “workforce housing”. Americans everywhere believe “when the market gives you an answer you don’t like, declare market failure”. There are approximately 1.5 million people in Palm Beach County. How $200 million, the price of a couple of teardown houses in Palm Beach itself, is going to change the affordability of housing for the average person here is unclear. It looks like it will at least make a huge difference for some government cronies. From a “quick summary”:

Some non-profit and government workers will get paid. Some favored developers will get rich off the spread between the market rate for interest and this slush fund.

If the typical unit holds 2 people, that’s 2,200 people who are being housed after 16 years of government and non-profit employees being paid. That’s roughly 0.15% of the people who live in Palm Beach County (1 out of every 700).

Which of the 1 in 700 people in Palm Beach County gets to live a subsidized life?

In other words, anyone whom the non-profit folks think is deserving!

Even in majority-Democrat Palm Beach County, the all-abortion-care-all-the-time Democrat running against the Tyrant of Tallahassee could not prevail. Ron DeSantis won by 51/48 here in the county (compare to 60/40 statewide).

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SARS-CoV-2 mindshare in New York

by philg

On our way back from Paris, we checked in at JFK and the TWA Hotel to see how COVID-19 was doing in terms of living in the heads of New Yorkers. I was quickly rewarded with the trifecta: outdoors, bearded, masked.

The Lockheed-turned bar is a lot of fun. Note the official encouragement for the drunken business travelers to break out in song during the flight (how may police agencies would be summoned if that happened today?). Also the barf bag reminder about the canine member of the household. Take a look at all of the cylinders that the flight engineer had to monitor.

The pool deck is directly across from a two-level Emirates A380 gate:

Wearing a mask is optional for workers, but quite a few still rely on the non-N95 mask rather than switching to a job that does not entail contact with the infected public:

(The $32 omelet is served without toast; Senior Management’s $20+ eggs came with toast… one piece.)

On the one hand, the folks who run the hotel want to help SARS-CoV-2 thrive by bringing people together in close physical proximity. On the other hand, they also remind visitors to “Stay Safe” by avoiding other humans. In-elevator screen:

What about on the web sites of New York institutions? COVID-19 gets mentioned directly below the menubar on the Whitney’s home page:

It’s the very first thing on the Metropolitan Museum’s home page:

If you don’t click the “x” to acknowledge, the message about masks will be present over every page that you visit.

What if you leave the city? Get your mask in the airport:

New York-based JetBlue reminds folks to “Keep a healthy distance” while deplaning. Note the Fall of Saigon-style conditions that were inevitable once the airline decided to sell 100 percent of the seats. In other words, COVID-19 is serious enough that a lot of warning should be displayed. But COVID-19 is not serious enough to refrain from cramming the airliners to the absolute maximum capacity.

That was the mid-October COVID mindshare situation in New York.

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