Brandeis students’ concerns while Ukrainians are shelled

by philg

A photo taken last week, while Ukrainian cities and homes were being destroyed, on the Brandeis University campus:

While bravely behind a Zoom screen, students identifying as BIPOC could participate in the “Surviving White Spaces” support group, for example. There was “drop-in” support for the pandemic (where “drop-in” is defined as clicking on a Zoom URL). For those who weren’t sure whether they belonged in the 2SLGBTQQIA+ community, there was “Gender & Sexuality Exploration”, from which one could presumably segue into “LGBTQ+ Support Group”.

What about Americans who aren’t in college and who aren’t in Ukraine? They too are experiencing a “tragedy” according to Atlantic magazine’s “How did this many deaths become normal?”:

The U.S. is nearing 1 million recorded COVID-19 deaths without the social reckoning that such a tragedy should provoke. Why?

Why did the CDC issue new guidelines that allowed most Americans to dispense with indoor masking when at least 1,000 people had been dying of COVID every day for almost six straight months?

America is accepting not only a threshold of death but also a gradient of death. Elderly people over the age of 75 are 140 times more likely to die than people in their 20s.

How much of this extra mortality will the U.S. accept? The CDC’s new guidelines provide a clue. They recommend that protective measures such as indoor masking kick in once communities pass certain thresholds of cases and hospitalizations. But the health-policy experts Joshua Salomon and Alyssa Bilinski calculated that by the time communities hit the CDC’s thresholds, they’d be on the path to at least three daily deaths per million, which equates to 1,000 deaths per day nationally. And crucially, the warning lights would go off too late to prevent those deaths. “As a level of mortality the White House and CDC are willing to accept before calling for more public health protection, this is heartbreaking,”

There is some good news in the article. Most of us do follow Science:

a poll that found that mask mandates are favored by 50 percent of Americans and opposed by just 28 percent

Apparently, there is nothing that can happen in Ukraine that will stop us from focusing on the concerns that we had prior to February 2022.

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Example of a standard car manufacturer’s time lag from invention to implementation (Ford Pet Mode)

by philg

“Ford Will Have a ‘Pet Mode’ Similar to Tesla’s, Patent Application Shows” (Car and Driver, 2/24/2022):

Perhaps trying to compete with Tesla’s Dog mode, Ford has filed a patent application for something called Pet mode, which would allow drivers to remotely control things including windows and temperature.

Tesla started offering its Dog mode feature around four years ago as a way for drivers to make sure any animals left inside of one of the company’s EVs don’t get too hot or cold, and that passersby would see a notification that lets them know the car is comfortable for the pet.

The patent application was filed in October 2018, which tells us that Ford had the invention in its possession four years ago. The Mustang Mach-E went into production 1.5 years ago yet still has no Pet Mode, thus encouraging anyone who likes to run errands with a dog in the vehicle to purchase a Tesla instead.

Related:

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Florida state politics stir passions primarily among those who don’t live in Florida

by philg

We recently had an election here in Jupiter that generated a fair amount of local advertising, e.g., lawn signs at street corners, and discussion at the playgrounds, soccer fields, dog parks, skate parks, beach, etc. People are very interested in who will be on the town council and who will be the mayor. The hot button issues are real estate development, traffic, and spending on open space and parks.

State politics, on the other hand, don’t seem to capture Floridians’ attention. Far more people in Massachusetts talked about Governor Ron DeSantis, for example, than people here in Jupiter.

Here’s a UK magazine reporting on a statement by a California resident on proposed Florida legislation: “Apple CEO Tim Cook slams ‘deeply concerning’ Don’t Say Gay bill as ‘proud member of LGBT+ community’”: Apple CEO Tim Cook has condemned Florida’s harmful “Don’t Say Gay” bill, which if signed into law would prohibit “classroom discussion of sexual orientation or gender identity”.

The UK’s BBC reports on another California’s opinion: “Disney apologises for ‘silence’ on ‘Don’t Say Gay’ bill”.

Walt Disney’s CEO has apologised for his “painful silence” on a Florida sex education bill critics warn will isolate LGBT youth.

“You needed me to be a stronger ally in the fight for equal rights and I let you down. I am sorry,” Bob Chapek told employees.

His comments come amid internal complaints that “gay affection” is routinely cut from some Disney films.

The so-called ‘Don’t Say Gay’ bill is due to become law.

It bans discussions of sexual orientation and gender identity from kindergarten to third grade classes (aged 8-9) or when “not age appropriate or developmentally appropriate for students in accordance with state standards”.

The BBC article is misleading, I think. It says that “discussions” of 2SLGBTQQIA+ are banned in kindergarten, but, in fact, I think it is only “instruction” regarding 2SLGBTQQIA+ that is banned. So the kindergarteners could discuss the 10 Best Gay Saunas in the USA and the teacher could say which one was his/her/zir/their favorite. But the teacher couldn’t organize a lesson about what happens inside the 10 best gay saunas. (3 out of the 10 best gay saunas in the above-referenced article are actually in Florida, in case an after-school program for K-3 or a pre-school needs to organize a field trip)

The UK’s Daily Mail also wrote about this, March 9, 2022:

White House Press Secretary Jen Psaki on Wednesday said a Florida bill that would place limits on instruction about gender identity and sexual orientation is a ‘form of bullying’ against LGBTQI kids.

The Parental Rights in Education bill, dubbed the ‘Don’t Say Gay’ bill by critics, was passed by Florida’s Republican-dominated Senate on Tuesday and will now head to GOP Governor Ron DeSantis’ desk.

Psaki said the bill ‘would discriminate against families, against kids, put these kids in a position of not getting the support they need at a time where that’s exactly what they need.’

Its text says that ‘classroom instruction by school personnel or third parties on sexual orientation or gender identity may not occur in kindergarten through grade 3 or in a manner that is not age-appropriate or developmentally appropriate for students in accordance with state standards.’

President Joe Biden himself condemned the bill as ‘hateful.’

A full-scale war in Europe apparently cannot distract the Biden Administration from focusing on Florida politics. Nor does a war in Europe distract news media in the UK from writing about what the Florida legislature is up to.

What do the haters say in favor of this bill, according to the Daily Mail?

[DeSantis spokeswoman Christina] Pushaw pointed out to DailyMail.com that the legislation does not include the word ‘gay’ or single out any one identity or orientation.

‘The idea that it’s inappropriate for adults to instruct kindergarteners about sexual topics should not be controversial in the least,’ she said in response to Psaki’s comments.

‘Children should never be sexualized. 4-9 year olds are far too young to be learning about these topics in school. If a student has any questions about sexuality or gender, it’s solely up to that child’s parent or guardian to decide how they want to answer those questions. This is not an LGBT issue, and most Floridians – gay or straight – are fully in favor of child safeguarding and parents’ rights.’

Separately, if we combine Ukraine and 2SLGBTQQIA+, we find a 2021 article, “‘Constantly pursued’: Ukraine’s LGBT+ activists attacked online and in the street” (Reuters):

Ukraine legalised gay sex in 1991, but conservative elements in the mainly Orthodox Christian nation often speak out against rights for LGBT+ people, and members of the far-right regularly target groups and events linked to the community.

The LGBT Human Rights Nash Mir Center, which monitors anti-LGBT+ violence in Ukraine, recorded 24 attacks on LGBT+ centres and events last year, more than double the figure for 2019.

From Wikipedia:

Article 51 of the [Ukraine] Constitution specifically defines marriage as a voluntary union between a man and a woman. No legal recognition exists for same-sex marriage, nor is there any sort of more limited recognition for same-sex couples

Will it soon be time for a NYT history rewrite in which Ukraine is presented as a long-established haven for the 2SLGBTQQIA+ community?

Circling back to the original topic… the most powerful political entities in Florida seem to be counties. They collect the lion’s share of property taxes, leaving the sales tax scraps for the state. Counties run the schools and parks that residents are passionate about. I wonder if the Florida legislature and governor are actually staging some of the stuff that they do simply to see how much they can wind up people in California, Washington, D.C., and New York.

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March Madness: How has Bitcoin done relative to the S&P 500 and inflation?

by philg

For basketball fans, today is the beginning of March Madness. For the rest of us, the primary kind of madness to which we’ve been exposed is the idea that humans can control a respiratory virus with bandanas as PPE. But what about the second maddest form of madness, i.e., the belief that “they’re not making any more bits” and therefore that Bitcoin is inevitably valuable?

What if we’d bought the S&P 500 and reinvested the dividends over the past year? How would that compare to a dividend-free investment (not to say “speculation”!) in Bitcoin? And how have both strategies fared compared to the inflation that we are assured is both minimal and transitory?

Let’s look at the S&P 500. It seems to be up about 6.6 percent. Then add in a dividend yield of just under 2 percent and we get an 8.6 percent bump in nominal terms:

Of course, inflation has been at least 10 percent (if we count the cost of buying a house) and therefore an investor in the S&P 500 has actually lost money over the past year (he/she/ze/they is down about 20 percent measured against the cost of buying a house in South Florida). Bitcoin is an inflation hedge like gold and therefore must surely have done better, right? Yesterday’s chart:

Down 32 percent! What about gold itself? Or, in this case, GLDM:

Up 15 percent, so losing value compared to real estate but perhaps roughly even with most other items.

What if we’d bought tanker trucks full of gasoline? It has gone up from $2.71/gallon to $4.10/gallon (EIA.gov), a 51 percent bump in nominal dollars.

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Medical School 2020, Year 4, Week 4 (Wound Care Elective II)

by philg

Monday is a typical day in wound care. I perform forearm squamous cell excisional biopsies. and suture the 3 cm incision. We chat about reimbursements. Wound care can be quite lucrative from debridement and graft procedures and marking up devices. “Our wound care clinic is not greedy,” said Daniel Boone. “We frequently use devices that are not reimbursed. The patients love the SNaP vacs [Smart Negative Pressure, a disposable mechanically powered vacuum]. If their insurance won’t reimburse for a stem cell-based graft that has a chance of working, we’ll find leftovers from another patient. We make enough from the debridement and graft procedures to make it work. Administration at the rural hospital gives us a little more wiggle room compared to the [flagship hospital].” 

Lunch is provided by a salesman from a home health agency. Most wound care patients require help at home with 2-3 times per week dressing and re-wrapping. The 45-year-old rep comes in with his company’s head nurse and food that we’d selected earlier that morning. While eating my $24 ribeye, I learn that this agency provides coverage seven days/week in our rural area, that they have two certified wound care nurses, and that a nurse will answer a help line 24 hours/day.

Clinic ends at 4:00 pm. Daniel Boone and I drive 45 minutes in his pickup truck to a trailhead. We are joining a continuing medical education (“CME”) course in which the wilderness medicine week attendees backpack for three days with evening lectures in the field. We hike for two hours to meet the class at their Day 2 campsite just as it is getting dark. I set up a tent while Daniel Boone strings his covered hammock cocoon between two trees.

At the campfire, we join 25 attendees from across the country. Half are emergency medicine physicians; the rest an assortment of general surgeons, orthopedic surgeons, and internists. The course is led by four EM physicians, two of whom regularly work at the Mount Everest base camp. We learn how to construct a rope carrier for an immobilized victim in the field. Around 8:30 pm, Daniel Boone gives a 30-minute lecture on tick-borne illness. I prepared some remarks on alpha-galactose hypersensitivity reaction (“alpha-gal”), an increasingly common allergy to red meat that leads to “midnight anaphylaxis” (delayed reaction).

Daniel Boone, a 35-year-old EM physician, a 55-year-old general surgeon who works in a rural hospital and I stay up late chatting around the fire. The EM physician got married last year at the Everest base camp. She explained that she works extra shifts when she’s home so that she can spend one third of the year in the mountains while earning a full-time income. This is doable in EM because a full time schedule is only twelve 12-hour shifts per month. The general surgeon covers a 50-mile radius in rural Tennessee. “I love it. I get to do things I would never be able to be able to do in a larger hospital. It makes no sense. I’ve been doing C-sections, amputations, and complex hernia repairs  for 15 years, but good luck getting credentialed by clueless MBA administrators of big health systems.” 

We wake up at 4:30 am to hike back in the dark, but we’re still late to clinic. We skip our showers and change into scrubs. 

Friday: Daniel Boone is a certified provider of hyperbaric oxygen therapy (HBOT; requires only a weekend course). “Almost everyone can benefit from HBOT,” he says, “but patients are limited by insurance coverage.” Insurance approves HBOT for refractory soft tissue injuries and radiation injury (e.g., proctitis after prostate radiation), but physicians are experimenting with a wide range of conditions. Daniel Boone is testing HBOT on a chronic Lyme disease patient, for example, and believes that stroke patients will also benefit from HBOT. “We don’t have enough chambers for the demand.”

Our institution has small individual hyperbaric chambers that hold just one person at a time. If the patient starts choking or simply panics due to claustrophobia, the staff has a 5-minute decompression protocol to get the patient out of the 3-atmosphere, 100-percent oxygen environment. (3 atm is the pressure experienced by SCUBA divers 100′ below the surface.) “It’s a massive bomb.” I expected to see the chambers located in a specialized room; instead, the chambers are behind a curtain next to the nurses’ station. Patients are patted down before going in to ensure no jewelry or flammable materials are worn.

One future candidate for HBOT is convinced that she was bitten by a brown recluse (Loxosceles reclusa) super spider that started her chronic, bilateral lymphedema ulcers (conventional medical wisdom would attribute these to her morbid obesity). This is her initial consultation at the wound care clinic. “DHS interviewed me. 14 people were bitten; I was the only one who survived. The superbug was engineered by a foreign government and is a test biological weapon.” Daniel Boone, “This is the beauty of being a specialist. Her PCP can deal with her concerns about DHS and the spider.” 

Daniel Boone is able to wind up clinic by 3:30 pm and fit in two house visits that had been planned for the weekend. The first patient is a 30-year-old overweight diabetic female struggling with a cesarean section incision from three months ago. “We were using Dakin’s (dilute bleach) wet-to-dry dressings until I was able to get a fresh supply of SNaP vacuums. Once she got negative pressure, the wound started to make progress.” He explained, “It’s just easier for the family for me to go to the house and change the dressings and restock them with gauze and silver and silicone dressings for the husband to apply.” Our second home visit is with a debilitated 30-year-old with severe mental retardation and skeletal malformations. He is unable to speak, cannot walk, and is dependent on a ventilator and feeding tube. “It’s really a tragic situation,” says Daniel Boone. “I keep calling him a child but he is a grown adult. The parents shouldn’t have continued to care for the child, but those goals of care discussions happened years ago. We’re here to deal with a stubborn sacral ulcer that is to bone [has eaten through skin and tissue and is now destroying the bone].” Although the parents have been turning the patient every hour, even in the middle of the night, and providing hospital-grade care, the ulcer continues to expand from too much pressure combined with malnutrition. “My plan is to debride some of the bone and put a wound vac on,” says Daniel Boone. The father works overtime to fund what is essentially a mini hospital in the house, but the family was still struggling financially despite Daniel Boone’s provision of complimentary wound care materials. The mother is on duty 24 hours/day, 7 days/week. She dismissed the home health nurses due to their not being as competent as she is. “They would have learned about these genetic defects in the second or third trimester of pregnancy,” says Daniel Boone, “but the disorder does not have a name or a well-understood prognosis. By the time the mental prognosis was revealed, he was part of their lives.”

Daniel Boone sends me off with a weekend Advanced Wilderness Life Support (“AWLS”) certification course that he is helping to teach. Practicing physicians, medical students, Physician Assistants, Nurse Practitioners, and EMS personnel from all over the country gather in our medical school’s auditorium. I thank him for signing me up and paying the $245 cost. He responds, “This is a great learning opportunity, I did not want you to miss it. Pay it forward when you’re an attending.”

Type-A Anita’s Facebook opinion on the climate protests of 2019:

Greta is great, but if we’re only centering and uplifting white youth leaders on an international scale, we risk recreating the exact same dynamics of instilling a culture of white supremacy and silencing BIPOC [Black, Indigenous and People of Color] voices that is present in modern, adult organizing spaces. We must work to center the most marginalized voices, especially since Indigenous youth and young adults have been tirelessly leading the fight for climate justice for millennia. So here’s a list including other amazing young climate organizers and activists! … 

@Isra.Hirsi [16] is the co-founder of the U.S. Youth Climate Strike and the daughter of Congresswoman @Ilhanmn. She says the climate crisis “is the fight of my generation, and it needs to be addressed urgently.” [via @vice]⁣⁣ … 

@GretaThunberg [16] is a Swedish environmental activist attempting to hold politicians to account for their lack of action on the climate crisis. Greta is known for speaking about her school strike activism and having Asperger’s. She is currently organizing #FridaysForFuture all over the world saying, “Everyone is welcome. Everyone is needed.”⁣⁣

This was the same week that the Trump administration disagreed with “everyone is welcome” and “everyone is needed” by proposing to cut the number of refugees admitted as immigrants to the U.S. Anita responded: “fuck the patriarchy. fuck white supremacy. fuck trump and his supporters …did I miss anything.”

[Editor: all refugees are immediately entitled to Medicaid, so Anita’s passion for refugees could simply be a desire to maximize her future income.]

Statistics for the week… Study: 4 hours. Sleep: 8 hours/night; Fun: 2 nights, both after the AWLS class. Instructors and attendees go to a local brewery with live music. A PA from Colorado: “I feel like whenever I go to these wilderness medicine gatherings, the presenters are longing for a disaster to hit so that we can apply these skills.”

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

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CDC says that not-tested-for-COVID-19 migrants are a low risk while U.S. citizens who travel are a high risk

by philg

“CDC revokes U.S. authority to expel migrant children” (CBS/Yahoo, 3/12/2022):

The Biden administration announced late Friday it is ending a Trump-era border deportation policy as it pertains to unaccompanied migrant children in response to a court ruling that could’ve forced officials to expel those minors without an asylum screening.

The Centers of Disease Control and Prevention (CDC), which first authorized the migrant expulsions in March 2020, terminated the government’s ability to expel children who enter U.S. border custody without their parents. U.S. border officials can still use Title 42 to expel single adult migrants and families traveling with children to Mexico or their home countries.

Last week, U.S. District Court Judge Mark Pittman said the administration could no longer exempt unaccompanied children from Title 42, arguing that Texas, which challenged the exemption, was financially harmed by the placement of migrant children in the state due to medical and schooling costs.

In a notice Friday, CDC officials said they recognized the “unique vulnerabilities” of unaccompanied minors.

“In the current termination, CDC addresses the court’s concerns and has determined, after considering current public health conditions and recent developments, that expulsion of unaccompanied noncitizen children is not warranted to protect the public health,” the agency said.

(Note the headline. It is the Covidcrats who decide the size and composition of the U.S. population by determining immigration policy.)

The CDC (Science personified) says that an undocumented unmasked unvaccinated untested migrant who says “I am under 18” (by definition there is no way to verify such a claim since he/she/ze/they is undocumented) does not present a risk to public health. But the same agency tells us that U.S. citizens returning from the world’s most vaccinated countries, e.g., Portugal, are such high risks that they can’t legally begin a trip home without first getting a COVID-19 test and wearing a mask in the airports, airliner, Ubers, etc. (except while eating or drinking all of the food and beverages served by the airline, of course!)

Science is truly marvelous!

Speaking of Science, here’s the Metropolitan Museum of Art’s web site captured on 3/12/2022:

They say that they’re “following guidelines issued by the Centers for Disease Control (CDC), New York State, and New York City” yet didn’t all of these experts on Science recently say that masks aren’t required? (except for kids in preschool)

How about the Getty in Los Angeles?

Vaccine papers are checked and masks are required because of the Department of Public Health’s Science-informed orders. Yet the referenced Department of Public Health ended its mask order on March 4. See “LA County’s indoor mask mandate ends as COVID metrics improve. Here’s what you need to know” (ABC):

Indoor mask-wearing will no longer be mandatory in Los Angeles County starting Friday thanks to revised data released by federal health officials showing a decreased impact of COVID-19 on the county’s health care system.

The U.S. Centers for Disease Control and Prevention on Thursday officially moved the county out of its “high” virus activity category and into the “low” category. The CDC updates its county-level data every Thursday.

The CDC designations are based largely on the number of new virus-related hospital admissions and on the percentage of hospital beds being occupied by COVID-positive patients, along with a county’s overall rate of new COVID cases.

County Public Health Director Barbara Ferrer said that given the CDC revision of the county’s classification, a new Health Officer Order will be issued that removes the county’s long-standing mandate for people to wear masks indoors regardless of vaccination status. That move will put the county in alignment with the state, which dropped its mask mandate on Tuesday.

It is possible to Follow the Science even while doing the opposite of what Science says to do.

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A world-class military tries to subdue a vast land (England versus the American rebels)

by philg

Portions of The Last King of America: The Misunderstood Reign of George III (Andrew Roberts) are, unfortunately, timely.

The American rebellion surprised the experts:

One of the reasons why British politicians failed to comprehend that Americans would soon be agitating for nationhood was the paradoxical one, considering the propaganda of the independence movement twelve years later, that they were not being persecuted in any discernible way. ‘The colonists were the least oppressed of all peoples then on earth, politically, economically and nationally,’ noted Hans Kohn in his seminal book The Idea of Nationalism in 1944, written when half the world knew genuine oppression. ‘Politically the colonists were infinitely freer than any people on the European continent; they were even freer than Englishmen in Great Britain. The favourable conditions of frontier life had brought Milton’s and Locke’s teachings and English constitutional liberties to faster and fuller fruition in the colonies than in the mother country.’19 Royal governors and colonial assemblies generally ruled Americans with the lightest of touches, and the colonists certainly paid the lightest of taxes in the empire. The average American in 1770 paid a tiny fraction of what his British cousin paid in direct taxes, and crucially all of what he did pay stayed in America.

In the words of Edmund Burke’s biographer, ‘The general belief was that responsible people in the colonies accepted British sovereignty; that the disturbances in America were the work of a small minority of trouble-makers; and that American resistance would collapse if confronted with a show of force. If a war proved necessary, Britain would win it quickly and easily. Not until Appeasement in the 1930s did virtually the entire British establishment get something so important so badly wrong.

The British Army was tasked with domestic policing as well as wars with foreign nations because there was no permanent police force in England until 1829. The number of soldiers was miniscule by modern standards:

In 1775 there were only 48,000 men in the entire British Army, including the 8,000 already stationed in North America, which with its other global commitments would be nothing like enough to subdue the 2.5 million inhabitants of thirteen colonies that stretched over a thousand miles from north to south and several hundred miles inland.

In the summer of 1775, the British Army had 10,000 men already in America (mostly in or around Boston) and Canada, or sailing there; 7,700 in Gibraltar, Minorca and the West Indies; 7,000 in Ireland, which at half its normal peacetime establishment was dangerously low; and the remaining 23,000 in the United Kingdom, the minimum number for defence and domestic control, of whom 1,500 were unfit for duty.

The Cabinet continued to suffer under the delusion that the British Army and Royal Navy that had defeated France (with her population of more than twenty-five million) and Spain (nine million) only a decade earlier, and won a great empire in Canada and India, would, if necessary, similarly destroy the untrained and semi-organized militias of far fewer Americans. The crucial difference was of course that Britain had not needed to invade and occupy France or Spain in order to be victorious in 1763.

What were these professional soldiers up against?

As well as their proficiency with firearms, the Americans also had the advantage of numbers. According to Benjamin Franklin’s calculation in 1766, if a quarter of the remaining male population bore arms, and Loyalists, pacifists and seamen were deducted, about a quarter of a million Americans could theoretically fight against the Crown.

Supplying troops in the field wasn’t any easier then:

The logistical supply problem was immense too: because the local population tended to be hostile – with the American Loyalists providing far fewer troops than the British government had hoped for and expected – food had to be either foraged (that is, requisitioned, with all the local unpopularity that entailed) or bought (routinely at high margins), or else transported 3,000 miles over an ocean that was vulnerable to storms, colonial privateers and, later, enemy navies. Once the British armies penetrated inland, their lack of knowledge of the interior and the inescapable problems of reinforcement and supply both told against them heavily.

I recommend The Last King of America: The Misunderstood Reign of George III, but you might want to skim over some of the exhaustive/exhausting explanations of 18th century English politics (at least as complex as anything we have today and political disputes quite often resulted in violent clashes).

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What happens to all of the Aeron and Steelcase chairs?

by philg

Coronapanic shut down America’s offices. It seems that a lot of us aren’t going back to work in the office or back to work ever. BLS:

If office buildings are turned into warehouses, apartments, etc., what happens to all of the Herman Miller and Steelcase high-end desk chairs? Unlike anything from IKEA, the $1,000 Leap v2.0 chair from Steelcase seems to be readily available as an “open box” item from Madison Seating (they fell off the back of a truck?). New chairs are also available at Amazon. In a world where nothing is in stock, this suggests that there is a glut of ergonomic chairs.

Wirecutter’s best office chair for 2022, the Steelcase Gesture, is also in stock at Amazon. Ditto for their budget pick, the HON Ignition 2.0.

Could there be a business in exporting all of our high-end office chairs to countries where people still work in-person, e.g., China?

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Medical School 2020, Year 4, Week 3 (Wound Care Elective)

by philg

This two-week wound care elective starts at 8:00 am. Most hospitals have a wound care service that is run by certified wound care nurses who change dressings, order offloading devices, and apply negative pressure wound vacuums to complex wounds. Unusually, our hospital has a wound care physician who joins the nurses in their morning rounds. 

Patients fall into three categories: (1) frail elderly with pressure wounds on their heels, sacrum, and buttocks (decubital ulcers), (2) obese patients with necrotizing soft tissue infections, and (3) IV drug users with abscesses. There are the occasional complex surgical patients with non healing incisions and fistulas (abnormal connects between two hollow organs, e.g., colocutaneous – colon to skin. The head nurse calls out: “We’re going to need all hands on deck for the next one.” A 450 lb. 38-year-old white male underwent debridement for a necrotizing soft tissue infection of the scrotum (perineal infections are common in the morbidly obese diabetic.) General surgery performed a debridement of the “dishwasher” fluid necrotic tissue and applied a wound vacuum to the 10″ x  6″ wound with three incisions merging in the middle. The ICU nurse, PA student on our team, the two wound nurses, and I hold up folds of skin, revealing his testicles, as we remove and reapply the wound vacuum. A first-year nursing student is observing. “Did you see her face?” asks the head nurse. “She was petrified, but I’ll bet she enjoys telling this story to her friends.” We finish rounds at 10:30 am.

[Editor: Let’s hope that nobody quoted Dr. Evil in his group therapy session: “There really is nothing like a shorn scrotum… it’s breathtaking- I suggest you try it.”]

After lunch, Daniel Boone, the 45-year-old attending, takes me to the outpatient wound care clinic and I learn about the Christian mission trips that he runs to Third World countries. “If the patient needs a tooth pulled,” he explained, “I pull it. Nobody else is going to.” After completing a residency in family medicine, he worked as a hospitalist for ten years. He overcame a short bout of alcoholism by switching to a new specialty: wound care. “I loved procedures and I loved guts and blood. I would never want to be a sissy family medicine doc who refers everything out. I realized I had a knack for taking care of complex wounds and that there was a huge need for these providers.” He exhibits old-school tendencies by making house calls and slaughtering pigs, sheep, and goats in his backyard.

The most severe complications of obesity and diabetes get a lot of press. People are warned about heart attacks, strokes, and blindness. After a day at the clinic, however, I appreciate that these patients spend years suffering from chronic issues, such as venous insufficiency and lymphedema that lead to leg ulcers that seldom heal. “People can say fear is not a motivating factor,” said Daniel Boone, “but I can tell you that fear of losing a leg is usually an impetus for change.” He’s living proof, doing a “20:4” intermittent fast in which he is restricted to one meal per day. “This all started because I checked my blood sugar and was technically prediabetic,” he said. “The nurses think I’m crazy, but I’ve lost 15 pounds and my sugars look great.”

(Leg ulcers don’t motivate everyone; many of the nurses on the service are more than 60 lbs. overweight. One of them is trying to bring her BMI down below 40 so that she can qualify for knee replacement.)

During a typical visit, the nurse will remove the patient’s dressings. After a bit of instruction from the attending, the PA student or I take a scalpel and debride non-viable tissue. We might apply a stem cell product (e.g., foreskin or placental-derived tissue) or collagen matrix. If the wound is deep, we’ll apply a wound vacuum. The nurse will then apply compression with a wrap or stocking. The patient will come back 1-2 weeks later and usually end up loving our attending, who has healed wounds that they’ve had for years. 

Wednesday we meet at 6:45 am in the Starbucks parking lot. Against LCME regulations that forbid students and attendings from sharing a vehicle, we hop in his 15-year-old pickup for the one-hour drive to a rural hospital where he runs another wound clinic. Unlike in our academic hospital, everyone here is relaxed and informal. The docs and staff are integral parts of the community.

(Sometimes things can get a bit too relaxed. The attending mixed some ghost pepper red gummy bears into the office’s bowl of regular Haribo bears. Loud Lucy, a refugee from Brooklyn who tells doctors and patients exactly what she thinks, ate one of the red gummies. “I was wrapping up one of the patients when it hit me and thought that I’d fall on her. I made it to my computer and Ginnie brought a wheelchair over. I was already on the ground under the sink in the fetal position.” It turned out that Lucy was suffering from a gastric ulcer. Before Lucy could be rolled to the ER, the attending gave her Pepto-Bismol. “Fortunately, she recovered. I was imagining having to explain this to George [ER doc] and saw my medical license flash before my eyes.”)

We see several diabetic foot ulcers, surprisingly in patients who are neither old nor severely overweight. “Diabetic ulcers” actually occur from neuropathy, or loss of feeling in the foot. Thus, repeated pressure from poorly fitting shoes or a sharp puncture wound goes unnoticed. A 34-year-old mother of two has been suffering from a heel ulcer. She stepped on a nail while setting up a soccer party. This went unnoticed until another soccer mom commented on the nail in her shoe. A person without neuropathy would start to limp from the pain, thus offloading the pressure on the wound.

[Editor: Trigger warning on the next two paragraphs!]

A 53-year-old hunter has had one of these foot ulcers for two months. He is the typical patient whose care was delayed by our overloaded multi-provider medical system. Primary care referred him to podiatry, but there was a two-week wait to get seen. The podiatrist was too busy to do surgery and therefore recommended a conservative treatment with antibiotics. The patient is without feeling in his foot so he couldn’t tell that the wound was getting worse. The wife insisted that he return to the primary care doctor, who eventually referred him to the wound clinic. “No one wanted to operate on this patient for some reason,” said Daniel Boone. “Even though he is not septic, he likely has chronic infection of the bone, which is why this wound does not heal even with offloading and appropriate care.” I probe the wound with a Q-tip and then proceed to insert my pinky to feel the exposed calcaneus (heel bone) in the 3 cm deep wound at the base of his foot.

“We could send him back to podiatry to perform a bone biopsy in the OR, or I could do it today so we get the answer.” Most physicians wouldn’t do a bedside bone biopsy with only local anesthetic, but he’s not most doctors. “We would do these all the time on mission trips, but we practice in a different environment here. This is a great example of how perfection is the enemy of the good. If I did the bone biopsy under local, I won’t get as great visualization but it will cost a hell of a lot less and we get results much quicker. If it’s infected, we know he needs to get an amputation. Most people think osteomyelitis is a medical illness, but it’s really a surgical problem. Get source control [remove the source of the infection].” The patient consents: “I trust you doc.” Daniel Boone supervises as I use the rongeur to bite out a few chunks of the calcaneus and we send them to pathology.

(We see the patient next week. The pathologist found infected bone, which means our patient will lose his foot in a below-the-knee amputation. We explain the situation: “You have osteomyelitis. You’re going to need an operation to try to remove the infected bone. You also have poor blood supply to the foot, which is further preventing healing. I’m going to see if a surgeon will manage this here or if we have to send you to the tertiary care center.” It turns out that a vascular surgeon can do the procedure in this rural hospital. 

“He could sue the hospital and every doctor he touches would go down,” says Daniel Boone. “It doesn’t matter that I got him where he needs to go.” What could have been different? “The podiatrist kicked him around instead of debriding. Everyone thinks that osteomyelitis is a medical illness, requiring 6 weeks of antibiotics. It’s not. Osteo needs debridement to remove the source. I would do it myself, but we are in a large hospital setting where there is an expectation of utilizing specialty services. On my mission trips I would use lidocaine and debride the bone in our makeshift tent. In our health system, I send them to a surgeon who putzes around for several weeks until the patient is septic and needs an amputation.”)

Daniel Boone summarizes his experience: “In my first year in wound care, I changed more people’s behaviors than during my 10 years as a hospitalist and family physician.”

Statistics for the week… Study: 5 hours. Sleep: 7 hours/night; Fun: 1 night. Burgers and beers with Mary and Luke. Mary just finished a one-month cardiothoracic surgery visiting elective at an outside institution. This was part of her interview process for their residency program. She is beaming when describing her first sternotomy (cut into the chest and open the sternum with a bone saw).

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

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Democrats are willing to fight anyone except a foreign invader?

by philg

Democrats frequently promise to “fight” when seeking election. Here’s the party’s thought leader, Alexandria Ocasio-Cortez: “‘We can and must fight‘: AOC urges Americans to ‘get to work’ to defeat Donald Trump following Ruth Bader Ginsburg’s death” (Independent 2020). Nancy’s Pelosi’s 2010 statement on President Obama’s Economic Speech says Democrats are “fighting” for the middle class. The most excellent of current Democrats, as evidenced by his/her/zir/their elevation to the Presidency: “I want to make sure we’re going to fight like hell by investing in America first,” said Biden. (NYT, December 2020) Biden’s inaugural address: “I will fight as hard for those who did not support me as for those who did.” Biden in April 2021: “the climate crisis is not our fight alone. It’s a global fight.” The godlike Obama in 2018: “You can make it better. Better’s always worth fighting for.” Obama in 2009: “I will fight for you. … I got my start fighting for working families in the shadows of a shuttered steel plant.” Hillary Clinton’s concession speech: “I have, as Tim said, spent my entire adult life fighting for what I believe in. … please never stop believing that fighting for what’s right is worth it.”

A Quinnipiac University poll, however, found that there was one thing Democrats did not want to fight against: a military invasion.

As the world witnesses what is happening to Ukraine, Americans were asked what they would do if they were in the same position as Ukrainians are now: stay and fight or leave the country? A majority (55 percent) say they would stay and fight, while 38 percent say they would leave the country. Republicans say 68 – 25 percent and independents say 57 – 36 percent they would stay and fight, while Democrats say 52 – 40 percent they would leave the country.

Here’s more granular data (from the above URL, click “download as PDF”):

White men were the group most likely to say that they were willing to fight, at 75 percent. We’re informed that Americans who identify as “women” are generally strong and independent, but, in the event of an invasion, only 40 percent say that they’d be willing to fight. Americans identifying as “Hispanic” were actually slightly more likely than whites to be willing to fight while Americans who identify as “Black” already had one foot over the border (only 38 percent would be willing to stay and fight, the lowest percentage of any demographic group).

Although most apparently won’t be fighting, Americans who identify as “white women” are the ones who are truly suffering from what is happening in Ukraine, with 65 percent saying that they’re feeling anxious:

When we combine decades of political rhetoric with the poll results, is it fair to say that Democrats are enthusiastic about any fight except one involving a foreign army that is trying to take over the U.S.?

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