Inflation prediction to check in 2028

by philg

“Will Inflation Stay High for Decades? One Influential Economist Says Yes” (WSJ):

When the global economy tanked in March 2020, the rate of inflation looked like it was heading to zero. That made it a surprising moment for former U.K. central banker Charles Goodhart to predict that inflation would hit between 5% and 10% in 2021—and stay high.

“The coronavirus pandemic will mark the dividing line between the deflationary forces of the last 30 to 40 years and the resurgent inflation of the next two decades,” said the 85-year-old economist in an interview. He predicted that inflation in advanced economies will settle at 3% to 4% around the end of 2022 and remain at that level for decades, compared with about 1.5% in the decade before the pandemic.

He argued that the low inflation since the 1990s wasn’t so much the result of astute central-bank policies, but rather the addition of hundreds of millions of inexpensive Chinese and Eastern European workers to the globalized economy, a demographic dividend that pushed down wages and the prices of products they exported to rich countries. Together with new female workers and the large baby-boomer generation, the labor force supplying advanced economies more than doubled between 1991 and 2018.

Now, he said, the working-age population has started shrinking across advanced economies for the first time since World War II, and birthrates have declined as well. China’s working-age population is expected to shrink by almost one-fifth over the next 30 years.

The beauty of the above theory is that we can mark our calendars to test it! I propose January 15, 2028. At least currently, the BLS releases CPI numbers on January 12. The economy is subject to heavy manipulation by politicians seeking reelection, but 2027 won’t have been an election year.

How about we say that this guy is a genius if inflation has, in fact, run at an average rate of higher than 3 percent for the period January 2021 through December 2027? I don’t think it is fair to demand that he be held to the 4 percent upper bound due to the fact that desperation and incompetence among politicians could easily result in some months or years of runaway inflation. I’m going to schedule a blog post for January 15, 2028!

With houses in any reasonably desirable neighborhood going up by 20-50 percent per year, you might argue that betting that Charles Goodhart is correct is too easy. But the WSJ mentions some naysayers.

A central criticism of Mr. Goodhart’s thesis is that countries with more retirees and fewer workers, such as Japan, have the opposite problem—very low inflation rates.

(Wikipedia says that he has a Ph.D. from Harvard and is an professor emeritus at LSE, but he is “Mr. Goodhart” rather than being presented as a colleague of Dr. Jill Biden, MD, PhD.)

I’m prepared to love Professor Dr. Goodhart because he references the Black Death in responding to the above criticism:

Mr. Goodhart argued that workers likely won’t save enough for their retirement, and that pensioners consume more than they produce, especially with healthcare. The dwindling pool of savings, combined with increased corporate spending to secure supply chains and make up for a lack of workers, will push up interest rates, he predicted. He said the Black Death, a 14th century pandemic, triggered a quarter-century of soaring wages and rampant inflation.

See

for my own Black Death obsession.

If Goodhart is correct, anyone who doesn’t take a fixed-rate 30-year mortgage offered at 3.25 percent is going to feel stupid!

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Two-year anniversary of National Naval Aviation Museum’s temporary coronapanic closure

by philg

Two years ago (CBS):

The National Naval Aviation Museum is temporarily closing due to concerns over coronavirus.

The museum will be open this weekend, and then close on Monday, March 16.

According to the museum’s official web site, the museum is now technically open, but practically closed because the taxpayers who have been funding it for the past two years are not allowed on the base.

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How is Women’s History Month going?

by philg

How is Women’s History Month going for you? Here’s what happens when you type “women’s history month” into an incognito browser (i.e., not affected by your previous search history):

Note that Black History Month and National Hispanic Heritage Month are related events, as far as Google is concerned. I’m not sure what corner of Google’s algorithms decided that “Oh Bondage! Up Yours!” was a good theme song for the month.

Some people think little girls should be seen and not heard
But I think “oh bondage, up yours!”
One-two-three-four!
Bind me, tie me, chain me to the wall
I wanna be a slave to you all

Here’s another choice from Google for “Women’s History Month” music, “Girls Need Love”:

I just need some dick
I just need some love
Tired of fucking with these lame n****s
Baby, I just need a thug
Won’t you be my plug, ayy

Do the above lyrics fall into the “resilient”, “brilliant”, or “boundless” category? (from the preceding image)

(Separately, if the girl seeking a “thug” to be her “plug” is also seeking $millions in tax-free cash, she might wish to verify the thug’s income with IRS Form 4506-C and also arrange for the plugging to occur in a state where unlimited child support profits are available. What rhymes with “4506-C” for updated lyrics?)

The first page returned by Google includes a link to a Presidential proclamation. Dr. Biden’s spouse notes that “LGBTQI+ women and girls are leading the fight for justice, opportunity, and equality — especially for the transgender community.” (contrast to the use of “2SLGBTTQIA+” by Justin Trudeau) Yet Mx. Biden never defines what he/she/ze/they means by “women” or “girl.” Maybe that is a job for a new committee?

I established the first White House Gender Policy Council to advance gender equity across the Federal Government and released the first-ever national gender strategy to support the full participation of all people — including women and girls — in the United States and around the world.

Readers: What have you done so far to observe Women’s History Month 2022?

In our family, we showed the kids Welcome to Earth, Descent into Darkness, in which Will Smith goes down in a research submarine with Diva Amon, who apparently identifies as a “woman of color” (26:40):

A big part of my work is trying to change that. I’ve been on like 16 expeditions now and there is hardly ever anyone who looks like me. Whether it’s a woman, a person of color, or a person from a developing country. And I want that to change. That’s a big part of why I do what I do.

Dr. Amon provides a technical explanation of the sub at 25:00 in which she explains that there is “horrible creaking” that is “unnerving.”

A person who doesn’t look anything like Diva Amon makes an unfortunate appearance at 3:09. It seems that the technical aspects of the dive and the submersible and, therefore, the safety of Will Smith and Diva Amon, are entrusted to someone who could appear in Mediocre: The Dangerous Legacy of White Male Power.

The Nadir submersible is an off-the-shelf product described in “Blue Planet gives super-rich their new toys – submersibles” (Guardian), a Triton 3300/3. The engineers who designed it are not credited in the show, but searching for the sub’s name eventually leads to the Triton Team page and the engineering team that made the machine possible:

Plus two engineers on the top management roster:

In addition to being an inspiring story for Women’s History Month, by not mentioning any of the engineers who made the dive possible, the show serves as a great lesson for anyone considering making the mistake of majoring in engineering!

Related:

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Medical School 2020, Year 4, Week 5 (Cardiothoracic Surgery, Week 1)

by philg

The cardiothoracic surgery service invites in some residents and medical students each year, but does not rely on them in the same way that other services do. For six months per year, PGY3 residents come in one month at a time. I am one of four medical students who will rotate in this year. Instead of the usual group of residents, an army of advanced care practitioners (ACPs, physician assistants and nurse practitioners) run the OR, ICU, and step-down units (separate wing of the hospital from general surgery’s).

The clerkship director is a portly bald 60-year-old with a truly general cardiothoracic practice:  4 CABGs (coronary artery bypass graft) per week, 2-3 lung resections (removing lung cancer tumors), and 3 esophageal resections per month. “Most CT surgeons that graduate focus on either thoracic or cardiac. If I had to choose, I would focus on more thoracic now just because the lifestyle is better. As I get older, I’m less enthusiastic about being paged in the middle of the night.” He also noted that demand for cardiac operations is weakening due to interventional cardiology with newer stents and endovascular heart valve replacements (e.g., transcatheter aortic valve replacement or “TAVR”). 

A typical day requires getting up at 4:30 am to look at the case board on Epic to select interesting operations, e.g., a CABG or an aortic arch replacement. I get in at 5:45 am to pre-round on patients on whose cases I previously scrubbed in. Each attending comes in at a different time to round on his or her patients with the ICU ACPs before cases begin at 7:00 am. I struggle to find them, roaming the OR, ICU, pre-op holding, and step-down units and pestering nurses every 10 minutes: “Have you seen Dr. Johnson yet?” I balance rounding on my patients with preparing for today’s cases and try to find the attending with whom I want to scrub in. I usually find the patient first and introduce myself before getting formal approval from the attending.

The first case is a video-assisted thoracoscopy surgery (VATS) lung resection for a pulmonary nodule highly suspicious for lung cancer. The nodule was not amenable to biopsy. We are removing his right upper lobe (about 35 percent of one lung). The patient’s lungs are terribly emphysematous from smoking. Large black spots and fluid-filled blebs line the lung surface. The attending points out all the relevant anatomy to me, for example, the pulmonary veins and aortic arch. I close the small incision after the PA closed the fascia and port sites. The case ends around 12:30 pm. 

(I follow this patient for the next week. A known complication of this surgery, especially when the lung has been compromised by smoking, is an air leak into the pleural cavity from damaged lung tissue. Air seeping into subcutaneous tissue inflates his left chest wall, giving him the appearance of a weightlifter who works only his left pec. After 24 hours, the air has expanded his neck and face to chipmunk proportions and we take him back to the OR to pour water on the lung in hopes of finding the leak. The anesthesiologist will inflate the lung and we spray talc powder wherever we see bubbles. The resulting scar tissue sealed up the lung for this patient. Pathology results came back a week later on the tissue we’d removed. He had adenocarcinoma, stage 1. Translation: we found it in time and cured him, at least until the next smoking-related cancer reveals itself.)

Each attending handles one major case per day, four days per week, and has an additional weekly clinic day to talk to pre-op and post-op patients. I can generally leave at 1:00 pm, but there is usually an interesting patient in the ICU and a lot to be learned from the ACPs. For example, we have two patients on extracorporeal membrane oxygenation (ECMO) after septic shock. While the PA and perfusionist are explaining ECMO indications and options, there is a rapid response on my patient after a post-op day 2 coronary artery bypass graft (CABG)..

Our 86-year-old patient is in atrial fibrillation with rapid ventricular response (“AFib with RVR”; pulse in the 150s). She is conversant, but disoriented and feels lightheaded. “My heart feels like it’s fluttering.” All patients in the cardiac ICU have defibrillation pads on. If there is time, we sedate patients with fentanyl or Versed before energizing the pads, but in this case we just shook her and she yells from the pain before returning to her disoriented haze. Unfortunately, she returns to AFib with RVR quickly. This cycle happens again. Her condition worsens. She goes into ventricular tachycardia, but still has a pulse so we don’t begin CPR (compressions). The ICU team pages the electrophysiology cardiology team for advice. They recommend something we’d already ordered: a bolus followed by a drip of amiodarone, an antiarrhythmic agent. This should have been on the code cart, but it hadn’t been restocked so we waited roughly 6 minutes for our dedicated pharmacist to bring it up.

The attending, our clerkship director, eventually arrives and instructs us to stop the dobutamine drip (heart stimulator). Our patient goes into and out of sinus rhythm and AFib with RVR now. The attending asks whether we are pacing her atrium. The NP running the code grabs the pacer machine. During the surgery, atrial (blue) and ventricular (white) wires were placed in the patient’s heart muscles. They’re capped when not in use, however, and the rushing NP plugs them into the wrong ports of the pacer machine. Due to the switched leads, we can’t program it to atrial pacing. “Who switched the leads?” the attending asks. “Our atrial lead is always blue. Who switched this? I want this written up.” The NP: “I did. I will take the blame for that.” The other nurses and ACPs shake their heads. The attending storms out.

[Editor: Why wouldn’t these leads and ports have connectors such that it was mechanically impossible to hook them up in reverse? How tough is it to crimp a 15-cent connector on the end of the lead instead of relying on bare copper and a color convention?]

As the staff return to the nursing station, my attending continues to unload on the NP: “I also need to talk to you about removing the Swan-Ganz catheter on my patient. When we are using that information to increase pressors, don’t remove it until we have stopped the pressors. How else will we know if we can stop that intervention? How do we know she still needs the pressors?” (He has a legitimate point, the NP should not have green-lighted the removal of the Swan-Ganz catheter while the patient was on an increasing pressor requirement, despite the pressure to remove it under the established standardized protocols.)

Cardiac surgeons have a reputation for being unfriendly to students, but I found them quite welcoming in the OR, if not prone to small talk. Nobody asked about my background or what I hoped to do after graduating.

Statistics for the week… Study: 5 hours. Sleep: 6 hours/night; Fun: 0 nights. Coffee with Ambitious Al at the hospital twice. To boost his resume for plastics residency, he is doing three away rotations, also known as “acting internships” or “visiting electives”.

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

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The Money Mandarins are responsible for our debased money

by philg

Raging inflation at the sushi and noodles place near Legoland (burned some $4.50/gallon dinosaur blood in the minivan):

Can we find someone to blame for our debased money? The Wall Street Journal can! “The Humbling of the Federal Reserve” (3/14/2022):

The central bank faces an inflation mess of its own making.

Government spending excesses in 2020 and 2021 played a role, but the Fed made all of that easier to pass by maintaining the policies it imposed at the height of the pandemic recession for two more years. Low interest rates make deficits seem more fiscally manageable than they really are. The Fed has continued to buy Treasurys and mortgage-backed securities even as inflation nears 8%—right up until this week’s meeting.

What went wrong? The Fed is supposed to have the world’s smartest economists and access to the best financial information. How could they make the greatest monetary policy mistake since the 1970s?

Part of the answer lies with the Fed’s economic models, which are rooted in Keynesian analysis in which demand trumps all. The Fed models give little thought to incentives for or barriers to the supply-side. As finance scholar Emre Kuvvet wrote recently on these pages, among economists in the Federal Reserve System, Democrats outnumbered Republicans by 10.4 to 1 in 2021. They prefer James Tobin over Milton Friedman.

This leads the Fed to overestimate the growth effect of federal spending but underestimate the growth benefits of regulatory and tax reform. For years after the 2008-2009 recession, the Fed’s governors and regional bank presidents predicted faster GDP growth than what happened. But they missed the faster growth after the 2017 tax reform.

What happens next? We’re told to expect an 0.25 percent increases in interest rates. How much of a difference can that make when interest rates remain lower than inflation (i.e., when you’d have to be a fool not to borrow)?

The news from Legoland isn’t all bad, incidentally. There are no problems too challenging for Presidents Biden and Harris to tackle from the White House:

History lesson: a stroller was often as important as a battle axe:

Related:

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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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