Book recommendation: The Great Siege, Malta 1565

Sadly topical, let me recommend The Great Siege, Malta 1565 by Ernie Bradford. For Americans softened by 150+ years without war on our soil, this is a sobering reminder of the nature of war and life in a besieged city. For those who are concerned about the fighting abilities of the innumerate 79-year-old whom Americans elected as our Commander in Chief, the book may provide some comfort. Suleiman the Magnificent, who ordered the siege, was nearly 71 years old at the time. Dragut, “The Drawn Sword of Islam”, who proved to be Suleiman’s best military leader, was 80 years old. Jean Parisot de Valette, who led the defense and gave his name to Malta’s capital, was 70.

Trigger Warning: the book’s author died in 1986, when Science was but poorly understood, and thus the book lacks coverage of how the 2SLGBTQQIA+ and BIPOC communities experienced the siege.

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Central Planning Success! (COVID-19 tests are arriving today)

Today is the day that muscular government action brings relief from COVID-19-related shortages. Our “free” (taxpayer-funded) at-home test kits are arriving. From USPS:

These were ordered on January 19, the first day of official availability. They’ll arrive approximately 5 weeks after the tests became generally available at retail in local pharmacies.

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Medical School 2020, Year 3, Final Weeks (Emergency Medicine)

Night shift: midnight – 8:00 AM. My resident is a 28-year-old whiz kid with slicked-back hair. An ED nurse rooms our first patient and drops off the paperwork. She teases, “Have fun, he’s here for bugs!” My resident sends me in there alone. “Good luck!”

The 55-year-old is presenting from home complaining that there are bugs crawling all over him. He wants us to write a note agreeing with him, so he can sue his landlord. “The bugs are everywhere. They are crawling inside me now.” I ask him where they are. “Everywhere. See.” He pulls out a zip block bag with a q-tip with ear wax on it. “See the bug.” He denies any drug use except marijuana. He is so convinced that he is convincing. Searching for the bugs, I am almost as confused as he seems to be. 

I present to my attending and resident. Within a few words, my attending has already figured out the problem. She states, “MJ is laced with meth around here. These delusions can be so strong that nothing will change their mind. I’ve had people bring in zip-lock bags with tampons claiming there are bugs. I just hope there are not any bed bugs on him.” We go in to see him together, and try to explain that there are no bugs on him but he may have taken meth. We offer to do a UDS [urine drug screen].” He becomes combative. He storms out of the ED.

My attending summarizes, “EM would be amazing if not for the addicts and psychotics. They suck out your soul.”

[Editor: Maybe she would be happier practicing medicine in a country where the government-run health insurance system doesn’t purchase opioids in tractor trailer quantities?]

My resident asks me what I want to do. I respond that I am not sure. “Well, if you’re debating between EM (emergency medicine) and IM (internal medicine), it’s easy. If you like to perseverate on stuff that probably doesn’t matter and will get better with time, do IM.” He continues, “EM is for people who have ADHD and want to fix things quickly and do procedures. We deal with putting out the fire. I’m not going to be great at everything, but we get the job done. We do eye procedures and central lines. We’re not as good at eye stuff as the opthamologist and we’re not as good at central lines as the intensivist. I had to put in a suprapubic catheter to drain 3 liters of urine [the bladder ordinarily holds no more than 0.5 liters]. I’ve never done that so I looked up the procedure steps and watched it on youtube. I got the job done.”

After a slow few hours, a neighboring resident comes over to our pod and asks if I want to do a lumbar puncture (LP)? A 45-year-old female presented with a several-week history of worsening headaches, gait disturbances, and visual changes. Neurology evaluated and is concerned about the possibility of a rare encephalitis. Neurology is busy so they asked if the ED wanted to perform the LP. After we consent the patient, the attending and resident help me prep the patient and numb her up with lidocaine. We lay her on her left side and ask her to bend over, thereby flexing her spine to open up the lumbar vertebrae. I insert a long spinal needle into her back, slightly off midline, while aspirating on the plunger. I keep hitting bone. After 3 attempts, the resident takes over and also struggles. The attending gets it on the second attempt. “That was hard, she must have some bad arthritis.”

After the last clinical day of M3 year, our entire class gathers in the medical school lecture hall for the M4 lottery. We are each assigned a number and go in order selecting M4 rotations. Straight-Shooter Sally is stressed because she would like to do “Acting Internships” at other institutions. “If I get the wrong order, I won’t be prepared when I have to do my AI.” (For example, someone interested in a cardiology AI would try to do the cardiology rotation at the home institution just prior.)

Statistics for the week… Study: 12 hours. Sleep: 7 hours/night; Fun: 2 nights. House party at Buff Bri’s house to celebrate the conclusion of M3 year. Sarcastic Samantha talks about her job distributing new admissions among the hospitalists.. She explains, “I have to fight with the hospitalists. They act like children. When we get a new heart failure exacerbation in the ED, they whine, ‘Why is it my turn?’ Because you haven’t taken one all week.”

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

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MIT weighs in regarding the war in Ukraine

Portion of yesterday’s email from Rafael Reif, president of the Massachusetts Institute of Technology. Note the implication that Russians are suffering just as much as Ukrainians (in bold):

To the members of the MIT community,

Though 4,500 miles separate Kyiv and Cambridge, several factors make the shock of the Russian invasion and its terrible consequences feel very close to home.

I write to let you know how MIT is responding to this catastrophe and to offer some personal reflections.

Caring for members of our community [bold in original]

First in our minds are our students, staff and faculty who are from the region or have family there; we have reached out directly to everyone we are aware of from Ukraine. We have in addition been in touch with our students from Russia, who are also a long way from home in a difficult time. (As always, support is available to all students at doingwell.mit.edu).

A fellow MIT alum pointed out “Catastrophe makes it sound like an earthquake or a tornado.”

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Eileen Gu plus affirmative action = path for billionaires to ski in the 2026 Olympics?

Originally-American Eileen Gu has been criticized by Americans for getting a Chinese passport and choosing to compete on China’s team at the 2022 Olympics. Let’s look at the BBC as a neutral source:

A San Francisco native who learned to ski on the pristine slopes of California’s Lake Tahoe, she is representing China, not the USA, in the Olympics – a move that has come at a sensitive time for Sino-American relations, and has inevitably placed Ms Gu at the centre of a global debate on geopolitics and representation.

Ms Gu has expressed support for movements Black Lives Matter and spoken out against anti-Asian violence in the US, but remained silent on issues like the mass internment of ethnic Uyghurs in Xinjiang and the arrests of pro-democracy protesters in Hong Kong.

“There’s no need to be divisive,” she told news site The New York Times.

Why would Eileen Gu prefer to represent China? Here’s what New York-based The Guardian US adds to every article displayed in Apple News:

An erosion of democratic norms. An escalating climate emergency. Corrosive racial inequality. A crackdown on the right to vote. Rampant pay inequality. America is in the fight of its life.

Given a choice, what rational person would want to be associated with a country that is packed with enough haters to create so many problems? Gu has personally experienced the Asian Hate that my former neighbors in Maskachusetts bravely put up lawn signs to #Stop: “Eileen Gu calls out ‘domestic terrorism’ of Asian-Americans amid spike in coronavirus-related violence – ‘killing more Asian people isn’t going to kill the virus’” (South China Morning Post):

“This was in San Francisco – supposed to be the liberal bubble within California, which is the most liberal state, in the most liberal country in the world. This was supposed to be the safest place and I felt physically in danger. I grabbed my grandma and we ran out. I was so scared. That moment was definitely a reset because I realised how close to home it hit. That anybody can be affected just because of the way they look or their culture and heritage.”

The superstar athlete’s response to the carping of her inferiors (NBC):

At a press conference after her victory, Gu said she’s trying to be an example for young women and has no interest in the politics or social media debates.

“If people don’t believe me and if people don’t like me, then that’s their loss,” she said. “They’re never going to win the Olympics.”

(Side note: What is the “example for young women”? That their lives too can have value if they win Olympic gold? Also, how does Eileen Gu define the term “women”?)

Let’s look at another recent story and see if it can be combined with the above inspiring tale of a young person who escaped “corrosive racial inequality”, “rampant pay inequality”, and “a crackdown on the right to vote.” “Competing in the Winter Games, Without a Snowball’s Chance” (NYT):

One by one they zigzagged down the mountain, near the end of a line of nearly 90 racers in a snowy giant slalom, looking more like ski hobbyists on a weekend jaunt than world-class competitors.

Many of the skiers were first-time Olympians, brought together by one very pertinent thing they have in common: a shortage of snow in the countries they are representing in Beijing, including Jamaica, Ghana, India, East Timor and Morocco.

“I always say, ‘There is a first league, and there is a second league. We are, for sure, the second league,’” said Carlos Maeder, 43, who is representing Ghana and is the oldest skier at this year’s Games. “Maybe even the third league,” he added, chuckling.

Keenly aware that skiing has been dominated by athletes from richer, colder countries, the International Olympic Committee and skiing’s world governing body have tried to make the sport more inclusive through a quota system that lowers the threshold of qualification.

“I was never going to be competitive,” said Benjamin Alexander, a 38-year-old Jamaican skier and former D.J. He finished last in the giant slalom in a race on Sunday. “The people I was competing against started skiing at 2 and had their first race training at 4 or 5,” he said.

Mr. Alexander started skiing when he was 32.

The typical rich American is a reasonably good skier. The U.S. allows dual passports. East Timor might be happy to give an American billionaire a passport and a place on its Olympic team in exchange for a small (by billionaire standards) cash payment. If not the billionaire then the athletic child of the billionaire. What better way to experience the Olympics than as an athlete? (and, in fact, this year it was the only way for an American to experience the Olympics)

Readers: What could go wrong with the above scheme?

Related:

NYT reader comments on the New York Times article regarding affirmative action for athletes who are not good at winter sports:

I think we should add meat packing and fruit picking in summer heat to the Summer Olympics. Perhaps it will show the world the horrors the migrants are treated in this country.

I don’t think Americans fully grasp what it means to some of these countries see themselves represented in the games. Seriously, the privilege of the comments in this article drives me nuts. Travel the world and you’ll learn that yes, being American is itself a privilege in more ways than you thought you’d be able to comprehend.

(Norwegians have even more privilege, therefore, since they win way more medals?)

A better way to diversify the winter games would be to include more sports that can be learned without fancy facilities. How about snowshoe racing? It’s really just running (in snowshoes) and there are many poor countries with great runners.

This is same thing as space voyeurism at this point except Olympic voyeurism.

I was fortunate enough to watch the bottom tier skaters the other day, stumbling or falling, getting up and finishing with grace and gratitude. Pure joy to be there…and the greatest lesson from the Simones and the Mikealas of the world is that a champions bad day can be someone else’s lifetime achievement. Nothing makes someone more weak and vulnerable than to be crushed because of lack of perfection, it is they who are without hope or faith.

(Paul, Bay Area) How about we simply stop Winter Olympics until we fix the climate ? I love the Olympic Games, winter sports, but it is so incongruous with the climate trends that my heart is not in it.

Nobody is getting into Harvard who can barely read. Penn, maybe. At least back in the day.

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Medical School 2020, Year 3, Week 40

The second week of EM. As soon as I put my bags down for the second shift (2:00 PM to 10:00 PM) at the physician/nurses station, a code blue is called over the loudspeaker – “Code Blue, Triage.” My PYG3 resident, a 30-year-old mountain biking enthusiast yearning for his upcoming Montana life after graduation in a few short months, waves for me to join as several residents, nurses, and attendings briskly walk over to triage.

A 70-year-old obese female is lying on the floor surrounded by six people. Two are taking turns performing chest compressions. A resident is attempting to ventilate the patient with an Ambu Bag manual resuscitator. We get the patient onto a stretcher, and cart her off to one of our rooms. The ED is divided into a trauma section, triage, a sick section, an observation unit, and a healthier section. Once she is on a bed in the sick section, an attending and her resident prepare to intubate.

The attending hands a GlideScope, a video-assisted laryngoscope to the resident.  Unlike a traditional direct laryngoscope that allows only the intubator to see what is happening, with the GlideScope both the attending and resident can see what’s in front of the scope, The resident then inserts the blade and visualizes the cords, but struggles to get the ETT (endotracheal tube) through the vocal cords. They are tight. He asks for a “boogie,” a long thin bright blue bendable plastic tube that he is able to pass through the vocal cords. He takes the laryngoscope out, threads the ETT over the boogie, and pushes the ETT forward aggressively. The attending asks, “Are you in?” He responds, “Yes, I feel the tube gliding over the [tracheal] rings.” The attending agrees, “I feel you too,” as she removes her hands from the neck.

The respiratory therapist (RT) hands us the tubing connected to the ventilator. Every tube  at initial intubation is hooked in series with an end-tidal CO2 colorimeter. If the ETT is correctly in the trachea (i.e., not in the esophagus) carbon dioxide on exhalation will change the color confirming correct placement. While this is going on, another attending and resident are “dropping lines” including a central venous catheter and arterial line.

We learn that a granddaughter brought the patient after she had trouble breathing with wheezing. The daughter said, “She was just in the hospital for a COPD exacerbation two months ago.” The patient was coding for 20 minutes. My attending asks if the family would like to come in during the code to watch. (Afterwards, she says there is evidence that the family seeing the end-of-life code is helpful for the grieving process.) The granddaughter, daughter, and son-in-law take one step into the room and begin sobbing. They step out after a few minutes. On the next pulse check, the patient is still in asystole. My attending asks if anyone has any other thoughts. “We’ve ruled out other reversible causes of arrest.” After a short pause with silence, she announces, “Time of death – 15:25.” There is a quick debrief afterwards, and then everyone scatters. I help the two nurses get the patient presentable for the family to come into the room for one last farewell. The charge nurse can tell this is my first code. “Oh sweetie, thanks. We cannot forget to clean their bottom.” The other nurse chuckles, “Post-mortem shits. Nothing quite like it.”

Immediately after this a mother brings in her 20-year-old daughter, a bone-thin IV drug user with uncontrolled type 1 diabetes who presents for weakness and confusion. She is found to be in diabetic ketoacidosis (DKA) and is septic from likely bacteremia. She is tachypnic (breathing fast) and becoming more lethargic. The attending states, “We need to intubate her now.” The attending and resident let me intubate the patient. The resident instructs the charge nurse to grab an induction agent and paralytic. We first pre-oxygenate the patient by placing a non rebreather (breathing mask) over her mouth. After two minutes, the attending tells the nurse to push the sedation followed by the paralytic. 

The resident hands me the GlideScope. “Watch the teeth! It’s not a rotation motion, it’s a lift up to the crease between the wall and ceiling.” I struggle with the motion, being too timid. The attending pulls my hands to the sky, supporting the entire weight of her head and neck off the table, pulling into view the vocal cords (pretty much a perfect view… she is an easy intubation). I guide the ETT through the vocal cords. Once through, the RT blows up the balloon. Once intubated, the RT connects her to the mechanical ventilator. 

After a few minutes, the nurse comes out to the station saying the patient is now hypotensive (low blood pressure). The attending asks, “How much fluid has she gotten?” The resident says, “She’s gotten two liters, and she is a tiny skinny lady.” My resident turns to me, “Would you like to place a central line?” I exclaim, “Yes.”. “If you can grab all the right stuff, it’s yours.” I speed off towards “Walmart”, the ED stockroom. I grab a central line kit, sterile ultrasound probe cover, enough suture to weave a sweater, and several pairs of sterile gloves. The resident jokes, “Not bad.” While I was off, he had already grabbed everything we needed. “Let’s get started, the hardest part is positioning everything.”

After we place the patient in Trendelenburg, we open up the kit on a stand. I put a sterile gown on with my resident’s help, and then my gloves. He does it all by himself. We prep the patient. The nurse hands us the ultrasound and we are ready. Okay, show me the internal jugular. I grab the ultrasound and scan up and down the neck. “It’s the plump vessel, next to the pulsing carotid.” I push down with the ultrasound probe, thereby compressing the internal jugular (IJ) vein. “Notice how the IJ nearly compresses on inhalation. She is quite hypovolemic.” The resident hands me all the tools in the right order. I insert the access needle into the IJ under ultrasound-guidance. “Don’t freak out when blood squirts back at you. Hold steady. I’ll hand you everything. We both will freak out if it is pulsatile (indicating we hit the carotid and not the IJ)” Once I get blood return, he hands me the guidewire that I thread through the needle. “Look at the ectopy on tele!” (when the guidewire knocks around in the atrium it can cause aberrant heart beats.) I communicate, “It’s threading easily.” I take the needle out, and he hands me the dilator followed by the flushed catheter. The catheter goes in smoothly, I suture it in place. I struggle placing a sterile covering, a fancy plastic lining that goes over to try to prevent infections. “I’ll do that, this is our signature for nurses.” 

As we walk out, the resident shares, “One of my best friends has type 1 diabetes. I’ve noticed that type 1 diabetics are either extremely health conscious and disciplined, or are complete wrecks and die of massive heart attacks in the 40s.”

I leave exhausted, but am too excited to fall asleep. Type-A Anita has been active on Facebook. She writes about a New York City article citing the rise in divorce rates: “I’m glad the divorce rate is higher. You want to know why the divorce rate was so low back in the Day? It’s because your grandmother did not feel safe to leave the relationship. It means women feel empowered now to leave their shitty husbands because they are not dependent on any man. #StandUp”

[Editor: Type-A Anita is on track to make $400,000 per year in ob-gyn and her fiancé (now husband) is in a much less lucrative career. If she is unwise enough to settle in one of the states that awards alimony, in about 15 years we might find that her opinion on this topic changes…]

Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 2 nights. Beers and burgers with Sarcastic Samantha. Mischievous Mary unexpectedly joins midway. She recounts walking away from her Tinder date without introducing herself to the young man because he showed up to the restaurant  in an undisclosed wheelchair.

[Editor: It would appear that the medical school’s heavy investment in diversity and inclusion education is not reaching everyone.]

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

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Individual Americans show Vladimir Putin how tough we can be

“More than 1,000 gather at SF’s City Hall to protest Russian invasion of Ukraine” (SFGate, 2/4/2022) will no doubt strike fear in the hearts of the any foreign military. The accompanying photo shows that a handful of the Followers of Science are equipped with hearts brave enough to go outdoors without a protective cloth mask (our 6-year-old pointed out, however, that “one has a chin diaper”):

The bellicosity of this partially masked Army of the Righteous is described in the text:

Many waved blue and gold Ukrainian flags, and there was a sea of signs within the crowd. Some read “Russians Go Home,” “No USSR 2.0” and “Support Ukraine.” Expressing both sadness and anger, the crowd chanted “Stop Putin” and “Hands of Ukraine.”

“The reason I’m here is to raise awareness of Putin’s war and show the world that Ukrainians in America stand with those in Ukraine,” said SF resident Andy Soluk, who held a flag.

While the shooting war raged and folks in San Francisco were sending thoughts and prayers, what other foes were significant enough to get the attention of the Army of the Righteous? Were they, perhaps, fighting to provide housing for the thousands of their brothers, sisters, and binary resisters who live in Bay Area tent cities? Working with Barack Obama to continue the planet healing that began in 2008? Here’s a February 25, 2022 letter from administrators at University of California Berkeley:

The campus leadership recognizes that it’s hard to adjust to the reality of masks no longer being required (even if they’re still recommended in some settings). That’s why our campus will be one of the last places in the Bay Area to still require masks prior to when our mandate is lifted on March 7. These changes are indeed difficult and I encourage anyone who would feel more comfortable wearing a mask to continue to do so. But I also encourage you to grapple with the fact that the consensus within the public health community is that it is no longer necessary to mandate masking.

Imagine the tenacity and inner strength of a person who can surmount the trifecta of (1) adjusting to reality, (2) coping with the difficult mask order change, and (3) grappling with the new facts of Science!

(Separately, regarding the impending mask-optional vaccine-and-booster-required Berkeley campus, Science tells us that (1) mask orders and vaccine coercion were highly effective at reducing SARS-CoV-2 infections and (2) the virus will be with us forever, including in potentially dangerous new mutants, Combining (1) and (2), it makes logical sense to drop these proven-effective-by-Science policies and let any future plague rage exponentially. Now that those who Follow Science know exactly how to fight COVID-19, they aren’t going to bother to exert any effort in that fight.)

And, in case that you think the valorous are limited to San Francisco, a friend in Colorado sent me the following today:

I sat in on the Zoom call our public health dept had on ending mask mandate a week ago. When asked why if they decided to end it on Monday the end wouldn’t go into effect till Friday they said they had to give people time to absorb and adjust to the new reality.

I also loved that they are voting on, and agreed to, ending a mask mandate on a zoom meeting because it was still too risky to meet in person.

Fortunately, many local business have followed the science and kept their own mandates in place.

On a vaguely related theme of cultural difference, can readers who speak Russian please tell us what the Russian recruitment video says? And, if military service is compulsory for Russian males, why do they have recruiting videos at all?

And our state-sponsored media (NPR) reminds us to curl up into the fetal position. From “5 ways to cope with the stressful news cycle” (2/25/2022; URL: “anxiety-tips-self-care”):

Russia invaded Ukraine this week, … don’t forget to care for yourself in other ways … Breathe … Nourish yourself. The kitchen is a safe space for a lot of us.

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The Guardian promotes open borders and decries 40 percent rent inflation

“Renters across US face sharp increases – averaging up to 40% in some cities” (The Guardian):

According to an analysis conducted by RedFin, rents in the US jumped 14% in December 2021 to $1,877 a month, the largest rise in more than two years.

Some of the most affected cities included Austin, Texas, with a 40% increase in rental prices compared with a year previous, New York City at a 35% increase, and several metro areas in Florida exceeding over 30% increases in rental prices.

Members of the 2SLGBTQQIA+ community are the worst-afflicted, according to The Guardian:

His $1,500-a-month rent was already a struggle for him to pay, and if late on rent payments he incurs a $100 fee. With the latest rental increase of nearly $450, he worries about his future in Sarasota, a community he’s lived in and helped build as a promoter and organizer for LGBTQ events over the years.

“Now, I can’t even afford to live in the community that I helped to create,” added Beadle. “This is not OK, There needs to be an answer for the young, single people who are trying to survive and thrive. We can’t just be happy with being able to pay rent one more month not knowing if we will have a place to live next month.”

One week before his wedding in January 2022, Joey Texeira and his partner received a lease renewal from their landlord in New York City, with a 30% increase to rent of $750 a month for a one-year lease renewal or a 41% rent increase of $1,050 a month for a two-year lease renewal for an apartment they have lived in since December 2020. The lease renewal would start on 1 May.

“We’re very stressed and don’t know exactly what we plan to do yet,” said Texeira.

His husband was also unexpectedly laid off recently and their neighbors downstairs were recently priced out of the apartment building with a rental increase of $250 to $500 added to their monthly rent.

How is it possible that the market-clearing price for housing is going up? Let’s look at the demand curve:

Why does the demand curve rise? Partly this is due to the no-fault (“unilateral”) divorce revolution, which creates more households per capita (the typical U.S. state’s family law takes people out of the workforce (successful plaintiffs face a huge disincentive to work because W-2 wages might result in a reduction of the family court gravy train), which reduces GDP available to build housing). But mostly the demand growth is due to immigration: “Modern Immigration Wave Brings 59 Million to U.S., Driving Population Growth and Change Through 2065” (Pew 2015).

A larger population might not result in a housing crisis if every new addition to the population had sufficient skills to earn enough to afford a new house, but even Americans at the median cannot afford to live in a new apartment (see City rebuilding costs from the Halifax explosion for some numbers).

Leading up to the shock and horror of the 40 percent rent increase story, The Guardian has been advocating for increased low-skill immigration to the U.S. Here’s an example explicitly calling for “open borders” … “Why Democrats should support open borders” (Reece Jones, February 2018):

… the Republican leadership has already settled on an extreme position that will substantially reduce all immigration to the United States. … In the face of this recalcitrance, the Democrats must rethink their current incoherent immigration policy and argue robustly for more open borders.

Open borders could have an enormous positive impact on GDP worldwide.

The concern that some citizens might lose jobs to immigrants is not supported by research. One study found migrant and native workers are employed in different sectors of the economy, another showed that migrants create 1.2 additional jobs beyond the job they do because they rent an apartment, buy a car, and frequent local businesses.

How many people would actually move if borders were open? A 2011 Gallop survey found that 14% of the world population would like to move to another country, with perhaps 100 million wanting to go to the US. These numbers may alarm some, but these movements would happen over years, or even decades.

… there is not a moral or ethical reason to justify restricting the movement of other human beings at borders.

I disagree with Professor Jones that there are only 100 million people who would want to come to the world’s 2nd most generous welfare state (measured by percentage of GDP devoted to welfare). The U.S. offers free unlimited health care via Medicaid and/or simply going into a hospital for “charity care.” Why wouldn’t anyone on Planet Earth who has a serious illness want to come to the U.S. for pull-out-all-the-stops treatment? The cruel National Health Service in the UK won’t spend money if the bureaucrats don’t think it is worth it (explanation). But if you’re 80 years old and think that you might benefit from some joint replacements, why not pop over from the UK to the US and get the $300,000 of surgery that the UK’s NHS is denying? Since the borders are open, it will always be possible to migrate back.

On the other hand, I agree with Professor Jones that, under the ethics and morality professed by a majority of Americans, there is no reason to deny people from the world’s poorest countries free housing, health care, food, and smartphone here in the U.S. If “housing is a human right” is our reason for providing taxpayer-funded housing to an American who chooses not to work, an undocumented migrant should be equally entitled to a free house since the migrant is equally human.

Maybe that “open borders” headline is an outlier? Let’s sample “opinion plus US immigration” in The Guardian. “The Biden administration has ended use of the phrase ‘illegal alien’. It’s about time” (Moustafa Bayoumi, April 2021):

Real immigration reform must follow. Paths to citizenship for the millions of undocumented people who are living in the shadows must be made into law. Unaccompanied minors must be afforded the same levels of safety and dignity we would want for our own children. And asylees must be admitted at far higher numbers than currently permitted.

Every asylum-seeker needs a place to live, presumably. And someone who claims to be an unaccompanied minor (there is no way to verify the age of an “undocumented” person since one cannot ask for his/her/zir/their passport) can’t have a safe and dignified lifestyle without a taxpayer-funded apartment.

“Calls to end inhumane border conditions aren’t enough. Ice must be abolished” (Natascha Elena Uhlmann, September 2019):

… where are we as a society if we cannot dream bigger? What does it mean that some of our most beloved writers – who have laboriously envisioned new and radical worlds – didn’t imagine a future that respects the right to human movement?

It is by refusing to concede to a rightwing vision of possibility that unimaginable prospects become reality.

With our imagination we can turn currently vacant land into 7 million houses/apartments for “extremely low-income renter households” (the “gap” as of March 2021).

“‘Australia’s loss is America’s gain’: the Nauru and Manus refugees starting anew in the US” (Anne Richard, January 2019):

Australia had stopped thousands of asylum seekers from reaching its shores and had arranged to detain them on islands in the South Pacific; the US had agreed to resettle some in America. … As the assistant secretary of state for population, refugees and migration in the US, I had signed the deal in September 2016. Had our team said no to the Australians, it might have kept the pressure on them to change their policy, but reports about the dire conditions on the islands worried us and my sense was the refugees would be better off restarting their lives elsewhere as soon as possible.

I met Sri Lankan parents of three children – including a baby born under difficult circumstances in the Pacific Island nation of Nauru – who are now living on the US west coast, happy that their children will receive an education, have a good future and experience freedom. The father, however, fears the earnings from his job at an Indian restaurant will not be sufficient to pay the rent for a two-bedroom apartment and other bills.

… three young men told me they had fled their village in Pakistan … One is working the graveyard shift at a convenience store and another, who had earlier studied medicine, is now a landscaper.

(Would the profiled 2SLGBTQQIA+ folks afflicted with 30-40 percent rent increases have preferred to pay their old rent and pulled a few weeds themselves and perhaps waited until 7 am for the convenience store to reopen?)

“Ice is a tool of illegality. It must be abolished” (Zephyr Teachout, June 2018):

On Sunday, Trump doubled down and took direct aim at our constitutional order when he tweeted: “When somebody comes in, we must immediately, with no Judges or Court Cases, bring them back from where they came. Our system is a mockery to good immigration policy and Law and Order.”

This is a direct affront to the most foundational principles of public morality and law. Our constitution insists that “no person shall be … deprived of life, liberty or property, without due process of law”. It should not need saying, but undocumented immigrants are persons.

“Why Trump thinks domestic violence victims don’t deserve asylum” (Jill Filipovic, June 2018):

What else, other than out-and-out hostility and a desire to hurt the most vulnerable, justifies Sessions’s decision to remove asylum protections from women suffering violence at the hands of their partners?

In other words, anyone willing to spin a tale of domestic suffering, which cannot possibly be verified from 1,000+ miles away, is entitled to live in the U.S. forever.

Going back to the happy days before the Trump dictatorship… “Bernie Sanders is wrong on open borders: they’d help boost the economy” (Cory Massimino, August 2015):

Bernie Sanders has come out against open borders, claiming they are a “right-wing proposal” that “would make everyone in America poorer.” He argues that, while we have a “moral responsibility” to “work with the rest of the industrialized world to address the problems of international poverty… you don’t do that by making people in this country even poorer.”

In other words, Bernie predicted, 6 years in advance, that non-immigrant Americans would become poor via rent increases! And some of the haters who comment here say that Comrade Bernie does not understand economics!

Related:

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Medical School 2020, Year 3, Week 39 (Emergency Medicine)

It’s May and we’re back from an uneventful week of vacation.

Emergency medicine rotation, 12 shifts in 30 days. I am one of the first medical students in my class to complete EM. One quarter of the class completes EM clerkship during the third year; the remaining wait for the fourth.

I begin at 7:00 am in the simulation center with the EM clerkship director, a toxicologist. He gives us an overview of the ED. “We have a mantra in EM: “Anyone, anything, anytime. You will see a bit of everything on your shifts. EM docs are a master of none, but a jack of all trades.” He continues:  “All of you have done internal medicine rotation already. I am sure you have the impression that the ED consults everyone. In fact, we discharge over 70 percent of the patients from the ED.” Emergency Medicine changed overnight when EMTALA passed in the 1980s. “This requires emergency rooms to screen and stabilize all patients that come in regardless of insurance or ability to pay.”

He explains that the ED risk stratifies patients and recommends we all become familiar with PERL rules, Nexus criteria versus the Canadian criteria for cervical spine clearance, and the HEART pathway and OTTAWA rules. 

After this introduction, my six classmates and I head over to the first simulation room. The room is similar to the trauma bay in the hospital with a mannequin on the bed, various screens showing vital signs and fully stocked closets with e.g., endotracheal airways and chest tubes. The first simulation day is focused on ACLS, and management of various cardiac arrhythmias. The EM clerkship director, and two simulation staff (a former medic and a former ED nurse) step out into the viewing section behind an opaque glass window. We hear them over the loudspeaker giving the simulation introduction. Then the EM clerkship director gets into character: “Ugggh, I don’t feel so good.” We begin to ask questions and request tests. “Can we get an EKG?” The staff put up various EKGs and we are supposed to respond by treating the arrhythmia, whether that is to shock the patient (synchronized cardioversion versus defibrillation) or administer medications. 

My first shift is slow and the 34-year-old PGY2 resident has plenty of time to teach. Before medical school, she worked for 5-years as an operations engineer. (EM residency is a three-year training, the majority do not go on to fellowship training). The attending’s high level of trust in her is evidenced by the fact that she manages 10 beds by herself and updates the attending on any admissions. We have a COPD exacerbation from a nursing home and an uncontrolled type 1 diabetic in DKA. My resident starts the patient on her preferred protocol (K+ and insulin drip) and then updates the attending. The attending discusses his view of bolus versus drip only, as he prefers bolus. “It’s your patient, your move.” We have a patient transferred about 150 miles from an outside hospital due to a stable GI bleed. I do not understand what hospital would transfer this patient. He doesn’t even need a blood transfusion. His only comorbidity is well-controlled type 2 diabetes and hypertension. The PGY2 summarizes the situation: “He was driven all this way for a digital rectal exam.” She continues, “He has supplemental insurance, so I’ll offer to keep him under observation. We might catch something to flip him into inpatient and get him an EGD and colonoscopy. But he frankly should be discharged and sent for elective outpatient colonoscopy. I feel bad for the guy and the wife who is driving here now.”

Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 2 nights. Brewery outing with classmates and pups. Lanky Luke and Sarcastic Samantha are training their puppy, however she only listens to Samantha because Luke is always working on his internal medicine rotation.

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

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Pinflation (pinball machine pricing compared to 2020)

We stopped into a Florida pinball machine dealer. He said that he went into the business as a labor of love, but has recently been making more money than he ever dreamed possible. “Prices for new machines are up 30 percent compared to 2020,” he said, “and the used machines have pretty much followed the new prices.”

New or old? “The new machines are much more engaging for home use,” he responded. “You could play one for an hour and not finish every mission. People get bored quickly with the older machines.”

How about the super wide super complex Jersey Jack machines? (Dialed-In is a prescient 2016 design about a city under attack.) “Remember the Fisker Karma? It looked great, but hardly any were made. Tesla, on the other hand, is still here.” (He wasn’t a believer in the maintainability of the Jersey Jack machines.) What company is the Tesla of pinball? “Stern.”

What if you’re not good enough to complete these complex games with 3 balls? “You can set them to up to 10 balls per game,” the expert responded, and explained that it was also possible to customize the amount of time within which the machine would provide a replacement ball for one that drained.

The Dialed-In game, above, made me think that a Coronapanic machine could be a lot of fun. The player would have to spell out R0, PCR, mRNA, Fauci, Wuhan, and WHO. The history section of the game would feature Robert Malone inventing the idea of an mRNA medication, being interviewed by Joe Rogan, and then being memory-holed by the New York Times. A wheel-o-masks would spin to bandana, cloth, surgical, and N95 locations. The virus would start spreading and the player would have to hit targets and ramps to #StopTheSpread. The successful player would shut down commercial airline flights, quarantine cities, order the general public to wear masks (slowing down the spread imperceptibly), order schools shut, etc. Hit the 14 Days to Flatten the Curve spinner once and then it inexplicably would continue to spin until the machine was powered down.

The Canadian Freedom Convoy would get its own subsection. The player would take on the role of Justin Trudeau. Don Blackface would be the first level. No matter how many times the player hit the trucks that converted in the center of the playing field, they wouldn’t break up. It would then be time to Invoke Emergency Powers and freeze the bank accounts of anyone who donated $20 to the truckers.

Separately, I wondered why pinball machines aren’t made in China. Everything else electronic is. You wouldn’t buy a smartphone assembled by clumsy Americans, right? It turns out that Homepin set up a factor in Shenzhen (factory tour video; the machine gets terrible reviews, but mostly because of its rules and layout, not because of the way it is built).

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