Medical School 2020, Year 3, Week 38 (Neurology, stroke service)

by philg

During our morning session on multiple sclerosis, a stroke alert is called. The clerkship director and I walk over to the ED. A 66-year-old female is presenting for left-sided weakness (arm more than leg), but there is no facial droop. Her husband explains she was normal when they went to bed, but when they woke up at 7:30 am, she “just wasn’t right”. She has already gotten the imaging workup, but there is nothing to be done because she is well outside the 3-4.5-hour window for TPA (tissue plasminogen activator) and this is not a large infarct. (Even if we did know the time from initial event, she has been on oral anticoagulants for atrial fibrillation. These are difficult to reverse and a contraindication to TPA.) We put in admission orders to optimize her recovery, including blood pressure and sugar control. We also order an MRI to diagnose and prognosticate the extent of the infarct. The attending cancels some of the orders placed by the ED and the psychiatry PGY2 resident. “This is the tyranny of the order set [default groups within Epic, intended to save time and typing]! Why order a carotid duplex when we just got a better picture of it with the CTA already performed? We are just wasting hospital resources and Medicare dollars.”

[Editor: The hospital CFO may not consider it a “waste” when Medicare dollars are transferred to the hospital…]

We arrive at the Situation Room, a narrow office crammed with two computers and an old couch. The clerkship director, resident, and I hang out here until the next stroke alert. I am pimped on the types of strokes. I fail miserably, citing only two of the common sites of brain bleeds. There are two main types of strokes: intracerebral hemorrhage (ICH, brain bleed, rarely lethal) and ischemic (occlusion of an artery, potentially fatal due to increased intracranial pressure). This neurologist gave a great lecture on strokes during second year, so I pull up the slides on Blackboard and then UpToDate each topic for more information. A common cause of ICH is hypertension due to cocaine and meth use among the young and poorly controlled chronic conditions among the elderly. ICH can also be caused by anticoagulants and Alzheimer’s (amyloid angiopathy). “You can quickly figure out what is the cause by the location of the bleed. Hypertension is a deep brain bleed, in the basal ganglia, thalamus, pons, or cerebellum. Dementia patients bleed into the cortex.”

He asks me, “What kind of workup would you do for the patient we just saw in the ED?” I answer, “Well, she is out of the window for TPA, and not a candidate for endovascular therapies [clot in proximal artery].” I recommend ordering an echocardiogram, carotid duplex, and EKG. “Right, we need to rule out the preventable causes of ischemic strokes” These include cardioembolism (a result of, for example, atrial fibrillation, an infected heart valve from iv drug use, or a ventricular thrombus after a heart attack), carotid stenosis, and a patent foramen ovale or hole in the heart, that can allow a clot to pass from the venous circulation into systemic circulation). We check Epic and see that the MRI images are available, though without a radiologist’s read yet. He points out a small infarct in her posterior limb of the internal capsule. Nothing to do.

(I followed up with her over the next several days and her condition was unchanged. She’ll have a permanent limp and some arm weakness, but can live independently.)

We get a stroke alert for a 76-year-old diabetic female who had a breast cancer lumpectomy one year ago. Her husband reports returning from grocery shopping to find that she was slurring words and unable to walk. He promptly called 911 so we’re probably seeing her about two hours after the onset. Her blood pressure is 215/100, too high for TPA, so she’s on a nicardipine drip in hopes of bringing it down. The neurologist calmly examines her with standard techniques (“follow my hand with your gaze”) and some of his own design (“close your eyes and tell me what you feel” as he hands her objects such as a key or lighter). She has a left facial droop, dysarthria (speech disorder due to muscle weakness), right gaze preference, and a left hemianopsia (blindness). Like most of our stroke admits, she gets a CT perfusion scan (five minutes and reimbursed at $12,000 by Medicare) to see if she is a candidate for endovascular intervention, i.e., clearing out a plumbing clog with a drain snake. Her scan is among the 10 percent that suggest endovascular intervention: proximal (closer to the heart) clot surrounded by potentially viable tissue. Her clog is in the middle cerebral artery (MCA, the main artery of the brain).

She is carted off to the endovascular suite. I call Straight-Shooter Sally, who did not get to see an endovascular procedure on her week of stroke service. We meet up in the Interventional Radiology suite; endovascular procedures are split between interventional radiology and interventional neurology. We’re both excited, but the neurologist doesn’t say anything during the 45-minute procedure. “Well that was useless,” says Sally. We follow up with the patient the next day and she has almost no symptoms, except mild weakness in her right wrist.

(It seems obvious that cleaning out the pipes would work, but there are no good clinical trials to support the anecdotal evidence. A lot of patients who get endovascular therapy would likely have recovered on their own.)

During the 4:00 pm debrief in the “Situation Room”, I ask if all stroke patients should get a $12,000 CT perfusion scan. “It depends whom you ask,” responds my attending. “The people who designed our current protocols say, ‘Yes.’ But they mostly are not neurologists. Medicare doesn’t understand the purpose of the CT perfusion scan. Two out of three scans that they pay for are unnecessary in my opinion. Only a small percentage of strokes are amenable to endovascular therapy. And we are not an institution at the cutting edge doing research on other indications. There is no excuse except laziness and dipping into a free pot of gold.” I ask about the VAN score to screen for patients for a large proximal clot. If a patient does not have focal weakness and one of the following: Visual disturbance, Aphasia, or hemi-Neglect, it is extremely unlikely to be a large proximal clot amenable to endovascular therapy. My attending doesn’t disagree with the VAN system, but thinks it adds little to an experienced neurologist’s judgment. “Stroke centers are graded by the door-to-needle time [time to get a stroke patient administered TPA]. The ED is so focused on taking the thought out of medicine with protocols.” He noted that every stroke patient now goes through the same steps: (1) non-contrast CT brain to rule out brain bleed, (2) CT angiogram to look for a clot, and (3) CT perfusion scan to evaluate salvageable brain tissue. “Though lucrative, most of this is unnecessary and doesn’t change management. CMS hasn’t investigated us yet, but I hope they do.”

In his opinion, what would help more patients at a tiny fraction of the cost is simply speeding up radiology. “During nights and weekends we don’t have in-house radiologists. We use teleradiologists who are contracted to get back to us within 30 minutes. We need a 5-minute look at brain anatomy, but they take the full 30 minutes to give us a detailed report so that they can’t be sued for missing something. We get a report on spine, teeth, lungs, etc. The ED can’t read images, so the stroke patient is sitting there for 30 minutes without any therapy. A good  neurologist reads his or her own films and a brave one will make the call without a radiologist.”

[Editor: Smaller hospitals are unable to do either the CT perfusion scans or the endovascular intervention (“thrombectomy”), so our near-octogenarian Presidential candidates might not want to spend too much romancing voters in small towns. See “A Breakthrough Stroke Treatment Can Save Lives—If It’s Available” (WSJ, February 6, 2018).]

Statistics for the week… Study: 7 hours. Sleep: 6 hours/night; Fun: 1 night. Burger and beers with live music. Mischievous Mary has already started looking for visiting away electives in cardiothoracic surgery.

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

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Democrats’ persecution of Donald Trump partly responsible for the Ukraine situation?

by philg

In a recent video chat among friends, a Russian immigrant to the U.S., asked about the Ukraine situation, said “I am not following it closely, but I assume that Putin has a reason for doing what he’s doing. Either it will benefit the country or it will benefit him.”

I chimed in, “How could it possibly benefit Putin? Doesn’t he already have everything that he might want?”

She responded, “He may be worried about what would happen to him if he loses power. Maybe he thinks that this Ukraine action will help him stay in power and he needs to do that.”

Her perspective is at odds with much of the American and recent Western European experience. Lyndon Johnson and George W. Bush were free to go home to their respective Texas ranches after starting and/or escalating disastrous wars, for example. But the quiet comfortable retirement of former leaders is unusual when compared to what happens in most countries and what has happened through most of human history. And, even in the U.S., the new rulers may try to make life unpleasant for former rulers. Consider what the Democrats are doing to Donald Trump right now. New York State Democrats have been seeking to put him in prison for alleged financial misstatements (“2 Prosecutors Leading N.Y. Trump Inquiry Resign, Clouding Case’s Future” (NYT) for the latest on this one). Democrats in the U.S. Congress are also seeking criminal prosecution (“The Jan. 6 Committee’s Consideration of a Criminal Referral, Explained” (NYT); “The Obscure Charge Jan. 6 Investigators Are Looking at for Trump” (Daily Beast)). Democrats were, in fact, already seeking to imprison Donald Trump at least as early as 2018. “The Presidency or Prison” (NYT):

Donald Trump — or, as he’s known to federal prosecutors, Individual-1 — might well be a criminal. That’s no longer just my opinion, or that of Democratic activists. It is the finding of Trump’s own Justice Department.

On Friday, federal prosecutors from the Southern District of New York filed a sentencing memorandum for Michael Cohen, Trump’s former lawyer, who is definitely a criminal. The prosecutors argued that, in arranging payoffs to two women who said they’d had affairs with Trump, Cohen broke campaign finance laws, and in the process “deceived the voting public by hiding alleged facts that he believed would have had a substantial effect on the election.”

Representative Eric Swalwell, a California Democrat and former prosecutor, told me, “This president has potential prison exposure.”

Ordinarily, you know that a democracy is failing when electoral losers are threatened with prison. But Trump’s lawlessness is so blatant that impunity — say, a pardon, or a politically motivated decision not to prosecute — would also be deeply corrosive, unless it was offered in return for his resignation.

So the original idea was to put Trump in prison for paying people who identified as “women” to do what people who identify as “women” have been doing for a long time. Then January 6 came along and the idea shifted to putting Trump in prison for “obstructing an official congressional proceeding”.

If Putin observes that Donald Trump is continuously at risk of a prison sentence, depending on the whims of Democrats working as prosecutors and serving on juries, wouldn’t he reasonably be concerned about his own post-leadership fate? The Russian legal system doesn’t offer superior protection against politically motivated prosecution compared to the U.S. system, does it?

Separately, Apple News sets up a visual comparison between Vladimir Putin and Joe Biden. One leader is using armored vehicles and soldiers holding rifles. The other leader has “sanctions”:

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Why drop mask requirements and vaccine paper checks after they’ve been proved effective?

by philg

A friend in Maskachusetts wrote yesterday that his son’s private school had dropped its mask requirement (public schools in MA are still generally masked), overruling at least one member of its own medical board who voted to keep the kids in masks. His son reported that none of the teachers wore masks, but some students continued to do so. In other words, the teachers sent a message that they hadn’t believed that the masks were necessary or helpful by all dropping them as soon as they became optional. Adults are free to party unmasked in MA and almost everyone else. “Soon only one U.S. state will still have an indoor mask mandate” (CBS, 2/23/2022):

New York and Rhode Island this month lifted indoor mask rules for businesses, but still require them in schools. Illinois, Oregon, Washington and Washington, D.C., plan to let mask requirements lapse by the end of March.

These Followers of Science are no longer Following the Science. “‘We Are Not There Yet’: As States Drop Mask Rules, the C.D.C. Stands Firm” (NYT, 2/9/2022):

The Biden administration said federal masking guidance would not change for now, but was seeking advice from public health experts on the way forward.

… Dr. Walensky said pointedly that while her agency is working on new guidance for the states, it is too soon for all Americans to take off their masks in indoor public places.

As officials examine the science and chart a careful course, they run the risk of making the Biden administration look irrelevant as governors forge ahead on their own.

Even without reference to Science, the idea of dropping vaccine paper checks and mask orders “because cases are down” is puzzling. A friend recently texted regarding “Denver to end COVID-19 vaccine mandate for city employees, teachers and workers in high-risk settings”. He wrote “Why would you end the mandate if you believed it’s what saved you in the first place?” A San Francisco friend, regarding extending the school mask orders: “every additional day might save one life.”

Let’s look at the Maskachusetts “cases”:

Checking vaccine papers began in Boston on January 15 and, as one can see from “the curve,” cases trended down smartly after that intervention. “Boston businesses bid farewell to vaccine mandate, but some still check vax cards” (2/20/2022) describes the elimination of this safety measure just as its effectiveness was proven.

The California curve similarly shows that vaccine paper checks and mask orders worked:

For comparison, the Florida curve shows how cases trend to infinity in an environment where there are no mask orders, vaccine checks, or vaccine coercion:

Science tells us that universal vaccination, achieved via coercion if necessary, stops COVID infection and that masks cut the near-zero risk of COVID infection for the vaccinated to even nearer zero. Why abandon Science at this point when Science in the Science-following states saved lives at what lockdown proponents characterize as virtually zero cost?

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Inflation chronicles: European windows

by philg

A friend imports European windows for Americans who are too rich to look at America through American windows. Price increases for components are happening every few weeks. Prices for the finished product are now 30 percent higher than two years ago. “We’re doing much better than our competitors with lead times,” he said. “Where we used to be at 12 weeks, for example, we’re now at 16.”

He surprised me by saying that the Europeans make windows with laminated and tempered impact glass, which is conventional for installation in new Florida construction. Why would they do that when there aren’t any hurricanes in Europe? “They like that nobody can break in,” he responded.

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Medical School 2020, Year 3, Week 37 (VA and neurology consults)

by philg

Neurology rotation. Three days at the VA and then three days at our home institution.

Groundhog Day: I meet the VA coordinator at 9:00 am to get my badge and a campus tour (it happened last month, but I have to do it again). I am joined by four trainees from other institutions: a third-year medical student starting her one-month psychiatry rotation and three podiatry residents doing three months of training on the “indigent” VA population. “There is an endless supply of feet to amputate. We meet our case log requirements from this month.” A new-hire struggles with the badge machine, but two hours later we all have badges and start our tour of the VA campus. I am dropped off at the neurology clinic at 12:00 pm. My physician turns out to be a rotund neuro-ophthalmologist. In the Department of Physician Heal-Thyself, he’s  recently returned to work after a quadruple bypass. The mid-day patients are no-shows so he sends me to lunch. We meet again at 2:00 pm to see four scheduled patients, two of whom show up (see Year 3, Week 33) and clock out at 3:30 pm.

A typical day starts at 9:00 am after a 45-minute commute. The attending prints out his most recent office note for each follow-up patient because students do not have access to the VA’s electronic medical record (EMR). Each new patient starts with me in a vacant office, then goes back to the waiting room, and eventually we go together to the attending’s office. Despite the 50-percent no-show rate, he’s usually running behind due to his struggles with the EMR. Each 30-minute or 45-minute visit with a patient is followed by 30 minutes of single-finger typing. Has he tried to dictate? “It’s just as bad. I spend more time correcting the damn machine than it takes me to type.” He has near-perfect recall of previous visits with patients, surprises patients by remembering details they offered months earlier, and would have thrived in a pre-EMR era.

[Editor: The good news for this guy is that he will be able to learn a whole new interface for the 2020s once the VA finishes with its $10 billion transition to commercial software.]

We see patients with multiple sclerosis (MS), Parkinson’s disease, pseudotumor cerebri (condition mostly occuring in obese females resulting in vision loss), and rare vision disorders, e.g., Charles Bonnet syndrome, which results in progressive blindness combined with intense visual hallucinations. If he thinks it will help a patient with a terminal neurological disorder, the attending will spend over an hour counseling on the prognosis and what everyday life will look like. The nurses grumble that he “destroys the schedule without warning”. He lets them go as soon as the last patient has checked in and will see his final patients without any support.

My attending misses the 1980s: “We don’t talk to each other anymore. We search blindly in the endless expanse of notes. The primary doctor orders a consult and wipes his or her hand. Then the specialist wipes his or her hand when the note is filed. No one calls.” He spends 10 minutes finding an example of a recent patient for me: a 68-year-old male had a stroke during a five-day hospitalization for pneumonia. After the stroke, he developed Parkinson-like tremors. “There are 240 pages of notes. Look at this! They have to put in where the meds were manufactured! Is that necessary?”

In the afternoon we walk 10 minutes to the inpatient wing to see consults. “All these damn hospitalists are useless,” my attending grumbles. “They consult for anything. A patient feels weak because they’ve been in the hospital for a week for heart failure. No shit they are weak. This is not a stroke. Did they go to medical school?”

Thursday starts at 8:30 am. Each week the three medical students on neurology clerkship meet in the office of our clerkship director, a quirky tall gentleman in his early sixties. We get a group text each night with cases to review and present and offer diagnoses in the morning. Today’s case is on Guillain-Barré syndrome, an ascending paralysis from an auto-immune response, typically after a viral illness. “The main concern is respiratory failure. That’s what they die of. If you can get them through it, they will typically have a complete recovery. When I was a medical student, we were in charge of getting daily PFTs [pulmonary function tests], but we no longer require this because the RT [respiratory therapist] can bill for the test each day.”

(A student in another class at our school developed Guillain-Barré syndrome during a medical charity trip to Central America, tipped off by a GI bug. She had to be transferred from the ventilator in the overseas hospital to spend three weeks in our own ICU. She graduated, but suffers from a permanent loss of dexterity.)

Around 9:00 am, the neurology resident texts me the three patients to follow today. I chart review the patients, then go see them in person before meeting the attending in the administrative section of the hospital to run the list. The physicians lounge is typically off-limits to students and residents, but no one is going to question Queen Maleficent, a 75-year-old attending infamous for rolling around a loud purple suitcase stuffed with diagnostic gadgets and, unlike my VA attending, has adapted to the computer era. “I’ve taken out a lot of the tools because of this new neuro App,” Queen M points to her iPhone. “It has all the color vision tests that I used to carry.”

Our primary role this week, which seems to be typical, is to relieve the hospitalists of liability for not checking every possible box. Out of 10 consults per day, an average of 2 will have neurological symptoms or deficits. We also coordinate with the psychiatry service for odd neuropsychiatric symptoms. One interesting case was a 55-year-old smoker presenting for worsening shortness of breath. A PFT done by his primary care clinic showed an unusual inspiratory effort, but nothing critical. A few weeks later, his wife called 911 saying that he couldn’t breathe. He demonstrated normal inspiratory effort in the hospital, so pulmonology has booted him to the neurology service. We cannot identify any neurological disorder so we consult psychiatry. Queen M: “Psychiatry might enjoy talking with the wife. My hypothesis: he is trying to compete with her fibromyalgia and chronic opioid use.”

Queen M asks me to do a brain death exam on an 80-year-old ICU brain bleed patient who has been on the ventilator for four days. “Text me when you are done, and I’ll confirm what you find.” I look on UpToDate for a refresher. Five family members (wife, two children, one daughter-in-law, one grandchild) are in the room and their refusal to withdraw care has prompted this exam. I ask them to excuse themselves while I cover the glass wall with curtains and perform the exam. I first test for reflexes, and response to pain (none). I then perform the primitive brain reflexes e.g., gag, corneal, oculocephalic (doll test, rotate head to see if gaze does not adjust to rotation), caloric nystagmus (squirt cold water into one ear and watch for nystagmus). The nurse and her nursing student join to watch. When Queen M arrives, she repeats the exam, then orders an apnea test (must be performed by two physicians independently). We preoxygenate the patient with 100 percent oxygen, then hold the ventilator as the respiratory therapist draws blood gases every few minutes. A positive apnea test is failure to initiate a breath once the CO2 level reaches a certain threshold (typically 60 mmHg). We put in our note for the primary team: brain dead.

We are paged for a 35-year-old male whom I previously met on surgery rotation for a problem with his gastrostomy tube. He is chronically disabled and epilectic after a car accident three years ago. His wife left him, taking the two-year-old and 6-month-old children. His mother now devotes her entire life to his care. We walk in and he is less responsive than usual. The mother explains: “Something has been off every since yesterday afternoon.” Queen M orders the nurse to administer Keppra and Ativan. The nurse asks “Have you put the order in? [into Epic]” Queen M responds quietly: “If you don’t do it, I will. Open the code cart if you can’t get it from the Pyxis.” (Pyxis is an automated pharmacy cabinet that dispenses common medications with a fingerprint and badge swipe.)

The last consult is a 28-year-old postpartum female in the labor and delivery ward. Five weeks after delivery, she was leaving backing out of the driveway with her newborn in the back seat. The husband rushed out when he heard the car hit a utility pole and saw her seizing for a few seconds, then go limp. We have to decide if this is postpartum eclampsia (90 percent of postpartum eclampsia occurs within the first week of delivery), new onset epilepsy, or an isolated seizure. She has no history of seizures and no family history of seizures. Her eclampsia labs and first 4 hours of EEG are both normal. We are skeptical this is postpartum eclampsia so the discussion turns to anti-seizure medication. “Once you are on seizure medications,” says Queen M, “very few doctors have the courage to take you off.” Having learned nothing definitive, we decide to do an overnight stress EEG, and re-evaluate. Considerations include balancing anti-seizure medication safety during breastfeeding against the risk of a seizure while driving or holding the baby. “I am willing to do a monitored outpatient experience where we follow you every two weeks,” says Queen M. “You cannot drive during this period.” We tell her that the average patient has a 24 percent risk of a seizure recurring. The mother weeps.

Statistics for the week… Study: 8 hours. Sleep: 8 hours/night; Fun: 2 nights. Gigolo Giogio’s birthday celebration includes a thirty-person pregame at his house followed by fruity drinks and dancing until 2:30 am at a Drag Queen club.

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

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Ukrainians on the Ukraine situation

by philg

The situation in Ukraine is bewildering to those of us who received parochial American educations. The Wall Street Journal attempts to explain it in “Putin’s Endgame: Unravel the Post-Cold War Agreements That Humiliated Russia”:

The Russian leader is trying to stop further enlargement of the North Atlantic Treaty Organization, whose expansion he sees as encroaching on Russia’s security and part of the West’s deception and broken promises. He wants NATO to scale back its military reach to the 1990s, before it expanded east of Germany.

In sum, Mr. Putin seeks to undo many of the security consequences of the Soviet Union’s collapse in 1991, an event the Russian leader has called the “greatest geopolitical catastrophe” of the 20th century.

Looking back, many current and former Western officials say it is clear that the U.S. and its allies handled relations with Moscow poorly in the 1990s, and that the triumphalism over winning the Cold War was excessive.

“Although I think that Western diplomacy was arrogant and incompetent in the 1990s, and we’re paying the price now, that is not a reason for Putin to put himself in a posture that makes other people think he’s about to launch a war,” said Rodric Braithwaite, who was British ambassador to Moscow when the Soviet Union collapsed.

Yet in 1994, Russia joined with the U.S. and U.K. in committing “to respect the independence and sovereignty and the existing borders of Ukraine” and “to refrain from the threat or use of force” against it, a security guarantee that helped persuade Ukraine to give up its nuclear weapons.

Where are the US and the UK today with their “security guarantee”? (See the Budapest Memorandum.)

A successful friend who grew up in Ukraine:

Overheard young Swiss on a chairlift:
Guy 1: All this stuff with Ukraine is crazy. If World War III happened, it would be kind of cool. But also kind of not cool.
Guy 2: Yeah, it would not be. But you know, if we [Switzerland] manage to repeat what we did in WW2, we should be fine.

An American on the European response (putting the amazing new undersea pipeline on hold):

Man the Germans are sticking it to Putin. They are only going to buy half of their natural gas from him.

A Deplorable American with a Ph.D. in biology:

New sanctions are going to be about as effective against Putin and Russia as cloth masks were against the coronavirus.

From an aircraft mechanic:

If Putin takes over the Ukraine does Hunter still get his board of director payments?

An American passionate about free speech:

I am curious to see how long it takes for Twitter to suspend Putin’s account for spreading misinformation. Or does suspension apply only to “mean tweets”?

One question is whether the 44 million people who live in the Ukraine can qualify for asylum in the U.S. A person who says “my spouse is hitting me” qualifies for permanent residence in the U.S. and, if he/she/ze/they does not wish to work all that much, a lifetime of associated means-tested subsidies for housing, health care, food, and smartphone. As fearsome and difficult to escape as a domestic partner might be, a shooting war involving the powerful Russian Army is surely scarier. (Note that the New York Department of Health actually spends more than what the Russians spend on their entire military.)

I asked a friend who gets a paycheck from the refugee-industrial complex what would stop all 44 million Ukrainians from going to Mexico, walking across the Rio Grande, and saying “I request asylum”. His response:

They might qualify, but due to Trump policy that courts have not let Biden rescind, asylum seekers are being sent back across the border to wait in Mexico. Supreme Court recently agreed to hear the case. They might have a better chance of getting asylum if flew into NY on a tourist or other visa and then got a lawyer and filed asylum claim.

Me: “I don’t see how one can argue that Ukraine is not a dangerous place to be right now.”

Covid rule is different. That’s called “Title 42” and allows for immediate deportations due to health crisis. It also depends which city your hearing is held in. Rate along southern border is much lower than in NY. And if you have a lawyer, about 10x better chance. I would agree those fleeing Ukraine have a decent claim, but you’d still have to convince asylum judge. Being a political dissident or member of religious minority is better than just saying “I’m scared of war”. If Russians or Separatists declare that they’re looking for you that would help. You need to be able to convince a judge that you have a reasonable fear of persecution. Asylum seeker must show that they have a “well-founded fear of persecution in their home country on account of either race, religion, nationality, political opinion, or membership in a particular social group.” That’s the legal principle.

He pointed out that Temporary Protected Status would also be an option for Ukrainians who wished to be far away from any armed conflict.

Haitians had it after earthquake.

(“Temporary” for Haitians began in 2010 and was recently extended to at least 2023. Children born in the U.S. in when “temporary” began are now biologically capable of having children themselves.)

The question of 44 million Ukrainians being entitled to come here makes me wonder a bit about what kind of society the U.S. is building by giving immigration priority to those who say that they are at risk of being attacked somewhere else. In the 19th and early 20th centuries, for example, people migrated to the U.S. because they liked the idea of living in the U.S. Now we are filling the U.S. to a Chinese/Indian density with people who say that they don’t want to live wherever they’ve been living. It isn’t that they are attracted to what they perceive as American cultural values, for example, but they are repelled by threats against life and limb wherever they are. They might find American cultural values, such as hatred of Asians and discrimination against Blacks and those who identify as “women”, abhorrent, as Eileen Gu does, but living in the U.S. is nonetheless preferable to suffering inescapable domestic or gang violence in their home countries.

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The PPP program generated asset price inflation?

by philg

“Where, Exactly, Did $800 Billion in PPP Money Go?” (Bloomberg):

Billions of dollars of federal funds may have been misappropriated as part of the government’s well-intentioned but loosely monitored effort to support entrepreneurs and their employees during the Covid-19 pandemic. Meanwhile, the Small Business Administration, which has supervised the massive rescue since last year, decided recently to speed up its completion by making it easier for borrowers to have their loans forgiven.

Analysts remain split on how best to assess the success of the PPP and the related Economic Injury Disaster Loan program. The Government Accountability Office puts the spending at $910 billion, of which $800 billion is PPP money. Any assessment, however, will rely on the release of more sweeping data about the push from the government and borrowers. It’s also becoming clearer that fraud may have been much more rampant than originally understood, although the likelihood of massive misappropriation because of lax supervision was obvious from the start. Any funds that wound up in the wrong pocket or were steered toward insiders also blunted the program’s effectiveness.

The question for today is not whether any of the $800 billion was obtained fraudulently (or whether forgiveness was obtained fraudulently), but what businesses actually did with the money. For example, my friends who own small-to-medium-sized companies enjoyed reasonably strong revenue in 2020 (a dip in the spring and then roaring back in the summer and fall), so the PPP money ended up being a an untaxed bonus of $millions that went straight into personal checking accounts. From there, what did or could they do with, e.g., $2-5 million? Mustafa Qadiri bought himself “a Ferrari, Bentley and Lamborghini” and got in trouble because he faked the number of employees that he had. But my friends were in a similar position, showered in cash that they had no use for in their respective businesses (which were continuing to show a profit).

Let’s assume that half the companies that got PPP didn’t need it. That’s $400 billion in cash that business owners needed to invest in stocks or real estate. This is only about 1 percent of the total value of the U.S. stock market, but it could still be significant if we believe the Wall Street Journal. “What Determines Stock-Market Prices? Here’s a New Theory” (11/6/2021):

A new study shows how much the flows of money into and out of the stock market affect stock prices—perhaps more than many investors realize.

Specifically, a dollar of cash from outside the stock market that is invested in equities will cause the combined market cap of all stocks to rise by about $5, while a dollar withdrawn from the market will have the opposite “multiplier effect,” the study says.

The reigning academic theory of the market up until now, in contrast, has insisted that investors are extremely sensitive to price, very willing to sell when prices go up. As a result, flows into the market that have no relevance to a company’s fundamentals should play no role. That is why academic orthodoxy up until now has been that the flow-based multiplier must be zero.

The new study that finds to the contrary, titled “In Search of the Origins of Financial Fluctuations: The Inelastic Markets Hypothesis,” was written by Xavier Gabaix, a professor of economics and finance at Harvard University, and Ralph Koijen, a finance professor at the University of Chicago’s Booth School of Business.

Another reason is investor psychology: We become more bullish as prices rise—not less. An illustration is how much stock market timers’ recommended equity-exposure levels have risen since the March 2020 bottom. According to my tracking of nearly 100 such timers, they on average were completely out of the market at that bottom, when the Dow Jones Industrial Average was below 19000. Today, with the DJIA nearly double where it stood then, the average exposure level is 63%. If these timers were more price-sensitive, you would expect their equity-exposure levels today to be a lot less.

It could the same phenomenon in real estate. In a country where it is ever-more-challenging to build anything (but we’ll bring in 59 million more migrants and hope to find somewhere for them to live!), extra money in bank accounts will generate insane bidding wars among those who were blessed by the Great Covidcratic Wealth Reallocation of 2020-2022.

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Medical School 2020, Year 3, Week 36 (Group Therapy)

by philg

Last week on psychiatry. I am paired with an outpatient psychiatrist who specializes in addiction medicine. He splits his time with group therapy sessions and individual appointments for general psychiatry patients.

Monday morning begins at 8:00 am. The psychiatrist explains the suboxone program enrollment agreement. A psychiatrist accepts the patient into the program at an initial consultation, also called “intake.” The patient then attends weekly group sessions for 6 months in addition to two individual appointments per month. Once stabilized, the patient attends a monthly one-hour group session and quarterly individual appointments. At each appointment, the patient takes a drug screen. “Most of my patients do multiple types of drugs, so although we call this opioid addiction therapy, each patient is unique in their social situation and drug addictions,” the attending notes.

Our first group session begins at 9:00 am. Of ten patients, two patients are brand new to the meeting, having just enrolled for addiction treatment. Most have been with us for 6 months to 2 years. Two are “oldtimers”, having been in this group for over 5 years. One female oldtimer is actually off suboxone completely.

The meeting starts off with short introductions. Our oldtimer: “You all know me. I’m a recovering addict of alcohol, heroin, pills, and cocaine. I’ve been sober now for 10 years.” The psychiatrist asks how her daughter is doing. “Well most of you know I got custody back of my daughter from my ex husband. She’s starting middle school!”

[Editor: Why should a plaintiff’s consumption of alcohol, heroin, pills, and cocaine interfere with an ultimate family court victory?”]

One of the two new members, a 22-year-old unemployed male addicted to pills, introduces himself. “Hello, I’m [Brad].” The psychiatrist asks him to share some hobbies or interests. “Well, I recently lost my job as a construction project manager. I play video games.” The oldtimer mother asks. “Great to meet you, Brad. Do you have a girlfriend? ” He responds, “No, my girlfriend overdosed last year.”

The psychiatrist goes around the room. He calls out one who tested positive for cocaine. “[Johnny], if this happens again I will have to kick you out of the program. This group is based on trust.” (He later tells me some psychiatrists have a zero tolerance policy, but he prefers to tailor it to each circumstance. Johnny had recently been sued for divorce by his wife.)

After the group session, he writes notes until the afternoon appointments, which start at noon. We see depressed and anxious patients and have new consults for addiction and bipolar disorder. I begin the interview of a new consult. The 30-year-old male electrician presents for methamphetamine addiction. He was arrested for possession, but our city has a program that enables those accused of drug crimes to avoid jail if they seek addiction help.

I ask about his employment. The patient makes $4,000 per week constructing power lines, “when I work.” The psychiatrist chimes in. “How many weeks a month do you work?” He responds, “Maybe one. Whenever I need money I find a job.” The attending acknowledges this, “You can be quite functional after a weekend cocaine binge, but coming down from meth, you’ll be out for a week.” He responds, “Yeah, cocaine didn’t do it for me after I found meth.”

“How badly do you want to be clean?” asks my attending. “How much are you willing to give up?” He responds, “I’ll do anything, Doc.” The psychiatrist states “Okay, I will set you up at the rescue mission. Take only a backpack. You will be gone for 6 months.” The patient looks distressed. “I need to think about it.” The psychiatrist acknowledges. “Okay, you let me know when you have decided.”

Once the patient leaves, the psychiatrist turns to me. “The patient is here only because he has to be. He has no interest in quitting.” He continues, “Meth is a destroyer. To get over meth, you have to hit rock bottom. The only times I see a patient conquer a meth addiction are via incarceration or if they drop everything in their life, leave all their friends and family, and move away for several months.” He asks me, “How do meth addicts die?” I cite heart attacks and strokes, recalling my internal medicine rotation where massive heart attacks and intracranial hemorrhages were common among the meth-addicted.

My attending adds, “I see a lot of female meth users. Meth, intensifies sex. It makes women do things they would never imagine. The acts they tell me they did is scandalous. Their boyfriend keeps getting it for them for more intense sex. Eventually, the woman cannot have sex without meth. I see so many pregnant meth addicts.” He concludes, “Once you treat meth addicts, alcohol and opioid addiction seem like nothing.”

Our next patient is a 40-year-old morbidly obese female nurse with major depressive disorder and anxiety well controlled on a serotonin and norepinephrine reuptake inhibitor (SNRI). She reports proudly that she finally got around to divorcing her husband. “He is addicted to pornography. He doesn’t acknowledge me. We haven’t had sex in eight months.” My attending congratulates her.

Another attending stops by the office to chat. He complains that the community service board (CSB, the regional safety net mental health organization) keeps prescribing the newest antipsychotics as a first-line agent. “I don’t understand why they jump to these new medications, which are so expensive.” My attending responds, “Medicaid pays for it. I completely agree, the older ones are cheaper and just as effective.”

[Editor: See the book Bad Pharma by Ben Goldacre, a British physician, regarding the typically marginal improvements (at best) of new expensive meds compared to old generic meds.]

Wednesday’s group session features a new patient, a 24-year-old male with schizophrenia and opioid use disorder. His psychiatrist managing schizophrenia started him on risperidone. “Google says I am going to grow tits. I’m not going to take it.” Another member exclaims, “Oh my God, don’t take that.” My attending responds, “[Jimmy], this is not the time to discuss this. Remember why you take this medication. I want you to talk with me afterwards and call your psychiatrist.” He agrees. After the session, a 35-year-old female asks if she can get an additional film of buprenorphine. She explained, “One of my friends overdosed on heroin. I ground up suboxone and injected it. I saved her! But now I don’t have enough to get through this week.”

We take the psychiatry exam. Example question: Which of the following patients should be admitted to an inpatient psychiatric bed? Answer: a patient expressing suicidal ideation with a clear plan rather than vague expressions of hopelessness and no plan. We then have a debrief session with the clerkship director who asks, “What surprised you on this rotation?” Sarcastic Sally, “The inpatient pediatric psychiatry wards were eye opening. There are so many troubled kids. Without protective factors, such as having a safe home without addicted parents, we could’ve been them.” 

Statistics for the week… Study: 2 hours. Sleep: 8 hours/night; Fun: 3 nights (gatherings at various bars with various classmates and their dogs).

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

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What are Americans doing with their additional leisure time?

by philg

American labor force participation rate is falling (BLS):

An evil (i.e., profit-seeking) company owner whom I know installed an activity logger on the Windows laptops that he provides to employees. “Actual work fell from about 30 hours per week in the office to 20 once people were working from home,” he said. (The young engineers, meanwhile, told HR that they were overwhelmed and suffering from a lack of work/life balance.)

So we have fewer Americans working and fewer hours per week spent commuting and working for those who are, at least in theory, still working.

Here’s a report from Disney World on a recent Monday:

Historically, we’ve seen low crowds throughout much of January and February, but this year has brought 6-hour lines and ridiculously packed parks for what is supposed to be the “off-season.”

By the time we got closer to the front [of the security screening line], the Cast Members were warning the guests at the back that it would be at least an hour before they’d be able to get into the park. WOW!

We finally got through and made it to the monorail, which, unfortunately, had a line of its own. This entire process usually takes us less than 30 minutes at this time of the morning, but today it took a little more than an hour to get inside Magic Kingdom from the parking lot.

But not everyone can be in a theme park.

Perhaps the new leisure hours were filled with people applying for all of the new government grant programs? Bad news… “Biden administration denies funding programs that hand out crack pipes to prevent infection and promote ‘racial equity'” (Daily Mail):

The $30 million grant program will distribute funds to nonprofits and local governments to make drug use safer and ‘advance racial equity’

Included in the grant is money to purchase ‘safe smoking kits/supplies’

A spokesperson for HHS said included in these kits could be pipes for users to smoke substances like crack cocaine and crystal methamphetamine

President Biden’s Health and Human Services department (HHS) denied that it is finalizing a plan for funding to dole out crack pipes to drug addicts as part of its ‘Harm Reduction Plan.’

The $30 million grant program, which accepted applications until Monday and will begin doling out money in May, intends to provide funds to nonprofits and local governments to make drug use safer, to advance ‘racial equity.’

I.e., no matter how hard someone worked on a new crack pipe design, the Biden administration won’t buy it.

What about meeting up (in a COVID-safe manner) with new friends? 2020 was a record year for Tinder and 2021 was even better (source; note that the scale is mislabeled (should be $millions)):

Watching TV, play games, and streaming? It is tough to find statistics for adults, but “U.S. Adolescents’ Daily Screen Time Doubled During Pandemic” (US News): “Recreational screen time among U.S. teens doubled from before the pandemic to nearly eight hours per day during the pandemic…”

What else is a realistic possibility?

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Massachusetts during Götterdämmerung (of the Coronagods)

by philg

With deaths from COVID-19 only about as bad as in January 2021 (when few were vaccinated), in both the U.S. as a whole and Maskachusetts alone, declarations of “Mission Accomplished” are becoming common, with associated rollbacks of orders to check vaccine papers and orders for the subjects to wear masks.

How do people who have clung to their cloth masks as security blankets react during the Twilight of the Coronagods?

“Massachusetts Mask and Vax Mandates: A (Temporarily Accurate) Guide” (Boston Magazine, 2/16/2022):

Whether you’re required to wear a face mask depends on where you are. When you see it on a map, it’s striking just how much variety there is when it comes to policies town-by-town and city-by-city. Boston still requires them for all public indoor spaces, as do neighbors Cambridge, Somerville, Newton, and Brookline. Some places, like Medford, Malden, and Melrose, require masks only in municipal buildings.

As you certainly know by now, Boston opted to make vaccine checks mandatory at indoor venues like restaurants and gyms in January. Brookline did the same thing. (Interestingly, Brookline’s vax mandate applies to restaurants’ outdoor patios, while Boston’s does not). Other cities and towns considered following in Boston’s footsteps—among them Arlington, Cambridge, and Somerville—but didn’t, although lots and lots of business owners have enacted their own vaccine rules. 

Meanwhile, Boston is nearing the next stage of its vaccine mandate policy—per the city’s B Together plan, kids 12 and older will need to be fully vaccinated to enter those places, too, beginning February 15. Kids ages 5-11 will need to have at least one dose by March 1, and two doses by May 1.

Even though lots of states have been dropping their school mask mandates, the CDC thinks it’s too soon to take that step, and is sticking with its guidance that kids stay masked in schools.

From the linked-to article:

“As small business operators we have a civic duty to take care of the health and safety of our guests and employees alike,” Tracy Chang told Eater in July 2021. Chang is the chef and owner of Pagu in Cambridge’s Central Square. “The past year has taught us just how vulnerable are the lives of essential hospitality workers, just how broken the existing hospitality industry is when it comes to wages, benefits, and welfare,” Chang continued. “We now have an opportunity to rebuild the industry to be a better, stronger one, starting one restaurant at a time. The least we can do is pay people more, check for proof of full vaccination, take temperatures at the door, and require masks indoors when not eating/drinking.” [later in the article it notes that Mx. Chang also requires government-issued photo ID, which is definitely not a racist policy]

If he/she/ze/they really wants to #StopTheSpread, why not close his/her/zir/their restaurant permanently? People eating at home won’t generate as many infections or breed as many mutations as people eating in restaurants.

Club Passim (47 Palmer St., Cambridge): All staff, performers, and customers are required to show proof of vaccination (the card or the photo) upon entering the club; ticket purchases will be refunded for those who cannot or will not show proof. Non-performers must wear masks indoors unless actively eating or drinking. Passim continues to offer livestream performances and online classes.

Again, if you’re concerned about COVID-19, why assemble COVID-19-spreading people to hear music when everyone has the capability of streaming audio and video at home?

How about those schools? February 17 email from a suburban district is presumably typical:

The Lincoln Board of Health met on Wednesday evening, February 16th to discuss the February 28, 2022 expiration of the Department of Elementary and Secondary Education school mask mandate. While they agreed that our positive case numbers have dropped to low levels, concerns were raised about the possibility of an increase in cases after the February vacation week. They would like to see that our low number of cases are sustained over the next few weeks. In addition, Board of Health member Dr. Kanner shared that state level data is still at rates higher than it was in August when the BOH instituted the Town and school mask mandate.

The Board of Health voted to hold off on a decision until March 9, 2022 when they will reconvene to review the COVID data for the schools, Town and state and consider rescinding the town mask mandate.

The School Committee met this morning and received an update on the outcomes of the Lincoln Board of Health meeting. The Committee voted to re-visit the decision regarding maintaining the mask mandate or moving to less masking in the schools at it’s upcoming School Committee meeting on March 10th.

From “Brookline Indoor Mask Mandate and Vaccination Requirement at Businesses to Remain in Effect Until Further Notice”:

Interim Health Commissioner Patrick Maloney announces that the Town of Brookline’s mask mandate and proof of vaccination requirement continues to remain in effect though the need for these requirements will be reassessed next month. [i.e., in March 2022]

Proof of vaccination will continue to be required for patrons at all: … [restaurants, gyms, theaters, museums, etc.]

Additionally, masks continue to be required in all public indoor spaces in Brookline.

(Most of the above is actually illegal in Florida, of course, which refuses to follow Science. The legislature, for example, passed a law that forbids public schools to order children to wear masks.)

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