Medical School 2020, Year 3, Week 12 (Exam week)

The last week of inpatient pediatrics is shortened by Thursday’s Shelf exam. I am woefully unprepared, having completed only 100 of the 400 pediatrics UWorld questions. Gentle Greg, a soft-spoken classmate: “No one has figured out a good balance between clerkship and studying.There is just no time.”. His father is a critical care hospitalist who trained as a physician in his native India and practiced in both India and England before emigrating to the US.

A new team of residents and attending start on Monday. I introduce myself and take on two overnight admissions, both asthmatics. Our hospital has had two deaths from asthma attacks the past year. The pharmacist who joins us on morning rounds comments: “There is no excuse for kids dying from asthma. It’s a completely controllable disease. More so than even T1D [Type 1 Diabetic]. The best insulin  control and medical communication can still sometimes not be enough to control hyperglycemia. The five-month-old who died from status asthmaticus is tragic but can be justified as unavoidable. There was no prior history. But that 16-year-old who died at her Subway job should have been flagged by her family and physician for using a rescue inhaler [albuterol] every few hours rather than taking her [steroid] controller medication daily as instructed.”

I take care of a 13-year-old T1D admitted for DKA [diabetic ketoacidosis]. We were taught about different types of insulin, but we were never taught practical lessons, for example, the three types of standard sugar control regimens, how to administer the insulin, how an insulin pump works. I ask my resident to go through the basics before I go into the room and make a fool of myself and the team. Most diabetics take daily or twice daily long-acting insulin (Lantus or Levemir)  to act as the foundation. In addition, after every meal they do a carbohydrate correction (e.g., 1 unit for 15g carbs for lunch and 1 unit per 30g carbs for dinner). Lastly, they do a sliding-scale adjustment every 2 or 3 hours, where they administer 1 unit for every 30 mg/dL glucose above 130 mg/dL. She has been hospitalized six times in the past 2 years for DKA after relatively good glycemic control since the diagnosis at age 3. We are not exactly sure what happened. The residents suspect that, given her age, she is refusing to take insulin as prescribed as a weight loss strategy (“diabetic anorexia”).

[Editor:A friend who has managed Type 1 Diabetes since childhood wrote the following private message: “I always see people posting on Facebook how they go to CVS to buy insulin and it is $500 a bottle (lasts me a month but lasts fat people 2 weeks) and they are so mad that companies are ‘allowed’ to charge this. I ask them why they go to CVS and pay retail when the same insulin is $40 a bottle mail order from Canada, including shipping. And the older kind is $29 a bottle at Walmart. Almost no one in the UK has insulin pumps because their health system doesn’t provide them for free. Pumps are $6000 here new, but I got two for free on Facebook and you can buy them on Craigslist for $300 except do-gooders report the listings and get the listing taken down as Facebook, eBay, and Craigslist don’t allow them to be resold.”]

An 8-year-old is admitted for poor weight gain (4th percentile for weight and BMI) and acute episodes of diarrhea. We need to get his charts from an outside institution also on Epic to determine when he fell off the growth chart. In theory this should be easy with Epic’s “Care Everywhere” reconciliation. However, we spelled his last name wrong in our system, causing a failure to synchronize with the outside institution. IT informs us we that it is impossible to correct this error until after the patient is discharged.

Part of the medical student’s role is to get medical records from outside institutions. How does this work, nearly 10 years after the American Reinvestment & Recovery Act, which included the “Health Information Technology for Economic and Clinical Health (HITECH) Act” that provided taxpayer funds for computerization of medical records? The core technologies are the telephone and a FAX machine. Here are the steps:

  1. 20 minutes on hold
  2. speak to the medical record department
  3. get their institution-specific medical request form faxed to us
  4. fill out the form with help from the family, e.g., to learn the Social Security number
  5. fax the request form back
  6. wait 30 minutes for the requested documents to appear on our fax machine

This is not to say that the electronic medical record (EMR) has had no effect on the process. EMRs may automatically add vitals at 15-minute intervals to the record and therefore even the simplest data request usually results in at least 10 pages of irrelevant notes before you get to the information that is sought. I learned that it is more efficient to ask the patient to call the institution and speak with a nurse who can relay relevant labs over the phone. I then type them into our Epic system. Even triple-checking the values on a voice call, the total time and effort is much less than using EMR+fax.

I say farewell to my team and head off Wednesday afternoon for a lecture on childhood GI bleeding. The lecturer speaks in a monotone, reading verbatim off the slides of a presentation that someone else created. I ask classmates if it was obvious that I was dozing off. Anki Alex, a class gunner who does 300 Anki cards daily on rotation: “Big Dawg, every person was dozing off. There was a wave of head bobbing. The few times that I myself wasn’t sleeping it was hilarious to watch.”

We take our exam Friday morning. Crisis ensues at the exam. The hospital WIFi is intermittent so every 10 minutes the private secure browser in which we take the NBME Shelf exam shuts down. Nervous Nancy’s computer works fine and she is taking her exam while the other 25 students shriek and hollar. Exams are typically proctored by two people: a clerkship administrator and someone from IT. Today, the IT proctor is sweating and scrambling. His best theory is restarting each computer after every shutdown, but today this is providing only another 10 minutes before the next shutdown. After 30 minutes, the clerkship coordinator kicks everyone out to give Nancy some quiet. We are then called in one at a time to log on and restart the exam. This process of getting people restarted for the 2-hour, 45-minute exam takes about 2 hours.

The exam is probably the hardest exam I have taken throughout medical school.The average is low enough the passing score is rumored to be 60 percent correct.  The pediatrics shelf includes questions on childhood skin lesions, upper airway versus lower airway disorders the amoxicillin drug reaction from mononucleosis, several challenging autoimmune disorders (e.g., compare Bruton-K agammaglobulinemia versus Common Variable Immunodeficiency), and an annoying nephrology biopsy image (Pinterest Penelope: “blast from Step 1 past”).

Type-A Anita complains to the administration that the disruptions affected her exam performance after we finished the exam. We got an email on Saturday:

We apologize for any added stress caused by the technology issues during testing this week. Thanks to the determination of our IT professionals, we understand now that the issue was beyond our control and that it has been resolved with the necessary groups.  … Although we will not receive results from the NBME until this weekend, please understand that all contextual factors will be considered in the case of any undesirable outcomes.

Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 1 night. We grab burgers and beer with Mischievous Mary who just finished her OB rotation. “You hear the most ridiculous stories. The residents and students sit in an alcove that is obscured by walls from the patient hallways. An African-American in his late 20s came up to the nurses and said: ‘Ma’am, my wife and girlfriend are in rooms next to each other. Could we move them so they are not near each other.'” She continues: “You’ll also hear the worst baby name choices. I asked the attending if she ever tries to change their minds? The attending responded: “Only once: the patient wanted to name their daughter Chlamydia. I talked them out of that.” She concluded: “I never appreciate how obstetrics is such a surgical field. I am actually considering OB now instead of CT surgery.”

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Medical School 2020, Year 3, Week 11

First week of inpatient pediatrics starts at 7:00 am. The team consists of a PGY3 (“senior resident”), a PGY2 (“the mid-level”), two interns (would be “PGY1”), an M4 in the role of an intern (“Acting Internship”  or “AI”), and two M3s, including me. The PGY3 pediatrics resident is a short quiet 31-year-old. He looks at the floor and around when he speaks to someone. He took several years off after college to live in NYC with his librarian girlfriend. The idea was to work as a researcher to improve his medical school application, but working as a “manny” for wealthy Upper West Side families turned out to be the job that paid enough to afford an apartment. The PGY2 is a 29-year-old Oregonian native who loves her three cats and is married to a tenuously employed man back home. Rockstar Rita is the attendings’ favorite intern. Her girlfriend is a resident in a city that is a four-hour drive away so they rarely see each other.

After meeting the team, I shadow the interns and residents on Monday while getting accustomed to the basic structure of the day. First, we preround on each intern’s 3-4 patients. The interns plus the “AI” write notes at the resident station until morning handoff at 8:00 am, packed into a 10-person conference room attended by the residents, interns, medical students, our pediatric hospitalist attending, and the hematology/oncology attending and/or fellow as well. We first go over the oncology kids. Rockstar Rita has all of these notoriously complicated cancer kids. She presents a patient summary for each of the four “regulars”: two acute myelocytic leukemia (“AML kids just get sick” [from the drugs used to destroy their white blood cells]), a rhabdomyosarcoma, and a Ewing’s Sarcoma. She highlights actionable items such as thresholds to transfuse platelets or red blood cells, when to draw another blood culture if they have a fever after 24 hours, and pain medication regimens. The night team then presents the new patients admitted overnight. Finally, we leave the conference room to round on each others’ patients in our pack of 8 and finish at the resident station for everyone to write notes.

The resident station is a short hallway outfitted with five computers that connect the nurses station with the snack room in the middle of floor. It is hidden from patient’s view but clearly not out of range from the loud conversations going on. “Alright, team lets get em out,” as he whistles. “The Discharge train begins.” Rockstar Rita complains that her “T1D” [12-year-old type 1 diabetic admitted for diabetic ketoacidosis] should be ready to leave the hospital, but is acting lazy: “She just won’t get up. She is lying in bed, not drinking or walking. This is a perfect job for a medical student [looks at me], Go get her up. I don’t care how you do it but get her to chug a glass of water.” What do we do if a patient doesn’t want to leave?” The senior resident chimes in: “Same exact thing with gastroenteritis girl. Vomiting is not a reason to be admitted to a hospital. They were admitted for concern of an appendicitis, which we have now ruled out. Go have diarrhea at home like everyone else.” The AI chimes in: “We ask him if he wants to go home and he replied, ‘No, let’s stay, it’s fun.’ Could we take the TV cord? (Oh no, cord broke what happened?)”

The senior resident added afterwards: “It sounds heartless, but we need to get these patients out of the hospital. The PICU is completely full so when we don’t have a room patients may have to be transferred to a less capable hospital. Also, the best thing for these patients is to get home and back to a normal schedule.”

I wake up our T1D, walk her to the water station for a drink, then drop her off with the video games in the Teen room. 

I then sit down with my classmate Diva Dorothy, one of the younger class members at 24. She’s a great resource now that our class has dispersed because she keeps up with gossip from every year within our school. She started a week earlier and gives me some advice about Inpatient Peds. “Unlike with adult medicine, pediatric patients recover so quickly that it’s tough to do any patient presentations. Grab any patient who will be here for a few days. Also, bring your own laptop because there won’t be room at the resident station.”

She confides her struggle during the previous week. “They think I’m lazy or not interested and ignore me. I’m sitting in the next room over and they’ll just leave and go to the consult without me. No one gave me any orientation, each medical student has had to rely on the previous medical student to get situated. We have no idea what note templates to use [within Epic]. No one gives me the AM rounding sheet showing new patients that they print out for everyone else. How did you get one?” (me: “I try to get in at least 15 minutes before the official 7:00 am start time. Then I can ask the night team resident for a printout.”) 

Dorothy: “I’m sad about this whole experience because I loved outpatient pediatrics. I’ve had such a bad time here that it’s making me question doing pediatrics.” I agreed that it is a shame that an unapproachable team during a clerkship can discourage someone from pursuing a residency. She complained last week to the clerkship director. Apparently this was conveyed to the pediatric hospitalist attendings because Dorothy remarked that this week’s orientation was substantially improved.

[Discussion with Hannah that night: “all of the rotations are poorly organized.” By Wednesday, Diva Dorothy is absent. Our team is told that she is sick with a stomach bug, but she texts me to say that she has been moved to hematology/oncology clinic at a different location.]

After rounds we sit at the residents’ station. I am surprised at how little we actually see patients. After the initial morning round, most patients do not get seen by a physician until the next day. The night team does not go in unless a nurse asks them to. Residents during the day spend most of their time writing notes, ordering labs, and finishing discharge summaries. The senior resident mentioned that one thing a medical student can do to help the team is check periodically on patients. [Editor: Doctors are so busy typing at computers that the medical students have to do the actual doctoring.]

We get two new admits from the ED at 4:00 and 4:30 pm. Diva Dorothy was packing her stuff. The attending had to convince her to stay later than the normal 4:00 pm sign out. The attending: “You can go, but it would be good practice to admit a patient.” She responds: “Okay, I’ll stay.” (We are only supposed to do one late sign out per week). The residents/interns regularly stay late. 

Tuesday is a typical day. I get in at 6:45 am for prerounding on my one patient. At 8:00 am, I head to the conference room for morning handoff. Diva Dorothy is complimenting Rockstar Rita on her new short haircut. “I love short hair, but I never know if I should get it. My parents are Sikh so they frown when I cut my hair.” (She references a tattoo, though, but I have never seen it.) Once everyone is present, we hear about the cancer patients. Rita is doing a fabulous job despite constant interruptions from the PGY2. The Attendings are chatting with each other, oblivious to this rivalry between the two young women. I pick up a new patient who was admitted by the night team.

The medical student or intern present the patient to the patient and the whole team in the room. We are instructed to use “layman’s terms” or explain the term if you use it to a patient: e.g., “afebrile means no fever overnight”; “leukocytosis with bandemia means high white blood cells with markers suggestive of immune response”. The quality of our presentation is a big part of how we’re evaluating, but it is challenging to select the right amount of information for the team and the desired level of detail will vary considerably depending on whether we’re ahead of or behind schedule. One attending later complimented me after I brought up a potentially disturbing question with him privately before we entered a patient’s room. I didn’t tell him that it was Rita’s whispered idea.

I struggle to present my patient in the clear “SOAP” format [Subjective, Objective, Assessment, Plan], forgetting a few lab values and symptoms that I mention in the wrong section. I need to work on this. Much different that presenting a surgery patient. 

She’s six months old and was taken to her pediatrician for a three-day history of diarrhea, nbnb (non-bilious, non-bloody) vomiting, and lethargy. The pediatrician gave the baby some Pedialyte and sent her to an outside ED, which administered a fluid bolus (20 mL/kg). and took an x-ray to look for possible obstruction. The extra hydration led to rapid improvement in her symptoms. The x-ray did not show any signs of obstruction, but there is a concerning left upper quadrant opacification suggestive of a mass. An abdominal ultrasound showed a large, heterogeneous mass separated from the kidney and spleen. The outside hospital did not feel prepared to evaluate this patient, so an 80-mile helicopter transfer to our tertiary hospital was ordered.

[Editor: Yay! Creating jobs for East Coast Aero Club graduates and Eurocopter mechanics.]

The baby arrived looking well and entertained the residents as the cutest kid on the floor.  Morning report from a night intern: “Given the location of the mass, our differential needs to remain wide. This includes: Wilm’s tumor, nephroblastoma, neuroblastoma, lymphoma, and other neoplasms of the adrenal gland, kidney, stomach cancer, etc.” PGY2 chimes in with statistics about the most common pediatric malignancies. Our Attending: “I called down to radiology and our pediatric radiologist is not convinced this is a mass. He wants us to insert a NG [nasogastric] tube to better visualize the stomach.” The heme/onc noted that the abdominal ultrasound did not show much vascularization of the unknown mass. We need to CT before we can have a definite plan. I’d like to CT before we biopsy.” The hematologist/oncologist attending goes in and tells the parents that there is a concerning mass that may be a tumor. The parents start crying.

A few hours later, after we get through our critical note-typing, I am tapped to insert the NG tube under Rita’s guidance. Every NG tube must have a x-ray to confirm correct placement, i.e., not in the lung or perforating the stomach into the peritoneal cavity. The baby gets her second x-ray.. We send the baby down to get another abdominal ultrasound while water is poured into the NG tube for better visualization of the stomach. 

I look at the NG tube-confirmation x-ray and notice that the mass is gone. I bring this up to the resident. “Hmmm that is very interesting.” A few minutes pass and the ultrasound tech calls to say that she cannot locate the mass. We go down to the radiologist who believes this “mass” was just a distended stomach. “Look at the air-fluid levels on the ultrasound. It’s just a really distended stomach from a large feed.” We learn that mom is feeding the child 9 oz of formula every 2-3 hours, about 3 times the recommended amount.” The senior resident jokes: “We just discovered a new disease: malignant constipation.”

We have two boys on our floor for constipation requiring manual disimpaction. The senior resident: “This would be a perfect job for our medical student. Ask the nurse to supervise.” The nurse explains how to do the procedure before we go in. I perform the digital disimpaction and insert an NG tube hooked up

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Obituary of Nathaniel Greenspun, 1930-2021

Nathaniel Greenspun died at age 90 on February 24, 2021 at home with his wife Regina in the Maplewood Park Place Retirement Community, Bethesda, Maryland.  He had been getting progressively weaker over the past few years and suffered a dramatic episode of weakness, leading to a fall, one week after receiving his second dose of the Pfizer COVID-19 vaccine. It is possible that a stroke accelerated his decline, but no definitive diagnosis was obtained. Most of the following was written by Nat himself in 2017.

He was the loving husband of many years of Regina, the father of Suzanne, Philip, and Harry, the grandfather of 11, and great-grandfather of 1. In addition to his immediate family, he is survived by his younger sister, Elinor Dulit.

Born in New York City, Nathaniel attended elementary and high schools in Forest Hills, Queens, and was the valedictorian of his class at Forest Hills High School. He then went to Harvard College where he was graduated summa cum laude and admitted to Phi Beta Kappa.

After college, he earned an M.A. in Economics from Harvard and was a Teaching Fellow  in the Economics department. Beginning in 1953, he served twenty-one months in the Army.

In 1956, he married Regina Gittes and in 1958 moved to Washington, D.C. where he worked at the Bureau of the Census on a new program of “company statistics.”  Four years later, he transferred to the Bureau of Economics at the Federal Trade Commission where he worked on an effort to collect data from the 500 largest companies. In 1962, he transferred to the Board of Governors of the Federal Reserve where he worked in a division that evaluated the competitiveness of bank mergers.

In 1966, he returned to the Federal Trade Commission where he mostly worked on issues relating to consumer protection, such as false advertising.

Living during an era of the rapid development of technology, he became an enthusiastic user of the computer, enjoyed music in stereo, frequently recorded TV programs, etc.

He and Regina loved to travel and over the years made numerous trips to many parts of the United States, Canada, Europe and Israel. Classical music was his constant companion, something he had enjoyed since perhaps the age of 10. He was a devoted supporter of Israel.

Contributions in lieu of flowers may be made to the Plant a Tree in Israel (JNF) organization.

A memorial service will be held in May 2021 at the Garden of Remembrance in Clarksburg, Maryland.

From a family history video project:

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Medical School 2020, Year 3, Week 10 (Pediatrics)

Day shift at the neonatal intensive care unit (NICU) begins at 7:00 am. The night shift neonatologist is finishing her notes in the physician lounge before the 7:30 am handoff. I asked why she isn’t using the hospital’s Epic system. She explains, “We are part of Pediatrix, a MEDNAX subsidiary. Forty percent of neonatologists are part of this group.” (When she’s finished with her note it will be exported to Epic as a picture, thus resulting in a hard-to-use chart for the patient. The Pediatrix system is problem-oriented and, though less flashy than the Epic screens, is superior in terms of information presentation and productivity.)

My attending, a 50-year-old who speaks softly in a thick Indian accent, arrives at 7:15 am, and opens a discussion regarding the consolidation of physicians (Pediatrix employs more than 1,750 doctors). The night neonatologist: “We have no one to blame but ourselves. Physicians want to only focus on patients and do not want to deal with billing so we just handed it to administrators who took over. We don’t get paid if we don’t bill.” He responds: “It just seems that the administrators took the power and have made it so complicated it is impossible for any physician to understand it. Every year they change the reporting requirements, change the codes. They purposefully make it such that you need an army of administrators behind the scenes.”

“The administrators think we are naive to their little ploys,” she added. “They make a big deal that they sent us a link to a live feed of the 9:00 am annual shareholder meeting. Are you freaking kidding!?! We have babies to take care of in the morning. They have no idea what we do.  They are just profiteers. Our company will never raise our salaries. New hires get paid more than we do. Instead of raises they’ll give us bonuses from the profit, but of course they take the first 50 percent.”

After the night neonatologist left, my attending summarized: “People remember the $500,000 per year salary from the good old days, but they forget that they had to work every single day, no weekends off, to earn that.”

We proceed to the actual NICU, double-washing our hands and sterilizing our phones and badges with UV light. We then take turns listening to the neonates from the individual child stethoscope hung on each pod (to avoid cross-contamination). I am assigned two babies. I try to conduct a full physical exam on them but the nurses shoo me away because it is outside of scheduled “Care Time”. Neonates are given four hours of undisturbed nap time in between medical interventions.

The attending heads off to the physician lounge to write notes while I set up in the respiratory supply closet, which doubles as a respiratory therapist (RT) station with three computers. I finish my note and then study UpToDate on various neonatology topics, e.g., respiratory interventions and feeding regimens.

Around 12:00 pm, a nurse pops her head in and asks if I want to “join for stairs.” I agree, despite not knowing what is involved. The 30-year-old nurse, my attending, a 60-year-old RT and I walk up and down the hospital stairs (13 floors) three times before we head to a meeting on provider well-being. The RT keeps going. We all get pretty sweaty and the nurse says, “We better not show up at the same time to the meeting. Could be questions.” Despite carrying 20 extra pounds, the attending is able to smile: “Yes, yes, I’ll show an hour later.”

[Editor: How long would a male nurse last after making a sex-related joke?]

The meeting regards the emotional fallout from caring for a particular baby, in his seventh week in the NICU, with skeletal dysplasia, a fatal disease with numerous bony deformities and cardiac anomalies. One nurse confides: “It’s just hard to go to work seeing this baby in pain day after day.” The child has a gastrostomy tube that has had two episodes of cellulitis. The infection is cured, but there continues to be wound breakdown. “No matter what position he is placed in he squirms.” Two nurses have refused to care for the child. The nurses have to suction out the tracheostomy tube to prevent the child from desaturating due to mucous plugs. The nurses thanked both physicians for their clarity to the family. “I think the family had different impressions from the beginning compared to what you two have conveyed.” The attending said that the family is slowly coming around to the idea of letting nature take its course.

We slip out of the meeting for a Caesarian section. A neonatologist is present at every vaginal delivery of a pre-37-week infant and at every Caesarian section regardless of gestational age. I get permission to watch from behind the surgical tech’s Mayo Stand (stainless steel table near the surgical field, holding commonly required instruments) the Ob/Gyn team performs a laparotomy (opening of the abdominal cavity). After they reach the anterior abdominal fascial sheath, the resident makes a small incision with her dissecting scissors. They widen the hole until the attending and resident can each fit one of their hands into the peritoneal cavity. “Lots of pressure,” announces the attending as she pulls laterally to tear open the fascial sheath. They’re casually chatting about a recently retired physician during this 8-minute procedure.

Once they’re inside the peritoneal cavity, I can’t see anything more so I head back to the baby response team (nurse plus neonatologist). The surgical team announces uterine incision time, then membrane rupture time. The baby response team doesn’t even look at the mother or surgical site until the surgical team announces membranes are ruptured. The nurse hangs a large blanket on my shoulder and demonstrates how to carry the baby. After a 15-second struggle, the resident pulls the baby out of the uterus, cuts the cord, and passes the baby to me. I wrap the baby in the blanket, take two awkward steps, and place the baby down on the warming bed for the neonatologist to evaluate.

The baby has a low blood oxygen saturation so we begin BIPAP (bilevel positive airway pressure). The neonatologist grabs an oxygen mask from the nurse and places it on the newborn. There is a small hole in the mask out of which the 44-percent oxygen mixture escapes until the attending places his index finger on the hole, at which point positive pressure is applied to the lungs. The neonatologist demonstrates how to deliver the pressure by toggling the pressure every two seconds. I take over and watch the oxygen saturation go from 80 percent to 86 percent. 

The neonatologist whispers, “Does this look like a funny baby?” I look for classic syndrome characteristics: he has a smooth philtrum (groove between mouth and noise; bad), macrosomia (bad), low set ears (bad). I open his hands: two palmar creases (good). My attending points out sandal gap toes (wide-space between big toe and the 2nd toe). The neonatologist admits the baby for respiratory distress and further evaluation of syndromic characteristics.

The nurses 10 feet away: “How does she think she’ll get to keep this baby?” The other nurse: “She doesn’t think we know about her other kids. She keeps having more kids thinking CPS won’t be notified and she’ll get to keep this one. Maybe stop doing drugs and be a mother.”

The nurses see me listening in and comment, “Welcome to the NICU. Not your Cinderella stories.” The notion that NICU care would be heroic work saving premature babies, a completely clean slate, from certain death to bring them to adulthood and productivity is typically wrong. Similar to my trauma experience, these patients are “high risk”. Unfortunately, a majority of the babies are in the NICU because of terrible mothers. And business is booming. They just doubled the NICU beds in a large renovation. 

I dig through the mother’s chart. She’s a 38-year-old Hispanic and this is her ninth child. She does not have custody of any of the previous eight, three of whom have Down Syndrome. (She likely has a Robertsonian translocation, which means each child has a 50 percent chance of Down Syndrome.) She admitted throughout this pregnancy to using crack and other narcotics, but did stop using meth at 14 weeks into the pregnancy. The neonatologist and I interview the mother. It is taboo to ask about who the father might be so the discussion centers on CPS and the likelihood of them taking over custody of this child.

We get called down for a 34-week vaginal delivery. Fetal ultrasound at 20 weeks showed excess amniotic fluid, but no renal abnormalities or tracheoesophageal atresia. The patient is only 7 cm dilated. We ask the Ob/Gyn resident if she needs our help. “No, I think it’ll be awhile.” Why did she page us? My attending: “OBs have no sense of time. Do they think we just sit up there twiddling our thumbs waiting for them to call? We have an entire NICU to run upstairs.” The baby is born two hours later, and nephrology is consulted for a rare inherited kidney disorder from a genetic defect in a kidney channel furosemide or hydrochlorothiazide use leading excess diuresis. (There are only an estimated 8,000 people in the world with this disorder. Prognosis: there is relatively good prognosis for the child if treated consistently with nonsteroidal antiinflammatory drugs and electroylte monitoring)

While finishing the day’s notes my attending says, “Look at this. A 34-weeker was given a portable warmer. This costs $600. A 34-weeker does not need this warmer. Under 28 okay, but 34-weeker. I don’t even know why I try to save money. It’s all Medicaid money. No one cares.”

Friday afternoon is our clerkship director leads a lecture from 1 to 6, ostensibly on the topic of Failure to Thrive. Looking at the weight charts, however, spawns a tangent on the subject of obesity. “Weight percentiles on growth charts are calculated off of the 1960s and 1970s NHANES [National Health and Nutrition Examination Survey] data. Over half the country are above the 75th percentile.” Pinterest Penelope asked when we would update them to reflect our actual population. “I don’t think we want to lower our standards.” Our clerkship director shared her personal secret for motivating children to lose weight: “You have to frame it as a personal problem. I tell the mom: ‘You unfortunately are an easy weight gainer, and you will have to work extra hard to get it off.’ The parents and child all have to lose weight together.”

She covered familiar ground about kids playing indoors with electronics rather than outdoors with neighborhood friends: “I flip out when I see a one-year-old swipe at a Fisher-Price iPad App before he can run. It’s scary, right? I can’t even do that.”

She concluded this topic: “Positive thoughts lead to positive feelings that lead to positive actions and positive results! Repeat after me.” We all repeat in unison.

[Editor: From Life of Brian… “You’re all individuals”; (in unison) Yes! We’re all individuals! “You’re all different!”; (in unison) “Yes, we are all different!”]

She talks about acetaminophen overdoses. Two classmates report seeing two acetaminophen overdoses each during their inpatient pediatrics rotations. She explains: “The parents a lot of time don’t think it is serious. They want to take their daughter home, but it hits them when we put one-one suicide precautions: minder in the room at all times, take their phone, place them in paper gowns. Parents think it is situational. Their teenage daughter is temporarily depressed after a break-up, so there is no need for treatment. Do the parents think there won’t be another boyfriend and another breakup? I had to get a restraining order to prevent a mother from taking her daughter home.”

She attributes the bulk of the problem to glorification of suicide in our culture. Pinterest Penelope responds by mentioning Amy Winehouse and the Netflix show 13 Reasons Why.

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College Today: Exercise by going to your twice-weekly COVID-19 test

“Amid COVID Outbreak, UMass Amherst Prohibits Students From Leaving Dorms for Walks” (NBC):

For the foreseeable future, all UMass Amherst classes will take place remotely, and students in dormitories and off-campus housing are instructed not to leave their residences except for meals, COVID testing twice per week and medical appointments.

The university says students can use trips for food and twice-weekly COVID testing at the Mullins Center as opportunities to take walks to support their health. Another option is virtual fitness classes.

Students living in the same residence hall are not allowed to hang out in each others’ rooms, and no guests are allowed in residence halls until further notice. Students are also not allowed to gather in any spaces during this time, UMass Amherst says.

All athletic practices and competitions have been canceled.

Students who violate campus restrictions or fail to comply with directives will face disciplinary action, according to the university’s website. Punishment may include removal from residence halls and/or suspension.

And on the other coast… “UC Berkeley bans campus residents from outdoor exercise as part of clampdown after COVID surge” (Mercury News):

The lockdown, imposed on Feb. 1 and expected to be lifted on Feb. 8 before being extended that day, even bans students from getting outside exercise. And to enforce it, the university is increasing its security presence.

The new restrictions will affect about 2,000 students, a “significant number” of whom are in quarantine, according to the university.

Under the restrictions, students can only leave their rooms for medical care, in case of emergency, to comply with testing requirements, to use the bathroom on their floor and to get food from a nearby outdoor kiosk, according to an email sent to students from the UC’s medical director and other campus officials.

Additional campus security officers will be patrolling outside the residence halls and students may be required to show their campus IDs more frequently. All students must be tested twice a week.

“Be aware that students are subject to serious residential conduct sanctions for not complying with campus directives including being disqualified from housing and suspended from the University,” the email stated. “We don’t wish for residents to be alarmed by this increased UCPD presence, but we must ensure the health of our community.”

If back in April 2020, a few weeks into coronapanic, someone had said that Americans would one day pay $50,000+/year for this experience (surveillance, regular medical testing for an infection that is typically irrelevant to the young, periodic absolute lockdowns), would we have believed him/her/zir/them?

Related:

  • COVID-19 and the MIT community: “I hope that Ms. Meredith is never sentenced to prison here in the Land of Freedom (TM), but if she does become part of the world’s largest imprisoned population, it sounds as though she has the right attitude for life in the Big House.”
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Medical School 2020, Year 3, Week 9 (Nursery)

My week in the nursery starts at 7:45 am. My attending, a specialist in NAS clinic (babies born addicted to opioids from addicted mothers), strolls in at 8:15 am. After residency two years ago, she did a fellowship in pediatric palliative care, and took the job at our institution expecting to be mentored by the palliative care team. However, the position evaporated, and she took the job in the nursery instead. “I needed a job,” she explained. “The goal of this week is for you to become comfortable being around a baby.” She goes over a basic newborn exam on newborn baby in the nursery receiving phototherapy for jaundice. “Tomorrow we’ll give you a newborn for you to follow. Today just follow me around.”

Afterwards, she catches up on the computer while I configure my Epic with all the best screens to view weight changes, bilirubin values, feeding schedules, and diaper changes. The 35-year-old PA student training with us arrives around 10:00 am, and I help set up his account. We then go into a conference room. She hands us a folder that every mother gets when she arrives on the floor. It includes information on breastfeeding and postpartum blues information. She also hands us a H&P (history and physical) form where we record all the patient’s information for handoff to the night team. She asks us to introduce ourselves. 

The attending does newborn checks on the four babies born overnight and this morning. Around 11:30 am, she sends us over to work with the lactation consultants. They instruct us to read a packet, titled “Breastfeeding for Dummies”, describing good breastfeeding technique and detailing the number of times a baby should feed in the first week of life. After 30 minutes, we each follow one lactation consultant. “No, no, no. That must be painful.” she explains to a mother, showing her how to get a good latch. “If it hurts at all, you need to start over. Babies are lazy, you need to teach them good habits from the beginning or it will be harder to breastfeed.” She breaks the latch with her finger, and then grasps the areola with her palm, opens the baby’s mouth and shoves the breast into the babies mouth. The mom exclaims, “Wow much better.” Are there any male lactation consultants? “I’ve been doing this a long time and have never worked with one, I think I saw one at a conference, but he may have been a doctor.” [Editor: Perhaps this male-appearing individual identified as a woman?]

The next patient is a baby who is not gaining enough weight. The pediatrician put in an order for formula, but the mom wants to breastfeed exclusively. The lactation consultant disagrees with the order, but shows the parents how to feed with a syringe and tube on which the baby will have to suck. “If you start the bottle this early, the baby will start to only want to use the bottle. You’ll have to pump all the time, but your supply will slowly go down. You need those hormones to kick in to keep the supply going.”

Our attending is trying to work her way down from 180 lbs. with salad and sends me out to grab lunch with Jane at the hospital outside the coffee shop. Jane is on her orthopaedic elective. She was in clinic this morning, and arrived at the hospital two hours early for her first OR case. Jane hasn’t done surgery yet, so I give her the basic tour of the OR, the various staff members in the operating room, where to get gloves, and how to help the nurses. “Make sure you wear a mask into the OR!”

After lunch, I watch the attending perform two circumcisions. The nurse grabs a chair and puts it behind me. “If you feel queasy, sit down.” A medical student last year passed out during the procedure. I give the baby sucrose (“Toot Sweet”) drops which help the baby ignore the pain. “It distracts them.” I squeeze the sucrose tube so hard that the entire tube is emptied by the end of the procedure. The nurse laughed: “That usually lasts their entire hospital stay!” The attending does one later in the afternoon demonstrating the World Health Organization technique to the residents. It’s definitely less efficient. I learned that a circumcised infant has a 1 in 1000 chance of a UTI in the first year of life compared to a 1:100 chance for an uncircumcised boy.

The PA and I leave at 1:00 pm for lectures in a nearby outpatient clinic lecture room. We have students present a 10-minute topic of interest followed by a 3-hour discussion on failure to thrive (“FTT”) led by the clerkship director, an 50-year-old pediatrician. She talks at the speed of light. We learn that she lives with her mom in a small apartment complex next to campus known to us graduate students as the party apartment. She tells us about yelling through the window at kids swimming in the pool without a parent present. “My mom tells me to stop, but I can’t help myself. I just can’t. What parent would leave their kid alone in a pool? Right, Right?” Southern Steve counts the number of times she says “Right” — 54 times in 3 hours of lectures.

Pinterest Penelope presents on the causes of hypoglycemia (low blood sugar). The clerkship director interjects: “What is the number one cause of hypoglycemia around Christmas time or New Years?” Blank stares. “Alcohol ingestion.The kids get up early and drink all the eggnog left over. [excess alcohol consumption increases insulin secretion, decreasing blood glucose levels.] We have lots of these patterns. Halloween is DKA season [diabetics eating too much sugar]. Halloween is also costume dermatitis season.”

Our clerkship director strays from the advertised topic of FTT. “We are so spoiled with vaccines. I’ve been in practice for 18 years. My mentor would tell me how they used to go into the hospital with 100 kids, and leave with only 30 on some days. That’s how bad HiB [the Haemophilus influenzae type B bacterium] was. It would decimate entire counties. The medical community worked hard to develop HiB vaccine. I was around when Prevnar 13 was developed from Prevnar 7. I had babies die from Strep meningitis.”

A student asks: “How do you deal with parents that refuse vaccines?” She explains: “Being a doctor means dealing with difficult decisions. Get used to it. Some practices refuse to see patients that do not get vaccines. If you see a nonvaccer baby, you’ll get sued by another patient who catches measles in the waiting room or if the child dies from a vaccine-preventable disease you’ll be sued cause every dead baby is a lawsuit. We have a large refugee population here. [Editor: Maybe the next caravan from Honduras will take refuge around the pool in mom’s apartment complex?] We need to take care of them, but they are all not vaccinated. Do we just refuse to see them? Where do they go? Well they come to us, we take everyone in the community. Everyone is different, but I love this part of our job.”

Wednesday starts with patients at 8:00 am and then presenting three babies to the attending. The first baby was found to have agenesis of the right kidney on prenatal ultrasound and, during the newborn exam, was found to have a sacral dimple. We take the baby down to get an ultrasound of her spine and her abdomen.

The PA asks why? I respond: “I think it is because of the VACTERL association (Vertebral abnormalities, Anal agenesis, Cardiac abnormalities, TracheoEsophageal fistula, Renal agenesis, and Limb defects). A baby with one of these anomalies has a much higher risk of another congenital defect.” We order a genetics consult to help us rule out any syndrome. The nursery turns out to be mostly a filter for identifying complicated babies that are sent for further evaluation.

The ultrasound exam takes about 30 minutes because of the newborn’s difficulty.

Several hours earlier, the mom had asked that the baby be moved to the nursery so that she could get some sleep. I go to ask if she would like the baby returned to her room for phototherapy. “Yes, please.” No one had been to see her for hours, so she’d never had a chance to ask for the baby back. I’m surprised how docile patients can be, afraid to ask for more information from the nurses and doctors. I ask, “Has anyone explained the ultrasound results?” She responds, “No.”

“Well as you were told a few months ago [at the 20-week anatomy scan],” I begin, “your baby doesn’t have her right kidney. We want to make sure she doesn’t have some other anomalies that can occur with this. It is possible this is an isolated finding. We are getting a genetics consult to rule out any syndrome.” She was really calm and relaxed about the whole ordeal.

After lunch, the attending invites us to go home, but I decide to wait around for the genetics consult. I fill the hours until 5:00 pm by taking notes on “High Yield Pediatrics” by Emma Holliday Ramahi, a slide deck of everything relevant to a pediatrics clerk. I shared the link on our Peds clerkship GroupMe, receiving six hearts. The geneticist still hadn’t show up, so I went home.

[The geneticist ultimately arrived at 7:30 pm and ordered genetic testing to rule out some rare syndromes. I opened the check a week later and found that the patient was discharged without any further abnormal findings.]

Jane is not enjoying the first week of her orthopaedic surgery elective. She is working with a new spine surgeon. “All he wants to do is operate so he is quite brisk with the patients in the office. He’s probably a great surgeon, but I am not in the OR until next week.” What does the surgeon do if they’re not in the OR? “He has clinic three days per week and sees 50 patients per day, including post-op follow-ups. Out of roughly 25 evaluations, he might select 5 to have surgery.”

She describes the orthopaedic lounge: “They talk about sports all the time. And the female pediatric orthopedist leads the conversation. She would’ve been the center of every fraternity party doing keg stands back in her day.” Jane is frustrated about the uncertain schedule. “We have no scheduled free time that we could use for studying, but a lot of time is wasted waiting around.”

I attend dumpling-making night with a few Asian classmates. Our vice president, Sleek Sylvester recounts his experience on OB/Gyn, specifically Maternal Fetal Medicine [MFM] service. “MFM has a pretty sick gig. They just consult for the obstetricians— confirm normal fetal growth or diagnose weird condition. They have no patients they are on call for. He described his week: “I work with the ultrasound techs a lot. We noticed this one kid… ” Ditzy Daphne, a classmate who can regurgitate Anki decks, but is slow at applying the information to a patient case, interrupts: “careful what you call the fetus.” Sylvester continues: “fetus sorry. Anyways, I know nothing about reading an anatomy ultrasound. But even I could see that this fetus did not have a normal arm. The tech zoomed in on the extremity. I suddenly realized that the extremity ended at the olecranon [elbow] and it had one small digit coming off of it. We could clearly see the fully formed single finger — with the MCP, PIP and DIP. It was moving! I looked at the tech, and wanted to say, ‘What the Hell?!?” The tech just nodded her head. When we left, I was like what the hell was that. She replied, ‘That was an elbow finger. I’ve only seen one other in my career.'”

Sylvester explained that the MFM attendings receive a live feed from the ultrasound machines. “We were doing an ultrasound on

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Sweden ignores the science on COVID-19 vaccinations

America’s science-following health care professionals and science-informed politicians decided that health care workers, police, and firefighters should have top priority in getting COVID-19 vaccinations. (example from Maskachusetts)

What about the wicked non-masked non-shut kids-in-school Swedes? Their Phase 1 is organized entirely around those old and/or sick enough to require nursing care. Their Phase 2 is for people 65 years and older and also includes health care workers. From the Swedish government:

How many shots has Sweden administered? About 6 per 100 through February 19, or right at the EU average:

As one colleague of Dr. Jill Biden has pointed out, the strict lockdown in the UK has been very effective at driving COVID-19 out of Sweden:

The same guy also looks at media analysis of North Dakota versus South Dakota:

Circling back to vaccine priority… we are told that public health authorities make decisions regarding vaccines based on science. Yet science apparently may give the authorities in every state and country a different answer.

Separately, how important are vaccines? Let’s compared locked-down, masked, and mostly-vaccinated Israel to unlocked, unmasked, and only-starting-to-vaccinate Sweden:

Sweden seems to have had a more dramatic fall in the death rate, starting at roughly the same time, and actually to a slightly lower value than Israel’s. (But maybe this is because party-on Sweden’s cumulative death rate is 2X forever-shut Israel’s and there is a limit to how many COVID-vulnerable people exist in any given population.)

A final thought on the science of vaccinations… “Vaccine Alarmism: We look at the costs of vaccine alarmism.” (NYT):

About one-third of members of the U.S. military have declined vaccine shots. When shots first became available to Ohio nursing-home workers, about 60 percent said no. Some N.B.A. stars are wary of appearing in public-services ads encouraging vaccination.

Nationwide, nearly half of Americans would refuse a shot if offered one immediately, polls suggest. Vaccination skepticism is even higher among Black and Hispanic people, white people without a college degree, registered Republicans and lower-income households.

Friends on Facebook have cited this disapprovingly. They can’t believe that any young healthy person wouldn’t welcome an “investigational” vaccine that would be illegal to give as soon as a declared “emergency” is over. I asked one of these guys why he expected young healthy folks to want it:

  • Him: because most of the information we have seems to show it’s much better than the alternatives.
  • Me: Better for whom? Italy was one of the world’s worst-afflicted countries by coronaplague. 60 million people live there. Among those 20-29 years old, exactly 46 have died over the past year with a COVID-19 tag. You’re saying that a healthy slender 24-year-old Italian should take an “investigational” vaccine to avoid becoming the 47th person in this age group to die with/from COVID-19 (remember that, as far as we know, the 46 who did die might have been extremely sick with some other diseases, extremely fat, etc.)?
  • Him: yes, to keep from spreading it.
  • Me; Here in Maskachusetts, our governor assures us that the vaccine does NOT prevent people from being infected with and spreading coronavirus. “At this time, vaccinated individuals must continue to comply with the Governor’s Travel Order and related testing and quarantine requirements. While experts learn more about the protection that COVID-19 vaccines provide under real-life conditions, it will be important for everyone to continue using all the tools available to us to help stop this pandemic, including quarantining after a possible exposure, covering your mouth and nose with a mask, washing hands often, and staying at least 6 feet away from others.”
  • Me: So you’re saying that young people should believe the government when it tells them that getting stuck with this experimental pharma product will stop them from spreading coronavirus. And they should also believe the government when it tells them that getting stuck with this experimental pharma product will not stop them from spreading coronavirus, which is why they need to wear masks, stay at home, quarantine after travel if they do somehow escape their home, etc.? (CNN: “Dr. Anthony Fauci said that Americans should continue wearing their masks and social distancing even after getting the vaccine because they can still spread coronavirus”)
  • Me: If the government doesn’t trust the vaccines enough to change the travel quarantine laws, why should healthy young people believe that they will help the old/vulnerable by experimenting on themselves?
  • Him: because they’re rational?

Readers: Do you expect your government overlords to grant any special privileges to the vaccinated? If so, when? And will these privileges be revoked as soon as mutant variant coronaplague is circulating?

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WHO guidance on pandemics then and now

We’re about a year into Worldwide Coronapanic. Let’s make sure that we’ve been following expert advice. How about checking out Pandemic Influenza Preparedness And Response, A WHO guidance document to see what #Science had figured out regarding a respiratory virus after 100+ years of study. This 2009 document is an update of previous work and the update is a result of five task forces laboring for years. There were 139 experts who participated substantially and another 428 folks who commented.

We are reminded that viruses can kill us:

Influenza pandemics are unpredictable but recurring events that can have severe consequences on human health and economic well being worldwide. Advance planning and preparedness are critical to help mitigate the impact of a global pandemic.

(also that the only thing worse than a pandemic is a global pandemic)

The case fatality rate can be as high as 2-3% (page 13).

Page 43 is about “Reducing the Spread of Disease”.

In other words, do not close borders unless you’re on an island with no undocumented inbound migration (“in rare instances where clear geographical and other barriers exist”). Do not take all of your money and spend it on Clorox wipes. Do not wear a mask unless you’re sick or treating someone who is sick.

Aside from the above, the 64-page document contains only one other use of the word “mask”:

If medical masks are available and the training on their correct use is feasible, they may be considered for symptomatic persons and susceptible caregivers in household settings when close contact can not be avoided.

The document is silent on the disease-preventing effect of a bandana that has been hanging from the rear-view mirror for months.

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Politicians tell scientists how dangerous coronaplague in Germany needs to be

From the Dutch NPR (February 9, 2021) plus Google Translate:

‘German ministry hired scientists to induce corona fear’

At the beginning of last year, the German Ministry of the Interior worked with several scientists on a strategy to increase fear of corona in order to foster understanding for drastic corona measures. The newspaper Die Welt reports this on the basis of a leaked email exchange.

The emails date from March and April 2020, when Germany was in the first lockdown. Seehofer was concerned about easing too quickly and instructed his State Secretary Markus Kerber to come up with a plan to create support for stricter measures.

Kerber sent an email to various scientists, universities and research institutes asking, among other things, for a worst-case scenario to get a “mental and systematic” grip on the situation. This would help to plan “measures of a preventive and repressive nature”.

The scientists provided plenty of suggestions, including proposals to put “fear and obedience in the population” on the agenda, writes Die Welt. For example, campaigns could be used with images of people dying of breathlessness because there are no IC beds available.

When you’re making up numbers, there can be a debate at what the numbers should be:

It is striking that scientists “negotiated” among themselves about the possible death toll that should be mentioned. The RKI, the German RIVM, proposed to work with their estimate of 0.56 percent of the infected persons, but an employee of the RWI, an influential economic research institute, argued for the death rate of 1.2 percent.

He wrote that they should think “from the purpose of the model”, which is to emphasize “a great deal of pressure to act” and therefore present the numbers “better worse than too good”.

The opposition demands clarification from Seehofer. It cannot be that politics gets “opinions on demand” from science, says Die Linke party chairman Dietmar Bartsch in Die Welt. According to him, politics and science are doing each other a disservice, because trust in science is being damaged.

The liberal party FDP wants an explanation of the ministry in the interior committee of the Bundestag tomorrow. FDP member Konstantin Kuhle writes on Twitter that it is normal for science and politics to exchange ideas, but it cannot be the case that “tailor-made” results are presented, he says.

The Dutch article links to one in German, but that is paywalled.

A photo from 1997(?) when Siemens was our software company’s customer…

The perfect place to hide from coronavirus!

Related:

  • “Coronavirus: Germans’ mental health worse in second lockdown — study” (DW): “Life satisfaction has decreased significantly — worries, stress and depressiveness have increased,” research group leader Dorota Reis told the German news agency DPA. … During the first lockdown, the study participants initially reported that society was moving closer together. They now assessed behavior as “rather selfish and drifting apart,” Reis added.
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A $5000 electric car

One of my worst predictions ever was a 2003 forecast that, by 2023, the Chinese would be able to sell a basic car for $3,000 in 2003 dollars (about $4,300 in today’s money, adjusted via the BLS CPI calculator). I further thought that Americans, instead of burying themselves in debt to buy a needlessly fancy car, would get around in these $4,300 cars.

The market has moved in the opposite direction, with cars over $40,000 being average (USA Today).

Perhaps there is hope, though! “Tesla’s Nemesis in China Is a Tiny $5,000 Electric Car From GM” (Bloomberg):

The Hongguang MINI EV, made by SAIC-GM-Wuling Automobile Co., is currently the hottest EV in China, the world’s biggest automobile market. Sales of the compact four-seater beat industry giant Tesla Inc. in August, with consumers wowed by its tiny price tag — the EV retails for between 28,800 yuan ($4,230) and 38,800 yuan — and its ability to run for as many as 170 kilometers (106 miles) on a single charge. Orders exceeded 30,000 units in just 50 days.

“A lot of consumers don’t need anything fancy, a commute is all they ask from a car,” said Yale Zhang, founder of AutoForesight, a Shanghai-based consultancy. “I’m all for a product like the MINI EV.”

Maybe by 2023 this will be improved? It already has a top speed of 62 mph, according to Wikipedia. That’s nearly double my proposed speed limit that will keep Americans safe.

The interior:

The exterior:

The commercial..

With two more years of Chinese-speed innovation, why wouldn’t this be a good car for Americans?

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