Thanksgiving

This year, I’m especially grateful that there is no war on U.S. soil. Regardless of which side in the Hamas-Israel fight one supports, nearly everyone will agree that war is hell and those who are insulated from war are fortunate. Since 1865, Americans have enjoyed better insulation than almost any other group of people, though, of course, quite a few Americans who identified as men have been sent off to fight.

Zooming all the way to the other end of the spectrum… I’m grateful that we can eat outdoors in nice weather in Florida without being besieged by yellowjackets, the wasps that ruin what would otherwise be great experiences in the Northeast U.S. I’ve enjoyed outdoor meals on both coasts and in Orlando and never been bothered. Florida is supposedly part of this insect’s range, so I have no explanation for why yellowjackets don’t swarm around restaurants and backyard barbecues.

For something in the middle… ChatGPT, which will be one year old on November 30, especially its ability to liberate programmers from the tedium of having to search for libraries and API calls (admittedly a tedium created by other programmers, drunk on the near-infinite memory capacity of modern computer systems). ChatGPT and similar have the potential to make programming an interesting job once again (see Is “data scientist” the new “programmer”?).

Readers: What are you grateful for this year?

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Medical School 2020, Year 4, Week 32 (Anesthesia, week 2)

The calm before the storm (March 9-13, 2020). All the talk in the hospital is about coronavirus. Small talk has become easier with physicians able to recycle the same opinions for multiple hall conversations. 

The first patient is getting a surgery for pes planus or “flat foot”. After I place the laryngeal mask airway (LMA; less invasive alternative to intubation, less protective airway that sits above the epiglottis), the anesthesiologist tells me I can do whatever I want today.  “You can stay and hang out with me, or you can try to get some other airways.” I stay for the first 30 minutes and watch as they cut the fibularis longus tendon and then hammer out the joints of the talus with the tarsal bones and then fuse it. It seems medieval, but that’s orthopaedics/podiatry. With another hour still to go, I head to the anesthesia ready room to snag some more intubations.

The admin anesthesiologist for the week is reviewing the OR assignments and a 26-year-old medic in training is sitting on the couch on his phone. “I just need 15 intubations for the month and then I’m done,” he said. “They told me to show up here, but I’ve just been sitting here for 30 minutes.” (By contrast, we medical students are assigned an anesthesiologist via an evening text from the anesthesia coordinator.) We wait for 1.5 hours as anesthesiologists periodically stop by. I ask if they have any intubations, but they are all LMAs.

The senior partner, who is more than 65 years old, is wiping down the keyboards, mice, and handles with disinfectant to cleanse fomites containing the coronavirus (fomite comes from the Latin fomes meaning “tinder,” a term for something that can start an infection first used in 1546 by Girolamo Fracastoro). A 37-year-old anesthesiologist with a thick Eastern European accent tries to warn him. She asks, “What are you doing? We’re all going to get COVID-19 from the Tunnel of Death and elevators.” (The “Tunnel of Death” or “OR tunnel” is the doorway and initial hallway through which patients and staff get to the ORs.)

More anesthesiologists funnel in to join the conversation. There is clear frustration among the anesthesia private practice group that staffs the entire hospital with the hospital’s administration regarding preparation for coronavirus. Several talk about the three anesthesiologists who died during the 2003 Toronto SARS outbreak. The senior partner: “Admins are in charge of the preparation, which invariably means we are screwed, though I am even more concerned about our hospital’s preparation after the meeting yesterday. There is no PPE. We have 8 respirators with only enough parts for 10 uses! I’m not coming in if they don’t get their act together. The administration is already working from home.” A younger new graduate responds, “I’ve lost $30,000 in the market. I’ll take your shifts!” He adds, “I’m still confused whether this is airborne versus requiring respiratory droplet precautions. Unless this is like TB, a surgical mask should suffice.”

The Eastern European: “I am not coming in if we don’t have the right equipment. I’d kill my father in five minutes.” The senior partner continues: “I wasn’t worried about this until I talked to my Italian doctor friend. If over 65 years old, no vent[ilator] for you.” The Eastern European: “It’s the same as dialysis. You don’t get dialysis in Europe if you’re over 65 years of age. And you know what, I can’t judge them when we put 91-year-old grandmas from the nursing home on dialysis.” The young graduate: “This whole discussion was the problem with ACA and the death squad panel. ” The senior partner: “But how much is age predictive of functional status? We see lots of 40-year-olds that look 80. There is just no good way to ration care.” The Eastern European anesthesiologist retorts, “I’m okay being in the death panel!” The young graduate walking to his next case: “Look look, the answer is a chronic disease severity score.”

The senior partner summarizes:  “The administration is useless. If they really wanted to help, get APRV (Airway pressure release ventilation, a mode of ventilation that gives a longer inspiratory time to help fluid filled lungs maintain oxygenation) on the new ventilator machines. It’s just a software update.” Anesthesiologists leave the room for the next case (no intubations…) as one spreads the rumor of a technologist stealing 2 cases of masks last month and selling them for $100 a box (of 20) on Amazon. “The hospital fired him and is pressing charges.”

The consensus opinion is that the hospital will be overwhelmed by COVID-19 demand. We have more than 1,000 beds, but just over 75 ICU beds, and a limited number of ventilators (though possibly a big stockpile of older models in a warehouse). The young guy who was enthusiastic about picking up extra work was the outlier: “It’s mostly going to kill old people.” The senior partner responded, “A lot of us are in that category.”

[One week later, we got our first confirmed case, transferred from a small community hospital in a remote area.]

At 9:00 am, I walk to the endoscopy suite, having heard this is the best place to get high frequency intubations with quick turnover between “scopes” (Esophagogastroduodenoscopy or “EGDs” and colonoscopies) that require ETTs due to position changes. The anesthesiologist in the endoscopy suite runs 4 rooms with the help of 3 CRNAs (certified registered nurse anesthetist). “Fine with me,” he replies when asked if I could join. “What’s your goal?” He quickly grins and says, “Go to room 2 and ask Todd. They do ERCPs [endoscopic retrograde cholangiopancreaticograms or an EGD with cannulation of the bile ducts] in there so a lot of intubations.” Todd, a CRNA, waves me in. I watch the interventional gastroenterologist biopsying a common bile duct stricture caused by a mass. The cases last about 45 minutes and the next patient is wheeled in quickly. I’m able to attempt five intubations before noon. Four go well, but, having failed to visualize the cords well, I mistakenly insert an endotracheal tube into the esophagus of a 40-year-old male with a recurrence of rectal cancer. Todd picked it up quickly before we delivered more than 3 bag breaths, and corrected it without issue. I placed an NG tube to decompress any air in the stomach. I am disappointed in myself, but an important lesson is given by the practical CRNA. “If something doesn’t go smooth, speak up. Never lie.” He continues, “I am amazed how when something doesnt go right, newer crna’s are defensive and withhold information from the anesthesiologist. I think it comes from insecurity. And they weren’t spanked for lying as a kid.”

Our last patient was a 65-year-old with an MI three weeks ago undergoing EGD for cirrhosis. “I don’t know if this patient should be getting an elective procedure right now so soon after a heart attack, but what do I know? I’m just a CRNA. My boss and the interventional gastroenterologist both signed off on it.” I check back in with the podiatry room, then leave at 12:30 pm. 

My intubations improve throughout the week with a clear technique developed and learn how to estimate the correct size of an oral airway by measuring the distance from the patient’s mouth to the tragus of the ear. My last day I got to use the GlideScope, a video laryngoscope. I was able to see the vastly improved relaxation using propofol as the induction agent compared to etomidate (used in shock and heart failure patients). Propofol drops the blood pressure a lot more than etomidate. The attending summarizes: “The most dangerous part of anesthesia is between induction and the operation beginning. Remember sometimes we want the blood pressure to drop during the extremely stimulating intubation.”

The last day of the rotation is at the outpatient surgery center. The pre-op nurse checks in the first patient, a 71-year-old male with COPD undergoing knee arthroscopy, asking if he brought his personal CPAP machine for the post-op recovery nap. The patient’s wife points to a duffel bag on the table. “I’ve never seen a Marlboro CPAP bag!” says the nurse. The patient’s wife responds, “We were such loyal customers that they sent us a bag. And it fits his CPAP machine perfectly!”

The anesthesiologist lets me lead the show. I hook the patient up to the monitor, preoxygenate for several minutes, push the meds that I drew up from the vials, and successfully intubate the patient. The anesthesiologist explains the importance of managing postoperative nausea. Post op nausea increases aspiration risk, impacts patient satisfaction, but most importantly money. He explains, “The post-op area is a high resource area, almost as high as ICU.” Every nurse can have at most two patients. He continues, “A patient with post-op nausea will hold the bed for longer. It’s not uncommon that after the patient is done in the OR, you are twiddling your thumbs in the OR on PACU hold.”

How to assess the risk for post-op nausea? If the patient has the four most important risk factors, there is an 80 percent chance of post-op nausea: (1) history of prior post-op nausea or motion sickness, (2) female, (3) lengthy surgery, and (4) inhalation anesthetic.

How to treat it? There are four treatments for post-op nausea, the most successful being Zofran, glucocorticosteroid, and an extremely low dose of droperidol. (Smoking cigarettes is helpful and supported by research, but no U.S. hospital has thus far set up a designated post-op smoking area.) Droperidol is an antipsychotic (a “typical” antipsychotic, and therefore a strong dopamine antagonist). This is less commonly used even though it has great results because of the antipsychotic term. Everyone is scared of the black box warning for QT interval prolongation (repolarization segment on the electrocardiogram that, if prolonged, can lead to serious arrhythmias). “Funny how the drug got the black box from FDA even though Zofran has the exact same QT prolongation risk. Somehow Zofran as a new drug slipped through it…”

The anesthesia rotation was highly instructive and it seems like a great lifestyle, especially for those who like to shop online from their phones for several hours per day. However, I would never be able to handle the waiting.

Statistics for the week… Study: 0 hours. Sleep: 8 hours/night; Fun: 2 nights. Example fun: Samantha purchased a smoker for Luke’s birthday. We smoked ribs and “beer” chicken (whole chicken stuffed with a cracked beer to keep it moist) for five hours while drinking beer and the new fad White Claws.  Lanky Luke, having completed anesthesia last month, jokes, “Let’s just say Samantha was not happy seeing our credit card bill after that rotation. I bought so much stuff on my phone during those two weeks.” Their bank account having survived, Sarcastic Samantha is excited to get a new job when Luke matches in a new town. She recounts a typical week at her job as a hospitalist PA rounding on psychiatry inpatients for medical consultations. The 50-year-old female told her, “Doc I need a disimpaction!” Why? “‘I haven’t pooped!” “Let’s start with some laxatives and a suppository first.” The next day, she asked how the suppository went. The patient  responds,”I don’t know.” “What do you mean you don’t know?” “I think I heard two things drop in the toilet.” “Good, good, that means you pooped. Let me know if you need more help.”

She tells us another story from the psych unit: “The next day, my 32-year-old just started screaming on the floor. You could hear her through the double closed door in each room. She wouldn’t shut up. We rolled her onto a sheet, and plopped her on her bed. Wouldn’t stop for an hour.” Since we were outdoors, Samantha gave a demonstration of the screaming volume. “A nurse overheard her whisper to another patient that she was going to pretend to fall and sue the hospital. She doesn’t realize we have everything under video surveillance so we

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Elon Musk and coronapanic

From Elon Musk by Walter Isaacson…

“The coronavirus panic is dumb,” Musk tweeted. It was March 6, 2020, and COVID had just shut down his new factory in Shanghai and begun to spread in the U.S. That was decimating Tesla’s stock price, but it was not just the financial hit that upset Musk. The government-imposed mandates, in China and then California, inflamed his anti-authority streak.

It was not being pro-Science that prevented Musk from embracing measures that proved ineffective against SARS-CoV-2, but a mindless anti-authority attitude. (Keep in mind that the author is a huge hater of Donald Trump, a passionate supporter of Democrats, and a believer in cloth masks against an aerosol virus)

When California issued a stay-at-home order later in March, just when the Fremont factory was starting to produce the Model Y, he became defiant. The factory would remain open. He wrote in a company-wide email, “I’d like to be super clear that if you feel the slightest bit ill or even uncomfortable, please do not feel obligated to come to work,” but then he added, “I will personally be at work. My frank opinion remains that the harm from the coronavirus panic far exceeds that of the virus itself.” After county officials threatened to force the plant to shut down, Musk filed suit against the orders. “If somebody wants to stay in their house, that’s great,” Musk said. “But to say that they cannot leave their house, and they will be arrested if they do, this is fascist. This is not democratic. This is not freedom. Give people back their goddamn freedom.” He kept the plant open and challenged the county sheriff to make arrests. “I will be on the line with everyone else,” he tweeted. “If anyone is arrested, I ask that it only be me.” Musk prevailed. The local authorities reached an agreement with Tesla to let the Fremont factory stay open so long as certain mask-wearing and other safety protocols were followed. These were honored mainly in the breach, but the dispute died down, the assembly line churned out cars, and the factory experienced no serious COVID outbreak.

The controversy became a factor in his political evolution. He went from being a fanboy and fundraiser for Barack Obama to railing against progressive Democrats.

(It cannot be that Democrats evolved, e.g., from being against same-sex marriage to being in favor of gender affirming surgery for teenagers. It is Musk who changed.)

Musk does not love our nation’s second most famous warrior against COVID-19:

… he wasn’t impressed by Joe Biden. “When he was vice president, I went to a lunch with him in San Francisco where he droned on for an hour and was boring as hell, like one of those dolls where you pull the string and it just says the same mindless phrases over and over.”

“Biden is a damp sock puppet in human form,” Musk responded [regarding Biden’s celebration of GM as the most important company in EVs at a time when GM was shipping 26 cars per calendar quarter]

Nor did Musk appreciate the evolution of California progressivism:

“I came there when it was the land of opportunity,” he says. “Now it’s the land of litigation, regulation, and taxation.”

Isaacson, much as he hates Republicans, attributes Musk’s mind-poisoning to libertarianism. But for this poison, Isaacson suggests, Musk might still be among the righteous. How stupid are libertarians? Isaacson describes Peter Thiel not wearing a seatbelt while Musk drives and crashes a McLaren:

Thiel got a ride with Musk in his McLaren. “So, what can this car do?” Thiel asked. “Watch this,” Musk replied, pulling into the fast lane and flooring the accelerator. The rear axle broke and the car spun around, hit an embankment, and flew in the air like a flying saucer. Parts of the body shredded. Thiel, a practicing libertarian, was not wearing a seatbelt, but he emerged unscathed.

Isaacson doesn’t explain why John Stuart Mill and Milton Friedman are against seatbelts in supercars. (I would like an explanation of why the rear axle broke! A pothole on Sand Hill Road?!? Quelle horreur! Acceleration per se doesn’t seem like a plausible cause. In the video below, Musk says “the rear end broke free”; Isaacson, the Harvard graduate, may not have understood that this describes wheelspin, not the rear axle and wheels coming off the car.)

Speaking of coronapanic, Musk and Bill Gates meet in March 2022. They had to agree to disagree on Mars colonization (Gates thinks lacks practical value, as do I, though planning to get to Mars means that if you fail your engineering work makes getting to orbit dirt cheap.)

At the end of the tour, the conversation turned to philanthropy. Musk expressed his view that most of it was “bullshit.” There was only a twenty-cent impact for every dollar put in, he estimated. He could do more good for climate change by investing in Tesla. “Hey, I’m going to show you five projects of a hundred million each,” Gates responded. He listed money for refugees, American schools, an AIDS cure, eradicating some mosquito types through gene drives, and genetically modified seeds that will resist the effects of climate change. Gates is very diligent about philanthropy, and he promised to write for Musk a “super-long description of the ideas.”

Money for refugees? I haven’t heard of Bill Gates doing anything for the 1.7 million Afghans recently expelled from Pakistan nor for the nearly 400,000 Palestinians expelled by Kuwait. Gates wants to fight climate change and also make some money betting that nobody wants electric cars:

Gates had shorted Tesla stock, placing a big bet that it would go down in value. He turned out to be wrong. By the time he arrived in Austin, he had lost $1.5 billion. Musk had heard about it and was seething. Short-sellers occupied his innermost circle of hell. Gates said he was sorry, but that did not placate Musk. “I apologized to him,” Gates says. “Once he heard I’d shorted the stock, he was super mean to me, but he’s super mean to so many people, so you can’t take it too personally.” The dispute reflected different mindsets. When I asked Gates why he had shorted Tesla, he explained that he had calculated that the supply of electric cars would get ahead of demand, causing prices to fall.

[after Gates keeps hitting Musk up for cash] “Sorry,” Musk shot back instantly. “I cannot take your philanthropy on climate seriously when you have a massive short position against Tesla, the company doing the most to solve climate change.”

“At this point, I am convinced that he is categorically insane (and an asshole to the core),” Musk texted me right after his exchange with Gates. “I did actually want to like him (sigh).”

Musk’s investments in Neuralink should be considered nonprofit donations in my opinion. This is blue sky research of the type that governments typically fund because there is no reasonable expectation of a return on investment.

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Nine minutes of Formula 1 glory at the Las Vegas Grand Prix

This is a report on the spectator experience at the Thursday evening Formula 1 practice session in Las Vegas 2023.

My friends had $1,500 three-day tickets in the West Harmon bleachers (the cheapest seats; the average price paid was, supposedly, $7,000). One week prior, I bought a Thursday night resale ticket for $180 plus $35 in Ticketmaster fees, managing to get into the same row as my friends.

The obvious hotels were Planet Hollywood, Paris, and Horseshoe, which are walking distance from the West Harmon entrance. These were available in the $100/night range (plus fees!). However, I was concerned that my flight from Burbank, California might be late and didn’t think that it would be possible to get from the airport to a hotel inside the track after 7 pm. (In fact, we saw cars and taxis going in and out continuously. There is at least one temporary bridge that was built over the track to allow access to hotel-casinos inside the track.) I booked a Hilton near the convention center for a slightly higher price and took the monorail with my friends.

How could hotel rooms during this event have become so cheap? Las Vegas has roughly 150,000 hotel rooms. “F1 claims a healthy 315,000 fans attended the grand prix over four days” (ESPN). That’s only about 100,000 people on any given day. If the predicted traffic and hassles scared off non-F1 tourists, the inevitable result was a lot of empty rooms.

The F1 hype began at the airport:

Our ticket enabled us to go in at 6 pm and begin eating the included Wolfgang Puck food and drinking the included non-alcoholic beverages. We arrived just after 7 pm to poke around the fan environment. A big screen displayed a pre-race TV show. There were a few fun activities for fans, but most had long lines. The food options included a weak hot dog, too-far-from-the-grill grilled cheese, a strange dry ramen box, chicken and waffles (cultural appropriation? they were good in any case), a purportedly Chinese-style chicken salad (more cultural appropriation), cider donuts (terrible), and churros (did not try). Lines for food were reasonable to non-existent. There were huge lines at the store until quite late:

Our bleacher seats had a good view, but the legroom was tight for anyone over 5’6″. The temperature was about 55 degrees. Here is what it looks like (1) walking up the stairs (note portapotties in the background; they really needed people to perform hourly cleanings on what became disgusting environments), (2) the (distant) environment for the rich and famous, and (3) the view of the track from near the top of our bleachers (we were actually sitting quite a bit closer).

When the cars began zooming by at 8:30 pm, it was impressive to see the showers of sparks from cars scraping minor bumps in the road in front of us. At around 8:39, however, the race was halted because, we were told, a manhole cover’s concrete frame had failed. I was deeply confused by this because the course is on a public street. If trucks drive over the manhole daily and don’t break it, how could an 1,800 lb. F1 car, even with a downforce multiplier, break it? I haven’t figured out the full story. The F1 folks say that a concrete frame failed, but not whether it was a new concrete frame installed for the race or the standard frame put in some years ago by the city. I think that the answer to the “why didn’t it fail when a truck drove over it a week ago?” question might be that the F1 car broke the cover/frame with force in the opposite direction. I.e., the cover was sucked up rather than pushed down. This is a force direction for which manhole covers aren’t normally engineered.

The second practice was scheduled for midnight. Quite a few people stayed to drink $12 beers and $39 LED-lit trophy-style glasses of booze:

We walked out to the nearby Horseshoe casino (formerly Bally’s) and relaxed. Even with the track being hot, people were getting in/out via taxi:

My friends went back to their apartment around 11 pm. They were unconvinced that the midnight practice would happen on schedule and were planning to return for Friday and Saturday. I decided to reenter the fan zone. The monitors displayed messages saying that there would be an update soon. There was no longer a line for podium photos, so I got a picture to take credit for winning the race on the damaged track via rugged Honda Odyssey:

At 12:30 am, the monitors promised that the next practice session would start at 2:00 am. I bailed out because I needed to get on an 11:20 am flight from LAS. What happened to the diehard fans who stayed? The organizers kicked them out of their seats at 1:30 am, then ran the practice beginning at 2:30 am with no spectators. It was like a CIA torture scheme in which the enemy is kept awake for hours and then denied what was promised.

I’m glad that I didn’t buy anything at the store because everyone received a follow-up apology email from the F1 folks with a $200 coupon for merchandise as compensation for the missed hours of racing action. Which two hats will I be able to get with this $200 coupon plus $50 for tax and shipping?

The next day I went past the Greenspun College for Urban Affairs and very nearly found the DEI gates:

Inside the terminal, I found Sainz’s car after the manhole cover encounter:

Would I go back? Even with the monitors provided, it was much more confusing to try to follow the race live compared to watching on TV and having things explained. For Jho Low types who don’t mind spending $10,000+ on a three-day ticket, I’m sure that the luxury zone with pit tours is fun and comfortable. It’s a permanent building so probably they have some decent bathrooms at least. I guess it would be worth it if you’re plugged into the international set of other people to whom $10,000 is pocket change and the event would be a chance to see a lot of your friends.

For everyone else, perhaps a last-minute ticket to the Friday evening event would make sense followed by watching the main race on TV in order to (a) save money, and (b) learn what was happening. It is straightforward to go in and out by monorail. If there is a long gap between races, it is easy to go out of the event, find a relaxing place to sit at a restaurant or in a casino bar, and then return.

Readers: Who understands the mechanism via which the manhole cover failed? Also, who enjoyed watching the race on TV?

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Medical School 2020, Year 4, Week 31 (Anesthesia, week 1)

We meet at 7:00 am in the “Anesthesia Ready Room”, a small office with only three computers shared by the 50-person anesthesia private practice. I was excited to be assigned to follow Dr. D, who is widely respected by surgeons. He’s a pale 38-year-old sporting wide circular glasses. We go into OR 17 to set up for the case, a left total knee arthroplasty. He shows me how to pull medications by inserting a needle attached to a syringe into the rubber sealed glass vial. We go over how to pull doses of common anesthesia medications, e.g., succinylcholine, rocuronium, propofol, etomidate. “As a general rule, the right dose is usually half of the vial. That was true during my training, but people have gotten a tad larger now so maybe round up.” He adds, “The exceptions are these.” He points to a nondescript compartment in the anesthesia cart where epinephrine, phenylephrine, and ephedrine are stored. “I’d say the most common medication that I see get overdosed with serious consequences is phenylephrine (“Neo”). It’s meant to be made into a drip (“gtt”, latin for guttae or drops) by inserting the dose into a 100 mL bag for pressor support over time. A typical rate is 100 mcg/min. We use it by giving 200 mcg as a one-time dose for pressor support between induction and the operation beginning.”

“One of the hardest things to do as an anesthesiologist is to do nothing. The patient’s blood pressure drops when we induce the patient. A lot of people want to reflexively fix that with a pressor like ephedrine or phenylephrine,”. Dr. D continues. “Watch how much the blood pressure increases once we start intubating and cutting on the patient.”  We put the pulled medications (in syringes with attached needles) into a locked drawer on the ventilator workstation. He then asks if I have intubated before and with which laryngoscope blade. I respond that I’ve intubated twice, and have used only a “Mac” (MacIntosh laryngoscope features a curved blade versus the straight Miller laryngoscope). “I don’t understand people who use Miller. It’s forcing the pharynx to be a straight configuration when it’s clearly not.” He grabs a “7 French” endotracheal tube (ETT) and Mac 3. I ask, “Should I get a stylet?” (Stylets are a stiff malleable metal wire that is inserted into the ETT to help guide it through the cords.) He laughs, “Stylets are not necessary. It’s $11 that goes down the drain.”

We head to pre-op to consent a 58-year-old for general anesthesia and potential blood products. She is about to undergo a total knee arthroplasty (replacement) with general anesthesia. He asks the patient standard anesthesia questions: any dentures? Previous anesthesia, and if so, any problems? The patient answers that she has terrible post-operative nausea. He asks her to open her mouth wide, and touch her top lip with her bottom teeth (assess range of motion of jaw). She signs the forms, and then the anesthesiologist performs an adductor canal nerve block under ultrasound guidance. A pre-op nurse is dedicated to assist with these nerve blocks. Looking for a good lifestyle job in healthcare? The nerve block nurse’s only job is to wheel an ultrasound cart over and hand the anesthesiologist a pre-op needle, which means she’s busy only about 30 percent of the time and then goes home at 2 pm. We head back to the OR.

After a few minutes waiting in the OR, the nurse wheels the patient in. I clumsily attach the pulse oximeter, three electrode lead stickers, and blood pressure cuff. I mistakenly attach the “left leg” lead, supposed to go under the left breast, on a layer of gown. “Honey, this isn’t my breast!” I grab another sticker and place it below her breast and attach the electrode. He supervises me closely as I preoxygenate the patient with a mask delivering 100 percent oxygen. He then pushes the propofol into the IV and we wait a few seconds. He instructs, “gently touch her eyebrows to assess if she’s asleep.” The first time her eyelid twitches but after five more seconds she is fully induced. 

“Let’s see how you mask ventilate. This is probably the most important skill in anesthesia. If you can mask a patient you can relax.” I adjust the pressure in the circuit with a knob as I squeeze a 2 L bag with my right hand and use a “C” grip on her mask and jaw to elevate the jaw. “Really squeeze at the angle of her mandible. Get in that crease.” I am squeezing the mask with my thumb and index finger in a “C” shape to rotate it against the jaw that is being pulled up and out to move the tongue forward and open the airway. The first breaths I hear a leak as I squeeze the bag with my other hand, but adjust my grip. I look for chest rise, fog in the mask on exhalation, and finally check the end tidal CO2 mass spectrometer waveform on the anesthesia workstation.

As I mask the patient monitoring the end-tidal CO2, tidal volumes, and peak pressures (keep under 20 mmHg to prevent air from going into the stomach), the attending asks me, “We know we can mask the patient, so we can relax. Why do we pre-oxygenate?” I answer with a snarky response, not understanding the full significance of the question. “Umm, to get more oxygen in them.” He responds with a smile, “Yes, but why does it work?” He explains that at the functional residual capacity (FRC, the amount of air in the lungs when exhaled such as when paralyzed) there is 2 L of air, and therefore 400 mL of oxygen (20 percent at 1 atm). Your body uses about 35 mL oxygen per kg per min, which varies depending on the health of the individual and food intake.” For a typical 70 kg person, that is 35 mL oxygen per second so I would only have about 10 seconds before the patient starts to desaturate if we intubate without preoxygenation. He summarizes, “Pre-oxygenation is really denitrogenation of the air.” Instead of only having 400 mL oxygen, by masking the patient with 100 percent FiO2, the patient now has 2 L of oxygen, allowing for about a minute before the patient begins to desaturate. In reality once you preoxygenate, you have several minutes before you need to worry.” After another few breaths, he states, “You’re ready. Give it a try… Wait. Take your badge off, you don’t want to cause a corneal abrasion. Those hurt more than a kidney stone!” He pushes the Rocuronium, a paralytic agent that will prevent the patient from moving any somatic (voluntary) muscle.

After I transfer my badge, notebook, and pens from the front scrubs pocket into my pants, I grab the Mac blade, scissor the upper and lower teeth with my thumb and index finger to open the jaw, and place the blade in horizontally, avoiding the teeth. My goal is to first locate the right tonsillar pillars, then sweep the tongue with the blade over to the left, and insert the blade deeper until I identify the epiglottis. I struggle to find the epiglottis in this patient, and hand it over to the attending who quickly inserts the tube. “Good technique, that was a hard airway. Better luck next time.” He adds, “Careful when removing the blade. A chipped tooth comes right out of my paycheck. $10,000, no question.” 

I auscultate both lungs (listen with a stethoscope) to confirm good airflow, look for fog in the tube, and confirm end-tidal CO2 for a few breaths. He laughs as he’s already given a few bag breaths and turned on the ventilator setting to pressure control (ventilator mode that delivers volume up to a set amount of airway pressure). “It’s good to do that as a habit, but I saw the tube go through the vocal cords, I see good fog in the tube, and consistent end-tidal CO2. Confidence in medicine is key, especially in surgery. Confidence comes from experience. Now, relax. You’re welcome to grab some breakfast or coffee. We’ll just be sitting here until the case ends.” (In search of a stooI, I wander the OR hallways until an OR nurse guides me to the stash. I lug the stool through the maze of gadgets in the OR suite while trying not to touch anything sterile.)

Dr. D has a dedicated chair. We sit together and look at our phones (no need to wear gloves unless touching the patient) for two hours while occasionally talking about subjects he thinks will be helpful, e.g., his ABCDEFGHI mnemonic for taking over a patient.  Airway (confirm placement of airway), Breathing (look at end-tidal CO2, peak pressures, pulse oxygen saturation, arterial blood gas, if applicable), Circulation (blood pressure and heart rate, EKG), Drips (ensure medications are in, including pain, nausea, etc.), Effluent and Fluids (ensure good urine output and adjust IV fluids accordingly), Heat (don’t forget the Bair Hugger), and Injury (make sure the neck is in a neutral position, the eyes are not in contact with anything, the arms are not under pressure and pronated; he explains to me that the ulnar nerve is the most common injury during anesthesia. A lot of time the surgeon is not present when positioning the patient, he explains this is a bad habit because the surgeon is just as liable for any positioning injury as the anesthesiologist). The surgeon tells us that they are starting to close as he unscrubs and steps out of the room to allow his PA to suture the skin and dress the patient.  

[Editor: “Doctor Says a Device He Invented Poses Risks” (New York Times, December 24, 2010), “Two decades ago, Dr. Augustine, an anesthesiologist in Minnesota, helped pioneer the idea of keeping a patient warm during surgery. Doing so, studies have shown, produces benefits like less bleeding and a faster recovery. Dr. Augustine’s invention, the Bair Hugger, changed surgical practices and made him a fortune. The device, which works like a forced-air heater, carries warmed air through a hose to a special blanket that is draped over a patient. These days, Dr. Augustine asserts that his invention is a danger to surgical patients receiving implant devices like artificial heart valves and joints. The forced air, he says, can spread bacteria associated with hospital-acquired infections. Coincidentally, Dr. Augustine, who no longer has a financial stake in the Bair Hugger, also says he has a safer alternative, a warming device that works more like an electric blanket and does not use forced air.” A twin-size electric blanket is $25 on Amazon in 2020. Why did 3M pay $810 million for a company making this hot air system? Why wouldn’t hospitals just buy blankets from Amazon and throw them out after each surgery? Ordinary blankets are used in the OR, washed, and reused.]

We turn off the anesthesia gas and reverse the rocuronium with sugammadex. The anesthesiologist explains as we wait for the patient to wake up that rocuronium has become the standard paralytic because of this new reversal agent. “It was a brilliant move by the pharmaceutical company. If you don’t use the reversal agent, the patient could feel short of breath and weak for several days.” He adds, “You also don’t want to get that call from a lawyer when the post-op patient has respiratory distress.  ‘Why didn’t you reverse her?'” When the patient starts to move her arms, and cough, I deflate the ETT balloon cuff, and pull the tube out. The anesthesiologist pushes the bed into “steer” mode and carts her off to the post-op recovery room, jumping on the frame and riding the bed around every turn as he waves to the OR staff. I struggle to keep up with him. He backs the patient into the post-op room, and “gives report” to the nurse. We head to pre-op (right next door) to get ready for the next

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Elon Musk and “pedo guy”

I was shocked and horrified when Elon Musk called a young brave Thai cave rescuer “pedo guy” for no apparent reason. Why would someone who’d volunteered to fly from his comfortable and safe British home to risk his own life to save Thai teenagers be subject to any kind of criticism?

Elon Musk, the book, sheds some light on this topic. First, Musk was goaded into helping and then told to continue working on a mini-sub:

“I suspect that the Thai govt has this under control, but I’m happy to help if there is a way to do so,” Musk tweeted. Then his action-hero impulse kicked in. Working with engineers at SpaceX and The Boring Company, he began building a pod-like mini-submarine that, he thought, could be sent into the flooded cave to rescue the boys. Sam Teller got a friend to let them use a school swimming pool for testing that weekend, and Musk began tweeting pictures of the device. The saga became a global news story, some criticizing Musk for grandstanding. Early on Sunday morning, July 8, he checked with a leader of the rescue team in Thailand to make sure that what he was building might be useful. “I have one of the world’s best engineering teams who usually design spaceships and spacesuits working on this thing 24 hours a day,” he emailed. “If it isn’t needed or won’t help, that would be great to know.” The rescue team leader replied, “It is absolutely worth continuing.”

Of course, the mini-sub wasn’t needed after all.

There the story would have ended, except that a sixty-three-year-old English cave explorer named Vernon Unsworth, who had advised Thai rescuers on the scene, gave an interview to CNN dissing Musk’s efforts as “just a PR stunt” that “had absolutely no chance of working.” Unsworth suggested, with a giggle, that “he can stick his submarine where it hurts.” Trolls and detractors fling insults at Musk every hour, and occasionally one sends him into orbit. He responded with a barrage of tweets attacking Unsworth, concluding one of them with “Sorry pedo guy, you really did ask for it.” When another user asked Musk if he was calling Unsworth a pedophile, he responded, “Bet ya a signed dollar it’s true.”

Musk sent an “off-the-record” email that BuzzFeed made public:

“I suggest that you call people you know in Thailand, find out what’s actually going on and stop defending child rapists, you fucking asshole,” Musk began. “He’s an old, single white guy from England who’s been traveling to or living in Thailand for 30 to 40 years, mostly Pattaya Beach, until moving to Chiang Rai for a child bride who was about 12 years old at the time. There’s only one reason people go to Pattaya Beach. It isn’t where you’d go for caves, but it is where you’d go for something else. Chiang Rai is renowned for child sex-trafficking.”

My impressions from following the headlines were, of course, wrong. The guy with whom Musk had traded insults was not one of the actual cave rescuers who’d left a comfortable English home. He was an old British guy living in Thailand who had a lot of experience exploring the cave, but his main role in the rescue was providing phone numbers for British cave rescue experts. Unsworth did not bring out any teenagers himself. Musk was simply guessing that Unsworth was a sexpat rather than merely an expat who loved Thai culture. The guess was not supported by tabloid investigation. Daily Mail found the 63-year-old Unsworth living with a 40-year-old girlfriend:

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Medical School 2020, Year 4, Week 30 (Radiology, week 2)

I ask to focus on abdominal CT during this final week of radiology, which turns me into an expert on finding steatosis (fatty liver, caused by alcohol, viral hepatitis, or obesity). It’s easy to identify because it’s on every abdominal and pelvic CT! Prasanna’s partner explains how to differentiate steatosis from fibrosis/cirrhosis by the liver morphology. CT can differentiate interfaces between air (-1000 Holmzfeld units), fat (-100), water (0), soft tissue (30), and bone (1000). The liver and spleen should be similar densities. As fat infiltrates the hepatocytes, however, the liver density begins to drop below 60. NASH (non-alcoholic steatohepatitis) is expected to surpass alcohol-associated liver failure to become the number one cause of liver transplantation. The radiologist explains, “The liver edge should be smooth. Once fibrosis occurs, it becomes nodular. Cirrhosis is also associated with enlargement of the caudate and left lobe. You can do a ratio, but just eye-ball it.”

The abdominal work list is exploding. The attending yells, “Six scans come off one scanner in one hour. Six abdominal scans. Why couldn’t they have interweaved some lumbar and head CT? Come on! I can do maybe 5 CTs per hour. Six from one scanner, and this seat covers five other scanners. We are just getting slammed.” As soon as he is done venting and has refocused on another case, his phone rings. “Come on!”

We overhear Prasanna yell, “God Dammit.” We walk over to investigate. Prasanna waves me in. “This is the MRI from the hip arthrogram we did earlier today. What do you see?” Based on irregular T2 signals with T1 replacement (bone marrow destruction) and articular cartilage flattening, I answer, “O-N.” Osteonecrosis is bone death, typically due to reduced blood flow. He tries to pull up the X-ray. “They didn’t get a f***ing X-ray. This is why you always get an X-ray first. This could have been diagnosed weeks ago instead of waiting for an MRI. He’s going to lose both hips.” I ask what caused this? “O-N can be caused by lots of things. Osteomyelitis (or infection of the bone) is one, but I don’t think both his joints are infected. It could be from long-term steroid use, inflammatory conditions, congenital abnormalities, and trauma. There’s a whole differential. Sometimes it’s just idiopathic [unknown cause].”

We do a leg bone length study on a 13-year-old. Children who suffer a broken leg can end up with one leg growing dramatically longer than the other. We measured from the top of the femoral head to the top of the talus. “The truth is orthopedists do their own measurements, so I don’t get too technical. Each has his or her own favorite method. Some old school private practice orthopaedists keep their radiographs in-house. I do all this for our health system billing and CYA. They need our help for MRIs and CTs.” Prasanna asks, “What do you think the most common lawsuit is for orthopaedists that keep radiographs in house? … Missing lung cancer on a shoulder X-ray.”

On Friday, I work with a guy who finished radiology training only three years ago. “This seat [MSK] is so boring that it erodes my soul.” He drones “Normal” into PowerScribe after every X-ray, which allows ample time to discuss the coronavirus: “I don’t think people realize what is coming. The virus is reported to have almost a 20 percent infection rate. On the cruise ship, one asymptomatic person infected 600 people. Our health system covers about 1 million people. We have 54 ICU beds. The numbers just don’t work.”

[Editor: This is late February 2020, about two months after the media began intensive coverage of COVID-19. As it happens, the hospital never did run out of ICU beds. The hospital filled up completely in January 2021, but mostly because patients couldn’t be discharged to their nursing homes so long as they tested positive for COVID-19. See “Our hero’s hospital is full (but not with patients who should be there)” in which I noted “Essentially, the hospital is packed because, even with nearly a year to prepare, state and local health departments that regulate hospitals and track hospital capacity couldn’t get organized to turn empty hotels into Covid-19 halfway houses.”]

The junior radiologist continues: “On top of this will be a supply crisis. Our health system reverts back to the medieval age when we don’t have common medications. Penicillin is not made in the US anymore. There is going to be a huge shortage of needles. China supplies everything, and they are shut down.” Is he stockpiling? “Oh yeah.” He grabs another coffee, his fifth today. “Let me get caught up.” He speeds through 10 radiographs in a few minutes, dictating with prefilled phrases. He turns to me. “The three fastest radiologists I have ever seen are all here. The fastest offered to do 1.5 lists and get paid at 1.5 FTE. I can see his point because he could handle it, but it would set a dangerous precedent if all you care about is speed. His offer was rejected, so he started the medical student clerkship. We’re not all as fast as him, so we fall behind when students are here.”

We review a pelvic CT. He laments, “Look at this! Hip pain. It doesn’t specify if the pain is in the hip joint, greater trochanter, or SI joint. No clinical history. I’m so used to it, but this lack of communication hurts the patient. Help me help you! The worst is when we get an abdominal/pelvic CT for ‘abdominal pain, unspecified’.” He continues, “Epic has made this communication crisis worse. The ED doc or PCP just clicks a worthless button and moves on. I can use Epic to read the doctor’s notes, but I shouldn’t need to do that. The MSK seat is not as bad as the abdominal seat as there are far fewer potential diagnoses.”

Statistics for the week… Study: 0 hours. Sleep: 9 hours/night; Fun: 2 nights. Example fun: Dog playdate at a local park followed by a dog-friendly brewery.

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

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Israel in Crisis, print edition

My mother is an American Jewish liberal Democrat (some redundancy in there?) and bought us a gift subscription to Moment, the magazine for American Jewish liberal Democrats. The latest issue arrived in the mail a few days ago. One of the cover stories is “Israel in Crisis”. Does this refer to the October 7 attack by Palestinians coming out of Gaza? To the military and political challenge of how Israel can fight a group that hunkers down in, around, and underneath hospitals? No. The “crisis” referred to relates to how power in Israel is divided between parliament and the supreme court (the democratically elected parliament is packed with haters, perhaps due to the large number of Jews in Israel who are descended from those who fled Arab countries starting in 1948 while the supreme court is enlightened, progressive, liberal, etc.).

I think this is a good illustration of the limitations of print-and-mail!

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Medical School 2020, Year 4, Week 29 (Radiology, week 1)

A two-week elective in MSK (musculoskeletal) radiology. The private practice radiology group that staffs our health system’s department offers 4 hours per day for medical students. I’ll be working in a large newly constructed clinic building from 9:00 – 11:00 am and 1:00 – 3:00 pm each weekday.

A typical day is as follows: I meet the attending on the MSK seat at 9:00 am. Precise Prasanna, a 39-year-old MSK fellowship-trained radiologist, is walking on the treadmill and dictating a shoulder MRI. He stops the treadmill to chat for a few minutes. Having arrived at 8:00 am, he is caught up on the worklist and has “parked” five interesting cases from this morning. He leaves the room for five minutes to refill his water and chat with his colleague on the abdominal seat while I go through them on the diagnostic monitor screen. 

I report what I have observed: “There is a high T2 signal in the right superior hip labrum.” He replies, “Good, look at the cam deformity [enlarged femoral head knocks into the acetabulum] causing femoral acetabular impingement.” He continues, “FAI is now known to be the most common cause of early osteoarthrosis. We see this all the time in female soccer players. A 10-year-old presents for anterior hip pain from a labrum tear. When you ask them they sometimes report their hip ‘stopping’ but kids get used to the impingement feeling. Twenty years ago we would have forgotten about it; now we realize FAI causes early OA so we intervene before destruction of the cartilage.” FAI can be diagnosed on a simple AP pelvis radiograph.

(Arthritis includes the suffix “itis,” suggesting inflammation, but most arthritis is due to wear and therefore osteoarthrosis is the preferred term.)

He points out the interesting aspects of 20 X-rays and 6 MRIs before it is time for live patients. We do three arthrograms, in which contrast agent is injected into the joint space under X-ray guidance. Most commonly, this is with gadolinium contrast in preparation for an MRI to fully assess the hip or shoulder labrum. Sometimes, this is to get better information from a patient who is not a candidate for an MRI. For example, Prasanna performs a shoulder arthrogram on a 28-year-old female bicycle accident victim whose implanted hardware following a previous humeral head fracture (motor vehicle collision) would distort the signal from susceptibility artifact. He points to the leaking of contrast from the joint space into the subacromial/subdeltoid bursa (fluid-filled cushion underneath tendons), indicating a full-thickness tear of the supraspinatus tendon. 

After lunch with Jane and our new puppy, I return for the 1:00 pm session. The radiologist in the abdominal seat calls me over to look at a CT scan of the chest and abdomen. “What do you see?” I respond, “There is a clear hypointensity disrupting the bright signal of the right pulmonary artery. Is this a pulmonary embolism?” He answers, “Yeah, I just sent her to the hospital. I don’t see any right heart strain. That’s all!”

Prasanna dictates reports with PowerScribe, voice recognition software specific to radiology. Every word he uses serves to further delineate the pathologic process. He explains to me that the main goal of an musculoskeletal radiologist is to pick up subtle findings of a pathologic process, e.g., rheumatoid arthritis, psoriatic arthritis or severe meniscus tears, before it severely damages the articular (hyaline) cartilage. Once destroyed the joint is unsalvageable and must be replaced (arthroplasty). “For some diseases we can stop the inflammation with drugs or for some mechanical injuries an orthopedist can operate and prevent OA. If you see acute, non-traumatic, monoarticular arthritis, treat it as a septic joint until tapped [remove fluid with a needle].”

Every hour with Prasanna is an opportunity to learn more vocabulary, e.g., the Lisfranc ligament, named after the French surgeon who pioneered the “Lisfranc amputation” of the tarsal-metatarsal joint (mid foot) during the early 1800s. I learn names for common injuries from a shoulder dislocation, including the Hill-Sachs lesion (humeral head fracture as it strikes the glenoid) and the commonly accompanying Bankart fracture of the glenoid.

[Editor: read Madame Bovary for some insight into 19th century French foot surgery.]

School administrators had stressed that I was to work only with the MSK seat and stick to the 9-11, 1-3 schedule. On Thursday, however, I asked the two radiologists if it would be okay to work from 9-1, spending half the time with the abdominal seat, and having the whole afternoon free with the puppy. “Of course,” was the answer.

I watch Prasanna perform a hip arthrogram in prep for an MRI on a 59-year-old with worsening anterior hip pain and clicking for 3 months. He weighs at least 300 lbs. Once the needle is in the joint space, straw-color fluid slowly flows out of the catheter. This went on for a few minutes, until Prasanna aspirates a total of 50mL. “That feels so much better,” exclaims the patient. “I’m glad, the pain might come back a bit as I inject the contrast now.” After the procedure, he asks, “Do I need a hip replacement?” The radiologist explains, “We’ll know more once we get the MRI, but from just this X-ray, I see preservation of the joint space so my guess is no. You do have a large joint effusion and at least a labral tear so you might still need surgery, but not a joint replacement.”

The abdominal seat is reading a pelvic MRI on a 49-year-old female for rectal cancer staging. “The most important thing is if the tumor invades the sphincter complex.” The internal and external anal sphincter muscles are highlighted by the clear “intersphincteric fat pad” that is being pushed by the tumor on the posterior lateral side. The radiologist: “This is bad. She is going to probably have to get an APR (abdominal perineal resection, in which they remove the anus and create a colostomy). We’ll see what the rectal surgeons say at tumor board next week.”

We have a CT angiogram of an 86-year-old for an adrenal mass, her fourth in two years, due to an anomaly discovered on a CT scan after a fall. The abdominal radiologist says that the test should never have been ordered. “Leave this woman alone. Adrenal masses are statistically benign in the absence of metastatic disease (e.g., lung cancer). Teleradiologists never have the guts to ignore something out of fear of getting sued so she’s subject to never-ending imaging follow up.” He continues, “It’s weird to say, but I don’t always want the ordering provider to follow every finding in my report. Don’t treat the image, treat the patient. We balance this with the knowledge that this report will be forever cemented into the patient chart for litigation years in the future. We used to call up the ordering provider, or he would come down to us. With teleradiology, the doctors don’t collaborate and each one tries to defend against any possible lawsuit. It’s almost like we are in a game of tug-of-war on who bears legal ownership of a patient. Tag, you’re it! The result is that a patient who lives 4 hours from the nearest MRI machine will be doomed to perpetual follow-up on a statistically benign tumor.”

Statistics for the week… Study: 0 hours. Sleep: 8 hours/night; Fun: 2 nights. Example fun: Jane and I attend an engagement party for Outdoors Oswald, a mountain biker applying to emergency medicine at prestigious institutions. His fiance works for Epic, which allows her to work from home most days. She hopes to end up in New York City, even though “we’ll be broke.” They rented a private downstairs room, but did not order any food for the gathering. About half of the class was invited and consequently the open bar was used to the fullest extent. We left at 1:00 am with several classmates to grab a slice of pizza before Ubering home.

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

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How is Rivian doing?

Back in November 2021, I asked “What edge does Rivian have in the truck or EV market?” and questioned the company’s stratospheric market cap. It has been two years. How is the company doing and how is the stock doing?

Given the calculation that working class subsidies to elite owners of EVs are $50,000 per vehicle (direct tax credits, higher costs for gas-powered cars due to EV percentage sales requirements, subsidized electricity), the company itself should be profitable. MotorTrend says otherwise: “Rivian Loses a Huge Amount on Every Vehicle It Sells” (October 5, 2023).

From May 2023, in the lower Manhattan neighborhood favored by elites (Chelsea):

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