goodells

Sure, the indications for using it can be clarified. EMS would go for chemical restraint (i.e. ketamine) for someone where "excited delirium" is suspected. This doesn't mean literally anyone being ornery with the police - and generally we aren't even involved in those calls. A person in a normal state of mind won't break their arms or dislocate their shoulders when they're put in handcuffs. Someone who took too much meth very easily could.

We have some level of training at my level (EMT), and the paramedics I work with have more. But the stuff we're expected to cover is really broad - anything from a sexual assault victim and preserving evidence to your garden variety suicidal ideation. So given our role it's mainly geared towards identifying potential medical causes for their behavior. The best thing we can do for a patient is keep an open mind to why they're acting strangely. It could be an infection, stroke, overdose, withdrawal syndrome, postictal state after a seizure, tons of stuff.

My point is that even the best training probably won't make the tradeoff of not having law enforcement on scene worth it. Patients with the kinds of issues I listed above - they tend not to respond to being talked down. No amount of babying is going to make the person who's been high on meth and awake for 4 days straight stop seeing the shadow people.

If someone doesn't get ketamine, the alternatives are:

- they get tased, pepper sprayed, and thrown around by law enforcement officers

- they get a less safe drug like midazolam, lorazepam, or haloperidol

- they get restrained and fight against the restraints which puts them at risk of sudden death and rhabdomyolysis

I work as an EMT for a 911 service. The general attitude that I have and other EMS providers I’ve talked with seem to share is that this won’t end well.

The first thing we’re taught is that the scene must be safe. If it’s not safe, we stage nearby until law enforcement or fire tell us to come in. The 911 dispatch is notorious for misevaluating the nature and severity of a situation, and generally we are toned out to an address and keep getting updates with call details as we are driving there. In this country where anyone can have a gun on them, there is no way in hell that I and my partner are approaching an emotionally disturbed person with no way to defend ourselves. If something goes wrong, the most effective weapon we have is an oxygen tank. And now the public’s perception of drugs like ketamine for chemical restraint is souring, so the message seems to be “Go deal with the worst our society has to offer, with no backup in case they try to hurt you, no not even safe chemical restraints. And no sorry we can’t pay you more than a cashier at WalMart... but you’re heroes!” Just last year a firefighter paramedic in my state was shot dead after administering naloxone to a man and saving his life.

Part of it is the compensation. Law enforcement officers are paid substantially more than the EMS folks here with the understanding that they take on more risk. We make $12 hourly... not enough to accept drastically increasing our chances of being hurt or killed.

This is a very polarizing topic in the field of medicine, especially when it comes to independent practice of midlevel providers. I’d just point out that NPs have a very aggressive national organization that promotes such studies, and the issue of equivalent patient outcomes is certainly not yet decided. There are significant questions about the study design, namely that midlevel providers are seeing less complex and critical patients, while physicians take on cases where their more advanced and thorough knowledge is needed (and outcomes tend to be poorer due to the patient condition, not the care provided).

This is well and good, aside from potentially misrepresenting the research - midlevels are supposed to handle what they can and escalate what they’re unable to handle to a supervising physician.

There is similar research that shows NPs and PAs order more unnecessary diagnostic tests like labs and imaging, and are more likely to prescribe antibiotics and narcotics when it isn’t indicated.

I'm surprised not to see Madison, WI on this list. Our tech sector has been strong and growing for several decades - locally we have Epic Systems, Exact Sciences, Promega Corporation, Thermo Fisher Scientific, several large insurance companies like American Family Insurance, Sentry Insurance. It might be easy to miss the agglomeration of these companies in one area because some of them are technically in different municipalities than the City of Madison. But it's a great area, and most of the big players here have been spared or even strengthened by the unique circumstances of the pandemic.

+1 for Elgato, I haven't used their CamLink but have had an excellent experience with their Eve products in my HomeKit setup.

I've had good luck calling the main Amazon customer support number (USA) and simply asking to speak to someone in the United States of America. I don't know how Amazon's systems work, but they seem to have more options available to them than the foreign call center reps.

Why do we need the federal government to fund these slots at all? Hospitals work resident physicians to the bone and bill patients exorbitantly for it. Their hours are capped at 80 per week yet they receive no overtime pay[1]. Yes, the residents are "in training" but it's not like it's a burden for a hospital to take them on - they are the workhorses that handle a huge number of cases and drive hospital revenue.

[1] - https://en.wikipedia.org/wiki/Medical_resident_work_hours

This a real issue. The American Medical Association lobbies to artificially limit the number of residency spots funded by the federal government. No change in compensation structure will change the fact that every dermatologist in my city is booked solid until next June, but allowing more of them to be trained might.

What’s interesting is that the market seems to be coping with this by giving more responsibility and autonomy to mid-level providers like PAs and CRNAs - and tons of physicians are livid about it. As a patient, for many health issues I’d prefer to be diagnosed and treated by someone with the rigorous education and training of a board-certified physician rather than a mid-level whose degree includes less than 1 year of clinical experience.

I just looked and it will add ~$3 to my electric bill to only use wind and solar. Thanks for the tip.

I (and many others) maintain that social security at the federal level is completely unconstitutional, and lament the system that has evolved around using it as the de-facto national identification in the United States. Of course there are externalities associated with the lack of a social safety net for the elderly, and at this point it very well may be "worth it" for the younger generation to pay it to avoid the consequences. What a mess.

Would one run into licensing issues with this? I'm honestly not sure if their usage is predicated on being served from Google, nor knowledgeable enough about the law to even guess.

Thanks for pointing this out. I guess this is something I had assumed Google does by serving the fonts for free, but I never really bothered to look into it. Going to remove all Google Fonts references from my projects now.

I use macOS as a development machine but usually deploy code to a headless Ubuntu Server instance in the cloud.

Primary API server development is in Elixir since it’s just an elegant beast and can handle the vast majority of “pure” business logic.

If I need a database, in-memory store, or anything that can run in Docker I use Docker compose to run it. If it needs a bigger box or something managed in production I’ll just use whatever the hosting provider exposes (e.g. DigitalOcean’s Managed Databases).

Some stuff like bulky user data, random binary files, etc. goes to AWS S3.

Automated tests are developed alongside features and get run with GitLab’s continuous integration. This configuration usually reflects the dependencies that are run in Docker in development, but sometimes for low-impact tests I’ll just have it hit stateless production services.

Documentation gets auto-generated by Elixir’s ExDoc, or whatever language’s mainstream solution. Generating this for production documentation gets handled by GitLab CI of course.

Clients that hit the API are variable based on my needs but I usually make a React + Redux SPA or something in the Unity game engine. Web development is always set up with Gulp so that I can run and forget about whatever Webpack, Sass, and the files are doing underneath, it just updates automagically. Depending on the size of the project I often have multiple clients accessing overlapping subsets of API actions.

If this sounds like what your company is using or wants to use, please feel free to reach out at sam (at) mangane.se (I am in the USA even though the TLD is Swedish).

What makes the student debt such a crappy situation is the fact that we're dealing with young people and families who may not necessarily have all the information to do an educated cost/benefit analysis. Students are pressured from very early on to plan to go to college. Teachers, guidance counselors, administrators, and often parents all fall into the narrative of "yes, college is a good decision and will pay for itself". It is completely taboo to tell a student that there are other options because that can be construed as telling the student they have less potential than others.

My understanding is that there was a bidding process wherein the school would publish a request for proposal and companies would win the contract through it. I'm sure such an approach would be valid in other contexts, but in this case it just speaks to the unnecessary bureaucracy surrounding the procurement of something that could realistically be bought off the shelf.

We were dumb kids, and it's a story. The director was quite nice and we were making conversation on what would otherwise have been a boring walk across campus. He was clearly appalled at how expensive they are as well, but I got the impression even he didn't have much agency to change it.

This is spot on. An anecdote from my undergrad studies and living in Madison, WI: the UW has a division of housing, which provides (shoddy) canvas carts to the students to use for moving in/out of the dorms. My student organization happened to "acquire" some of these carts, and when using one I was confronted by none other than the director of housing, who promptly called the police on me. In the end I was happy to return it and he asked the police not to press charges on the condition that I help him walk the cart back to the dorm where it belonged. He told me that people stealing the carts drives him crazy because they cost about $800 each because there's a complicated bidding process to even attempt to sell them to the school! I told him I'd be happy to go to the Home Depot and bang some together if he paid me half that for carts.

I can see two distinct groups of people who would take issue with this, not that they'll necessarily have their way:

- people who were realistic about their finances and did not take on debt to "drag for a lifetime" in the first place. Why should the "rich" and/or reckless kids who lived in overpriced dorms with unnecessary amenities get bailed out when "I was smart and didn't screw myself from the start"?

- people who were able to afford a university education out the gate and were not burdened by any or much debt in the first place (and their parents!). Why should the "poor" and/or reckless kids who reached for something they couldn't & shouldn't have been able to afford get bailed out when "I worked hard to provide for myself / my family from the start"?

This is anecdotal, but I had an experience where I was flying from LaGuardia to Madison, WI with a layover in Chicago. The last leg of the flight from Chicago to Madison was delayed by several hours, to the point where it would be significantly faster for my boyfriend to drive down from Madison, pick me up at the airport in Chicago, and drive me back. I don't recall which airline I was using at the time, but the gate agent told me that it was their policy to refuse to pull someone's checked luggage if someone didn't "want" to complete the last leg of the journey, but if I told someone that I was not feeling well and wished to end the trip early due to health reasons, that would be the easiest way to do it. So that's what I did - I went up to a different gate of the same airline, told them I was sick and would not be getting on the connecting flight, and the luggage was downstairs in a special area of the baggage claim within 20 minutes. It felt like being in grade school and telling the nurse I was sick to get a day off...

As EMTs we are trained to provide the best possible care for all of our patients unless very obvious signs of death are present - brain death is not something we really consider because that's something the hospital determines. Obvious signs of death include dependent lividity (blood settling to the lowest point in the body) and decapitation, among other things. EMTs are not qualified to make such judgements in the field (outside of a mass casualty incident and triaging) and opt to be "better safe than sorry" and let someone with an MD after their name and malpractice insurance worry about making the final call. I expect the signs and symptoms of someone with brain death would be indistinguishable from any other apneic unconscious patient without a pupillary response, but some of those can be saved, so we transport them all.

At the hospital, protocols for determining brain death vary depending on the institution, but we have more advanced tools than just EEG now. I see a lot of radiological investigations that measure cerebral metabolism with scintigraphy - here's an example of what that looks like with a poor outcome (I am not a radiologist by any means, and I explored this outside of being an EMT) [1]. Notice how the brainstem is dark but the rest of the brain isn't doing much. Other investigations such as some MRI sequences may prove useful to identify ischemic insults and damage that strongly correlate with poor outcomes. Based on the phrasing of your question, I would point out that these tests would only be performed on a patient where brain death were clinically suspected based on e.g. prolonged cerebral hypoxia from a drug overdose... not every dying patient.

I don't know enough about the medicolegal or surgical side of things to go into more detail there.

[1] - https://img.medscapestatic.com/pi/meds/ckb/59/26659tn.jpg

Could you provide more specific examples of his not acting normal? It’s not something I keep up with so I’m not necessarily saying you’re wrong, just curious what this looks like from the public’s viewpoint.

I’m only an EMT, but I can try to answer this for you. The organ donor was brain dead, but the heart continued to beat and a ventilator was used. The organs would stay perfused with oxygen and nutrients and the surgery would be performed as if the donor were otherwise alive. Surgery is inherently risky - risks include spontaneous bleeding or clotting that could abruptly end the organ recovery. I believe this is the situation they are referring to.

On “ghost rowers” - sometimes people go too hard on port or starboard and we need to even things out before running into a moored sailboat ;)

Obviously some situations are complicated or don't lend themselves to doing so in a timely manner, but my healthcare/insurance provider (UWHealth and Quartz) has a priceline and online message center for immediate quotes without insurance. I use it even though I have insurance, especially before appointments where I anticipate what tests the doctor is going to order. They're usually reasonable, at least by American standards. Surgery has been more difficult to pin numbers down for because of the facilities.

Yeah, I probably should have referred to her by name. Remzi seems to be the best-known professor in the CS department here.

This book rocks! I took the OS class with Remzi’s wife my junior year and it was the one that made everything “click”, bridging the gap between the computer engineering/circuits and higher-level C code we otherwise did. OSTEP and Xv6 were really integral for understanding things inside and out because we had to implement what we learned about in class.

Anecdotally, I am in Madison, WI and it would be feasible with kids in the right neighborhood here. Lots of bikes have little carriages for small children.

To elaborate why a CT scanner is really really important in this case - there are two general kinds of strokes. Ischemic strokes are caused by a blood clot occluding an artery, preventing blood from reaching part of the brain. On the other hand, hemorrhagic strokes are caused by bleeding within the brain. We can use thrombolytic drugs (e.g. TPA) to break up a clot in an ischemic stroke. However, impairing clotting in a hemorrhagic stroke just makes it bleed faster.