It's interesting how different standards for behavior on public transit are over there compared to the US. The €100 fine for playing music out loud introduced by Irish Rail sounds heavenly. Here in Dallas, half the trains I get on have someone openly smoking (cigarettes, weed, meth) on them and the rare transit security officers supposed to be doing something about it are the ones playing loud videos on their phones!
I would disagree for a few reasons, at least for its application to cardiac arrest. It might have some niche applications, but that's only speculative.
The main determinant of successful CPR is maintaining coronary perfusion pressure with unrelenting chest compressions so that the heart has a fighting chance at starting to beat normally again. Moving the blood so that it has enough pressure at the aorta where the coronaries branch off of is way way way more important than keeping it oxygenated, which we're already pretty good at. In fact, over-oxygenation in CPR has been shown to be detrimental to outcomes because it causes oxidative stress at the cellular level. Oxygen is nasty, it's amazing that life evolved to harness it.
I do agree that modern medicine (especially emergency medicine) is really cool, that's why I switched careers after working in software engineering. We have lots of tools at our disposal, it's already science fiction. Modern resuscitation involves drugs that manipulate the ion channels of the heart in various ways, we can shift fluids around by changing the osmolarity of IV fluids (and we can pump them into you through your bones after drilling into them if needed...), cardiac monitors and AEDs will time a shock just right depending on the dysrhythmia to increase the odds of success, we can even just repeatedly shock a heart to make it beat in some situations like an AV block. And that's just the stuff that they let paramedics do (i.e. trained monkeys, I am one).
In an acute situation where oxygenation isn't sufficient, the imminent threat of anoxic brain injury and end-organ dysfunction is the concern. Measures would obviously be taken to correct that, up to and including rapidly sedating and paralyzing a patient in order to mechanically ventilate them with an increased fraction of inhaled oxygen and/or additional pressure (PEEP) to increase the surface area in the alveoli available for gas exchange.
Respiratory acidosis (i.e. the accumulation of CO2 and acidification of the blood due to inadequate breathing) is generally not harmful on its own, the concern there is just adequate oxygenation. However there are metabolic causes of acidosis, usually due to lactic acid accumulation, which lead to end-organ dysfunction because lots of enzymatic reactions in the body expect a very narrow pH range to work effectively. This occurs over a period of days, though.
It would be quite distressing because of the accumulation of CO2 in the blood, even with completely adequate oxygenation delivered intrarectally. The slight change in acid-base balance is what makes a person feel the need to breathe, and CO2 is an acidic byproduct of metabolism. This is why people with metabolic acidosis (e.g. in diabetic ketoacidosis or sepsis) have an increased respiratory rate.
I also built a 3D portfolio website[1] using React and react-three-fiber but I took a different approach design-wise, the HTML content is scrollable like a normal website but the 3D scene subtly matches the perspective of the screen as you scroll.
For my apartment, I run rtsp-simple-server[1] on my home server and use Raspberry Pis with generic USB webcams running ffmpeg to stream the audio/video to the RTSP server. Then I run camera.ui[2] separately for a nicer interface on top of all the cameras, HomeKit integration, etc.
The only downside hardware-wise is I don't get any indoor IR night vision with these, which some of the nicer "smart home" account-locked ones do.
It's honestly not too bad to set up if you run [1] and [2] in Docker. I've done disaster recovery scenarios of my home infra where I straight up disconnect the modem's uplink and everything works without any issues.
The fixation on comparing this to a toilet plunger is unnecessary and somewhat off-putting, but yes, this is pretty common nowadays. The LUCAS is a huge help and makes running a cardiac arrest feasible with a crew of 2-3 people, previously it required a larger team and lots of switching out who was doing chest compressions. It also makes it much easier to move a patient while CPR is in progress since you don’t need to pause compressions moving in and out of the back of an ambulance, etc.
They do tend to be… rougher… apparently they do _such good_ CPR that the risk of damaging the great vessels is much higher than with manual CPR, but I think the tradeoff of getting consistent chest compression quality works out in favor of it still.
There’s a saying in EMS: “lift with your firefighter, not with your back!”. My heart goes out to any firefighters named Lucas.
Yep, it has issues so frequently. I wonder how many companies/teams start using AWS and blindly choose us-east-1 without realizing what they're getting into.
<rant>
It's also quite annoying sometimes that some things _need_ to be in us-east-1, and if e.g. you are using Terraform and specify a different default region, AWS will happily let you create useless resources in regions that aren't us-east-1 that then mysteriously break stuff because they aren't in this one blessed region. AWS Certificate Manager (ACM) certificates are like this, I believe.
Your mentioning the pantheon gave me a flashback to how one of my old companies named their non-prod environments. The dev environment services were named after all the Greek gods, and the QA/demo environment services after the Roman gods. It was so horribly confusing…
I’m also now mildly disturbed/worried by the idea of going about my business in AI-generated VR a few years from now (maybe with some 2D-to-3D-ifying compatibility layer) and being haunted by ghosts of stock image watermarks.
Agreed, and virtually anything not enumerated would fall under either the Elastic Clause[1] or the Commerce Clause[2] giving Congress power to regulate it.
Sometimes I check out /r/teachers to get an idea of what's going on in education. The general consensus is that behavior issues are completely out of control for a variety of reasons:
- Shortage of dedicated special education teachers
- Parents who won't discipline kids at home
- Top-down pushes from administration such as "restorative justice", "least restrictive environment", and a few other phrases that will make any classroom teacher's skin crawl
- Unwillingness from administration to apply suspensions or expulsion due to how this ties to school funding
- Lack of flexibility in the teaching job market due to teachers being a licensed profession and most states suspending a teacher's license if they quit mid-year, leaving apathetic teachers trapped in bad schools
- Attempts to discipline non-white students frequently resulting in accusations of racism, making it not worth the trouble
In the classroom, the end result seems to be that behavior meltdowns take up a disproportionate amount of a teacher's attention and they aren't empowered to deal with it, all at the expense of the quality of instruction for the rest of the students. The standardized test score metrics discussed here are a not too surprising consequence.
Paramedic here - I could see this being useful in the emergency medicine world, if it ever gets to market. Lots of cool things are starting to get included in our cardiac monitors (LifePak 15, Zoll X Series, etc.). And guess what ... almost every single patient already gets 4-10 stickers put on them :).
Recent-ish advancements in tech here have made it possible to continuously measure the amount of exhaled CO2 from a patient's breath, transmit EKGs wirelessly for review by a physician in a hospital, and automatically cycle a blood pressure cuff at any interval we want. All in a patient's living room with equipment carried in one hand. In the very near future these devices will widely incorporate video laryngoscopy using their screens to assist in endotracheal intubations. Video laryngoscopes are already everywhere in the field, but they use their own screen/tablet and require extra work to get recordings out of for documentation purposes.
Ultrasound (the traditional kind - nothing like this article's stickers) is already on board some ambulances. Mostly used for locating deeper veins on people that are otherwise tough/impossible to get IV access on, checking for pneumothorax, or verifying death by confirming there's no heart wall movement.
It's not out of the realm of possibility for the cardiac monitors to gobble up the ultrasound functionality next, and incorporate that into the EKG lead stickers.
I remember years ago, Citus offered people a free pair of socks as a bribe for signing up for their newsletter. I loved my database socks and gave them some free advertising during college.
I can try to break it down for an uninitiated audience.
"isotonic crystalloids" - Solutions such as normal saline used to restore volume proportionally to the bloodstream and intracellular spaces (as opposed to hypotonic or hypertonic, isotonic solutions just match the normal blood's osmolality)
"sedation agents" - The patient is out, you keep 'em out, ideally without tanking their blood pressure. Different than paralysis.
"electrophysiology" - Electrical conduction through the heart.
"acid-base balance" - Various chemical processes and enzymes in the body only work well within a certain pH range, and long-term, only a narrow pH range is compatible with life.
"hematology" - Blood and its components, including the cascade of enzymes and clotting factors involved in coagulation.
"TXA" - Tranexamic acid - An anti-anti-clotting agent, which stops the body from breaking down blood clots. In the context of trauma, it allows your body to form the needed clots to avoid imminent exsanguination.
"ACLS" - Advanced Cardiac Life Support - The AHA algorithm for identifying and treating life-threatening heart rhythms that most paramedics, RTs, nurses, etc. and above are trained on. In practice, this means that an unresponsive patient or code situation can be run to a certain standard with the staff who are immediately summoned in any clinical area of any hospital within about 30 seconds.
"antidysrhythmic" - In the ACLS algorithms, it's a drug (usually a potassium channel blocker or sodium channel blocker or both) that acts on the cardiac action potential to do something that tends to make lethal dysrhythmias stop and return to a normal sinus rhythm. How exactly, you'd need to ask a cardiologist or specialized pharmacist.
"FAST [ultrasound] scan" - Focused assessment with sonography for trauma - it's just an ultrasound of the flank area to detect blood around the kidneys ("retroperitoneal space") which has a high mortality rate and usually requires emergency surgery.
"cranial nerves" - Your brain can communicate with the rest of your body either through your spinal cord, or through the cranial nerves which are direct interfaces for things like smell, sight, tongue movement, etc. Checking these is an important part of determining of a brain injury or spinal cord injury is present.
"rectal sphincter tone" - If it's present, then it's unlikely that spinal cord injury above a certain level has occurred.
"intracranial bleed" - It's bleeding, in your brain.
"magnetic resonance spectroscopy" - The original MRI technique was based on spinning all the hydrogen atoms in your body such that they aligned head to toe, then detecting electromagnetic induction in a coil as they were jarred back and forth at a megahertz frequency. Nowadays, we can do this with other atoms like phosphorus in the same way.
"precessing" - The pattern of relaxation of an atom similar to a spinning top where it goes from the aforementioned align orientation (forced by a strong magnet to align head to toe), and gradually relaxes to its random orientation while spinning at the Larmor frequency (megahertz frequency of the corresponding type of atom).
"penumbra" - The border between healthy living brain tissue and dead brain tissue at the outside territory of a brain injury post-stroke.
"neoplastic" - Uncontrolled cell growth, similar to cancer except not all neoplasms are cancer, some are benign tumors which will never be able to metastasize/spread to other parts of the body.
I'd offer some pushback, from someone with hands-on experience. I'm a paramedic and work alongside other medics, nurses, and physicians who have seen a wave of change in evidence-based medicine over just the course of a few decades. Not everything is flashy and glamorous like a brain-computer interface. No press release that makes it to the top of HN is going to talk about the choice of isotonic crystalloids or sedation agents on intracranial pressure, but we're making great strides, even if by definition "marginal" ones.
Modern resuscitation is like nothing I have ever seen before. Over the past 100 years, we have gained an almost complete understanding of cardiac electrophysiology, acid-base balance, hematology. In the worst-case scenario that you get hit by a car in a major US city, you will likely have TXA forced into your bloodstream through an intravenous catheter within 13 minutes to counteract the body's incorrect hyperfibrinolytic reaction. Your heart rhythm will be constantly analyzed and treated according to ACLS which has essentially been studied and modified to death by the AHA in a gradient descent pattern - we're stuck in a local minimum where the antidysrhythmic of choice alternates between amiodarone and lidocaine. When you arrive at the hospital, a FAST ultrasound scan will be performed where the culmination of materials science and informatics comes together to quickly identify blood in the retroperitoneal space without incurring the logistics of getting a trauma patient into a CT scanner. All this while a neurologist checks 12 of your cranial nerves and someone checks the tone of your rectal sphincter - because evidence shows us this is an important sign. In the case that you have an intracranial bleed, you'll be followed with MRI (which I'm convinced is the closest we've gotten to Star Trek scanner technology) to identify the penumbra of a stroke based on the deoxygenation of hemoglobin. We can now scan a variety of elements with magnetic resonance spectroscopy besides just precessing hydrogen atoms, which is helpful in identifying neoplastic lesions without the daunting task of a brain biopsy.
Not everything is gloom-and-doom at the financing of some big company.
#1 - Funky/misleading statistics - Generally they claim that these NPs with uncomplicated patients do as well as physicians with complicated patients. It's not claiming that of any randomly selected patient, regardless of who they see, the outcome is the same. Therefore, if uncomplicated patients saw physicians, outcomes for the physicians could improve. In primary care managing hypertension or diabetes, this isn't as pertinent. For something like anesthesiology, it's more so counting how many times shit hits the fan, and brain cells die when the anesthesiologist takes time to be summoned.
#2 - They're not conserving expensive resources. Imagine a patient comes in with a lump on their hand. An NP might see a weird lump, order an MRI which gets read by a radiologist, refer to an orthopedic surgeon who specializes in the hand, who removes tissue to send to a pathologist, who determines it's a common benign tumor of the fascia. That's three physicians who spent much more time here! The patient no longer has use of their interphalangeal joints. The physician would probably try to shine a light through it, note the patient's Scandinavian ancestry and family history of plantar fasciitis, and tell them to live with it and come back if it changes.
No resources were saved here, but the patient's DASH score (disability of the arm, shoulder, and hand) is still 0 so the outcomes are the same.
This happens all the time.
#3 - Bad incentives - Medicaid would not in a million years cover this, but the game of medical pinball where patients bounce around through in-network referrals can funnel those with decent insurance into procedures. Especially when most people have poor health literacy. A hospital executive probably just splooged in his pants seeing how much money their loss-leader of primary care is driving to radiology and the surgical specialties where they actually make money.
#4 - It's insincere. All of this can be viewed as possibly successful when the midlevels are part of the healthcare _team_ and know their limitations. But the NP groups are increasingly pushing for independent practice and prescribing rights in state legislatures across the country. CRNAs require a physician supervisor... in many places, that doesn't necessarily need to be an anesthesiologist, and the surgeon performing the procedure can suffice. The AANA recently changed its name to the "American Association of Nurse Anesthesiology"... It used to be "Anesthetists". The CEO and president (two different people) of the American Nurses Association both refer to themselves as "Doctor" in a healthcare setting even though one holds a DNP and the other a PhD. It's pervasive.