Etiquette



DP Etiquette

First rule: Don't be a jackass. Most people are good.

Other rules: Do not attack or insult people you disagree with. Engage with facts, logic and beliefs. Out of respect for others, please provide some sources for the facts and truths you rely on if you are asked for that. If emotion is getting out of hand, get it back in hand. To limit dehumanizing people, don't call people or whole groups of people disrespectful names, e.g., stupid, dumb or liar. Insulting people is counterproductive to rational discussion. Insult makes people angry and defensive. All points of view are welcome, right, center, left and elsewhere. Just disagree, but don't be belligerent or reject inconvenient facts, truths or defensible reasoning.

Friday, April 3, 2020

What is Involved in Being on a Ventilator

There hasn't been much detail about what ventilators are, how they work and are used. After some rummaging around the interwebs, the answers that come back are quite unpleasant. If you need to go on a ventilator, you are extremely sick and in deep trouble. I wish the situation was not so  unpleasant. Here's some info from various sources.

A ventilator, also known as a respirator or breathing machine, is a medical device that provides a patient with oxygen when they are unable to breathe on their own. The ventilator gently pushes air into the lungs and allows it to come back out like the lungs would typically do when they are able.

In order to be placed on a ventilator, the patient must be intubated. This means having an endotracheal tube placed in the mouth or nose and threaded down into the airway. This tube has a small inflatable gasket which is inflated to hold the tube in place. The ventilator is attached to the tube and the ventilator provides “breaths” to the patient.

If a patient is on the ventilator after surgery, medication is often given to sedate the patient. This is done because it can be upsetting and irritating to the patient to have an endotracheal tube in place and feel the ventilator pushing air into the lungs. The goal is to keep the patient calm and comfortable without sedating them so much that they cannot breathe on their own and be removed from the ventilator.

Patients who are not able to be removed from the ventilator immediately after surgery may require weaning, which is a process where the ventilator settings are adjusted to allow the patient to attempt to breathe on their own, or for the ventilator to do less work and the patient to do more. This may be done for days or even weeks, gradually allowing the patient to improve their breathing.”

Patients have to be sedated because they instinctively want to pull the tubes out of their lungs. One can imagine how irritating is it to have a tube run through your mouth or nose and into your lungs. Sometimes the tube is inserted through the trachea after a hole is cut through the neck:
Ventilators normally don't cause pain. The breathing tube in your airway may cause some discomfort. It also affects your ability to talk and eat. 
If your breathing tube is a trach tube, you may be able to talk. (A trach tube is put directly into your windpipe through a hole in the front of your neck.) 
Instead of food, your health care team may give you nutrients through a tube inserted into a vein. If you're on a ventilator for a long time, you'll likely get food through a nasogastric, or feeding, tube. The tube goes through your nose or mouth or directly into your stomach or small intestine through a surgically made hole. 
A ventilator greatly restricts your activity and also limits your movement. You may be able to sit up in bed or in a chair, but you usually can't move around much. 
One of the most serious and common risks of being on a ventilator is pneumonia. The breathing tube that's put in your airway can allow bacteria to enter your lungs. As a result, you may develop ventilator-associated pneumonia (VAP). 
The breathing tube also makes it hard for you to cough. Coughing helps clear your airways of lung irritants that can cause infections. 
VAP is a major concern for people using ventilators because they're often already very sick. Pneumonia may make it harder to treat their other disease or condition. 
VAP is treated with antibiotics. You may need special antibiotics if the VAP is caused by bacteria that are resistant to standard treatment.”



A 2016 research article focused on the sedatives given to keep people from pulling the tubes out of their lungs. This article directly contradicts the statement above that ventilators normally do not cause pain. It sounds like they cause a lot of pain.
“On June, 2016, Klompas and colleagues published an article in the Chest entitled Associations between different sedatives and ventilator-associated events, length of stay, and mortality in patients who were mechanically ventilated, which investigated the effects of different sedatives on ventilator-associated events (VAEs), length of stay, and mortality in patients who were mechanically ventilated. ..... This study raises important questions about the sedation of critically ill patients.

Critically ill patients are submitted to several interventions that can lead to distress and pain, like endotracheal intubation, mechanical ventilation, and central venous and arterial catheterization. Indeed, pain is one of the most common memories from patients admitted to intensive care unit (ICU) and can lead to agitation and its consequences, as accidental extubation, and removal of intravascular devices (1). Accordingly, one of the most used drugs for patients in the ICU are sedatives and analgesics (1).” 

Thursday, April 2, 2020

An Irrational Mind Meets Coronavirus

A favela in Brazil


The New York Times reports that Jair Bolsonaro, Brazil's president, has called the virus a “measly cold.” He is the last major world leader who questions lockdown measures. The NYT writes
“RIO DE JANEIRO — As coronavirus cases and deaths mount in Brazil, President Jair Bolsonaro has remained defiant, the last notable holdout among major world leaders in denying the severity of the coronavirus. 
Brazilians, he declared last week, are uniquely suited to weather the pandemic because they can be dunked in raw sewage and “don’t catch a thing.” 
Defying guidelines issued by his own health ministry, the president on Sunday visited a busy commercial district in Brasília, the capital, where he called on all but elderly Brazilians to get back to work. 
Then he insisted that an anti-malaria pill of unproved efficacy would cure those who fall ill with the virus that has killed more than 43,000 people worldwide.”

It will be interesting and sad to see how the virus will ravage a country that doesn't even try to deal with it. The US is projecting up to 240,000 deaths if containment measures are strictly adhered to. With no containment measures Brazil is probably going to experience the collapse of its health care system and several million deaths. The next 3-4 weeks will be instructive.





Coronavirus Compared to the Flu Virus

Vox produced an excellent 7-minute video on the difference between the flu and the current coronavirus. This really puts the two viruses in an easy to understand context. Vox writes:

“Covid-19, the disease caused by the coronavirus, can look very similar to the flu. They have similar symptoms — a fever, cough, and the possibility of leading to pneumonia — and even spread the same way. So wanting to compare the two is natural and, frankly, understandable. 
But Covid-19 is very different from the flu. It’s more dangerous in almost every way. 
Not only is it twice as contagious, but the time it takes you to realize you are contagious is much longer. With the flu, the average time it takes you to feel sick from the moment you become sick (called the incubation period) is two days.”










Wednesday, April 1, 2020

Book Review: Democracy for Realists

Peepsheep


The book, Democracy For Realists: Why Elections Do not Produce Responsive Governments (Christopher H. Achen and Larry M. Bartels (“A&B”), 2016) analyzes data on the nature of voting and democracy in America and other countries from the early 1900’s through 2012. Much of they find isn’t anywhere close to what people believe about the elements of democracy under the folk theory, e.g., where sovereignty resides, “the will of the people”, or the true nature of voters’ role in democracy.

A&B, both social scientists, have found that most American's vision of what democracy is has little to do with the reality of democracy. Instead of ideology and logic defining voter's political beliefs, party affiliation and voting preferences, the evidence points instead to people's social identities. Due to their misunderstanding, frustrated voters try to “fix” certain aspects of democracy by, e.g., imposing term limits or resorting to state level ballot measures. Analysis of the data suggests that those measures mostly backfire and tend to shift power from voters to special interests. The key lesson this book has to teach is that fixing democracy requires understanding it first.


The folk theory of democracy
The common perception holds that the people elect their leaders at the polls and then hold them accountable for representing their will. The folk theory is appealing because it puts the will of the people and their interests at the heart of government. Sovereignty resides with the people who control the agenda. Voters act as government watchdogs to enforce shared values and curb abuses. Voters correct their mistakes or punish failure at the polls by changing governments, while rewarding competence with continued time in power.

My guess is that many readers would at least suspect that the there’s something not quite right with the folk theory. For example, many people believe that one or both parties and the will of the people are often or usually co-opted by special interests backed by money in politics. That’s out of synch with the common perception of democracy. Those people would be correct in their suspicions.

If the current election season is any indication, most Americans are pretty unhappy with the state of affairs in their democracy. They see something wrong. So do A&B:

“One consequence of our reliance on old definitions is that the modern American does not look at democracy before he defines it; he defines it first and then is confused by what he sees. We become cynical about democracy because the public does not act the way the simplistic definition of democracy says it should act, or we try to whip the public into doing things it does not want to do, is unable to do, and has too much sense to do. The crisis here is not a crisis in democracy but a crisis in theory.”

Give that observation a moment to sink in. Don’t overlook the phrase “is unable to do.” That reflects the reality that most people (> 90% ?) don’t pay attention to politics, often can’t pay attention and are biologically too limited to understand what’s going on even if they tried:

“. . . . the typical citizen drops down to a lower level of mental performance as soon as he enters the political field. He argues and analyzes in a way which he would readily recognize as infantile within the sphere of his real interests. . . . cherished ideas and judgments we bring to politics are stereotypes and simplifications with little room for adjustment as the facts change. . . . . the real environment is altogether too big, too complex, and too fleeting for direct acquaintance. We are not equipped to deal with so much subtlety, so much variety, so many permutations and combinations. Although we have to act in that environment, we have to reconstruct it on a simpler model before we can manage it.”

From the biological point of view, that’s reality, not a criticism of people or their limitations. Almost everything in politics, if not everything, is more complex than people give it credit for. And, most if it is either at least partially hidden from the public, distorted in the name of “free speech”, or both.

It is hard to understate the role of cognitive biology and associated human behavior in politics. A&B point out that “a democratic theory worthy of serious social influence must engage with the findings of modern social science.” Although A&B’s book dissects democratic theory and analyzes mountains of science and history data from the last hundred years or so, the exercise is really about analyzing the role of human cognitive biology as it pertains to how democracy works. Our beliefs about democracy are shaped much more by human biology than political theory.

In Democracy for Realists, A&B assert that democratic theory has to adapt to the reality of what democracy is. That directly reflects the necessity of understanding human biology by analyzing the data.

Two points exemplify the case that this is about human biology first and what political theory needs to do to be helpful. The first point is that the “will of the people” that’s so central to the folk theory is a myth. There is no such thing as the will of the people. The people are divided on most everything and they usually don’t know what they want.

For example, voter opinions can be very sensitive to variation how questions are worded. This reflects a powerful cognitive bias called framing effects. Marketers and politicians are acutely aware of unconscious biases and they use them with a vengeance to get what they want.

For example in one 1980’s survey, about 64% said there was too little federal spending on “assistance to the poor” but only  about 23% said that there was too little spending on “welfare.” The 1980s was the decade when vilification of “welfare” was common from the political right. Before the 1991 Gulf War, about 63% said they were willing to “use military force”, but less than 50% were willing to “engage in combat”, while less than 30% were willing to “go to war.” Again, the overwhelmingly subjective nature of political concepts is obvious, i.e., assistance vs. welfare and military force vs. combat vs. war. Where is the will of the people in any of this? If it is there, what is it?

Serving the will of the people under the folk theory of democracy is often hard or impossible because there’s often no way to know what it is.

The second point is that voters usually don’t rationally hold politicians accountable for failure or reward them for success. People don’t logically distinguish success from failure. A&B point out that politicians are routinely voted out of office for things they cannot logically be held accountable for. For example, droughts, floods and an increase in shark attacks (yes, shark attacks) routinely cost incumbent presidents significant numbers of votes.

On economic issues, voters only consider a few months leading up to an election to decide if a president or party has done well. Data analysis suggests that if the 1938 recession had occurred two years earlier, FDR would not have been reelected and the New Deal would have ended. Similar “myopic” voting in the 1930s occurred in other countries and ideology had nothing to do with it. Perceptions of success and failure dominated voting in response to the Great Depression, not anything else.

That voting behavior contradicts the notion that voters rationally reward success and punish failure. In other words, politicians have little incentive to adhere to the folk theory. They know that their own success and failure can easily depend on things outside their control. That’s another key aspect of the folk theory that the data blows to smithereens.

If democracy is so strange, then what’s the point of doing more research? A&B give compelling reasons. They argue that “the mental frameworks” that both liberals and conservatives employ can be defended “only by willful denial of a great deal of credible evidence . . . . intellectual honesty requires all of us to grapple with the corrosive implications of that evidence for our understanding of democracy.”


Social identity & flawed fixes
Collectively, A&B see the data as showing that most voters vote less on policy preferences or ideology, and more on who they are or their social identities. For most voters, social identity shapes most thinking and voting behavior. That largely “reflects and reinforces social loyalties.”

A&B observe that our flawed perception of democracy led to failed remedies to reform it. Such fixes, including term limits and state level ballot initiatives, often undercut what people want from their democracy. Instead of acting to make democracy fit the theory, “more democracy” fixes that voters keep trying usually shift power to organized special interests. That outcome is precisely what voters did not want.


Why understanding democracy is critical
The point is clear. If you don’t understand how and why democracy works, you can’t change what you don’t like about it. Therefore, go figure out what democracy really is, not what one thinks it is or should be. A&B have gone a long way toward pointing out how and why it works. However, solutions to democracy issues are not clear. It may require years of empirical trial and error. Despite the surprising nature of democracy, A&B point to a more rational understanding of how things work. That is encouraging. The disappointment is that solutions are not obvious.


DP repost: 4/1/20