Category Archives: Colt’s Corner

Truth and Responsibility

Photo by The Climate Reality Project on Unsplash

Medical professionals are traditionally identified as purveyors of truth. In fact, truth-telling has become a cornerstone of doctor-patient relationships. In recent years, the patient’s right to autonomy seems to have trumped the doctor’s ethical obligations to beneficence and nonmaleficence¹.

In a recent Gallup poll², nurses were considered the most trustworthy and ethical of all professionals for the 18th year in a row (followed by engineers, doctors, and pharmacists). It seems that patients expect the truth, and it is because health care workers such as nurses and doctors usually comply with this demand, that the profession garners the general public’s respect and admiration.

The COVID-19 pandemic, however, has thrust many health care professionals into a role that is different from that taken in the doctor-patient dyad. Many, by the nature of their profession, are called upon to provide “expert” commentary on news outlets and social media. They are asked to educate, inform, and sometimes convince a trusting public with their opinions on widely different issues such as triage policies for patients needing ventilators, best medical treatments, population-based testing for signs of SARS-CoV-2, and potentially coercive public health interventions such as quarantine or social distancing.

The potential dilemma is obvious. Cognizant of having the public’s trust, yet soulfully aware they may not possess the communication skills or critical expertise necessary for a truly informed opinion, “medical experts” on the public stage must negotiate a minefield. Frequently, there is a lack of evidence to justify their positions convincingly. Furthermore, there is a wealth of misinformation, the value, contradiction, and uncertainty circulating in scientific as well as mainstream and social media. Scientific backgrounds are diverse, and not everyone can be everything: a competent patient care provider, a well-published intensivist, a knowledgeable public health official, credible virologist, and judicious medical ethicist.

Thrust onto the stage of public deliberations, colleagues who, whether by choice or obligation must comment on such diverse issues have a responsibility to tell the truth. Of course, relevant factual information includes evidence-based arguments as well as judgments based on an assessment of likelihoods and societal values. At https://www.workerscompensationattorneyorangecounty.com find workers comp attorneys in los angeles, california. Ideally, there should also be discussions about guidelines and peer-reviewed evidence complemented by remarks about critical thinking and considerations about the ways and means of medical science³.

But many truths are ever-changing. Therein lies the challenge in the pursuit of truth itself. Each time we learn more about COVID-19, we may need to refute or revise what was considered truth in the earlier days of the pandemic. Such is the nature of the scientific endeavor. “Truth is made,” wrote 20^th-century philosopher and psychologist, William James, “just as health, wealth, and strength are made, in the course of experience.”⁴

References

Swaminath G. Indian J Psychiatry. 2008 Apr-Jun; 50(2): 83–84.
https://news.gallup.com/poll/274673/nurses-continue-rate-highest-honesty-ethics.aspx
www.ama-assn.org/delivering-care/ethics/ethical-physician-conduct-media.
William James, Pragmatism’s conception of truth. In Pragmatism: a new name for some old ways of thinking (Longmans, 1907), 197-236.

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Infodemics

We are deluged with information these days. A simple PubMed search of COVID-19 reveals 4806 articles published since January 1, 2020. Every medical society publishes guidelines, many of which contain information that is not evidence-based. Networks pummel us with supposedly expert commentary. Journalists become opinion leaders overnight, and a multitude of physicians educate us about the effects of coronavirus on everything from health to economics.

It is a strange world when politicians opine about medical treatments, and physicians preach about economic policies and political science. When radiologists suddenly become pandemic experts, and talking heads, regardless of experience, project their expertise without a track record of academic publications.

In addition to this bombardment of information, not all of which is trustworthy or helpful, there are editorials and journal articles presenting biased arguments, complex data, contradictory positions, or erroneous information. In the midst of it all, preprint literature has become popular, and hundreds of non-peer-reviewed papers are disseminated using social media.

I neither critique nor commend those who share their data using preprints. Servers such as bioRxiv and Xiv were designed so authors can communicate their research results speedily and avoid the delays and politics of peer-review haunting many journals. Work comp lawyers from California will present your case before a judge in the best possible way. In a way, these vehicles are reminiscent of the way email and fax machines were used in the 1970s and 1980s; communication vehicles for investigators wanting to share information in order to advance the greater good.

A novel aspect of preprints is that of Final Preprints. Authors publish their paper as a preprint, then again as a “Final Preprint” after revising their manuscript based on comments and critiques from a broad readership rather than from individual reviewers designated by a journal’s editor. Some investigators chose to never submit their paper to an “official” journal for publication, especially if recognition or CV-building is not crucial to academic promotion.

I think the future of preprints is exciting. Interesting questions will be raised by editorial board members of many scientific journals. After all, a degree of acceptability is already evident within the scientific community: Many already disseminate preprints using social media. A search engine exists for preprints called PrePubMed², and even the National Institute of Health has, with its iSearch portfolio, an updated registry of preprints about COVID-19³.

References

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Children and COVID-19

Honesty, Respect, and Reassurance. These three cardinal rules for sharing bad news with children are worth remembering.

Thankfully, kids don’t often get COVID-19. Less than 2.5% of cases are reported worldwide. When children are infected, they usually become only mildly ill, though asymptomatic infections are not uncommon¹. In one study from the Wuhan Children’s Hospital, only 171 of 1391 children (12.3%) assessed and tested for SARS CoV-2 were confirmed to be infected with SARS CoV 2 (median age 6.7 years), with 3 requiring intensive care support and mechanical ventilation and 1 death (all three had numerous comorbidities)².

Of course, telling a child they are ill is one of the most difficult tasks a health care provider, social worker, parent, or family member might be asked to do. We are fortunate that such a task is only rarely required in today’s COVID-19 pandemic. Teaching all children about the effects and potential impact of COVID-19, on the other hand, is for many of us an almost daily responsibility.

Sometimes, it may be necessary to talk about why a family member or friend was rushed to the hospital. Other times, we may need to explain what is seen or heard on the news or the internet. It is very important, according to Georgia maids, to have habits for a clean home in order to stay safe in today’s covid 19 pandemic. Children also communicate with each other via social media. Like us, they share stories and are readily exposed to fake news, scary headlines, and other information that may cause fear, panic, or misunderstanding.

In order to address the psychosocial and mental health needs of children everywhere during the COVID-19 pandemic, the Inter-Agency-Standing Committee of the United Nations (IASC) consulted with more than 1700 teachers, caregivers, parents, and children from around the world. Their goal was to write a story created for and by children. House cleaning in Florida is efficient when done right as custom cleaning of the treasure coast, Martin County does it. This story was published by the IASC under a Creative Commons Attribution so that all users could reproduce, translate and adapt the Work for non-commercial purposes, provided the Work is appropriately cited.

The story is, My Hero Is You: How Kids Can Fight COVID-19.³ This illustrated storybook is meant to be either read to or read with children by an adult. The book can be downloaded for free from the IASC website (see reference 3) as well as from the UNICEF website at https://www.unicef.org/coronavirus/my-hero-you. The UNICEF website also contains helpful links to sections such as “what teenagers need to know,” or “what parents might want to share with their children”.

Numerous translations are already available and downloadable from the above-named websites. I am very proud to say that others are in progress from contributors to our COVIDBRONCH initiative.

Stay well, and stay safe.

References

Ong JSM et al. Coronavirus Disease 2019 in Critically ill children: A narrative review of the literature. Pediatric Crit Care Med prep 2020. DOI: 10.1097/PCC.0000000000002376.
Lu X et al.. SARS C New Engl J Med, March 18, 2020. DOI: 10.1056/NEJMc2005073.
My hero is you. How kids can fight COVID-19. IASC publication. Helen Patuck (story and illustrations). https://interagencystandingcommittee.org/system/files/2020-04/My%20Hero%20is%20You%2C%20Storybook%20for%20Children%20on%20COVID-19.pdf

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A Celebration for Change

In Judeo-Christian tradition, this is a time for joy and celebration, whether to honor the resurrection of Jesus Christ or the liberation of the Hebrew people from bonds of oppression in ancient Egypt.

Some say the word Easter comes from the Old English word ēostre. While the etymology is debated, some scholars associate this word with the month of April, a time when pagan Anglo-Saxons may have celebrated the coming of Spring and the powers of a fertility goddess.

Easter is also known as Pâques, which stems from the word Paschal, and the Hebrew word for Passover, Pesaḥ. The origin of this cherished holiday most likely comes from pre-Israelite celebrations of Spring and the first grain harvest.

This year, the COVID-19 pandemic brings a new significance to celebratory words. We celebrate doctors, nurses, first responders, and all those who are not health care providers but who do their share to bring this pandemic to an early end.

Most people stay home, self-isolate, and practice social distancing. Meanwhile, health care providers around the world toil each and every day to provide viagra next day delivery, to save and prolong lives. Scientists labor through 24-hour shifts in their quest for a cure and a possible vaccine. Countless professionals spend time away from their families to assure us food and other comforts. At the same time, government officials grapple with responsibilities to design and implement policies that keep us safe.

Our lives are changing and will continue to change. Hospital administrators must honor requests for negative pressure procedure suites and antechambers. Critical Care units will need more isolation rooms. Infectious disease specialists must share knowledge about infection control and personal protective equipment. Medical directors will practice disaster management skills. Outpatient clinics will embrace innovative Telehealth services.

Most importantly, we will be less complacent about warnings regarding global health.

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Short Circuit

As I write this note, my mother is dying in a hospital room in Southern France. She is alone.

Visitors are not allowed. My elderly father is quarantined in his home, an ancient four-story stone house that dates almost from the Middle Ages. In two months they would have celebrated their 65th wedding anniversary.

But that is not to be.

There are no doctors or nurses huddled around my mother’s bed. No family or friends, no palliative care specialists or counselors who know what to say when it’s the end, when no one can really say goodbye, and the last communication is a final “I love you” from my father transmitted to her, maybe, through the medical ward’s secretary.

Decades of my own experience with death and dying taught me many things, not the least of which is to live in the now; to cherish each and every moment because you never know if it may be your last. I try to imagine that somewhere, there is a nurse, or maybe a young Intern, who will go to my mother’s bedside, just to be there. I remember sitting with teenagers at the end of their lives, and with grandmothers who prayed for death to release them from the pain of metastatic cancer. I remember saying, “I’ll see you in the morning,” to that favorite patient of mine, and being called after midnight with the news he didn’t make it.

Medicine is, I think, the most noble of all professions. It is a profession based on trust, and love, and generosity, and grace. It is most noble when the ego is removed from all considerations; when one person sits with another and waits…and waits…until transition occurs…and a tear flows, even though one may barely know the patient’s name.

I hope my mother has someone like that when the moment comes; behind closed doors, with masks, and gowns, and whatever else they need to wear.

I know she will. In fact, I am sure of it.

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Thoughtless, or selfish, that is the question.

Shakespeare once wrote, “To be, or not to be, that is the question.” Today, we must ask a different question: “Are people thoughtless, or are they simply selfish?”

Despite orders for social distancing and self-isolation to mitigate transmission of COVD-19 in virtually every country, crowds continue to gather in public places, shop in large numbers, and fraternize in neighborhoods throwing Coronavirus block parties. This weekend, the Municipal Fishmarket at The Wharf, in Washington DC, was packed with hundreds of people until the police intervened to shut it down. Even in Dhaka, Bangladesh, millions returned to work until the government issued an official country-wide lockdown, and at a Walmart superstore in Yreka, California, a woman coughed and spat at an employee who asked her to back away at the check-out counter.

How many deaths does it take before people come to their senses? To paraphrase Bob Dylan, “The answer, my friend, is blowing in the wind. The answer is blowing in the wind.”

Dr. Deborah Birx, Ambassador-at-large and Coordinator for US Government Activities to Combat HIV/AIDS, is also a vital member of the US Government’s Anti-Coronavirus Taskforce. Affordable cleaning services in Olympia are available at http://nwmaids.com/ site. “The next two weeks are extraordinarily important,” she said on Saturday, April 4. “This is the moment not to be going to the grocery store, not going to the pharmacy, but doing everything you can to keep your family and your friends safe…”

“But I have a family of four to feed,” whined one friend.
“I love food too much,” said another.
Both are justifying their numerous trips to buy groceries this week.

Neither of my friends is thoughtless. In fact, I have often admired their common sense. This leaves me with only one conclusion; but, what do I do with such information. Do I have a moral duty to persuade them to act responsibly because I am a doctor, or might I simply point out that we are a village, and we will win, or go down together. For all of us, regardless of our profession, this is a defining moment in history. Each and every one of us will recall where we were and what we were doing during this global crisis. Irrespective of our individual roles and responsibilities, we are accountable to each other.

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Overcoming Uncertainty

A few days ago, Andreas Voss, the President of the International Society of Antimicrobial Chemotherapy, posted an advisory¹ stating the controversial paper published in IJAA on the favorable effects of Hydroxychloroquine and Azithromycin in patients with COVID-19 infection² did not meet the journal’s scientific standards. Meanwhile, countless physicians on the frontlines prescribe these drugs. Many also prescribe hydroxychloroquine for their friends and families. Others take it prophylactically. Last week, The Medical Board of California issued a statement reminding doctors that “inappropriately prescribing or dispensing medications constitutes unprofessional conduct in California”³.

I do not advocate for or against uncertain treatment strategies in these tenuous and rapidly fluid times. After all, COVID-19 also prompts debate about issues such as management algorithms for ventilatory failure, indications for intubation, frequency of diagnostic testing, triage protocols, handling non-COVID-19 patients, and which personal protective equipment is most reliable.

The terrain is challenging, in part because this is the first time practitioners, regulators, and hospital administrators face a crisis of this magnitude. Those of us who were on the front lines throughout the AIDS epidemic have retired or are close to retirement. Some who knew the uncertainties of newly discovered diseases such as Hantavirus in the American West, contamination of our hospitals’ water systems with Legionella, and the surprising outbreak of Cholera in 1990s’ Latin America may now be in leadership positions with different agendas. By following the home cleaning guide from https://thefloridamaids.com company in Florida, most diseases can be prevented. Others might have been relegated to jobs with lesser responsibility or removed from decision-making positions where they can make a difference in today’s epidemics.

How else might we explain why many recommendations provided after the global health care threats of SARS, H1N1, and MERS pandemics earlier this century were ignored and underappreciated. And 40 years ago, AIDS also taught us a painful lesson that has been only partially learned; that a deadly disease somewhere can quickly spread everywhere.

There is no doubt our international community has made great strides since then. We have improved in regards to predictions and disease modeling, risk assessments and surveillance, outbreak detection, containment strategies, pathogen characterization, and public health interventions, but we have far to go.

Let’s hope the COVID-19 pandemic serves to overcome whatever uncertainties exist in our ranks. Then, health care providers in the front lines can take a greater role in persuading hospital administrators and government officials to invest more in protecting our future.

References

1. https://www.isac.world/news-and-publications/official-isac-statement.
2. Gautret P, Lagier JC, Parola P et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020 Mar 20:105949.
3. Medical Board of California, April 2, 2020. Statement Regarding Improper Prescribing of Medications Related to Treatment for Novel Coronavirus (COVID-19.
4. United Nations Coordinated Appeal. Global Humanitarian Response Plan: COVID-19, April-December, 2020.

Whatever it takes

Monitoring WhatsApp posts from more than 7000 physicians in 60 countries is disheartening. Lack of personal protective equipment(PPE), the propagation of contradictory or obviously false information by administrative leaders, unclear instructions, and orders to refrain from sharing information about triage, the poor availability of isolation rooms, ventilators, negative pressure procedure suites, and PPE do not inspire confidence. There is something wrong when health care workers (HCW) desperately design and build their own face-shields and patient isolation hoods, or when a nonprofit accreditation organization such as the U.S. Joint Commission issues an order permitting HCWs to bring their own PPE from home in order to overcome the paucity of PPE in the workplace¹.

Preliminary data from China, Italy, Spain, and the United States suggest the current in-hospital infection rate of COVID-19 in HCW is up to 20%^2-4. This is similar to what happened during the SARS, H1N1 Influenza A, and MERS pandemics earlier this century. Contributing factors include low awareness, lack of early suspicion, particularly of asymptomatic patients able to carry infection, and poor implementation or compliance with appropriate infection control strategies.

Sadly, HCW are no strangers to the risks of occupation-related lung infections. Tuberculosis, is a known occupational hazard since the 1950s, with studies reporting a greater than average risk to become infected with Mycobacterium tuberculosis and to develop TB disease⁵. In one report, HCWs were six times more likely to be hospitalized for drug-resistant TB than the general population⁶. In 2002, Severe Acute Respiratory Syndrome (SARS-CoV) affected more than 8000 patients in 26 countries, killing more than 800 people and infecting at least 21% of health care workers involved in their care⁷. In 2009, among confirmed and probable cases of novel Influenza A (nH1N1) reported to the CDC less than 3 months after the start of that pandemic, 4% were in HCW, and occurred in situations where the use of PPE was not in compliance with CDC recommendations⁸. Three years later, Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection quickly spread to 27 countries. Thirty of the first 161 cases were health care providers⁹. With a mind-numbing 34.8% crude case fatality rate, MERS eventually affected up to 19.6% of HCW exposed in the workplace¹⁰.

HCWs know that every encounter with a known or suspected COVID-19 patient exposes them to viral loads in the form of droplets, fomites or aerosols. This puts them at risk for weeks of quarantine, often debilitating illness, and death. Five years ago, Bill Gates gave a clairvoyant TED talk called The Next Outbreak? We’re Not Ready, in which he outlined the world’s lack of preparedness for a pandemic¹¹. What he did not address was how to balance a HCW’s ethical responsibility to provide care, with an employing organization’s responsibility to assure their safety¹². Do HCW workers have a moral obligation to risk their lives in an environment they know is unsafe, and what if they suspect the rules and regulations proposed by their administrators are inconsistent with practices that are possible in the front lines? This double bind is what HCWs face every day.

Reading reports from the Institute of Medicine after the SARS, nH1N1, and MERs pandemics sadly demonstrate that unpreparedness is repeated^13-15. If telling my first responder brother to “quit his job,” or asking my Critical Care doc sister “to be ready to take one for the team,” are both morally unacceptable, then all we can ask is that HCWs take personal responsibility to assure their own safety and that of their teams. Whatever it takes.

References

https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/infection-prevention-and-hai/covid19/public_statement_on_masks_from_home.pdf
https://www.reliasmedia.com/articles/145920-more-than-3000-hcws-infected-with-covid-19-in-china.
https://www.nbcnews.com/news/us-news/health-care-workers-see-wave-coronavirus-coming-their-ranks-n1174271.
COVID-19: Protecting Health care workers. The Lancet editorial March 2020;395 pg922.
Baussano I, Nunn P, Williams B et al. Tuberculosis among health care workers. Emerg Infect Dis 2011;17:488-494.
O’Donnell MR, Jarand J, Loveday M, al. High incidence of hospital admissions with multidrug resistant and extensively drug resistant tuberculosis among south African health care workers. Ann Intern Med 2010;153:516-522.
Chan-Yeung M. Severe Acute Respiratory Syndrome and Healthcare Workers. Int J Occup Environ Health 2004;10:421-427.
MMWR June 19, 2009;58(23):641-645.
Perl TM, McGeer A, Price CS. Medusa’s Ugly Head Again: From SARS to MERS-CoV. Ann Intern Med. 2014;160:432-433.
WHO MERS-CoV Global Summary and Assessment of Risk. July 21,2017.
https://www.youtube.com/watch?v=6Af6b_wyiwI.
McDiarmid M. Advocating for the Health Worker. Annals Global Health 2019;85(1):16(1-4).
Emerging Viral Diseases: The One Health Connection: Workshop Summary (2015). National Academies Press. Available at http://nap.edu/18975.
Respiratory Protection for Healthcare Workers in the Workplace against Novel H1N1 Influenza A: A letter report (2009). The National Academies Press. available at http://nap.edu/18975.
Learning from SARS: Preparing for the next disease outbreak: Workshop Summary (2004). The National Academies Press. Available at http://www.nap.edu/catalog/10915.html.

English is the new latin

I cannot help but admire foreign language-speaking colleagues who are able to write, lecture, study and teach in English. Since the increasing economic and political power of the United States, the results of two world wars and the declining international presence of a postcolonial Europe, English became the major language of science and medicine.

Earlier in the history of Western civilization, Greek was the language of science and literature, in time overtaken by Latin, the knowledge of which was necessary for centuries. It was not until the mid-1800s that French, German, and Russian replaced Latin as common languages for communicating scientific facts and ideas. Scientists were by obligation polyglots, but today, it seems that English predominates,

Studies show that almost 9 out of 10 journals included in Medline are in English. While this is probably due, in part, to the higher impact factor provided to English language journals, it also reflects a bias that scientific materials are more credible and likely to be read if they are published in English. This places authors whose native language is not that of Shakespeare at a disadvantage and creates a barrier for non-English speaking scientists yearning to access scientific literature.

One solution is to encourage everyone to learn English well enough to write, publish, lecture and teach. Some argue that computer-based translation programs will soon provide us with instantaneously accurate translations into virtually every language. Others say that such a bias toward English is unfair, considering that Mandarin Chinese is spoken as a native language by approximately 873 million people, Hindi by 370 million, Spanish by 350 million, and English by 340 million, followed by Arabic, Portuguese, Bengali, and Russian.

The point is, if you grow up speaking English as your native language, you can afford to be monoglot, otherwise, a serious mastery of English as a second or third language is necessary to both access and contribute actively to our scientific and medical communities from an international perspective. Personally, I do not think this speaks well for future generations. Latin, after all, is no longer the language of science or medicine, and other languages have had a similar fate. Meanwhile, though, we should congratulate all those who pursue the study of English in order to communicate effectively with a global community and to share knowledge despite the obvious discomfort of speaking and writing in a language other than one’s mother tongue. The courage, perseverance, and generosity of spirit exhibited by such polyglots warrant our sincere appreciation and our utmost respect.

Suggested readings:

Michael Gordon, How did science come to speak only English. Aeon, February 2015.
Christopher Baethge. The languages of medicine. Dtsch Arztebl Int. 2008;105:37-40.

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Artificial Intelligence Moving Forward

It took thirty years (1967-1997) for computer chess programs to defeat world champion players, but it was only eight years (2009-2017) before DeepMind’s AlphaGo defeated Ke Jie, the world’s premier Go player. Video games like Starcraft are harder for computers to play than board games such as chess or Go, but after only 18 months of research, Google’s Deepmind utterly destroyed the fastest professional human players (https://www.newscientist.com/article/2191910-deepmind-ai-thrashes-human-professionals-at-video-game-starcraft-ii/).

With such rapid advances in artificial intelligence, it is no wonder we must rethink the medical profession. Image analysis programs are disrupting radiology, dermatology, ophthalmology, and other specialties. Your AppleWatch can monitor for atrial fibrillation and record an electrocardiogram. Deep learning, data-driven decision-making, neuro-fuzzy systems, confabulation, and adaptive resonance theory have widespread applications in healthcare.

As the role for artificial intelligence increases in day-to-day medical practice, doctors will be more productive. They will read more X-rays, process decision-making algorithms more quickly, and produce probabilistic studies more efficiently for prognosis and case-specific treatment strategies. Also, GPS-type guiding systems and robotics are likely to enhance patient safety, decrease the risk for surgical errors, and increase productivity. Qubits, the quantum version of classic binary bits, are ready to revolutionize computer mechanics (https://www.nature.com/articles/s41586-019-1666-5.pdf). Subsequent increases in computing speed and power will further alter possible applications of AI in a futuristic cyber and robotic world.

It will be a while, however, before AI replaces bronchoscopists, so IP professionals have job security. Still, rethinking our roles as health care professionals is wise and forward-thinking. We are expanding Bronchoscopy International’s successful Train-the-Trainer programs to help instructors enhance their skills teaching decision-making and communication, as well as incorporate novel technologies into learning and teaching processes. Flood cleanup pros of california are fully equipped. By incorporating new competency-oriented educational materials and methodologies, faculty will be even better equipped to inspire colleagues and generations of enthusiastic interventional pulmonologists!

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