Category Archives: Colt’s Corner

More action, less words

Imagine a hands-on experience where experts work with small groups of learners instead of the traditional “pre-conference workshop” followed by hours of lectures.

We did this at the recent Asian Pacific meeting held in Australia under the leadership of Dr. David Fielding, and again at a bronchoscopy course led by Dr. Javier Flandes in Spain. Feedback was positive and encouraging. In the next paragraphs, I will identify just a few advantages and disadvantages of such conference strategies.

Advantages: (1) People learn something. Active engagement time is maximized by using predetermined learning objectives and focused hands-on training with a low teacher/student ratio (one instructor for less than five learners). Teachers identify weaknesses by incorporating checklists and assessment tools into workstations. Learners reinforce skills they already have and identify areas they need to work on. (2) Keeping didactic lectures to 10 minutes forces speakers to improve communication skills. They focus on what is truly important and not necessarily learned by reading. A short didactics program forces organizers to identify core competencies and prompts speakers to give lectures that are complementary rather than all-encompassing. Didactics are modifiable based on audience needs (learner-centricity). (3) Workshops enhance exposure to a variety of technologies, instruments, and teaching techniques. Companies see users get their hands on their equipment. Learners prefer doing to listening. Simulation using models, computers, and role-playing exercises forces teachers to learn how to use specific scenarios. This skill is essential for tomorrow’s educators today.

Disadvantages: (1) People are resistant to change, despite statistics showing the value of short lectures. Materials can be provided before or on-site in the form of on-line PDF files or presentations. (2) Organizers must work to organize workshop style formats.They must carefully select instructors and assignments. This bruises egos. Course directors might need to learn how to organize such programs and how to assess value. Instructors might need to improve small-group teaching skills. Expect resistance for the same reasons as above. (3) Not all topics can be covered, although special lectures, pro/con debates and interactive panel discussions for controversial issues and new technologies are warranted.

We are a technology and empathy-driven profession where actions speak louder than words.

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In Mourning: Viktor Sokolov

In 1826, The Russian poet Alexander Pushkin wrote “But with the truth he attracted hearts. But with science he quelled mores.” (From, Stanzas). Such words could be used to describe the life and work of my friend Professor Viktor Sokolov (1946-2019), who died last month at the young age of 73.

Viktor was an accomplished surgeon, anesthesiologist and bronchoscopist. He created the Russian Bronchology Group and was the first Russian regent to the WABIP. He fought to defeat conventional wisdoms and dedicated his life to modernize bronchoscopy practice in his country. In addition to numerous leadership positions, Professor Sokolov was also a former Chair for the Endoscopy Commission of the Russian Ministry of Health, and a long time member of the Academic Council.

As department head at the Moscow Research institute he led efforts to perform novel interventions in patients with early cancer of the larynx, trachea and bronchi, esophagus, stomach and duodenum, bile duct, choledochus, rectum and colon. He helped promote the use of electrosurgery, argon plasma coagulation, laser thermal destruction, photodynamic therapy and stent insertion. He published more than 300 original scientific papers, dozens of monographs, clinical care guidelines, and 10 teaching manuals. He held 26 patents for scientific methodologies and instruments.

For more than ten years, I corresponded frequently with Viktor and his son Dmitry (also an expert bronchoscopist). It was a great honor to help them build a training program in Moscow. A few years ago, with my colleagues Nikos Koufos, Rosa Cordovilla, and Enrique Cases, we helped faculty implement the use of training models, checklists and assessment tools in bronchoscopy education. This has been particularly helpful for building skills in endobronchial ultrasound.

Viktor was a scientist at heart, and it is as a scientist that he approached his medical practice. His dream was to cure lung and digestive cancers in their earliest stages, and for this he was always on the alert for technologies that might assist with early diagnosis and treatment. Because his first love was actually pediatric surgery back in the 1970s, Professor Sokolov was particularly excited to see the recent growth of pediatric bronchoscopy (we have more than 400 doctors communicating through our WhatsApp Peds Groups).

Viktor, we shall miss your humor, your intelligence, and most of all the inspiration of your relentless pursuit of truth.

Farewell, my friend.

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The Bronchoscopist’s Umwelt

Traditional bronchoscopy (Photo H. Colt)

Ten years after Shigeto Ikeda first introduced the flexible bronchoscope to the world, I gazed into the incredible fractal anatomy of a patient’s tracheobronchial tree. Back then, flexible bronchoscopes were made of fiberoptic bundles that required an external light source for illumination. Today’s instruments incorporate increasingly complex technologies that provide greater visibility and access than ever imagined.

If previous generations were inspired by their newfound ability to view, diagnose and treat airway tumors, tracheobronchial strictures, and pulmonary infections, a new generation of health care providers can only marvel at the increasing indications, therapeutic possibilities and promising future for this already proven medical procedure.

During the recent meeting of bronchoscopy educators in Venice, I plunged into the sea of possibilities that exists for present and future bronchoscopists. New diagnostic technologies, therapeutic alternatives, increasing indications, robotics, real-time image-guided tissue analysis, and possibilities for less invasive genetic sampling provide a glimpse of what is yet to come.

What amazes me most, however, is how the bronchoscopist’s “surrounding world”, also known as an “umwelt” is drastically changing for the better. The word umwelt was introduced more than one hundred years ago when Jacob Johann von Uexküll, an Estonian biologist, fused biology with semiotics, proposing that living organisms could not be separated or divided from their environments. ANCHOR. This idea prompted many anthropologists, animal behaviorists, biologists, and philosophers to embrace the idea that organisms, essentially us, exist in a dependent relationship with other organisms and our environment.

As students of our own umwelt, we can abandon our narrow views of the world to adopt instead a position where seeing the world through another’s eyes helps us to understand not only the other’s world but also the perceptions of those we are related to both directly and indirectly. As some might say; we are in this all together, so we might as well get along, but we might also do our best to see the world through others’ eyes.

Uexküll’s proposition was an important parallel to theories of Darwinian evolution, which in its more vertical approach reduces organisms to a survival of the fittest evolutionary schematic. When an organism’s evolution is viewed instead as being primarily interdependent on surrounding worlds, it means there are as many surrounding worlds as there are organisms. The dog sees its world a dog’s way, which is surely different from yet related to the world view as seen by a mosquito. If you are in need off heating installation in New Jersey, fell free to contact contact allied experts. Each and every one of us, whether we are homo sapiens basking in the sun of Southern California or wild lions struggling to survive in the Serengeti must “perceive and act from the standpoint of our own unique world” (From, Ian G.R. Shaw, Geoforum 2013;48:260-267). Each living thing possesses, as Dr. Shaw explains in his article, “a unique signature of existence.”

Fifty years ago, the bronchoscopist’s umwelt began with the realization that we could effectively intervene both diagnostically and therapeutically in a region of the human body that had previously been virtually inaccessible. Discover orchid maids reviews how you can get a legal advice from work injury lawyers, CA when it comes to immediate medical treatment. Our instruments then, as are many now, appear somewhat primitive, but the procedure itself led chest physicians to increasingly assume roles of responsibility in the care of patients with critical illnesses and cancer.

Our human potential within such an environment continues to expand as technologies evolve. I believe this entices us to relate with a surrounding world that is ever expanding, evolving, and drastically changing. How we adapt to that world, including how we modify our own world views accordingly, will determine our specialty’s relevance in a changing health care environment.

Death in Venice

Venice has 150 waterways and 455 bridges connecting more than 120 small islands. There are hundreds of narrow alleyways, art museums, shops, restaurants and outdoor cafés. The city is an emblem of Italy’s charms, and its people have a history rich with experience in diplomacy, the humanities, and intellectual creativity.

This week, a limited-attendance conference named “An International Workshop in Interventional Pulmonology: The road map towards competence” was organized by my friend and Venetian native, Professor Lorenzo Corbetta (University of Florence). Cosponsored by The Fondazione Internazionale Menarini, and held at Ca’ Foscari Academy, this conference included a small group of physician-educators from Europe, Australia, South America, the United States, and China. Our mission was to discuss and debate issues related to training for our growing medical speciality.

During my sojourn in this city known as “La Serenissima”, I reread Thomas Mann’s turn of the century novella, Death in Venice. In this story, a writer’s life is tragically marked by his obsession with beauty, and by his sensual attraction for a young boy on holidays with his mother. The screen adaptation was done in 1971 by Italian director Luchino Visconti. His famous movie starred Dirk Bogarde and Bjorn Andresėn, with a soundtrack using music by Gustav Mahler.

Oddly, the words death in Venice also seemed to reflect what I believe is the result of this week’s international conference. What I mean is they signal the end of an antiquated Halstedian education model historically linked to a “see one, do one, teach one” paradigm of medical procedural education.

For example, conference participants unanimously concluded that patients must not be used as subjects for medical procedural education. This modern educational paradigm is justified by ethical practices, educational philosophies, and an increasing availability of robust alternatives.

Participants also agreed agreed that (1) validated, objective measures of learning outcomes are beneficial and should be implemented in our training programs; (2) these learning outcomes and other training milestones should be routinely documented as a roadmap toward competency; (3) specifically structured training programs should be designed using a multidimensional curricular approach; and (4) Train-the-Trainer programs (faculty development) are warranted to help trainers become more familiar with a large variety of teaching techniques, assessment tools, learning principles, and education-related philosophies.

For example, a program that helps ensure ethical procedural practice and efficient, effective teaching might include documented learning outcomes with checklists, identifying strengths and weaknesses using a combination of learner-centric assessment tools, and deconstructing clinical issues using a combination of simulation and problem/case-based exercises with opportunities for feedback and two-way conversation.

Just as importantly, conference participants concluded that it is no longer necessary to debate the primeval question of why these modern educational tools should be used Instead, we should move into an age of widespread implementation in order to answer questions of how these tools can be used most effectively in our quest for competency.

My personal interpretation of the conference’s outcome is as follows:

– Our focus can shift from that of resisting change to that of implementation.
– Our objective should be to create a training environment that is coherent with learning habits of a younger generation of doctors, yet adaptable to diverse medical and cultural environments.
– Our inspiration derives from the dedication and intrinsic motivation of physician-educators who actively learn from each other during Train the Trainer workshops (certified and master instructors from Bronchoscopy International are two examples of such a process).
– Our sense of achievement comes from competently serving patients and training a new generation of doctors who refuse to use patients as training victims.

In my opinion, therefore, this landmark conference signals the end of an era stained by Halstedian philosophies. In its place is a commitment to implement a multidimensional approach to procedure-related education. Training programs that incorporate checklists, assessment tools, step-by-step learning, simulation, procedural logbooks, data collection and analysis, knowledge of educational philosophies, instructional techniques, and structured opportunities for learner-teacher feedback constitue a solid framework for what clearly is a new beginning.

Bronchology and the 20th anniversary of The Matrix

Twenty years ago this week the science fiction film The Matrix was released in the United States. This film directed by the Wachowskis brothers stars Keanu Reeves and Laurence Fishburne. The film grossed more than 460 million dollars worldwide.

The Matrix describes a dystopian future in which the hero is a computer programmer named Thomas who actually lives a double life as a hacker named Neo. Neo feels trapped within an inauthentic life. He goes in search of a man called Morpheus to ask him the truth about the world. Morpheus offers Neo a choice between swallowing a “red pill” which will allow Neo to live a life of constant awareness and truth or a “blue pill” after which Neo will continue living his current life in blissful ignorance and security.

When Neo swallows the red pill, he is immediately awakened to a new reality. He learns that The Matrix in which he lives is actually an illusory 20th-century world that is sustained in order to prevent people from knowing they are being exploited…and the adventure begins.

The red pill-blue pill meme described in The Matrix has become part of our culture. In this piece, however, my goal is not to discuss red pill-blue pill life philosophies, but to briefly reflect on how using educational tools offered in the Bronchoscopy Education Project provide red pill opportunities.

For example, if trainers successfully use assessment tools to identify a learner’s place on the learning curve and ascertain the effectiveness of their own teaching techniques (akin to swallowing the red pill), it follows that they will want to incorporate assessment tools into competency determinations. This new reality morally obliges the trainer to identify competency measures and to change educational practices accordingly.

As a second example, if trainers experience that checklist-type assessment tools are helpful for teaching bronchoscopic inspection (example BSTAT), or EBUS-guided TBNA (example (EBUS-STAT), it follows that a similarly designed assessment tool for intubation over the bronchoscope would also be helpful. Aware of this new reality, trainers would design such a tool and incorporate it into competency determinations.

In Australia, for example, colleagues designed and validated new assessments for ultrasound-guided thoracentesis and chest tube insertion (available on www.bronchoscopy.org) with excellent results. These tools are increasingly used around the world and form an important element of competency-based training for lung doctors in Australia and New Zealand.

A third example of red pill philosophy relates to experiential evidence for using a four-box approach to procedural consultation. This structured approach to case-based learning identifies cognitive pathways and allows trainers to explore the multiple facets of a particular clinical scenario in a stepwise fashion (akin to swallowing the red pill). The harshness of this new reality is that trainers now discover their need for additional education in order to learn how to maximize case-based instruction, which is very different from giving didactic lectures. This red pill-related truth has a global impact because it means that bronchology societies around the world should take steps toward offering more focused training of bronchoscopy educators. Programs might include information about how to organize learning units, how to provide and receive feedback, and how to facilitate case discussions. Learning the intricacies of two-way communication as an educational product requires practice and repeated simulation with guidance. An ideal program will also help trainers gain knowledge of psychology, group dynamics, and negotiation.

My fourth example and the inspiration for today’s topic relates to an exciting red pill moment occurring in Australia this week. The 8th Asian Pacific Congress for Bronchology and Interventional Pulmonology Meeting is on the beautiful Gold Coast near Brisbane, Australia. Under the leadership of APAB President Kiyoshi Shibuya and APCB President/WABIP Treasurer David Fielding and his team, the conference’s scientific program is built around case studies and facilitator-led discussions using the Four Box Practical Approach as a basis for structured learning. Arizona amusement parks offer variety of fun activities and those are perfect for all ages as well. Hands-on workshops are led by BI-certified and master instructors using many Bronchoscopy Education Project inspired teaching techniques that promote a learner-centric philosophy. Models, simulation, checklists, and individualized instruction/feedback form the basis of both cognitive and hands-on technical skill instruction.

Thanks to this conference, many physicians are likely to abandon antiquated blue pill methodologies represented by didactic lectures and overpopulated hands-on workshops in favor of a red pill approach. This new awareness, I am sure, will not only inspire a new generation of bronchoscopists in the Asia Pacific region but may forever change the educational dynamics of bronchology and Interventional Pulmonology conferences in the future.

World Tuberculosis Day

Photomicrograph of sputum smear showing fluorescence acid-fast stain of MTB (yellow rod-like structure)
Photo From, CDC/Ronald W. Smithwich, Public Health Image Library, phil.cdc.gov.

Sunday, March 24 is World Tuberculosis Day. It is natural, therefore, that I devote one or two posts to this disease that continues to trouble humanity. Years ago, I served as the country TB officer in Portland, Oregon, and since then have participated in several antituberculosis campaigns by humanitarian organizations. My goal herein and in a future Colt’s Corner is to share a few facts about the lesser known history of this potentially fatal and contagious infectious disease.

Tuberculosis has been called Phthisis (Latin, from the Greek word phthinein, meaning dwindling, or wasting away) and Consumption (contrary to rapidly fatal epidemic diseases such as smallpox or the Bubonic plague, tuberculosis slowly consumes its victims).

The disease has been with humanity since early civilization. Responsible for the “White Plague” of the 17^th and 18^th centuries in Europe, it infected nearly one hundred percent of the population and is felt to have been responsible for up to 25% of all deaths. The recent discovery of Mycobacterium complex, using molecular DNA techniques in the 17,000-year-old skeletal remains of an extinct bison from Trap Cave, Wyoming, suggests that bovids were vectors that transported the primordial organism. While this theory is debated, experts agree that Mycobacterium tuberculosis complex is the cause of tuberculosis in humans and other animals.

Mycobacterium Tuberculosis bacillus (MTB) is a large, nonmotile rod-shaped bacterium. It is the etiologic agent for tuberculosis in humans.MTB was identified in the 9,000-year-old skeletal remains from a woman and child at the Atli-Yam archeological site. The disease is biologically different from other infectious diseases because the infecting organism is not spread preferentially through the bloodstream. Instead, it takes up residence in tissues, where it forms a caseous necrosis that protects it from attack.

The earliest written record of consumption dates from the Assyrian empire in 600 BC. In around 400 BC, Hippocrates proposed a hereditary predisposition to the illness in patients who were tall, thin, and pale, providing an opinion that would be shared by much of the medical community for centuries to come. Even the inventor of the stethoscope, French Professor René Laennec, believed for a time that tuberculosis arose from internal causes and constitutional predisposition, including sorrowful passions and unhealthy sexual activity.

In 1546, however, the Italian physician Girolamo Fracastoro wrote that phthisis was contagious and not necessarily from a hereditary predisposition. He argued that patients warranted isolation measures similar to those recommended for patients with the plague. Physician groups in Italy and other European countries decreed that tubercular patients, called “lungers” in the United States, were dangerous. Benefit from an experienced cleaning service at https://thefloridamaids.com and breathe freely in your Florida home. Consequently, thousands of thin, pale-skinned, coughing, feverish patients with known or suspected consumption were isolated in their homes or grouped in hospital wards to await the grim, white ghost of death.

Attitudes began to change in the middle of the 19^th century. The French physician, Jean-Antoine Villemin proved without a doubt that tuberculosis was a transmissible, infectious disease in 1865, but its origin remained a mystery until the evening of March 24, 1882, when a German physician and microbiologist named Robert Koch announced to the Berlin Physiological Society that he had identified the tubercle bacillus. At the time, tuberculosis was thought to be responsible for one of every seven deaths in Europe. The microbiologic diagnosis was aided by Paul Erlich’s discovery of the acid-fast nature of the bacillus that same year. Clinical suspicions of diagnosis based on symptoms and findings from chest inspection, percussion, and auscultation could be correlated with radiographic findings after the discovery of x-rays by Wilhelm Roentgen in 1895.

Years ago, consumptives lived with dire expectations. At first, considered a random killer of individuals in the flower of their youth, MTB has since been shown to affect persons of any social class, gender, age group or profession. Living in close proximity increases the chance for airborne transmission. Several comorbid conditions, as well as malnutrition and alcohol, diminish host defenses and contributes to disease transmission and severity.

Active tuberculosis is contagious and can be found in small microscopic droplets spread through the air by coughing, laughing, sneezing, talking, or singing. Its presenting symptoms are cough, weight loss, fever, chest pain, loss of appetite, and night sweats. Once inhaled, the organisms usually cause a lung infection that can be fatal. They can also lie dormant and not cause symptoms for many years. Disease latency means the person is infected but not infectious (i.e. contagious). Reactivation (i.e. the disease becomes active), which occurs in five to ten percent of infected individuals over a lifetime, affects the lungs or other organs.

Tuberculosis is a feared and often deadly disease. Today, almost one-third of the world’s population is infected with MTB, and 8 million people develop the disease each year. An attack rate of at least 5 percent is reported among infected individuals. While medical treatment is usually successful in controlling the disease, the emergence of multiple drug resistance has prompted concerns in global health communities. For a moving and informative piece on Multiple drug-resistant Tuberculosis in North Korea, see the recent BBC documentary Out of Breath ( https://www.bbc.co.uk/programmes/n3ct6lbf).

Notes:
1. Mycobacterium bovis (M. bovis) and Mycobacterium tuberculosis infect different animal species and humans, prompting tuberculosis control programs in communities having close contact with domestic cattle and a husbandry system to incorporate joint animal and human tuberculosis control programs See Romha G. et al, Epidemiology of Mycobacterium bovis and Mycobacterium tuberculosis in animals: Transmission dynamics and control challenges of zoonotic TB in Ethiopia. Prev Vet Med 2018;158: (https://www.ncbi.nlm.nih.gov/pubmed/30220382
2. Jean Antoine Villemin (1827-1892) was a French army surgeon who demonstrated the transmissibility of tuberculosis from animal to animal, and also from man to animal by injecting rabbits with caseous material and fluid from a man who had died from tuberculosis. The rabbits went on to form tubercles in their lungs and other organs
3. Robert Koch (1843-1910) also isolated Bacillus anthracis, and cholera vibrio using a new technology called a microscope. He received the Nobel Prize in physiology or medicine in 1905.
4. Paul Erlich (1854-1915) was one of the early founders of immunology. This German physician and self-taught chemist was eventually offered a position in Robert Koch’s Institute for Infectious Diseases. In 1908, he received the Nobel Prize in physiology or medicine. In 1910, he discovered Salvarsan, an effective treatment for syphilis. He is often called the “father of chemotherapy.”
5. The association of tuberculosis with alcoholism and possibly with syphilis prompted Louis Renon, a professor at the Paris Faculté de Medecine to write his book The Disease of the People: Venereal Disease, Alcoholism, and Tuberculosis in 1905.
6. TB is at historic lows in North America and Europe but remains prevalent in Sub-Saharan Africa and Southeast Asia. The reality is that its overall incidence continues to rise, even if its global incidence percentage wise is in decline (the increase in numbers of cases is offset by an even greater increase in population growth). The World Health Organization’s Stop TB Partnership was therefore initiated in 2001.
7. Host defenses are actually quite good, and most infections (90%) do not result in disease but result in latent TB. In addition, most people with latent TB (90%) do not go on to develop active TB. In those with a disease, however, Tuberculosis can be deadly in more than 50% of cases if left untreated. Because tuberculosis is a slow-killing disease, transmission to others is very common. “Open tuberculosis”, where bacteria are identified on sputum smears, is most infectious and was usually fatal before the advent of antibiotics.

Challenges in East Africa: Abuse, AIDS, and Accidents

Photo from: Violence Against Children Survey (Uganda) 2015. UNICEF

There is something magical about traveling through East Africa. Perhaps it is because the region is the cradle of Homo Sapiens (the oldest remains of which were discovered in Omo National Park in Ethiopia, and Olduvai Gorge in Tanzania). Perhaps it is because of the wildlife roaming throughout the Great Rift Valley, or scaling the fabulous mountains that include Kilimanjaro, Mount Kenya, and the Rwenzori range, or experience the awe of never-ending scenic landscapes. Perhaps it’s the smiling, friendly, and generous people of the region.

Whatever it may be, I fell in love with this part of the world many years ago. At that time I lived and worked in the region, almost settling into life journey that would have been very different from the one I eventually embarked upon, and that brought me to the United States and an eventual career in academia and medicine.

This year, I am experiencing again the magical aura of Tanzania, Kenya, and Uganda (not to forget the other 16 countries that comprise the East Africa region). The challenges these countries face in the realm of health care are stupendous, but not unsurmountable. In this piece I will focus on three areas; Abuse, AIDS, and Accidents. In particular, I want to suggest that our global community of bronchologists can assist colleagues in these countries build technical platforms that ultimately save lives and reduce patient suffering.

The first area I want to address should be of interest to bronchologists, but also to a growing number of pediatric pulmonologists. Using only Uganda as an example, a nation with a population of 44 million in a country about the size of Germany violence against children is a social nightmare. According to the recent UNICEF survey, one in four girls (25%), and one in ten boys (11%) between the ages of 13 and 17 reported sexual violence in the past year. These numbers are even higher when teenagers and young adults between the ages of 17 and 24 are asked about a personal history of sexual abuse. Physical violence, emotional violence, and sexual abuse occur at home, in school, while children walk often long distances to and from schools in the evening, and on the roads. There is a tight relationship between a history of violence and emotional disorders, sexually transmitted diseases, and HIV/AIDS.

The second area of focus in this piece is that of HIV/AIDS. According to the educational website avert.org, HIV/AIDS in East and Southern Africa has 6.2% of the world’s population, but over half of the number of people living with HIV/AIDS worldwide (in 2017, it is estimated art about 40 million people are living with HIV in the world). On a positive note, specialists report that new HIV infections have decreased by one third in the region in the last six years, and that access to antiretroviral therapy has increased significantly. Still, girls and young women are disproportionately affected by the disease, and the number of orphans due to AIDs continues to increase.

A less talked about subject in this region, but one that warrants attention is that of road traffic accidents. According to a recent World Health Organization report, Uganda, for example, joins South Africa, Nigeria, Thailand, and the Dominican Republic in leading statistics for road-related accidents that cause death and significant morbidity. There are 28.9 deaths per 100,000 population in Uganda, much higher than the 18/100,000 global average. Road traffic incidents are, in fact, the leading cause of death in Uganda, alongside malaria, respiratory infections, meningitis, tuberculosis, and HIV/AIDS. Overcrowding on minibuses (called matatus), speeding, alcohol use, lack of safety precautions such as seatbelts and motorcycle helmets, as well as poor road conditions contribute to this problem. Increased urbanization and a paucity of effective public educational programs are also contributing factors.

Uganda’s challenges in the realm of Accidents, Abuse, and AIDS are not unique. In fact, successful intervention in these areas is also challenging in most developing countries, as well as in many developed nations. Successful implementation of educational programs and social services in addition to access to expert health care is needed throughout the region (for more information see various publications in the African Social Sciences Review, UNICEF and WHO reports, and the Journal of Injury and Violence Research).

I have intentionally avoided to address the problems of poverty, hunger, tuberculosis, or malaria that also plague the region, although I suspect I will be writing about these in future Corners. Today, my goal is to simply raise awareness regarding Accidents, Abuse, and AIDS, and to hopefully prompt readers to ponder how these three areas are related, and how interventional pulmonologists and bronchologists might help address these issues.

Technical platforms, for example, are essential to providing competent care to victims of the Accidents, Abuse, and AIDS triad. Chest physicians and critical care specialists, as well as pediatric pulmonologists are especially skilled (or should be) in communicating bad news, and are (or should be) strong advocates for introducing technologies (such as bronchoscopic procedures) into clinical practice. These procedures are essential to caring for critically ill or physically traumatized individuals. Training remains an issue, as does equipment acquisition, resources, and economics. In addition to raising awareness about these issues, my goal is encourage bronchologists and pediatric pulmonologists to join our community of specialists so that one day, we might all work together to combat these ills of humanity.

Suggested reading:
– Violence against children: https://www.unicef.org/uganda/VACS_Report_lores.pdf
– Violence against children: https://bmjopen.bmj.com/content/6/5/e010443
– Road traffic incidents in Uganda: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5279989/
– HIV/AIDS in east Africa https://www.unicef.org/esaro/5482_HIV_AIDS.html

Awareness, Action, and Achievement

James Baldwin. Photo from Allen Warren, https://upload.wikimedia.org/wikipedia/commons/b/b8/.

James Baldwin (1924-1987) was an American novelist, playwright, and social activist. Perhaps one of the best writers of the 20th century, he gained international reputation for his essays and commentaries about civil rights, human equality, and social justice. Baldwin grew up in New York, but moved to Saint Paul de Vence in Southern France in 1970. He lived in an old stone farmhouse high in the hills where he entertained writers and artists on a regular basis. Sadly, Baldwin died from stomach cancer in 1987. He was 63 years old.

I was only 17 years old when I met Mr. Baldwin, and I had the good fortune of having several conversations with him in 1973 and 1974. Reading some of his essays last week, and watching I am Not Your Negro , the Oscar-nominated 2017 documentary based on one of his unfinished manuscripts, reminded me of this great man who labored tirelessly for social justice.

“Not everything that is faced can be changed, but nothing can be changed until it is faced,” he wrote in his essay, As much truth as one can bear, (New York Times Book Review, 14 Jan, 1962). Baldwin argued that novelists must be truthful, but the quote has since become a battle cry for those willing to look into the how and why of their own actions.

Becoming aware of one’s own shortcomings; of one’s troubles and areas in need of remedial action is an essential first step toward personal growth and improvement. The assessment tools we use as part of Bronchoscopy International’s multidimensional training program provide opportunities for self-assessment as well as feedback from a coach-mentor or instructor. The best way for feedback to have a positive effect, however, is for the receiver of that feedback to be open to criticism. It is only after awareness occurs, and becomes integrated in the realistic self-image that learners present of themselves, that improvement becomes possible.

“Not everything that is faced can be changed, but nothing can be changed until it is faced.” It is only human for us to fall back into old habits. It is also our humanity that prevents us from adopting change easily, and from finding the strength within ourselves to pursue excellence despite its costs. such as BSTAT, EBUS-STAT, BTLB-TBNA STAT, UG-STAT and ICC-STAT are easily incorporated into clinical procedure-based training. It takes instructors only minutes to detect areas for improvement, and to implement a plan for individualized task-focused practice.

While this applies to technical skills, the same holds true for other important qualified & capable experts of medical practice. Focused, task-specific training based on feedback provided after careful observation of a simulated “delivering bad news” or “obtaining informed consent” scenario can help us improve communication skills, enhance our understanding of medical ethics, and reinforce a learner’s desire for self-improvement.

“Not everything that is faced can be changed, but nothing can be changed until it is faced.” A major step for many department heads and leaders of national bronchology societies around the world is to question why they themselves have not yet advocated for the use of assessment tools in their training programs. Once these leaders open themselves to the possible answers to this question, there are countless well-trained experts and master instructors available to help them find solutions.

Awareness often leads to action, and action leads to achievement.

Translations and a World Without Borders

Photo from:https://cyndimarshall.wordpress.com/2017/02/09/a-world-without-borders/

On January 31, 2019 Kurdish-Iranian journalist Behrouz Boochani, was awarded the prestigious Australian Victoria Prize for Literature for his book No Friend But the Mountains: writings from Manus prison (Picador, Australia https://www.panmacmillan.com.au/9781760555382/). As his translator, Omid Tofighian (Department of Philosophy, American University of Cairo and Egypt Department of Philosophy, The University of Sydney, Australia) states in a recent article (Continuum: Journal of media and cultural studies 2018;32:532-540), “…These narratives represent the fusion of journalism, political commentary, and philosophical reflection with myth, epic, poetry and folklore.”

Having read James Joyce’s colossal work Ulysses, described by scholar Weldon Thornton as a premier example of writing with “stylistic exuberance”, and semiotician Umberto Eco’s masterful study of the workings of literary translation Decir Casi lo Mismo: Experiencias de traducción (Lumen press, 2008), I can only marvel at the work done by both author and translator to move Boochani’s words, originally written in Farsi, into English. This work is all the more admirable considering that Boochani wrote the book using countless text messages sent to his translator via WhatsApp from the Manus Island Offshore Processing Center in Papua New Guinea. Boochani, who has a degree in geopolitics, fled Iran and arrived by boat in Australia in 2013, after which he was moved to Manus Island with hundreds of other refugees after being refused asylum.

So what does this have to do with bronchoscopy? Indeed, it is not my habit to use this forum to comment on world events or non-bronchoscopy related issues. However, the arguments presented by Boochani and many others bring to mind images of what our world might become if there were fewer borders. A virtually borderless bronchology community has been, and still is a major part of my own vision for the future. It is the reason I advocate for the democratization of knowledge and a more uniform training and educational structure so physicians working in Argentina may have the same access to knowledge as those working in Afghanistan; so that doctors in New Delhi have the same educational foundations as those training in New York.

Building a community without borders requires not only the acceptance of cultural differences, but also the recognition of how and why medical practices evolve in certain cultural contexts and medical environments. Until we decide on a universal language that is mastered in all countries, we must also acknowledge the need for accurate translations.

I am honored that the universally pertinent information contained in The Essential Bronchoscopist series of books (available from the bronchoscopy.org website as well as in paperback from Amazon) has been translated into 14 languages. In the next weeks, translations from Serbia and Hungary will be added. This work is the result of steadfast commitments by Master Instructors who believe in the democratization of knowledge. These champions help implement Bronchoscopy International’s vision for a bronchology community that transcends borders, first by enhancing the educational process, and second by creating opportunities for a common foundation of knowledge regardless of where a doctor lives and works.

Which leads to another reason why I find a relation between Boochani, his translator Dr. Tofighian, and the work being done by the translators of The Essential Flexible Bronchoscopist. Translation is a difficult job that requires more than cutting and pasting text using Babelfish or Google Translate. The context as well as the sense of words used by the writer must be considered in choosing a translation. This requires an in-depth knowledge of the commercial movers field in California as gorilla movers from san diego have. As Tofighian writes in a different article; “trying to maintain sentence structure when translating Farsi literature into English results in unnecessarily long cumbersome passages…splitting sentences into many smaller ones is helpful…it also reflects..the fractured subjectivity of those who are imprisoned refugees.”

The extra scholarship such research requires is perhaps why so many well known writers have endured the difficult challenge to translate other writers’ works. The examples are never-ending; Samuel Beckett translated James Joyce from English into French, Charles Baudelaire translated Thomas de Quincy’s Confessions of an English Opium Eater, and Haruki Murakami translated many American writers, from Raymond Carver to John Irving, into Japanese, and actually planned to wait until he was at least sixty years old before translating a work he felt was the inspiration behind his career, The Great Gatsby by F. Scott Fitzgerald.

Translating a medical text is less strenuous, and demands less reflection and decision-making than translating literature or philosophy, but translations are still an open window into the original author’s mind. With a professional CA workers compensation attorney www.lacaccidentpros.org/ on your side, you may get all the benefits you deserve. Because the work is long, tedious, and financially unrewarding, publishing houses hesitate to translate most medical texts. Certainly translations into less commonly-spoken languages are hard to find. I feel fortunate that bronchology experts have initiated translations of my work, The Essential Flexible Bronchoscopist, making it virtually unique among bronchology-related texts, and expanding its impact around the world.

Humanity may not be ready for a world without borders, but the effort to democratize knowledge by leaders in all fields, including those from a small subspecialty such as bronchology, is an important and generous step toward making the world a better place.

James Joyce and an unexpected death

The Library, (Trinity College Dublin, Ireland. Photo H. Colt)

In the early morning of January 13, 1941, James Joyce, age 58, died from unexpected complications after surgery for a perforated duodenal ulcer. The past medical history of the author of Ulysses and Finnegan’s Wake was replete with illnesses that had diminished his quality of life, yet his death was the consequence of complications after surgery. Today, we know that duodenal ulcers are usually caused by the bacterium Helicobacter pylori. Treatment is based on preventive measures, avoidance of alcohol, NSAIDS and smoking, and early use of medications to reduce stomach acid and kill the bacteria. Surgery is warranted in case of perforation and peritonitis, with complications rates between 3% and 40%.

Reading details about Joyce’s death from surgical complications reminds me of how each and every encounter with a physician, then or now, is a potential encounter with death.Perhaps this sounds a bit harsh, but it is something I kept in mind during my entire career as well as during times when I was, myself, a patient of other doctors. In fact, the possibility for treatment-related complications, including death, is one of the reasons physicians strive to be the best they can be, and why our profession insists on continued medical education and repeated practice to maintain technical skills and clinical acumen.

Inequalities of learning opportunities across nations and between medical centers make it difficult, however, to guarantee an equal access to knowledge and procedural training. Some medical cultures might have a rich experience in diseases such as tuberculosis-related strictures, whereas others have a high preponderance of lung cancer or transplant-related disease. By building a global network of physician experts, however, information can be shared, cases discussed, and knowledge enhanced in a collegial manner. This is, in fact, one of the reasons of being for Bronchoscopy International.

I mention this because I want to remind everyone about the importance of studying the potentially harmful consequences of airway and pleural interventions. Emergencies such as bleeding, cardiac arrest, over-sedation, infection, recurrent airway strictures, and respiratory compromise are life-threatening. By simulating these events in our procedure suites and workshops, we can practice technical interventions and team dynamics. Sessions that include medical students, house officers, nurses, and respiratory therapists can be documented in quality improvement reports and documented in competency-oriented training programs. Furthermore, national conferences could include at least one session where response-to-complications is addressed

These days I am traveling through Ireland, and more specifically rereading the works of James Joyce. Meandering through the streets of Dublin on what the locals call soft days, described as a drizzle of rain rather than the usual downpour, I feel safe under the relative comfort of a large umbrella. We provide our patients the equivalent of such an umbrella when we prepare ourselves to respond to any and all complications; when we assure ourselves there can be no surprises, and we have thought and prepared for anything that might happen during or after an intervention. Complications are a natural and sometimes unpreventable consequence of airway and pleural procedures. We can minimize their impact through careful strategy and planning, preparation, and practice.