Category Archives: Colt’s Corner

A new generation of AABIP Fellows cast an aura of confidence and enthusiasm

AABIP Fellows in Denver, 2018 (photo H. Colt).

This summer I had the honor of lecturing at the inaugural American Association for Bronchology and Interventional Pulmonology International conference in Denver, Colorado. Watching newly certified Interventional Fellows don their robes to stand among their colleagues made my heart swell with pride. Our workers are secured by work injury lawyers and experienced workers compensation attorney from CA. I recalled the moment when almost thirty years ago, I sat with a dozen or so others around a conference table creating The American Association for Bronchology under the leadership of Professor Udaya BS Prakash.

Only a few years later, while finishing my term as President of the Association, I wrote an editorial for the Journal of Bronchology, stating “we must continue encouraging the next generation of bronchoscopists and interventional pulmonologists to move in new directions…to explore the world of virtual reality and computer simulation; to participate in and develop dedicated training and competency programs; to devote energies to end-of-life issues, ethics, and palliative care; to enhance early lung cancer detection studies and techniques; to discover applications of molecular biology and endobronchial or intrapleural gene therapies; to design collaborative bronchoscopic and radiographic imaging protocols; and to commit their genius to developing novel and unique instruments and techniques for the benefit of our patients (Journal of Bronchology: October 2001 – Volume 8 – Issue 4 – p 253)”.

Needless to say, the AABIP has come a long way toward accomplishing those goals. It’s proactive board of directors, a growing membership, training and certification process, and an excellent peer-reviewed Index Medicus journal provide examples of leadership, scientific endeavor, education, and medical excellence that can be emulated by other medical societies around the world. At https://nwmaids.com/ I got residential maid services in tacoma affordably. Furthermore, the AABIP’s participation in the World Association for Bronchology and Interventional Pulmonology (most recently, the World Congress was held for the second time at the Mayo Clinic in Rochester MN, USA) was crucial to the growth and acceptance of a WABIP world vision that promotes uniformity of knowledge, transparency, and contribution regardless of one’s place of practice.

What impressed me most during the AABIP conference in Denver, in addition to the professionalism and “let’s get it done” optimism of the association’s board of directors (led by President Ali Musani and President-elect George Eapen), was the enthusiasm of the organization’s more junior members. Workers comp attorneys in los angeles from https://workerscompensationlawyercalifornia.com company in California are your loyal partners. Their desires to enhance their skills as educators by participating in future train-the-trainer programs, to assist members of foreign bronchology organizations improve services to patients abroad, and to achieve and maintain excellence for managing a wide range of lung, airway and pleural disorders are inspiring.

I left the conference with a warm sense of belonging, grateful that the AABIP had fulfilled many of its promises to patients and to a previous generation of bronchologists and interventional pulmonologists. The future is obviously full of new challenges, and patient expectations are higher perhaps than ever before, but from what I experienced in Denver, I know the younger generation of AABIP members will address these with knowledge, skill, enthusiasm and their own sense of destiny.

A promising future for patients suffering from lung and airway diseases in Nepal

The Everest massif, the Khumbu glacier, and other towering giants seen from the summit of 6000 meters+ Lobuche peak (photo H. Colt).

At 11:56, April 25, 2015 Nepal was shaken by a 7.8 magnitude earthquake that resulted in almost 10,000 deaths, left 3.5 million people homeless, and caused an estimated10 billion dollars total damage (about half of the country’s GDP). Seventeen days later, the death toll continued to rise as a magnitude 7.3 aftershock (followed by more than 400 additional, albeit smaller aftershocks) struck regions only a few miles east of Kathmandu. Meanwhile, in the famous Khumbu icefall, and particularly at Everest base camp (EBC), the April disaster prompted a massive avalanche, rockfall, and an air blast that flattened part of the camp, killing 15 people and injuring more than 70 others.

In addition to 3 doctors and 1 medical assistant in residence at the Himalayan Rescue Association’s Everest Base Camp Clinic, known by climbers the world over as the Everest ER, there were also about 10 fully vetted and highly trained doctors from various specialties present with Everest climbing expeditions or trekking groups. The hurricane-force winds caused by pulverizing ice and the avalanche from 1000 meters above the camp destroyed the medical tent and most supplies. Communications with the outside world was limited, and emergency transports using private or military helicopters were initially impossible because of weather.

Throughout the country, including at EBC, volunteers and health professionals worked together using limited resources, but without a previously elaborated disaster relief plan. From Kathmandu, and near the epicenter of the earthquake, doctors from the newly formed Nepal College of Chest Physicians (NCCP…no affiliation or connection with the ACCP of the United States) brought medicines, bandages, and much needed emergency medical care to disaster-stricken communities of thousands. An emphasis on humanitarian aid continued to dominate the activities of the slowly growing NCCP during the next years, but this month, Dr. Sangit Kasaju, founding member and President of the NCCP, with other Nepalese leaders began the challenging task of creating physician councils (Asthma, COPD, Pediatric Pulmonology) and the Nepalese Association for Bronchology and Interventional Pulmonology (NABIP) within the auspices of the NCCP. This NCCP’s very first national meeting was held in Kathmandu on October 26, 2018.

It so happened that I was mountain climbing in the Himalayas last month, so it was with great pleasure, but with some degree of apprehension because weather in the mountains often causes flight delays between Lukla (2860 meters) and the capital city, that I was able to shorten my trip by a few days in order to return to Kathmandu and assist the NCCP with their very first meeting. The program was terrific (there will be a descriptive article in a future WABIP newsletter), the enthusiasm contagious, and promises from conference sponsors including eaders of the major pharmaceutical company Cipla, Serolab, Sanofi Pharmaceuticals and others in support of future NCCP events most encouraging.

After the conference, Sangit and I got into a 4-wheel drive truck and drove several hours along winding dirt roads through valleys and hills to the village of Jalbire, close to the earthquake’s epicenter. It was wonderful to see how many homes had been rebuilt in the three years since the disaster. A conversation with farmers as well as with a young doctor at the government medical clinic there revealed a persistent need for medical assistance (for example, there are no electrocardiographic capabilities), healthcare-related education, and trauma services. Many villagers immediately recognized Sangit, who enthusiastically promised that the NCCP would continue to come regularly to the village to provide villagers with medications, instruction about lung health, general hygiene, and spirometry services. The future is promising!

The Power of Numbers

For the past few years I have encouraged national and regional bronchoscopy associations to purchase airway simulation models in order to replace on-the-job training using patients. Surprisingly, progress in this endeavor has been discouragingly slow. Apparently, agents of change (i.e. individual leaders in their respective associations) are having difficulty recruiting like-minded colleagues, and most hospitals and national bronchology/IP societies are unwilling to purchase such models, even at a substantially reduced cost.

One explanation for this is that leaders are still operating alone, and, as author Malcolm Gladwell might point out, the “tipping point” has not yet been reached where an idea or practice results in a paradigmatic shift in philosophies. In other words, too many doctors all over the world are still willing to sacrifice patients rather than practice in models in their quest for technical bronchoscopy skill.

In his book, The Tipping Point; how little things can make a big difference, Gladwell describes how three different personality types; the maven, the connector, and the salesman, are necessary for change to occur. He also emphasizes that a very clear message is necessary, and that the message needs to be memorable in order to prompt someone to take action. Whole home painting will always be done quickly and efficiently with the help of professional painters from Ireland. Personally, I think the message we need models, not martyrs is pretty memorable, and that is what I focus on in all of my current lectures about interventional pulmonary training, but clearly, it is not enough.

Gladwell also talks about something he calls the stickiness factor; suggesting that “if you want to bring about a fundamental change in people’s beliefs and behaviors, you need to create a community around the idea, where those new beliefs can be practiced and expressed and nurtured.” Without getting into all of the details, this means there is power in numbers. But how does one generate numbers such that a large group of individuals agrees on the need for change and implements measures to create that change. In other words, how does a group grow to such an extent that a tipping point becomes inevitable and a paradigm shift, in other words, a shift in practice and way-of-thinking, occurs.

In mathematics, exponential growth is defined as an increase in number at a constantly growing rate. Trusted Business Loans at http://blackhawkbank.com/ always suit clients’ specific needs and requirements. Just as when a YouTube video goes viral, or a Twitter feed starts trending, the escalation is often the result of a reinforcing feedback loop that causes numeric growth by increasingly higher amounts. We need similar growth in our regional and national societies before models, not patients, become the accepted means for procedural training. Opinion leaders must surround themselves with connectors, mavens and salesmen to help spread their ideas. Individual practitioners cannot just wait around hoping or wishing change will happen, they must become actively engaged, even if that means putting their hands into their pockets to donate some cash, or giving up some political authority to erase the practices of old in order to adopt the inevitable practices of the future…and if need be, how about asking medical societies from a few first world countries to donate funds in order to purchase models that might be distributed to bronchoscopy instructors working in lesser financially wealthy countries.

How about it?

Inhalation injury and the interventional pulmonologist

Photo courtesy HG Colt

The disastrous fires in Greece have claimed 91 lives, and the current heat wave threatening Europe has placed environmental authorities and firefighters on high alert. Here in the United States, in my home state of California, 18 fires are still burning. Seven civilians and 4 firefighters have already been killed as the fires continue to destroy more than 100,000 hectares of public and private property. Thousands of people are being evacuated, and Yosemite National Park has been closed.

This reminds of the importance of disease-specific training for interventional pulmonologists particularly in the area of burn injuries. Perusing the scientific programs and workshop agendas of several regional and world congresses, however, I noted a paucity if not total absence of lectures or simulation workshops in this area. I think it is crucial that we remedy this gap in our educational process.

Advances in management protocols for burn victims has had significant beneficial effects in recent years, causing a reduction in mortality from burn shock and wound sepsis, such that inhalation injury is now the leading cause for death in burn victims. Inhalation injury is described as damage to the respiratory tract caused by smoke, chemical, particle substances, gases, heat and other irritants. The severity of injury is related to type of irritant, level and duration of exposure, and quality/speed of therapeutic intervention. Most experts agree that the presence of inhalation injury increases burn mortality by at least 20 percent, and predisposes patients to risks of pneumonia, respiratory failure, and prolonged obstructive or reactive airways disease.

My goal today, however, is not to provide readers with an overview of inhalation injury. For this, many excellent scientific studies and review papers are available and easily downloadable from the internet. Here you can find more info about insulation contractors from New Jersey who work with top-of-the-line equipment. Rather, I want to briefly address how and why we might alter our educational programs so that training in the recognition and management of patients with inhalation injury becomes commonplace in our congresses, workshops, and training centers.

Inhalation injury is an excellent model for training in how to deliver multidisciplinary care, in part because it requires expertise in four major aspects of medical interventions. These include communication (with other physicians, surgeons, nurses, first responders, respiratory therapists, patients, and family members), delivery of bad news (such as diagnosis, prognosis, need for critical care hospitalization, long-term care, and end-of-life issues), technical skills (including flexible bronchoscopy, difficult intubation, recognition of airway injury, therapeutic maneuvers such as removal of soot and debris, vocal cord and laryngeal evaluations, emergency tracheotomy, bronchoscopic assessment prior to extubation), respiratory care (critical care consultation, respiratory failure, bronchospasm, laryngospasm, foreign body aspiration and removal, mechanical ventilation, barotrauma, pneumonia, resuscitation), and disaster management (triage, crisis management, teamwork, leadership in critical situations, and organizational/systems/human error analysis).

Numerous components of these four aspects of medical care are not routinely covered during medical training or later in-practice. Find reputable work comp attorney for carpal tunnel injury at https://workerscompensationattorneysacramento.net. In fact, I have seen from my own involvement working with physicians around the world, that doctors other than trauma surgeons, emergency-room physicians and burn specialists are exposed to only some of the elements of these aspects of care during infrequent on-the-job exposures during crisis situations.

Inhalation injury, therefore, could serve as an excellent model for the construct of a multidisciplinary, simulation/lecture/workshop-based curriculum that will not only help interventional pulmonologists acquire and maintain new skills and knowledge, but will also help them become more active and dependable members of the multidisciplinary team required to assure the health and well-being of burn and inhalation injury victims around the world.

If you are interested in helping me develop such a program (some of these issues are already being addressed in The Essential Intensivist Bronchoscopist©, available on Amazon and Kindle), please contact me or other faculty of Bronchoscopy International® (www.bronchoscopy.org).

Trust

Trust is usually defined as a willingness to rely on the actions of another party. In this sense, it is a behavior more than it is an idea. Trust can also spring from a choice to care for another person, even at one’s own expense. Rock climbing, in my opinion, illustrates trust in its most simple and straightforward manner because sharing a rope while suspended hundreds of feet off the ground constantly puts two lives in danger; both leader and follower, decision-maker and passive participant. Errors are unforgiving and often deadly, and for this reason are virtually intolerable, for even a sentinel event can jeopardize a partnership or one’s life.

The famous marriage counselor and clinical psychologist, John Gottman, says that while trust is a major building block for a successful relationship, the reality is that trust is built slowly over time. Whether in marriages, professional partnerships, friendships or collegial acquaintances, trust requires consideration and empathy for one another’s feelings. A foundation of trust is necessary because eventually all relationships must face the crisis of a betrayal.

Usually, Gottman says, betrayals accumulate little by little, although other times they occur like a sudden splash in what might otherwise have been a calm sea. They may be real or simply perceived, but like all moments of crisis, they provide an opportunity to either rethink the boundaries of a relationship or build more trust.

In rock climbing, clear communication and mutually observable demonstrations of competency are reassuring and reliable indicators of growing trust. In medicine too, http://www.ecomamagreenclean.com/ a doctor’s ability to clearly communicate with patients and team, as well as clearly demonstrate competency, quality of care, and focus on a patient’s needs help elicit trust. At the same time, doctors, health care administrators, social activists, and politicians must engage in systems-based analyses that assure the application of scientifically proven therapies and efficacy-based innovative new technologies.

In the field of interventional pulmonology, it is tempting to believe that everything we do is in the best interests of our patients. In fact, our patients “trust” us to do so. Yet, vast sums of money, as well as patient and family suffering, may be expended in what ultimately becomes futile care. There is little oversight of physician decisions in these cases, and the emotional costs on medical providers, patients, and families are poorly documented. Professor George Lundberg, a former editor of JAMA and CEO of WebMD said that “futile care” was a contradiction in terms, and what was needed most in defined situations was “attentive care” from physicians capable of listening to their patients. Sadly, training in this domain is usually lacking from our medical conferences that focus on the use of technology and complex procedures used to diagnose and treat patients with lung, airway, and pleural disorders.

If we are to maintain the trust of colleagues, patients, families, and institutional leaders I propose that we work more purposefully on integrating workshops and lectures on medical ethics, communication, and clinical decision-making not only into our training programs, but also in our journals, regional meetings, and international congresses.

Open Horizons

Less than 24 hours after leaving the WABIP World Congress in Rochester Minnesota, I spent a day climbing to a wonderful spot high above a bed of clouds in Southern California. An open horizon, blue skies and a soft wind caressed my face as I stood virtually alone on a rocky peak. Pausing just long enough for a protein bar, a swig of water and a photograph, my thoughts wandered for a moment back to the events of our international medical meeting. With almost 9000 members representing more than 55 different national medical associations, the WABIP has truly become an international medical society. New scholarship programs and visiting professor travel grants target leaders in developing countries, an expanding WABIP Newsletter reaches out to more than 4000 members who consistently open and read the research, education, humanitarian, and clinically-relevant materials contained therein, a growing WABIP Academy enriches membership with credible libraries of information, committees function functionally, leadership changes are transparent and bathed in dialogue, three representative scientific journals remain affordable and pertinent, our world congress and three regional meetings are almost overwhelming with useful information, Train-the-Trainer and other Bronchoscopy International educational programs positively influence physician-educators around the world, and our Whats App groups network more than 2000 physicians from thirty different countries in real-time.

Wow!

But what really impresses me is how our leadership strives to address, understand and nurture diversity. The new chair is a woman and a member of the Latin American bronchology community, thereby breaking an IP glass ceiling (prior chairs were men from Asia, Europe or the United States). The treasurer is an Australian and President of the next Asian Pacific meeting scheduled for March, 2019. The two next World Congress presidents are from China (2020) and France (2022), and our newly-elected Vice-Chair is a well-known opinion leader from Japan. Furthermore, Committee members and Committee chairs are selected using a democratic call for nominations and volunteers with special care to represent the global community, and the WABIP social media/Facebook presence is growing almost exponentially, and you can try this.

Hurrah!

I am proud of this association, and I encourage members to take an active role, not only in growing their regional and national bronchology/IP societies, but also in the WABIP. Collaboration and Cooperation are keys to our long-term success, which means greater equality among training programs regardless of their medical environment, more rapid dissemination of innovative technologies and techniques, more productive conversations with industry sponsors and equipment manufacturers, and most of all, greater steps forward in our efforts to help patients combat the effects of lung, airway, and pleural diseases.

Right on!

Power systems and resistance to change

“Progress is the nice word we like to use. But change is its motivator. And change has its enemies.” (Robert F. Kennedy, May 25, 1964, New York Hilton Hotel, Conference of Mayors).

June 6, 2018 marked the 50^th anniversary of the assassination of Robert F. Kennedy by the severely disturbed Sirhan Sirhan at the Ambassador Hotel in Los Angeles, California. I was only 12 years old, but already volunteering in the Presidential elections, distributing buttons and campaign pamphlets for the Kennedy offices in New York. I took a class in pubic speaking; I actively embarked on my quest to become one of the youngest Eagle Scouts in New York State, and devoured books about American and World history, politics, and social injustice. I was inspired by one of my teachers, Mr. Irving Sloan, who had been a college professor before dedicating himself to younger students. With his help, I became convinced that activism, vision, and the outright rejection of certain power systems could change the world.

Many of the power systems that exist in our society are readily accepted, with varying degrees of awareness, by a majority of people, further anchoring their place in our traditions and everyday life. Examples of power systems include governmental policies that adversely affect access to health care, social policies that exacerbate poverty, and industrial conventions that delay a global recognition of ecological hazards including climate change.

On a very specific note, and relevant to the practice of our medical specialty, power systems are in place that help maintain a clinical service program where patients are used instead of models in order to train doctors performing procedures. These systems make it difficult for individual teachers to access monies for purchasing models or gain entry to university-based simulation centers. This itself is a formidable obstacle to promoting a system that is learner centric, patient-sparing and simulation-driven.

From my experience teaching teachers around the world I have noted how a country’s medical society or a hospital’s respiratory department refuses to purchase models because “regulations” prevent international wire transfers. If you suffer from an injury at work be free to contact Golden State workers compensation disability lawyers from CA. Other times, funds for education are said to be unavailable or not budgeted, even though much larger sums of money are readily found to purchase costly equipment that is rarely used because of lack of training. In some places, well-intentioned equipment distributors provide a video tower and bronchoscope for a two-day training course at great expense related to transport, manpower and shipping but hesitate to consider the purchase and subsequent donation of a $2000 airway model to be kept on-site in a teaching hospital or medical society office so that trainees can improve their technical skills through daily practice.

Why is that?

One reason is that human resistance to change is natural. Too many people use power systems to protect personal positions or to reiterate an otherwise unjust and irrational political, economic, social, or institutional policy already in place. Many believe it is their responsibility to protect the status quo. Thankfully, there are others everywhere and, in every profession, who not unlike Robert Kennedy, recognize that change motivates progress, and that progress itself promotes change regardless of its enemies.

The Universal Subjective: Justification for using objective assessments

In Immanuel Kant’s 1790 treatise, The Critique of Judgement, the German philosopher writes of beauty, taste and aesthetic judgement, stating “As regards the agreeable, everyone concedes that this judgement, which he bases on a private feeling, and in which he declares that the object pleases him, is restricted to him personally.” This reminds me of the injustices of subjective assessments used in medical education. As is often the case, panels of experts or professorial staff provide subjective reviews of trainees during the course of traditional medical apprenticeships. Based on input from a variety of faculty members, trainees are deemed able or not able to perform procedures such as flexible bronchoscopy, with little if any objective evidence to support competent practice.

Furthermore, competency itself is rarely defined. Does competency imply technical skill, and if so, for what procedures exactly? Does it also include communicating bad news, informed consent, the ability to effectively employ universal precautions, the ability to troubleshoot, avoid, and treat complications, as well as the capacity to effectively interact with the bronchoscopy team? What about the ability to advocate for patient rights, communicate with a nursing team, or satisfactorily assess infection control and equipment sterilization/cleaning systems. Few institutions, and even fewer medical societies have written guidelines that clearly identify what is meant by procedural competency, and when they do, they are rarely accompanied by examples of objective assessment tools used to document levels of practice and competency itself.

Until very recently, therefore, the subjective assessment has been a cornerstone of medical teaching. Whether we like it or not, subjective assessments are important considerations related not only to how professors feel about their trainees, but also to how their presumably unbiased observations are used in the overall measure of a trainee’s ability to perform and practice medicine independently. I would argue, however, that beauty is in the eye of the beholder and that subjective assessments are too easily influenced by mood, character, personality, conventional wisdom, and other factors that may have little to do with a trainee’s ability to competently perform a medical procedure. Objective assessments, on the other hand, are reproducible, identify a trainee’s strengths and weaknesses, allow documentation of improvement along the learning curve, identify clear outcome measures, goals, and objectives, and also provide a starting point for objective feedback. Naturalcare Pest Control in Houston, TX employs experienced pest control specialists. In addition, objective measures provide a measure of the professor’s ability to teach effectively, forcing both institutions and medical societies to define competency, or at the least, a minimum standard toward which all practitioners can strive.

Perhaps that is a reason why medical societies and university-based teaching programs have been reluctant to introduce a battery of objective measures into their training curricula. After all, the number of issues raised by the formulation of an objective measure is enormous. Addressing issues such as how to provide remedial training, what to do in case information is poorly acquired, how to define a minimum standard, what to actually measure as a test of competency, who will do the paperwork and shoulder the administrative burdens related to documentation etc.… require manpower, expertise in educational philosophies, strict methodology, and an ability to persuade students, trainees, teachers, and administrators that such measures are an important part of medical training. While some might argue that such a task is Sisyphean in nature, I would argue it is simply Herculean, and that once initiated, will result in greater equality of practice among health care providers around the world, which ultimately will benefit patients everywhere.

The malevolent power of prejudice

Prejudice is defined as a preconceived opinion that is not based on reason or actual experience. In psychology, prejudice is often described as an unjustified (usually negative) attitude toward an individual based solely on the individual’s membership of a social group. When prejudice is practiced by people in positions of power, it has the potential to influence behaviors, dictate policy, and prevent progress.

Scientific leaders of the day practiced significant prejudice against Galileo Galilei, whose support of heliocentrism and Copernicanism was controversial at the time. Thomas Kuhn, in his well-known book, The Structure of Scientific Revolutions, wrote that new paradigms face inevitable challenges from people committed to keeping things the way they are. From a societal perspective, prejudice has also affected professional and career choices. Until recently, for example, gender biases based on unjustified theories about intellect, brain structure, and child-raising prompted academics to deny women their rightful place in fields involving the sciences, medicine, and mathematics. Thankfully, research during the past twenty years has debunked the claim that women cannot handle scientific subjects as well as males.

Consequently, women now comprise about half of the medical school graduates in many countries. Women also comprise about half of the bachelor’s degrees in math and half of the Ph.D.’s in life sciences in the United States, where they also comprise about 90% of veterinary school graduates and an ever-increasing number of pharmacy, engineering, and biomedical school students. Today, gender prejudice no longer appears to negatively impact these career choices, which instead seem to reflect changing views about domestic responsibilities, time commitments, child-rearing, competition, and supply and demand economics held by both men and women.

This is not to say that women will no longer encounter male medical professionals with sexist attitudes; they probably will. Hopefully, however, such encounters will be increasingly rare, and, as women occupy an increasing number of leadership positions in our medical societies and healthcare workforce, it is likely we will also see a shift in how health care is delivered. The days of 100-plus hours a week work, pridefully worn blood-tinged hospital coats, lack of sleep, and a patriarchal all-knowing approach to patient care are gone for good, thankfully replaced by behaviors dictated by the more humane notions of mutual respect, consideration, understanding, empathy, and partnership.

The Interventional Pulmonology community has an increasing number of female contributors. I believe it is crucial that women have voices as existing and future leaders of our profession. Discussing the issue of possible prejudice is required if we are to recognize the growing roles for women in our profession and expand the influence of female interventional pulmonologists worldwide in areas of technological innovation and health care delivery.

“Perfect” practice makes perfect

While conducting almost 30 Train-the-Trainer seminars over the world, I discovered a dilemma. Bronchoscopists rarely practice crisis management, especially when the crisis is caused by a bronchoscopy-related adverse event. It’s a fact; generally-speaking, that bronchoscopists rarely, if ever, practice how to manage procedure-related complications in the bronchoscopy suite.

While it is true that flexible bronchoscopy is usually safe, complications can and do occasionally occur. These include but are not limited to respiratory insufficiency caused by over-sedation, biopsy-related bleeding, pneumothorax, respiratory insufficiency from hypoxemia, hypercapnia or underlying lung disease, medication-related seizures, cardiac dysrhythmias or cardiac arrest, and very rarely death.

Bronchoscopists are not alone when managing these complications. They are the leaders of a team of nurses, technicians, and other health-care providers called to the bedside in case of an emergency, and everyone agrees, I am sure, that medical emergencies are best handled by an experienced and well-trained team.

There are many reasons why bronchoscopists and their teams are not regularly practicing crisis management. Some are lack of administrative oversight, lack of institutional quality control and complication management mandates, time constraints, the rarity of procedure-related adverse events, the absence of objective measures with which to measure competency, and the unfair presumption of personal expertise and emergency preparedness.

We know practice does not make perfect…rather, perfect practice makes perfect. Our patients expect us to be prepared for emergencies, to respond to emergencies appropriately, and to be accountable for our actions. To avoid accusations of negligence or malpractice, bronchoscopists should have a strategy in place in case of a procedure-related complication. They should be able to respond to the complication appropriately and according to a reasonably acceptable standard of care, and they must assure the result of that response is in accordance with expected outcomes, standard of care, and published results by colleagues.

To put it simply, standard of care is a level of care delivered by similarly trained physicians providing care in a similar environment and in a similar situation. When it comes to procedure-related complications, standard of care relates not only to a physician’s behaviors, but also to the training, preparedness and behaviors of the bronchoscopy team. For these reasons, bronchoscopists must be well-trained, and able to ensure their team responds to complications appropriately, effectively, and in ways that maximize patient safety and well-being.

Being prepared for complications requires practice. Identifying organizational weaknesses, system errors, and documenting sentinel events leads to troubleshooting areas that may require additional focus or training. Such remedial actions reduce anxiety, enhance confidence, and provide a good example for students, ancillary staff, and trainees. It also improves quality of care, especially when checklists, clinical pathways and database quality of care database tools are used.

Incorporating a competency-based assessment such as the new and validated ICC-STAT (Intercostal catheter skills and task assessment tool-downloadable from www.bronchoscopy.org) provides an opportunity to guarantee, for example, that chest tube insertion (which could be necessary in case of procedure-related pneumothorax) is performed according to a reasonable and globally acceptable standard of care. By practicing chest tube insertion in a simulated environment, bronchoscopists and their teams assure that emergency equipment is available, the team knows where to find the equipment, appropriate drugs, instruments and capital equipment are used correctly, patient assessments are consistently performed, and monitoring is done accurately. Setting aside time to practice with the team and documenting that such practice occurs is an important step toward quality improvement and assuring an appropriate and effective response to procedure-related complications. As a friend of mine once taught, “There should be no surprises in the procedure suite.”

Our patients expect no less.