Tag Archives: pulmonary

Burton Rose MD (1942-2020)

(Screenshot of Burton Rose M.D)

On April 24, 2020, Medicine lost one of its great innovators and educators. Burton Rose passed away at the age of 77, a victim of SARS-CoV-21. A graduate of Princeton University, he went to Medical school at New York University and served on the faculty at Brigham and Women’s Hospital in Boston, Beth Israel Deaconess Medical Center, and Harvard.In 1992, Dr. Rose created UpToDate®, a computer-based online medical resource now including 25 specialties, and used by more than 1.9 million physicians from 197 countries.

I first met Dr. Rose in the early 1990s, shortly after he decided to expand his novel UpToDate® computer-based educational programs to include topics on Pulmonary Medicine. At first, the program was available on 3.5-inch floppy disks. If I recall, back in 1995, having a PC with a 1-gigabyte hard drive was cause for celebration, and a Mac LC-500 was an educator’s dream, with its all-in-one desktop design, 14-inch CRT display, and built-in CD-ROM. 

Dr. Rose’s colleague in Boston, Professor Steven Weinberger (former Executive Vice-President and CEO of the American College of Physicians), served as Editor-In-Chief of UpToDate®’s new Pulmonology and Critical Care Medicine (a position currently held by Peter Barnes, Talmadge King, and Polly Parsons). I had the honor of authoring several chapters and serving as an editor with my friend, Praveen Mathur, who sadly passed away a few years ago. We were delighted when the leadership team approved our request to start an Interventional Pulmonology Section, and it is with pleasure and pride that I continue to serve UpToDate® as an author and section editor, sharing the IP editorial role now with Professor David Feller-Kopman.

Burton Rose was amazing. In addition to being a brilliant physician, medical writer, and dedicated teacher, he had the entrepreneurial instinct to recognize that physicians thrive on evidence-based medicine. By creating UpToDate®, he designed an easy-to-access program that allowed health care professionals to query the text with questions as well as by disease. Beginning with a proof-of-concept using his own specialty, Nephrology, he moved on to Primary care Medicine and all subspecialties. UpToDate® quickly became a leading resource for point-of-care medical practitioners and students everywhere.

According to a short video on the UpToDate® website, the program is accessed more than 1 million times and contributes to 300,000 medical decisions each day. This makes it an essential element of health care practice3. Subscriptions are available to individuals as well as institutions, and UpToDate® generously provided affordable subscriptions to trainees and hospitals in countries with low financial resources. 

The greatest key to the program’s success, of course, is the accuracy and timeliness of its content. Material is constantly reviewed and updated by a team of professional editors, deputy-editors, writers, contributors, and peer-reviewers4. Quality is of the utmost importance. This has not changed since UpToDate® was bought by the global provider of professional information and software solutions, Wolters Kluwer in 2008.

Doctor Burton Rose was a true believer in the democratization of knowledge. He did all he could to provide information to medical practitioners around the world, and he assembled a team of dedicated individuals who made his mission their own. He will not be forgotten. 

References

  1. https://www.legacy.com/obituaries/BostonGlobe/obituary.aspx?page=lifestory&pid=196075793
  2. https://www.statnews.com/2020/04/25/remembering-uptodate-creator-burton-bud-rose/
  3. https://www.uptodate.com/home/uptodate-story
  4. https://www.uptodate.com/home

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English is the new latin

Photo H.Colt

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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Death in Venice

April in Venice (Photo, H. Colt)

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.

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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 17th and 18th 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. 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 19th 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.

 

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. 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. 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).