Occupational and Environmental Health
Black lung disease in the 21st century
Drew Harris
Inhalation and deposition of coal dust particles cause a range of lung injury from coal workers’ pneumoconiosis (CWP) to dust-related diffuse fibrosis to COPD. Despite workplace standards and improved environmental controls to limit dust exposure within coal mines, incidence of “black lung disease” in the United States has increased since the turn of the century (Antao VC, et al. Occup Environ Med. 2005;62[10]:670). Coal miners working in the Appalachian Mountains have been particularly vulnerable to developing rapidly progressive and severe pneumoconiosis. In 2018, three black lung clinics in central Appalachia uncovered the largest cluster of progressive massive fibrosis (PMF) ever reported (Blackley DJ, et al. JAMA. 2018;319[5]:500). An investigation by National Public Radio (NPR) and the Public Broadcasting Service (PBS) program Frontline identified more than 2,000 Appalachian coal miners suffering with PMF from 2011 to 2016, while only 99 cases of PMF were identified by the current federal monitoring program during the same period (https://goo.gl/ZJXp1W). Only about one-third of coal miners may participate in screening for black lung disease, and lack of participation could result from barriers such as fear of retaliation from employers (Siddons A. CQ-Roll Call, Inc. March 1, 2019; https://goo.gl/5mfVFvl). Ongoing research is studying factors leading to the resurgence in CWP. Increasing silica content in coal dust is a likely culprit that has escaped mine safety regulations. Given the rising incidence and the increasing morbidity and mortality of black lung disease, there is a need to educate and engage pulmonologists and others to improve surveillance and early recognition of the spectrum of coal-dust-related lung diseases to decrease morbidity and mortality among this vulnerable occupational group.
Amy Ahasic
Drew Harris, MD
Amy Ahasic, MD, MPH, FCCP
Steering Committee Members
Palliative and End-of-Life Care
Importance of language and word choice when discussing cardiopulmonary resuscitation (CPR)
Words matter. Whether spoken or written, the words we choose when communicating with each other are fundamentally important, both by intention of the originator and the understanding of the audience, whether or not the meaning is imparted faithfully.
Benjamin Moses
In medicine, we identify patients with their illness, “the septic patient,” or category, “the terminal patient” or “the DNR patient” (Altillio, et al. AAHPM Quarterly. 2013;14-18). We escape responsibility for adequate communication by adopting a language filled with anatomic and pharmaceutical references where we blame patients for their disease process, eg, “the patient failed extubation” or “the patient is noncompliant.” We tend to resort to medical jargon or terror language in order to achieve the desired outcome. Never is this more evident than when discussing code status. In the ICU, when one hopes to “get the DNR,” it is not uncommon to hear the phrase, “If your heart stops, we would have to break all of your ribs, and that would be torture.” While the data are clear on harmful effects of CPR, and its general lack of success for people with a serious illness (Dunham, et al. Eur Radiol. 2018;28[10]:4122), it is unnecessary to use threatening language in our communication.
Compassionate care begins and ends with effective communication. The Palliative and End of Life Care NetWork supports making better word choices. We encourage framing end-of-life care around what will continue to work to help support the patient and not doing things that we know do not work. “We will do everything to help manage his/her breathing and heart rate, and when his/her heart stops, we will allow him/her to die naturally” (Curtis, et al. Intensive Care Med. 2014;40:606).
Benjamin Moses, MD
Anne Kelemen, LICSW
Steering Committee Members