The Interview: July - September 2019

THE

INSIDE THE ISSUE 02

Turks and Caicos Islands Hospital donates AED to TCIG Sports Department

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InterHealth Canada sponsor and host cancer-awareness/VTE walks on main islands

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TCI Hospital pursues Go Clear Award for smoke-free operating theatres

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Country's first Antimicrobial Workshop hosted across medical centres

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Allied Service Professionals honoured during TCI Clinic Exploration Program Banquet

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NEWS

INTERHEALTH CANADAÂ DONATES AED TO TCI GOVERNMENT DEPARTMENT OF SPORTS AEDs can increase the survival rate from sudden cardiac arrest.

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Inside the AED handover.

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INTERHEALTH CANADA SPONSOR AND HOST CANCER WALKS

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BREAST CANCER AWARENESS WALKS

THE INTERVIEW 5

NEWS

TCI Hospital seeks international recognition for smoke-free operating theatres InterHealth Canada – Turks and Caicos Islands Hospital is currently seeking international recognition for its ‘smoke-free’ operating theatres from the Association of Perioperative Nurses (AORN) and Medtronic with the Go Clear Award. The award is part of an international comprehensive campaign to help surgical team members and hospital administrators reduce and eliminate surgical smoke in the operating rooms to protect patient and employee safety.

Surgical smoke is the by-product of using energy-generating devices, which may include but is not limited to electrosurgery units, lasers, ultrasonic devices and powered surgical instruments such as orthopedic saws.

THE INTERVIEW 6

high flow vacuum sources

According to the Association of

The surgical smoke evacuation

Perioperative Nurses, the need to

systems, which are high-flow

evacuate and appropriately filter

vacuum sources used to capture

surgical smoke is being recognized

smoke aerosols and gases

around the world as countries

generated at the surgical site, were

move to provide a safer

implemented since the inception of

environment for both

TCI Hospital. However,

perioperative personnel and

the international recognition

patients.

program can provide the tools required to advance the current

Using an electrosurgery device on

initiative at the health care facility

one gram of tissue is akin to

beyond the current framework to

inhaling the smoke from 6

further promote a safe surgical

unfiltered cigarettes in 15 minutes.

environment. More than 300

While the long-term effects for

surgical teams worldwide

health care workers exposed to

have adopted the program.

surgical smoke is still unknown, there is an extended list of shortterm effects. For example, perioperative nurses experience twice the incidence of many respiratory problems as compared to the general population.

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THE INTERVIEW

IHC Medical Technologists attend the 71st American Association for Clinical Chemistry (AACC) Annual Scientific Meeting 2019

it's about the science A duo of medical technologists from InterHealth Canada – Turks and Caicos Islands Hospital attended the 71st American Association for Clinical Chemistry (AACC) Annual Scientific Meeting and Clinical Lab Expo held at the Anaheim Convention Center from August 4 -8, 2019.

The AACC Annual Scientific Meeting and Clinical Lab Expo is the world’s largest meeting devoted to clinical chemistry and clinical laboratory science in general.

Medical Technologists, Andrico Garland and Vernon Silvera were able to garner a wealth of knowledge about the latest industry practices, vital research and innovative technologies in the field.

The conference offers nearly 300 educational opportunities in the form of plenary sessions, symposium, short courses, and roundtable sessions, which allows attendees to tailor their educational experience to their needs.

These meetings covered the basics of performing laboratory tests before during and after the process across the five disciplines that fall under medical technology.

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THE INTERVIEW

71st AACC Annual Scientific Meeting

Sessions included topics such as Trials and Triumphs of HIV Testing; Fatal Hemostatic Disorders; Predicting and Diagnosing Gestational Diabetes; Interferences with Thyroid Function Tests; Patient-Centered Laboratory Medicine; Worldwide Challenges in Point of Care Testing (POCT) – A focus on molecular POCT; Tackling Infectious Disease Testing and interpretation: Considering the Perspective of the Core Clinical Laboratory and Point of Care Testing.

The event provides attendees with the opportunity to learn about cutting edge technology during the AACC Clinical Lab Expo. This component of the conference is a dedicated Innovation Zone with more than 800 exhibitors that focuses on forward thinking innovators in laboratory medicine.

It also provides a platform to connect with global leaders in clinical chemistry, molecular diagnostics, mass spectrometry, translational medicine, lab management, and other areas of laboratory medicine.

Commenting on the experience, Andrico Garland said: "It was a truly a valuable learning experience. I not only benefited from a stunning lineup of expert speakers and scientific sessions but also I was able to observe a vast array of emerging technologies and high quality immunoassays by Global suppliers contributing to diagnostic efficiency. I am most grateful for the opportunity afforded to me."

Commenting on the experience, Vernon Silvera said: “My attendance to some of the sessions offered by AACC allowed me to see

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many of the innovations in point of care testing along with the benefits and challenges that come with these new kinds of technologies.

Point of care testing does not start and stop at the little strip or cassette or device that is used for testing. It goes beyond that. It starts with policies and processes and involves many other factors that lead to ensuring quality results in a timely manner. With that little strip, cassette or device comes great power and with great power comes great responsibility. Many of the sessions also highlighted the ever-expanding number of tests available and the increasing accuracy of test that are available. I am pleased to have been afforded the opportunity by InterHealth Canada - Turks and Caicos Islands Hospital.”

CONTINUING MEDICAL EDUCATION

EBOLA PROTECTION TCI Hospital employees learn about Ebola Personal Protective Equipment Protocol

OVERVIEW:

Inside the CME Turks and Caicos Islands Hospital conducted a special CME session on the Ebola virus disease (EVD) for employees. The presentation was steered by Senior Infection Prevention and Control Nurse, Surbrena Pedican as a standard precaution and educational exercise, which included a Level 5 Hemorrhagic Fever PPE Protocol demonstration and the latest information on the virus disease.

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The Ebola virus disease (EVD) is a potentially fatal type of hemorrhagic fever and has an over 50% fatality rate. It is spread by contact with contaminated objects and surfaces, respiratory droplets and consumption of bush meat.TCI hospital has a policy and plan to treat patients with Ebola and ensure the safety of staff in collaboration with the TCIG Ministry of Health and Human Services. The protocol includes a personal protective equipment (PPE) protocol, which seeks to ensure the delivery of medical care to patients with maximum protection for staff against contracting the Ebola virus disease.

The signs and symptoms of EVD include high fever, muscle pain, headache, diarrhoea, vomiting and bleeding or bruising. From 2018 to present, the Congo region of Africa has recorded the second largest outbreak of Ebola with over 3054 reported cases and over 2052 deaths. The hospital's CME and training sessions are frequently tailored to cover the latest information on topics trending in health care today.

Other topics examined included drug preparation and therapeutic drug monitoring, antibiotic resistance patterns in TCI, antimicrobial strategies for nurses, doctors and sampling techniques.

Over 50 health care practitioners participated in the first Antimicrobial Stewardship Workshop hosted by InterHealth Canada – Turks and Caicos Islands Hospital to examine topics related to antimicrobial resistance and infectious diseases.

Real case scenarios were provided for attendees to complete prescription writing using antimicrobial stewardship guidelines. Antimicrobial resistance is the ability of a microbe to resist the effects of medication that once could successfully treat the microbe. Resistant microbes are more difficult to treat, requiring more powerful antibiotics.

The workshop was held on Tuesday, October 8th 2019 at Cockburn Town Medical Centre and Thursday, October 10th 2019 at Cheshire Hall Medical Centre. Dr Corey Forde (bottom left), Infectious Disease, Infection Prevention and Control, Antimicrobial Resistance and Stewardship Consultant of Barbados was the guest presenter.

Commenting on the workshop, Isha Honore, Quality, Risk and Patient Safety Manager with responsibility for the Infection Prevention and Control Department said: “The Antimicrobial workshop was very successful and marks a significant milestone for the TCI Hospital as we address the global challenge of antimicrobial resistance.

The success of the antimicrobial stewardship program calls for unity and collaboration of all stakeholders. This workshop helps to start the necessary conversations that further drive programs and practice interventions that promote patient safety education.”

Forde gave a presentation on notifiable disease reporting, surveillance and the effective implementation of an antimicrobial stewardship program.

The cadre of presenters included Emergency Department Physician -Dr. Roxanne Allen, Pharmacy Manager - Tony Wilton, Medical Technologist Lessonjulle Dobney and Nurse Educator - Lurline Barnett, who are employed at the Turks and Caicos Islands Hospital.

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ALLIED SERVICE PROFESSIONALS HONOURED DURING TCI CEP BANQUET

A group of allied service employees were honored during the 2019 TCI Clinic Exploration Program Banquet at the West Bay Club on August 10th. The banquet recognised Turks and Caicos Islanders in allied health care careers and is the culminating event for the annual summer program.

The honorees among the InterHealth Canada team were (L-R) Latavia Ingham and Andresha Gardiner - Radiographers, Derak Dean - Dialysis Technician, Patricia Stubbs - Pharmacy Assistant, and Kennita Myers- Pharmacist.

Other honorees were: Andrico Garland - Medical Technologist, Margaret Roberts - Pharmacy Assistant, Carol Robinson - Laboratory Manager, Tanya Parker - Assistant Laboratory Manager, Bridget Williams - Medical Device Reprocessing Technician, Denwell Cox - Medical Device Reprocessing Technician, Akela Forbes Phlebotomist and Lashadra Ferguson - Medical Technologist .

TCI Clinic Exploration Program (TCI CEP) was developed to raise awareness of the wide range of careers available in both the Public and Private Health Sector, while also providing adequate and modeled mentorship to participants.

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MEDICAL DEVICE REPROCESSING WEEK 2019 CRITICAL TO QUALITY CARE International Medical Device Reprocessing (MDR) Week is observed during the second full week of October. Students from the Helena Jones Robinson High School on Grand Turk received a demonstration on the activities involved in Medical Device Reprocessing to raise awareness of careers within the field.

The department held an educational booth inside the foyer of Cockburn Town Medical Centre during the special week for the students and general observers. The department is responsible for the decontamination, packaging and sterilisation of reusable instrument sets Members of the public are often unaware of the activities that occur behind closed doors. The department is located in an isolated area of hospital with powerful specialized equipment and rigorous infection prevention and safety procedures. This year’s theme is “Critical to Quality Care.”

Other initiatives held during the week included a special continuing medical education (CME) session for health care providers. Medical Device Reprocessing is critical to the delivery of health care as surgeries and other medical procedures cannot be performed without safe and sterile medical instruments.

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Aspiring health care practitioners embrace observership at TCI Hospital Sanadia Forbes is a third-year student at the University of Bristol in the UK pursuing a degree in Physiological Sciences. Forbes gained beneficial exposure to health care operations during a recent observership at Cheshire Hall Medical Centre.

Certain compounds and other remedies were stored and administered to patients by apothecaries, which is akin to today’s version of pharmacies.

Books related to the then known pharmaceutical compounds and their preparation methods were published in the 1600’s to standardize the process since these items were sold in shops. The Society of Apothecaries was formed in London as the primary suppliers of these compounds.

The program requires participants to select a topic of their choice, research and prepare a 20-minute presentation to select members of the hospital team.

She was enthused by her stint in the Pharmacy Department and decided to present on the history of drug discovery and development, the processes used before modern day drugs came on the market, case studies of marketed drugs and clinical trials with unfavorable outcomes.

The 1800’s witnessed the birth of some major pharmaceutical companies, which isolated certain active ingredients of pre-existing compounds and this reduced the potency and degree of side effects, and provided improved dosage monitoring. Her presentation extended into the 1900’s.

Her presentation was multi-faceted as it also delved into the ethical considerations ingrained the initiation of clinical drug trials, given the need for scientific proof and weighing the benefits and the risks of such.

She also emphasized what is described as turning points in the evolution of drugs. These included the first antiseptic and the discovery of IV drug administration in the 1600’s, which triggered the exploration of other methods such as topical creams etc.

From the historical perspective, Forbes stated that in the middle ages, there were herbal remedies such as plants and other concoctions to treat common ailments such as peppermint leaves for indigestion.

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Earlissa Tucker examines kidney disease She then examined how ESRD is diagnosed via a health history and tests to check a person’s kidney function, which includes a blood test to examine specific compounds such as creatinine levels and a urinalysis.

Earlissa Tucker, 18, is a student at Champions for Christ Learning Institution pursuing her A-Levels. Tucker gained insightful exposure to health care operations during a recent observership at Cheshire Hall Medical Centre to help guide her future career path.

It was her time spent in the dialysis department that sparked her interest in learning more about the lifesustaining treatment provided by a dialyzer. Dialysis is a treatment that filters and purifies the blood using a machine. Her presentation was on end-stage renal disease and provided an overview of the risk factors of renal disease, symptoms, diagnosis, complications and treatment.

End-stage kidney disease or ESRD is the final stage of chronic kidney disease. It means a person’s kidneys no longer function well enough to meet the needs of daily life.

ESRD is chronic and irreversible. Tucker underscored that the risk factors of kidney disease include conditions such as diabetes, high blood pressure, lupus and nephrotic syndrome. Symptoms may include nausea and vomiting, loss of appetite, an increase or decrease in urine.

However, kidney disease can also often be symptomless.

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She continued to highlight that complications or effects of ESRD may include anemia, bone disease, heart disease and fluid buildup. Treatment options include a kidney transplant, hemodialysis or peritoneal dialysis. The administration of each of these treatment options were then explored.

Patients are typically required to undergo dialysis three times per week for several hours. Tucker stated: “As I rotated through the dialysis unit, it was so amazing how medicine has changed over the years. Now artificial kidneys can be used to filter the blood and do what a normal organ kidney would do.”

D'Janelle examines the Human Microbiome

There was a special focus on the gut, which is home to scores of microorganisms. Many of these are beneficial to our overall health. Hence, poor gut health can contribute to the development of different health

D’Janelle Tennant, 17, is a year thirteen student at the

ailments. Tennant cited research on the links between

British West Indies Collegiate in Providenciales

the development of cancerous tumour cells and bad gut

currently pursuing her A-Levels. Tennant gained

bacteria.

invaluable exposure to health care operations during a recent observership at Cheshire Hall Medical Centre.Â

The presentation also delved into the Human Microbiome Project (HMP), which is an interdisciplinary

Inspired by her time spent in the Laboratory

US-based research effort, which seeks to understand

Department, Tennant gave a presentation on the human

the microbial components of our genetic and metabolic

microbiome. The human body contains trillions of

landscape, and how they contribute to our normal

bacteria cells and she emphasized the symbolic and

physiology and disease predisposition.

parasitic nature of microorganisms, the different types and where they are found around the human body.

Interestingly, fecal microbiota transplantation (FMT) was also highlighted by the young aspiring medical doctor. FMT is the administration of a solution of fecal matter from a healthy donor into the intestinal tract of a patient in order to directly change the recipient’s microbial composition and confer a health benefit.

We wish her all the best in her future endeavors.

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The evolution of diagnostic imaging Stuart Ewing, 23, is a second year medical student at the University of the West Indies, Mona in Jamaica. Ewing gained invaluable exposure to internal healthcare operations during a two week observership at Cheshire Hall Medical Centre, which commenced on August 2, 2019. Ewing rotated across various hospital departments. Under the program, participants are required to select a topic of their choice, research and prepare a 20 minute presentation to selected members of the hospital management team.

On the final day, Ewing gave a presentation on diagnostic imaging covering various topics. He explored the evolution of various modalities and how radiological scans are generated.

Ewing also delved into the clinical applications of radiological scans, the use of contrast agents in specific procedures and the benefits and limitations of each modality.

The presentation was wellreceived, unveiled a number of interesting historical facts, and in a special twist, hospital team members were quizzed on their knowledge of diagnostic imaging with special treats for their answers.

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World Breastfeeding Week is celebrated every year from 1 to 7 August to encourage breastfeeding and improve the health of babies around the world.

The Ten Steps to Successful Breastfeeding are: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff.

In observance of the occasion, doctors and nurses at Cockburn Town Medical Centre held an information table and small-group sessions to provide antenatal and postnatal breastfeeding education to mothers.

2. Train all health care staff in the skills necessary to implement this policy.

A similar initiative was held at Cheshire Hall Medical Centre as lactation management professionals seek to increase the initiation and duration of breastfeeding within the local community via the provision of hands-on support and advice.

3. Inform all pregnant women about the benefits and management of breastfeeding.

The World Health Organization recommends exclusive breastfeeding starting within one hour after birth until a baby is 6 months old. Nutritious complementary foods should then be added while continuing to breastfeed for up to 2 years or beyond.

5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.

4. Help mothers initiate breastfeeding within one hour of birth.

6. Give infants no food or drink other than breast-milk, unless medically indicated.

TCI Hospital continues to keep breastfeeding education at the forefront as a continuation of its effort to implement the steps underscored in the global Baby-friendly Hospital Initiative (BFHI).

7. Practice rooming in - allow mothers and infants to remain together 24 hours a day.

The Hospital’s Baby Friendly Policy is erected across both medical centers with the Ten Steps to Successful Breastfeeding established

by WHO and UNICEF.

8. Encourage breastfeeding on demand.

Baby-Friendly hospitals and birthing facilities must adhere to the steps to receive, and retain, a Baby-Friendly designation. TCI Hospital seeks to acquire the designation in the future.

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.

9. Give no pacifiers or artificial nipples to breastfeeding infants.

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BREAST IS BEST

THE INTERVIEW 19

HEALTH BOOTHS There are several important numbers that we all need to know in order to safeguard our health. Cholesterol, blood pressure, blood sugar, and body mass index are among the key indicators of a person’s risk for major illness.

By knowing these numbers, persons can take action to reduce their chances of developing heart disease, diabetes and other major illnesses.

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TCI Hospital health care professionals continue to provide health screenings to capture various sectors of the community at different events and through various avenues,

FAREWELL MESSAGE Message from Dianne Hinneh, Former Emergency Department and Ambulatory Clinics Nurse Manager I write to express my heartfelt gratitude to the Interhealth Canada Company for giving me this opportunity and work exposure. This experience has caused me to sharpen my skills and gain further expertise in my domain. At the TCI hospital I have learnt to multi-task, in areas such as team management, strategy building, real-time plan execution, etc. Because of this I can say that I am leaving with a wealth of knowledge that I will always treasure.

new ones, it's all too easy to lose sight of the most important element of any organisation – THE PERSON, THE PEOPLE. I would like to take this opportunity to thank everyone for the support received in TCIH. Thanks to the Senior Management Team, Managers, The nursing fraternity and all members of staff.

I would like to say a special thank you to the Teams under my purview, the Emergency, Outpatient, Oncology and Dietetics departments. These units have demonstrated outstanding performance during my term and I am certain that they will continue to thrive.

During my tenure, I have developed important and essential qualities, which have grounded my professional maturity.

This was achieved by, but not limited to, participation in trainings, accreditation inputs and outputs, daily dedication to patient safety, staff wellbeing and astute round table communication and management skills.

I have found working here to be stretching, taking me out of my comfort zone and breaking new grounds. I have learnt to think bigger and involve others outside of my discipline when it comes to problem- solving, and have witnessed the creative energy that fuels solutions.

Our team has been involved in some outstanding projects together, for example, the “Accreditation 2018” program, which for me was incredible, being part of the history of TCIH and by extension this country. This is motivating work that will impact the healthcare sector across the region and beyond.

I've already packed memories of fun, collaboration, consultation, and friendship into my heart to take with me.

The date for my leaving is 30th September, 2019. I hope to connect with most of you before my departure. I am proceeding towards my next assignment that God has purposed for me and as always will do my best to be his consul of positive transformation in the healthcare sector.

None of us achieve in isolation and the successes we've enjoyed together have been the result of our mutual cooperation and collaboration. In the middle of our daily business: meeting targets, initiating projects and developing 21

InterHealth Canada - Turks and Caicos Islands Hospital announced the appointment of Shantell Gardiner to the post of Emergency Department and Ambulatory Clinics Nurse Manager in October.

JOURNEY TO ED NURSE MANAGER

In this role, Gardiner becomes a member of the Nursing Management team and is charged with responsibility of the Emergency Department, Outpatient Department, Oncology and Dietetics.

Gardiner is a native of North Caicos and has been in the nursing profession for the past 19 years. She commenced employment at InterHealth Canada – Turks and Caicos Islands Hospital in 2009 and was promoted from Senior Registered Nurse Midwife to Supervisor within the Emergency Department in September 2016.

Gardiner holds an Associates Degree in General Nursing, Post Graduate Diploma in Midwifery, Bachelor of Science in General Nursing and is currently in pursuit of a Masters degree in Health Administration. The appointment is aligned with the private health care management company’s succession plan, which seeks to mentor, educate and elevate belongers to key positions.

PROMOTIONS

THE INTERVIEW 22

"...EVERYTHING I'VE EVER WANTED IS ON THE OTHER SIDE OF FEAR." Question and Answer Shantell Gardiner

• Did you envision this current upcoming promotion, and if not why? "Years ago, if someone had told me I would become a nurse manager for this department or any department I would not have believed them. Earlier in my career, I did not have confidence in myself and my fear of potential failure limited my potential. In my early career, I considered myself a follower, but as I have grown, both personally and professionally, I realize that everything I’ve ever wanted is on the other side of fear. I consider myself a considerate leader, working to provide the best outcomes for patients, staff and the Hospital."

• Roots and upbringing: What inspired you to pursue nursing/healthcare career? "I was born on the island of North Caicos where I attended the Adelaide Oemler primary School and graduated from the Raymond Gardiner High School (RGHS) in 1996. As a child, growing up, I loved North Caicos and never thought about leaving. I remember my mother getting annoyed because I did not have a plan for my future when I was studying for my final secondary school exams. My mother encouraged me to become a nurse.

She felt that I needed independence, discipline and structure and that nursing would help me build those skills. So, thank you mommy, you were right."

• What will be your first target area following the appointment? "I have been blessed to work with amazing, hard working nursing staff that are very knowledgeable in emergency nursing. My first target is to make the department as patient centered as possible. I will also work with the senior management team to reinforce the zero violence policy within the department. I will strive to be an advocate for my staff as well as my patients and ensure that we continue to work together as a team to administer first class patient care in a safe environment."

• What types of training have you received over the years to prepare you for this career advancement?

"I have served as acting nurse manager for the emergency department in the absence of managers during vacation periods for the past 3 years . I have attended yearly trainings and conferences in nursing management and leadership where I have received certificates in those areas. I have also successfully completed the mass casualty and disaster training. I have completed educational programs such as Advancing quality though management,” Introduction to people centered care with the accreditation Canada and also possess several clinical certifications.. During my career, I have been mentored in management and emergency room nursing by several people, including Mr. Douglas Moore, Chief of Clinical Services Mikette Been, Dr. Denise Braithwaite-Tennant, Moira Scott and Dianne Hinneh former ED Nurse Managers. This provided me with a substantial amount of knowledge and experience for which I am grateful."

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Bon Voyage Nurse Percy JosephÂ

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NURSE MICHAEL WILLIAMS PROMOTED TO DEPUTY SITE MANAGER INTERNAL NEWS

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new team leaders introduced across departments

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THE INTERVIEW

AUGUST 22, 2019

Endoscope Reprocessing Certification

This course aims to empower nurses by enhancing their understanding of nursing leadership and management principles that can be utilized in the practice of nursing.

The course uses practical exercises and case studies incorporating major issues to be addressed in the development of nursing leadership competencies.

Medical Device Reprocessing (MDR) Technician, Erica Williams (above has successfully acquired certification in the key technical skills, techniques and knowledge required to successfully reprocess endoscopes of all types. The certification in endoscope reprocessing was acquired via the International Association of Healthcare Central Service Material Management (IAHCSSM) IAHCSSM is the premier association representing healthcare central service professionals worldwide. With the certification, recipients are successfully able to demonstrate skills of endoscope care, handling and infection prevention.

Williams also obtained a second certification in health care leadership in September 2019. The course is designed to equip individuals with the necessary leadership principles and concepts required in a highly specialized department such as MDR.

Technical Certification Biomedical Engineers, George Mushuje and Chubby Jakosalem, have successfully completed their certifications in Level II Fresenius Dialysis Machine Management.

The Technical Training team from Fresenius Renal Technologies, a division of Fresenius Medical Care, offers a variety of detailed technical training courses for biomedical technicians who are responsible for servicing Fresenius Renal Technologies manufactured and distributed equipment.

Healthcare facilities comprise of a variety

Nursing Leadership Certification Surgical Suites Lead Nurse, Fiona Burnett (L) and Haydee Dayupay (R) has successfully completed a nursing leadership certification program from the Pan American Health Organization.

of different roles, most of which are simple to decipher. The biomedical engineering department is a behind the scenes department, which comprise of indispensable members of a healthcare team as health care delivery is heavily reliant on technical support for medical technology.

"Continuous learning is the minimum 27 requirement for success in any field." - Brian

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