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Although rare, perforation can be a devastating complication of colonoscopy. Incidence ranges from 0.012 to 0.65% during diagnostic procedures and is higher in therapeutic procedures. Early diagnosis and management are of paramount importance to decrease morbidity. Diagnostic imaging after colonoscopy can reveal extraintestinal air, but overall clinical status including leukocytosis, fever, pain, and peritonitis is equally important to determine management. With the expanding availability of complex endoscopic interventions, an increasing number of perforations are recognized during colonoscopy or immediately afterward based on high degree of suspicion. Colonoscopic management of these early perforations may be feasible and avoid the morbidity of surgery. Patients who require surgery may be managed with laparoscopic or open surgical techniques. Surgical management may consist of primary repair of the injury, resection with anastomosis, or resection with ostomy. Mechanical bowel preparation before endoscopy decreases fecal contamination after perforation, often obviating the need for ostomy creation.

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To the Editor-The novel coronavirus pandemic accelerated the development of overdue health care solutions in the United States. Proposals have included a new public insurance program, a plan to permanently shore up the national equipment stockpile, and new funding for rural hospitals, among many others. But a glut of interest groups has lobbied aggressively to shape the pandemic response [1, 2].As future practitioners of public health, bioethics, and medicine, we know that one principle is clear: students should lead the charge in this critical moment to enact lasting federal, state, and local policy improvements for all Americans. Ultimately, students are best positioned to advocate for the most important stakeholder: the patient.The best public health practice uses a moment of crisis as an opportunity for long-term change. This is the "triple axel" of public health practice: establishing credibility, explaining a problem, and fighting for a realistic solution [3]. Academics, reporters, and others have established credibility at a moment when messaging from government officials is confused and sometimes contradictory. Experts have also explained the overflowing cornucopia of latent problems in our health care system that COVID-19 brought to the fore: underfunded rural hospitals, treatments that patients cannot afford, and dismantled city and county public health infrastructure [4]. The American public now deserves public policy solutions to support population health-Medicaid and Medicare expansion, surprise billing regulation, and appropriately funded public health agencies.But the third element of the triple axel, fighting for realistic policy solutions, is the most difficult to land. It is here that students and student groups should lend their voices to guide elected leaders' actions. To the public, students are unsullied by negative behaviors that are often a result of training and practicing in our health care system, and they are less likely than other groups to face conflicts of interest [5]. Additionally, in the last decade advocating through social media became increasingly common, and students are using social media platforms to more actively work toward social justice causes [6]. Recently, the American Medical Association formally left a lobbying group prevent-