Online Letters to the Editor
than 8,000 adults from the National Health and Nutrition Examination Survey, found a similar strong RDW-mortality association even after adjustment for these variables. The preservation of the RDW-mortality relationship after adjustment makes it unlikely that the RDW is simply measuring a single confounding comorbidity, such as anemia. Karagöz and Tanoglu (1) also inquire as to the time between taking the blood samples and measuring RDW. RDW has been shown to be stable for 48 hours (5). All cohort blood samples analyzed were obtained from hospitalized patients and analyzed on site. The hospital clinical laboratories where the assays were performed are Clinical Laboratory Improvement Amendments certified, and in general, complete blood count samples obtained are analyzed within 6 hours. Although our study suggests that higher RDW values at hospital discharge correlate with worse postdischarge outcomes in critical illness survivors, significant questions remain regarding the pathophysiology of this relationship and the best use of RDW in clinical practice. Dr. Purtle is employed by the University of Colorado Hospital (Pulmonary/Critical Care Fellowship). Dr. Christopher disclosed that he does not have any potential conflicts of interest. Steven W. Purtle, MD, Pulmonary Sciences & Critical Care Medicine Division, University Colorado, Aurora, CO; and Department of Medicine, Brigham and Women’s Hospital, Boston, MA; Kenneth B. Christopher, MD, The Nathan E. Hellman Memorial Laboratory, Renal Division, Brigham and Women’s Hospital, Boston, MA
REFERENCES
1. Karagöz E, Tanoglu A: The Relationship Between RBC Distribution Width at Hospital Discharge and Out-of-Hospital Mortality in Critically Ill Patients. Crit Care Med 2014; 42:e485 2. Purtle SW, Moromizato T, McKane CK, et al: The association of red cell distribution width at hospital discharge and out-of-hospital mortality following critical illness. Crit Care Med 2014; 42:918–929 3. Lippi G, Targher G, Montagnana M, et al: Relation between red blood cell distribution width and inflammatory biomarkers in a large cohort of unselected outpatients. Arch Pathol Lab Med 2009; 133:628–632 4. Patel KV, Ferrucci L, Ershler WB, et al: Red blood cell distribution width and the risk of death in middle-aged and older adults. Arch Intern Med 2009; 169:515–523 5. Gulati GL, Hyland LJ, Kocher W, et al: Changes in automated complete blood cell count and differential leukocyte count results induced by storage of blood at room temperature. Arch Pathol Lab Med 2002; 126:336–342 DOI: 10.1097/CCM.0000000000000358
Contribution of Emergency Medicine-Critical Care Medicine Physicians to the Intensivist Workforce To the Editor:
I
would like to comment on the recent article by Halpern et al (1) in Critical Care Medicine. The authors state that “there are also a limited number of emergency medicine (EM) physicians trained in critical care with critical care medicine (CCM) certification.” Up until 2011, there was not a formal pathway for EM-trained physicians to achieve CCM certification, and only e486
www.ccmjournal.org
a small number of fellowship programs, such as University of Pittsburgh and University of MD Shock Trauma Center, welcomed EM trainees. There has been a growing interest in CCM by EM-trained physicians over the last decade as the original small group, mostly comprised internal medicine (IM)-trained physicians who were either “grandfathered” in EM or who did an additional EM residency, has been joined by EM-trained physicians who pursued CCM fellowships as well as those who have completed combined EM-IM-CCM programs. The numbers of EM-CCM physicians will only continue to increase steadily and more rapidly as there are now agreements with American Board of Internal Medicine (ABIM), American Board of Surgery, and American Board of Anesthesiology for EM graduates to train in these Accreditation Council for Graduate Medical Education– approved Critical Care programs and then to be qualified to sit for the certifying examination. To date, the first two classes of EM physicians who completed an ABIM fellowship program were eligible to take the CCM examination in 2012 and 2013; there has been a 100% pass rate for these 47 candidates. As a reflection of this growing interest, the Critical Care Medicine Section of the American College of Emergency Physicians has expanded from approximately 50 members to nearly 700 members in the last 5 years. The Emergency Medicine Section of the Society of Critical Care Medicine has also continued to grow in numbers and involvement in Society of Critical Care Medicine (SCCM) as there are members involved in committee work, lecturing at Congress, moderating of research presentations, and are even on the SCCM Council; additionally, we have an increasing number of members who have achieved the respected Fellow of the American College of Critical Care Medicine status. We agree with many of the suggestions by the authors for addressing the shortage of intensivists but believe that EM-CCM physicians will be able to contribute a significant amount of person-power and value to the delivery of future high-quality CCM. The author has disclosed that he does not have any potential conflicts of interest. Joseph Shiber, MD, FACEP, FACP, FCCM, Department of Emergency Medicine and Critical Care, University of Florida, College of Medicine, Jacksonville, FL
REFERENCES
1. Halpern NA, Pastores SM, Oropello JM, et al: Critical Care Medicine in the United States: Addressing the Intensivist Shortage and Image of the Specialty. Crit Care Med 2013; 41:2754–2761 DOI: 10.1097/CCM.0000000000000304
The authors reply:
W
e thank Shiber (1) for his interest in our point of view article on the state of critical care governance, training, delivery, and practice of critical care in the United States (2). We completely agree with him that as the number of emergency medicine-critical care medicine (EM-CCM) physicians steadily increases, these dually trained clinicians have the potential to help alleviate the current June 2014 • Volume 42 • Number 6
than 8,000 adults from the National Health and Nutrition Examination Survey, found a similar strong RDW-mortality association even after adjustment for these variables. The preservation of the RDW-mortality relationship after adjustment makes it unlikely that the RDW is simply measuring a single confounding comorbidity, such as anemia. Karagöz and Tanoglu (1) also inquire as to the time between taking the blood samples and measuring RDW. RDW has been shown to be stable for 48 hours (5). All cohort blood samples analyzed were obtained from hospitalized patients and analyzed on site. The hospital clinical laboratories where the assays were performed are Clinical Laboratory Improvement Amendments certified, and in general, complete blood count samples obtained are analyzed within 6 hours. Although our study suggests that higher RDW values at hospital discharge correlate with worse postdischarge outcomes in critical illness survivors, significant questions remain regarding the pathophysiology of this relationship and the best use of RDW in clinical practice. Dr. Purtle is employed by the University of Colorado Hospital (Pulmonary/Critical Care Fellowship). Dr. Christopher disclosed that he does not have any potential conflicts of interest. Steven W. Purtle, MD, Pulmonary Sciences & Critical Care Medicine Division, University Colorado, Aurora, CO; and Department of Medicine, Brigham and Women’s Hospital, Boston, MA; Kenneth B. Christopher, MD, The Nathan E. Hellman Memorial Laboratory, Renal Division, Brigham and Women’s Hospital, Boston, MA
REFERENCES
1. Karagöz E, Tanoglu A: The Relationship Between RBC Distribution Width at Hospital Discharge and Out-of-Hospital Mortality in Critically Ill Patients. Crit Care Med 2014; 42:e485 2. Purtle SW, Moromizato T, McKane CK, et al: The association of red cell distribution width at hospital discharge and out-of-hospital mortality following critical illness. Crit Care Med 2014; 42:918–929 3. Lippi G, Targher G, Montagnana M, et al: Relation between red blood cell distribution width and inflammatory biomarkers in a large cohort of unselected outpatients. Arch Pathol Lab Med 2009; 133:628–632 4. Patel KV, Ferrucci L, Ershler WB, et al: Red blood cell distribution width and the risk of death in middle-aged and older adults. Arch Intern Med 2009; 169:515–523 5. Gulati GL, Hyland LJ, Kocher W, et al: Changes in automated complete blood cell count and differential leukocyte count results induced by storage of blood at room temperature. Arch Pathol Lab Med 2002; 126:336–342 DOI: 10.1097/CCM.0000000000000358
Contribution of Emergency Medicine-Critical Care Medicine Physicians to the Intensivist Workforce To the Editor:
I
would like to comment on the recent article by Halpern et al (1) in Critical Care Medicine. The authors state that “there are also a limited number of emergency medicine (EM) physicians trained in critical care with critical care medicine (CCM) certification.” Up until 2011, there was not a formal pathway for EM-trained physicians to achieve CCM certification, and only e486
www.ccmjournal.org
a small number of fellowship programs, such as University of Pittsburgh and University of MD Shock Trauma Center, welcomed EM trainees. There has been a growing interest in CCM by EM-trained physicians over the last decade as the original small group, mostly comprised internal medicine (IM)-trained physicians who were either “grandfathered” in EM or who did an additional EM residency, has been joined by EM-trained physicians who pursued CCM fellowships as well as those who have completed combined EM-IM-CCM programs. The numbers of EM-CCM physicians will only continue to increase steadily and more rapidly as there are now agreements with American Board of Internal Medicine (ABIM), American Board of Surgery, and American Board of Anesthesiology for EM graduates to train in these Accreditation Council for Graduate Medical Education– approved Critical Care programs and then to be qualified to sit for the certifying examination. To date, the first two classes of EM physicians who completed an ABIM fellowship program were eligible to take the CCM examination in 2012 and 2013; there has been a 100% pass rate for these 47 candidates. As a reflection of this growing interest, the Critical Care Medicine Section of the American College of Emergency Physicians has expanded from approximately 50 members to nearly 700 members in the last 5 years. The Emergency Medicine Section of the Society of Critical Care Medicine has also continued to grow in numbers and involvement in Society of Critical Care Medicine (SCCM) as there are members involved in committee work, lecturing at Congress, moderating of research presentations, and are even on the SCCM Council; additionally, we have an increasing number of members who have achieved the respected Fellow of the American College of Critical Care Medicine status. We agree with many of the suggestions by the authors for addressing the shortage of intensivists but believe that EM-CCM physicians will be able to contribute a significant amount of person-power and value to the delivery of future high-quality CCM. The author has disclosed that he does not have any potential conflicts of interest. Joseph Shiber, MD, FACEP, FACP, FCCM, Department of Emergency Medicine and Critical Care, University of Florida, College of Medicine, Jacksonville, FL
REFERENCES
1. Halpern NA, Pastores SM, Oropello JM, et al: Critical Care Medicine in the United States: Addressing the Intensivist Shortage and Image of the Specialty. Crit Care Med 2013; 41:2754–2761 DOI: 10.1097/CCM.0000000000000304
The authors reply:
W
e thank Shiber (1) for his interest in our point of view article on the state of critical care governance, training, delivery, and practice of critical care in the United States (2). We completely agree with him that as the number of emergency medicine-critical care medicine (EM-CCM) physicians steadily increases, these dually trained clinicians have the potential to help alleviate the current June 2014 • Volume 42 • Number 6
