CORRESPONDENCE
Guidelines for Letters to the Editor Annals welcomes letters to the editor, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor should not exceed 500 words and 5 references. They should be submitted using Annals’ Web-based peer review system, Editorial ManagerTM (http://www.editorialmanager.com/annemergmed). Annals no longer accepts submissions by mail. Letters should not contain abbreviations. Financial association or other possible conflicts of interest should always be disclosed, and their presence or absence will be published with the correspondence. Letters discussing an Annals article must be received within 8 weeks of the article’s publication. Published letters may be edited and shortened. Authors of articles for which comments are received will be given the opportunity to reply. If those authors wish to respond, their reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors.
0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians.
Credentialing for Emergency Ultrasonography To the Editor: We read with great interest “Credentialing for Emergency Ultrasonography” by Gaspari et al.1 Emergency physicians, and the American College of Emergency Physicians (ACEP) in particular, have worked tirelessly during the last several decades to make ultrasonography available in daily clinical practice to improve the care of patients. Policies and procedures for credentialing, performing, interpreting, documenting, and billing for these examinations have been clearly delineated. ACEP and emergency medicine are frequently noted as leaders in point-ofcare ultrasonography and especially policy and procedures formalization for the specialty. Clinical ultrasonography requires a unique knowledge base, skill set, and expertise, involving not only technical image acquisition but also interpretation and integration into decisionmaking in regard to patient care. As such, ultrasonography is a core component of emergency medicine residency training, and emergency ultrasonography fellowship training programs have expanded this even further in scope of practice, research, education, and program development. Fellowship guidelines do exist, and the movement toward Accreditation Council for Graduate Medical Education subspecialty development is under way. Emergency medicine is viewed as the clear leader among nontraditional ultrasonographic specialties. Critical care and other specialties have incorporated ultrasonography into their practices modeled after the progress made in emergency medicine. A recent Society of Critical Care Medicine article references ACEP ultrasonographic credentialing and training criteria and establishes hospital credentialing criteria for critical care physicians according to the ACEP model.2 Many emergency
Volume 64, no. 3 : September 2014
physicians now lead multispecialty clinical ultrasonographic programs in their institutions. We agree that in certain practice environments external certification could lead to “political wins” for an individual practitioner or program in the short term. However, American Registry for Diagnostic Medical Sonography is an organization with clear roots in the specialty of radiology. We would compare the suggestion of asking for permission to perform clinical ultrasonographic examinations to the days when emergency physicians requested the right to intubate patients from anesthesiology departments. This battle is still being fought in many locations. These short-term wins are typically attributed to a lack of complete comprehension of what RDMS and like certifications really are: a technician’s merit badge. Furthermore, there is monetary incentive for external certification programs. Encouraging these programs could lead to mandates in the future, with no control or voice over cost containment for physicians and departments. External certification could be tied to hospital credentialing in some locations. There could be onerous training or continuous medical education requirements necessary to complete certification programs, with no input from emergency medicine. If a critical mass of emergency physicians buys into a potential local short-term gain from external certification for ultrasonographic use, the specialty and patients will be hurt in the long term. This is 2014, and this is emergency medicine. Ultrasonography is a part of daily clinical practice in the United States and around the world. External certification for the use of ultrasonography in clinical practice will present unnecessary hurdles for emergency physicians desiring to use this technology to improve the care of patients.
Annals of Emergency Medicine 331
Correspondence Christopher C. Raio, MD, MBA Department of Emergency Medicine North Shore University Hospital Manhasset, NY Gerardo C. Chiricolo, MD Department of Emergency Medicine NY Methodist Hospital Brooklyn, NY Rajesh Geria, MD Department of Emergency Medicine Robert Wood Johnson University Hospital New Brunswick, NJ Paul Sierzenski, MD Department of Emergency Medicine Christiana Care Health System Newark, DE Michael Blaivas, MD Department of Emergency Medicine St. Francis Hospital Columbus, GA http://dx.doi.org/10.1016/j.annemergmed.2014.05.024
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Recommendations for Achieving and Maintaining Competence and Credentialing in Critical Care Ultrasound with Focused Cardiac Ultrasound and Advanced Critical Care Echocardiography. From the Ultrasound Certification Task Force on behalf of The Society of Critical Care Medicine: Aliaksei Pustavoitau, MD, Michael Blaivas, MD, Samuel M. Brown, MD, MS, Cristina Guitierrez, MD, Andrew W. Kirkpatrick, MD, Benjamin A. Kohl, MD, Achikam Oren-Grinberg, MD, Heidi L. Frankel, MD. Official Statement of The Society Of Critical Care Medicine. 1. Gaspari RJ, Bailitz J, Lewiss RE, Stone M. Credentialing for emergency ultrasonography. Ann Emerg Med. 2014;63: 628-629. 2. Ultrasound Certification Task Force on behalf of the Society of Critical Care Medicine. Recommendations for Achieving and Maintaining Competence and Credentialing in Critical Care Ultrasound with Focused Cardiac Ultrasound and Advanced Critical Care Echocardiography. Available at: http://journals.lww.com/ccmjournal/ Documents/Critical%20Care%20Ultrasound.pdf. Accessed June 2, 2014.
332 Annals of Emergency Medicine
Radiation Dose Justification and Optimization Should Not Be Applied to Medical Imaging in Emergency Medicine To the Editor: I read with interest the recent article on justification and optimization of radiation dose for medical imaging in emergency medicine in Annals.1 The article raised concerns about the projected increased cancer risks caused by low-dose radiation exposure to patients from the computed tomography (CT) scans performed in emergency departments, by referring to a sentinel event alert by The Joint Commission (TJC). The alert quoted an estimate of 29,000 future cancers attributed to CT scans performed in 2007 in the United States as an example of the stated concerns. This estimate used risk projection models recommended by the Biological Effects of Ionizing Radiation (BEIR) VII report according to the linear no threshold model for radiation-induced cancers. The model was justified in the BEIR VII report by referring to atomic bomb survivor data (p 10) thus: “The arguments for thresholds or beneficial health effects are not supported by these data.” The report (p 336) also claimed consistency of cancer risk factors from the 15-country study of radiation workers as additional supporting evidence. As described in a recent article,2 analyses of the updated data for the atomic bomb survivors have shown that the data no longer support the conclusion of zero threshold dose, and corrections to the 15-country study of radiation workers have negated their earlier conclusion of the carcinogenicity of low-dose radiation. In addition, a considerable amount of additional evidence has been published in the past few years (analysis of atomic bomb survivor data, analysis of cancer incidence in Taiwan apartment residents exposed to low-dose radiation from contaminated building materials, and analysis of second cancers per kilogram of tissue as a function of dose in radiation therapy patients), contradicting the linear no threshold model and supporting the concept that low-dose radiation reduces cancers.3 One quoted reason for the carcinogenic concerns about CT scans is the increased DNA damage from the low-dose radiation, as, for example, discussed in the BEIR VII report. However, DNA damage is known to be ubiquitous from common activities such as physical and thinking exercises that have been shown to result in reduced cancers and reduced cognitive decline in the elderly, respectively,4 rendering such concerns not justifiable. Another consequence of low-dose radiation is the stimulation of the immune system.5 Because the immune system is known to play an extremely important role in preventing cancers, low-dose radiation would be expected to reduce rather than increase cancers, again obviating the low-dose radiation carcinogenic concerns.5 The reasons for the linear no threshold model–based low-dose radiation carcinogenic concerns expressed in the TJC sentinel event alert are thus no longer valid. Without these concerns, the concept of dose optimization does not have any justification because it
Volume 64, no. 3 : September 2014
Guidelines for Letters to the Editor Annals welcomes letters to the editor, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor should not exceed 500 words and 5 references. They should be submitted using Annals’ Web-based peer review system, Editorial ManagerTM (http://www.editorialmanager.com/annemergmed). Annals no longer accepts submissions by mail. Letters should not contain abbreviations. Financial association or other possible conflicts of interest should always be disclosed, and their presence or absence will be published with the correspondence. Letters discussing an Annals article must be received within 8 weeks of the article’s publication. Published letters may be edited and shortened. Authors of articles for which comments are received will be given the opportunity to reply. If those authors wish to respond, their reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors.
0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians.
Credentialing for Emergency Ultrasonography To the Editor: We read with great interest “Credentialing for Emergency Ultrasonography” by Gaspari et al.1 Emergency physicians, and the American College of Emergency Physicians (ACEP) in particular, have worked tirelessly during the last several decades to make ultrasonography available in daily clinical practice to improve the care of patients. Policies and procedures for credentialing, performing, interpreting, documenting, and billing for these examinations have been clearly delineated. ACEP and emergency medicine are frequently noted as leaders in point-ofcare ultrasonography and especially policy and procedures formalization for the specialty. Clinical ultrasonography requires a unique knowledge base, skill set, and expertise, involving not only technical image acquisition but also interpretation and integration into decisionmaking in regard to patient care. As such, ultrasonography is a core component of emergency medicine residency training, and emergency ultrasonography fellowship training programs have expanded this even further in scope of practice, research, education, and program development. Fellowship guidelines do exist, and the movement toward Accreditation Council for Graduate Medical Education subspecialty development is under way. Emergency medicine is viewed as the clear leader among nontraditional ultrasonographic specialties. Critical care and other specialties have incorporated ultrasonography into their practices modeled after the progress made in emergency medicine. A recent Society of Critical Care Medicine article references ACEP ultrasonographic credentialing and training criteria and establishes hospital credentialing criteria for critical care physicians according to the ACEP model.2 Many emergency
Volume 64, no. 3 : September 2014
physicians now lead multispecialty clinical ultrasonographic programs in their institutions. We agree that in certain practice environments external certification could lead to “political wins” for an individual practitioner or program in the short term. However, American Registry for Diagnostic Medical Sonography is an organization with clear roots in the specialty of radiology. We would compare the suggestion of asking for permission to perform clinical ultrasonographic examinations to the days when emergency physicians requested the right to intubate patients from anesthesiology departments. This battle is still being fought in many locations. These short-term wins are typically attributed to a lack of complete comprehension of what RDMS and like certifications really are: a technician’s merit badge. Furthermore, there is monetary incentive for external certification programs. Encouraging these programs could lead to mandates in the future, with no control or voice over cost containment for physicians and departments. External certification could be tied to hospital credentialing in some locations. There could be onerous training or continuous medical education requirements necessary to complete certification programs, with no input from emergency medicine. If a critical mass of emergency physicians buys into a potential local short-term gain from external certification for ultrasonographic use, the specialty and patients will be hurt in the long term. This is 2014, and this is emergency medicine. Ultrasonography is a part of daily clinical practice in the United States and around the world. External certification for the use of ultrasonography in clinical practice will present unnecessary hurdles for emergency physicians desiring to use this technology to improve the care of patients.
Annals of Emergency Medicine 331
Correspondence Christopher C. Raio, MD, MBA Department of Emergency Medicine North Shore University Hospital Manhasset, NY Gerardo C. Chiricolo, MD Department of Emergency Medicine NY Methodist Hospital Brooklyn, NY Rajesh Geria, MD Department of Emergency Medicine Robert Wood Johnson University Hospital New Brunswick, NJ Paul Sierzenski, MD Department of Emergency Medicine Christiana Care Health System Newark, DE Michael Blaivas, MD Department of Emergency Medicine St. Francis Hospital Columbus, GA http://dx.doi.org/10.1016/j.annemergmed.2014.05.024
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Recommendations for Achieving and Maintaining Competence and Credentialing in Critical Care Ultrasound with Focused Cardiac Ultrasound and Advanced Critical Care Echocardiography. From the Ultrasound Certification Task Force on behalf of The Society of Critical Care Medicine: Aliaksei Pustavoitau, MD, Michael Blaivas, MD, Samuel M. Brown, MD, MS, Cristina Guitierrez, MD, Andrew W. Kirkpatrick, MD, Benjamin A. Kohl, MD, Achikam Oren-Grinberg, MD, Heidi L. Frankel, MD. Official Statement of The Society Of Critical Care Medicine. 1. Gaspari RJ, Bailitz J, Lewiss RE, Stone M. Credentialing for emergency ultrasonography. Ann Emerg Med. 2014;63: 628-629. 2. Ultrasound Certification Task Force on behalf of the Society of Critical Care Medicine. Recommendations for Achieving and Maintaining Competence and Credentialing in Critical Care Ultrasound with Focused Cardiac Ultrasound and Advanced Critical Care Echocardiography. Available at: http://journals.lww.com/ccmjournal/ Documents/Critical%20Care%20Ultrasound.pdf. Accessed June 2, 2014.
332 Annals of Emergency Medicine
Radiation Dose Justification and Optimization Should Not Be Applied to Medical Imaging in Emergency Medicine To the Editor: I read with interest the recent article on justification and optimization of radiation dose for medical imaging in emergency medicine in Annals.1 The article raised concerns about the projected increased cancer risks caused by low-dose radiation exposure to patients from the computed tomography (CT) scans performed in emergency departments, by referring to a sentinel event alert by The Joint Commission (TJC). The alert quoted an estimate of 29,000 future cancers attributed to CT scans performed in 2007 in the United States as an example of the stated concerns. This estimate used risk projection models recommended by the Biological Effects of Ionizing Radiation (BEIR) VII report according to the linear no threshold model for radiation-induced cancers. The model was justified in the BEIR VII report by referring to atomic bomb survivor data (p 10) thus: “The arguments for thresholds or beneficial health effects are not supported by these data.” The report (p 336) also claimed consistency of cancer risk factors from the 15-country study of radiation workers as additional supporting evidence. As described in a recent article,2 analyses of the updated data for the atomic bomb survivors have shown that the data no longer support the conclusion of zero threshold dose, and corrections to the 15-country study of radiation workers have negated their earlier conclusion of the carcinogenicity of low-dose radiation. In addition, a considerable amount of additional evidence has been published in the past few years (analysis of atomic bomb survivor data, analysis of cancer incidence in Taiwan apartment residents exposed to low-dose radiation from contaminated building materials, and analysis of second cancers per kilogram of tissue as a function of dose in radiation therapy patients), contradicting the linear no threshold model and supporting the concept that low-dose radiation reduces cancers.3 One quoted reason for the carcinogenic concerns about CT scans is the increased DNA damage from the low-dose radiation, as, for example, discussed in the BEIR VII report. However, DNA damage is known to be ubiquitous from common activities such as physical and thinking exercises that have been shown to result in reduced cancers and reduced cognitive decline in the elderly, respectively,4 rendering such concerns not justifiable. Another consequence of low-dose radiation is the stimulation of the immune system.5 Because the immune system is known to play an extremely important role in preventing cancers, low-dose radiation would be expected to reduce rather than increase cancers, again obviating the low-dose radiation carcinogenic concerns.5 The reasons for the linear no threshold model–based low-dose radiation carcinogenic concerns expressed in the TJC sentinel event alert are thus no longer valid. Without these concerns, the concept of dose optimization does not have any justification because it
Volume 64, no. 3 : September 2014
