Re: ‘A Case Report: A Child with a Rash and Lead Poisoning History ‘ (January 2024)

I applaud “A Case Report of Microcytic Anemia in a Pediatric Patient.” This report demonstrates the need for routine screening of children for exposure to lead. It is frightening to think what might have been the long-term outcome had the child not been screened by his pediatrician, unrelated to the initial presenting problem to the emergency department. Many years ago, our emergency room agreed to send a blood lead level for screening for any child younger than 5 years of age, regardless of the presenting problem. We found many children who had elevated blood lead levels that might not have been identified otherwise.

Lead exposure is an example of an environmental disaster. The authors stated that the child was living in a “lead safe environment.” The X-ray revealed the presence of radio-opaque materials suggesting/proving recent exposure to lead-containing material. During my career in academic medicine, I experienced innumerable cases in which children were sent home to “lead-safe” not “lead-free” homes, to be readmitted within weeks, with evidence of renewed exposure.

The treatment for lead “poisoning” is really not chelation, it is separating the child from the exposure! The blood lead level will drop by itself as long as no further exposure occurs, chelation simply speeds the process.

Preventing lead exposure should be a societal goal. It is the most preventable cause of neuro-cognitive impairment.

—Steven M. Marcus, MD

Re: ‘Artificial Intelligence in the ED: Ethical Issues’ (December 2023)

I read with interest Dr. Iserson’s article Artificial Intelligence in the ED: Ethical Issues.

The degradation of physician skill is not a patient-oriented outcome. These days, every time an automatous vehicle has a mishap, especially were injury to occur, it is national news. Invariably, these news stories neglect to point out how many people are injured from motor vehicle collisions in this country. Even at this nascent stage, the majority of car accidents involving self-driving cars were the result of the other driver. If (an admittedly big if) this technology can be demonstrated to be safer than human physicians, our relevance and our roles in medicine may as well be moot. Will there be marginal cases where AI performs worse than a human? Undoubtably. But humans make frequent mistakes that cost patients in morbidity and mortality.

In an era when medical spending has far outstripped inflation, outcomes have failed to keep pace, our population aging, and Medicare is constantly on the verge of insolvency. It may very well be that AI could be a potential part of the solution. Agreed, physicians are not the most costly component of health care in this country. However, we must always be arguing on the side of what is best for our patients, not our positions.

—Greg Neyman, MD, FACEP

Re: ‘Things Aren’t Always Black or White’ (January 2024)

Judging by Dr. Kendall’s piece, “Things Aren’t Always Black or White,” the state of racism in health care is troubling indeed. Assumptions about humans based on immutable characteristics like skin color used to be called racism. Now it’s championed under the banner of “antiracism.”

Rebuking emergency physicians about “white fragility” doesn’t improve emergency department boarding, understaffing or the morale of those trying to provide safe and compassionate care, especially in underserved areas.

No doubt there are many personal stories of racism, as discrimination and bias are human flaws that escape no one, regardless of skin color. “White people do not exist under a non-racist force field,” writes Dr. Kendall, but she is only partially correct—no one does. Pushing the idea that whites are hopelessly racist has no resolution, as it ensnares our society into endless racial division. Dr. Martin Luther King Jr.’s words, “I look to a day when people will not be judged by the color of their skin, but by the content of their character,” provide a better solution.

Reducing humans to their immutable characteristics and assigning value or scorn based on these traits normalizes their dehumanization. This leads to the belief that certain humans hold more value than others—a dangerous perspective used to justify such past atrocities as forced sterilizations, the Tuskegee experiment and the Holocaust, as well as the explosion of antisemitism today.

Doctors should focus on healing all humans—regardless of skin color or any other attributes.

—Aida Cerundolo, MD