Re: “Space Medicine: Emergency Physicians Voyage into the Final Frontier”

We read the article in ACEP Now titled, “Space Medicine: Emergency Physicians Voyage into the Final Frontier,” by Sophia Gorgens, MD, with interest, since, as physicians certified by the American Board of Preventive Medicine (ABPM) in Aerospace Medicine, we are also excited about the prospects of expansion of commercial and private spaceflight and its promise to open space travel to a larger and more diverse group of people. We also fully agree with Dr. Gorgens that with this promise comes a responsibility to ensure the health and safety of those who participate in suborbital and orbital spaceflight.

However, we must respectfully disagree with several points and assumptions made in the article, several of which are materially important and, left unaltered, will result in an increased risk of injury or death to crew and passengers in both commercial and government-sponsored spaceflight.

As an initial matter, and maybe most surprisingly, throughout the article, the entire specialty of Aerospace Medicine, which encompasses space medicine, including its history of innovation and its contributions to space travel and the safety of astronauts, is consistently ignored or dismissed. Space medicine is not a “whole new field of study” as it is described in the article but instead, an area of practice that for over 50 years has been incorporated into the robust Aerospace Medicine curriculum. In fact, Aerospace Medicine specialists have been training in and practicing space medicine since the 1950s and, since 1953 the ABPM, a member board of the American Board of Medical Specialties (ABMS) has certified physicians in Aerospace Medicine.

Although Dr. Gorgens asserts that “our understanding of the effects of space on human anatomy and physiology is ever-expanding, and space medicine has grown to fill that niche,” Aerospace Medicine specialists have studied the effects of space on humans since the dawn of the space age and have created and continue to refine countermeasures for the physiological effects of aviation and spaceflight. We applaud emergency medicine physicians for their “new” interest in what is, in reality, a long history of space medicine practiced by experts in the field and who are certified by the ABPM in Aerospace Medicine.

Not only is the long history of Aerospace Medicine’s role in space medicine dismissed in the article, but also the rigorous training of Aerospace Medicine specialists is mostly ignored. The new purportedly “space medicine” fellowships have been created and implemented with the knowledge that the specialty of Aerospace Medicine already exists while neither collaborating with ABPM nor bringing in Aerospace Medicine specialists as faculty to ensure appropriately rigorous and meaningful training occurs in these fledging fellowships. It is difficult to understand how emergency medicine physicians without any meaningful practice in Aerospace Medicine are sufficiently prepared to teach and train those emergency medicine physicians with even less experience. It is, in simplest terms, dangerous to think that such training would properly prepare an emergency medicine physician to practice in any austere environment, much less the hostile environs of space. Further, and while the article states that “[providing acute care in space] is a team effort and doesn’t belong to just one specialty,” proponents of the “new” space medicine seem to have overlooked the one specialty whose focus is entirely on caring for people during air travel, in space, and in other austere environments: Aerospace Medicine.

Dr. Gorgens also contends that the difference between “space medicine fellowship programs,” such as those offered by UCLA and UTHealth Houston, and Aerospace Medicine residency programs whose graduates go on to become Certified by the ABPM, is that the former concentrates “on acute medicine rather than preventive medicine.” Further, the article quotes Dr. Heft, saying “One day in the near future, we will need physicians who are trained and equipped to provide acute care on missions that take you beyond the immediate reach of Earth.” While we certainly agree this is the case, even a cursory review and rudimentary understanding of the practice of Aerospace Medicine would establish that such physicians already exist: Aerospace Medicine specialists possess both clinical and Aerospace Medicine-specific training and skills and are qualified to treat a host of acute and chronic conditions in austere environments, including space. Indeed, most Aerospace Medicine physicians provide the full spectrum of acute care, chronic disease management, human performance enhancement guidance, and preventive medicine. Aerospace Medicine physicians do not simply focus on prevention, although preventive medicine principles are critically important to maintain the longitudinal health and safety of a highly trained crew.

The article further, and wrongly implies that the skills required to provide medical care for spaceflight crews and passengers can largely be gained through non-specialized clinical training. Dr. Gorgens quotes Dr. Aintablian who posits that Emergency Medicine physicians “have 80-85 percent of the skills already” to be a “space doctor” – a misleading statement as clinical training alone does not provide the 80-85 percent of skills to effectively care for and ensure the safety of people in space. We cannot help but be curious as to which patients Dr. Gorgens believes would prefer a surgeon with 80-85 percent of the skills to competently remove an appendix versus a surgeon that has both the depth and breadth of practice to do so competently in every instance. Similarly, and over the decades that Aerospace Medicine specialists have cared for astronauts and advised space agencies, it is the broad-based Aerospace Medicine-specific knowledge that has proven their most valuable contribution and thinking otherwise is misguided and jeopardizes the health and safety of the crews and passengers that rely on the expertise of physicians that successfully complete the wide array of training that is required to become a thoroughly trained and ABPM Certified Aerospace Medicine expert.

The article also offers misleading statements regarding the career prospects of space medicine physicians who lack full training in Aerospace Medicine. Dr. Gorgens implies that space medicine fellowships provide the training required to “meet [the] demands of the space industry” and states that “job opportunities for well-trained space-medicine doctors continue to grow, from NASA to the private space industry.” Contrary to those opinions, the reality is that physicians trained and Certified by the ABPM in Aerospace Medicine already lead the medical teams at commercial flight organizations. NASA also primarily hires Aerospace Medicine Certified physicians because they offer the level of skill, expertise, and experience the agency requires. Aerospace Medicine physicians have a long history of working closely with NASA scientists and engineers to select and train astronauts, develop life support systems, monitor astronaut health, and provide medical monitoring and guidance – from selection through mission completion. Aerospace Medicine trained and Certified physicians continue to excel in this role today and, given the choice, any crew or passenger would undoubtedly prefer an Aerospace Medicine physician and not a generic, emergency medicine physician to be responsible for their care, whether on the ground or in space.

Lastly, and most alarmingly, Dr. Gorgens implies that space medicine promises that people can travel to space regardless of their fitness for spaceflight, ignoring the very real dangers of space for people with chronic medical conditions and the likelihood that traveling with such conditions will result in medical emergencies. Dr. Aintablian is quoted in the article as saying, “If space isn’t accessible to everyone, even to people with chronic medical problems, then it’s really not as exciting.” While space medicine proponents’ expanded view of who might qualify to travel to space is admirable – we, too, want to see more diversity in the people who participate in spaceflight – the accessibility of space to people with chronic medical problems should not define how “exciting” space is. While we are getting better at mitigating the effects of chronic disease and acute medical issues in space, the reality is that some conditions are incompatible with spaceflight. It’s shocking that we have to restate the obvious that it is better to prevent a death or serious health event from happening than to create a situation where an in-flight emergency happens. Again, such thinking increases the risks to crew and passengers and is diametrically opposed to ABMS and its Member Boards’ credo of being committed to providing higher professional standards and delivering better patient care.

The unique and challenging environment of space demands specialized medical knowledge and skills to address the physiological and psychological effects experienced by individuals in microgravity, high acceleration forces, and extreme conditions – the specialized knowledge and skills that Aerospace Medicine training alone provides. Aerospace Medicine physicians’ expertise has been instrumental in ensuring the safety of astronauts since the dawn of the US space program, and as space travel becomes a reality for a greater number of people, it is imperative that the physicians who ensure the health and safety of spaceflight crews and passengers are fully trained and qualified in Aerospace Medicine and not simply weekend warriors who deem themselves to be space medicine “experts.”

In a post-COVID environment where misinformation is increasingly offered with impunity, the ABPM believes that it is necessary and appropriate to correct the various misstatements and misleading information in the article referenced herein. Therefore, the ABPM is formally requesting the opportunity from your organization to provide a written rebuttal to the article written by Dr. Gorgens that would be printed in a conspicuous location in the next issue of your publication. The intention of the rebuttal would be to set the record straight on the robust training that is required to be considered an expert in space medicine, how for over 50 years Aerospace Medicine specialists Certified by the ABPM have met those demanding standards and the voids in the proposed training of emergency medicine physicians that will increase the risk of both injury and death to those who seek to travel into the unfriendly environs of space.

Thank you for your consideration of this request and we look forward to your favorable response.

Sincerely,

—Cheryl L. Lowry, MD, MPH

Re: “How to Avoid Missing an Aortic Dissection”

In a recent article, the authors have provided a thoughtful review of aortic dissection (AOD) cases while promoting the aortic dissection detection risk score (ADD-RS) to improve the ED diagnosis of these patients.¹  Unfortunately, the ADD-RS was not constructed using appropriate methodology for creating clinical decision rules (CDRs) and should not be relied upon.^2,3 The ADD-RS was derived by cardiologists via a consensus and retrospectively tested on patients entered into an AOD registry.^4,5 

Relying on a chart review of clinical features, potentially obtained after hospital admission, when the final diagnosis is known is unreliable and inappropriate for creation of a CDR. Importantly, that “validation study” did not follow standard chart review methodology and did not follow basic reporting guidelines for observational studies (STROBE). There was no blinding to final diagnoses, no prospective evaluation of individual criteria, no assessment of interrater reliability for individual features, no statistical evaluation of the contribution of each criterion to a final model, no purposeful model building, no inclusion of patients without AOD, and no comparison of this rule to clinical judgement. A prior meta-analysis of the ADD-RS included eight retrospective chart reviews and one prospective study with no study being registered, no study following STROBE guidelines with comprised populations already suspected of having AOD, and most patients already selected to undergo advanced aorta imaging (CT or transesophageal echocardiography).⁶ 

Importantly, flaws in patient selection and data collection within these studies would tend to over inflate the sensitivity of the ADD-RS and D-dimer in diagnosing AOD potentially missing AOD cases scored as low or indeterminate risk. Looking at individual ADD-RS features, trained emergency physicians are already aware of classic AOD high risk historical features (connective tissue disease, aortic valve disease, known aneurysm), high risk complaints (abrupt onset, tearing/ripping, severe), and examination findings (pulse deficit, new aortic regurgitation murmur, neurologic deficit, shock). Many of these “high risks” may be absent from ED medical records or unknown to patients (connective tissue disease, valvular heart disease), are subjective (onset, pain descriptors, and severity) while the interrater reliability of physical examination and subjective historical features is unknown. In particular, the suggestion that abrupt chest pain requiring morphine should be a red flag is anecdotal and not evidence based while the term “abrupt” can be interpreted in multiple different manners by patients and providers (i.e., potentially poor interrater reliability and thus useless for CDRs). While the ADD-RS might be useful to remind physicians of selected known risk factors for AOD, current studies only show this to be a potential predictor in those already suspected of having AOD. It is unknown if this score (with/without D-dimer) can accurately predict AOD in a general ED population that includes patients not initially suspected of AOD. As such, this score cannot and should not be promoted as a proven predictor of AOD in the general ED population of patients with chest pain, back pain, syncope, weakness, or the multitude of other potential presentations.  

References

Pilcher C, Dajer A. How to avoid missing an aortic dissection. ACEP NOW 2023; 42 (6): 14.

Green SM, Schriger DL, Yealy DM. Methodologic standards for interpreting clinical decision rules in emergency medicine: 2014 update. Ann Emerg Med 2014; 64: 286-291

Phillips B. Clinical decision rules: how to build them. Arch Dis Child Educ Pract Ed 2010; 95: 83-87.

Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. Circulation 2010; 121: 1544-1579. 

Rogers AM, Hermann LK, Booher AM, et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for the identification of acute aortic dissection at initial presentation. Circulation 2011; 123: 2213-2218. 

Tsutsumi Y, Tsujimoto Y, Takahashi S, et al. Accuracy of aortic dissection risk score alone or with D-dimer: a systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care 2020; 9: S32-S39.

—Steven G. Rothrock MD, FACEP, FAAP

Re: “Toxicology Q&A: The Fig Tree” 

I read with great interest Dr Hack’s article on the toxicity of fig trees. Growing up in my village of Deir-el-Qamar, or Monastery of the Moon, a reference to a Phoenician temple in the mountains of Lebanon, we had native fig trees everywhere. The delicious “refreshing waterdrop-shaped packages of goodness” as he describes their fruit so aptly was a daily late summer treat for us. There were so many varieties, including white figs, brown figs, and the late early-winter ripening red figs. Figs were called “the king of fruits” with many varietals and even more lovers. To Dr. Hack’s point, we were always warned, as kids, while picking figs to never touch our eyes. The white milky sap that oozes from the stem once you pick the fruit can cause blindness. And indeed, my dad often referenced an elder in the village who had lost his sight because of that; he was sadly blinded as a child in the 1920s. On a historical note, it is well known in modern Lebanese history that around 1798–1799, during Napoleon Bonaparte’s Egypt-Syria campaign and his two-month siege of the old city of Acre, his troops who were starving, were saved by Emir Bashir al-Shihaby, ruler of Deir-el-Qamar and the Emirate of Mount-Lebanon, after he sent him caravans loaded with dried figs.

And to come full circle with the story, my wife and I have a beach house on Emerald Isle, NC, not too far from Dr. Hack’s East Carolina University. And we have a native fig tree in the sandy soil, but the birds eat all the fruit before they ripen. That fig tree in particular has a smell that I hate, but my wife loves it. For years, we argued. So what was the denouement? The rest of the story will be for another day.

—Rashid Baddoura, MD, FACEP, FCCP