The Skeptics Guide to Emergency Medicine

Date: April 2, 2026 Reference: Lee et al. GRADE-Based Clinical Practice Guidelines for Emergency Department Delirium Risk Stratification, Screening, and Brain Imaging in Older Patients With Suspected Delirium. AEM Feb 2026 Guest Skeptic: Dr. Christina Shenvi is a board-certified emergency physician, educator, keynote speaker, coach, and academic leader. She is widely recognized for her work in geriatric emergency medicine, faculty development, and professional identity formation in EM. She brings deep clinical expertise along with thoughtful perspectives on systems-level change and guideline development. Case: An 82-year-old woman with hearing impairment and mild baseline dementia is brought to the emergency department (ED) by her daughter because she became “not herself” over 24 hours. She is more sleepy, intermittently agitated, keeps losing the thread of conversation, and cannot say the months backward. She arrived by ambulance from home after nearly falling twice. Vitals show fever and mild tachycardia. The daughter reports foul-smelling urine and poor oral intake for two days. On examination, there is no head trauma and no focal neurologic deficit. The question in the ED is not simply “Is she confused?” but “Does she have delirium, how do we confirm it efficiently, and does she need a head CT as part of the workup?” Background: Delirium is an acute brain dysfunction: a disturbance in attention and awareness that develops over hours to days, fluctuates, and is accompanied by additional cognitive disturbances such as memory, language, orientation, or perceptual changes. In older adults, it is common, dangerous, and often goes unnoticed. The latest GED Delirium Guidelines indicate that delirium occurs in about 6% to 38% of older ED patients, increases mortality, contributes to functional decline, and imposes a significant burden on health systems. ED-based geriatric screening tools also highlight that delirium is frequently under-recognized by emergency clinicians and that hypoactive delirium is most common, making bedside detection even more challenging. For emergency physicians, delirium matters because it is rarely the final diagnosis. Delirium is usually a clue that something else serious is also wrong. The practical ED task is to identify the syndrome, search for precipitants, and avoid worsening the situation. But one reason the new guideline is so useful is that it is honest about the evidence gap. Prior reviews found no consistent ED-based strategy to prevent incident delirium or to treat prevalent delirium, so this guideline appropriately focuses on the parts of care for which there is sufficient evidence to guide bedside decisions now. It addresses risk stratification, diagnosis, and brain imaging. This delirium guideline is also notable because it was built using the newer GED 2.0 model for subspecialty guideline development [1]. The Geriatric Emergency Department initiative moved beyond the older consensus-based 2014 framework and adopted a transparent GRADE process: multidisciplinary working groups, explicit PICO questions, systematic reviews and meta-analyses, Evidence-to-Decision frameworks, attention to feasibility, equity, and stakeholder values, plus external stakeholder review. This SGEM episode highlights the first EM subspecialty guideline effort to fully adopt GRADE, and this delirium guideline shows that process in action. Clinical Questions: Which older ED adults are at the highest risk on walking in, and who should then be further assessed for delirium? (or CLS addition, should have special prevention measures or expedited treatment or bed placement). Which tools should be used to identify ED delirium? Should acutely confused older ED patients undergo head CT as part of the delirium evaluation? Reference: Lee et al. GRADE-Based Clinical Practice Guidelines for Emergency Department Delirium Risk Stratification, Screening, and Brain Imaging in Older Patients With Suspected Delirium. AEM Feb 2026 Authors’ Conclusions: “Rigorous ED-based research is needed to strengthen evidence and guide delirium care for older adults in geriatric emergency medicine.” Quality Checklist for a Guideline: The study population included or focused on those in the emergency department? Yes An explicit and sensible process was used to identify, select and combine evidence? Yes The quality of the evidence was explicitly assessed using a validated instrument? Yes An explicit and sensible process was used to value the relative importance of different outcomes? Yes The guideline thoughtfully balances desirable and undesirable effects? Yes The guideline accounts for important recent developments? Yes Has the guideline been peer-reviewed and tested? Yes/No Practical, actionable and clinically important recommendations are made? Yes The guideline authors’ conflicts of interest are fully reported, transparent and unlikely to sway the recommendations? Unsure Key Recommendations: They came up with six recommendations

Date: March 23, 2026 Dr. Christina Shenvi Guest Skeptic: Dr. Christina Shenvi is a board-certified emergency physician, educator, keynote speaker, coach, and academic leader. She is widely recognized for her work in geriatric emergency medicine, faculty development, and professional identity formation in emergency medicine (EM). She brings deep clinical expertise along with thoughtful perspectives on systems-level change and guideline development. This is another SGEM Xtra episode. Today’s show focuses on how to build high-quality subspecialty clinical practice guidelines, using the Geriatric Emergency Department Guidelines 2.0 (GED 2.0) as a model. We’ve talked about Geriatric EM a lot on the SGEM over the years. And if we’re serious about evidence-based emergency medicine, we must be serious about geriatric EM. Here are some previous SGEM episodes: SGEM#89: Preventing Falling to Pieces SGEM Xtra: Don’t Bring Me Down – Preventing Older Adult Falls from the ED SGEM#261: Cristal Ball to Assess Older Patients in the ED SGEM#280: This Old Heart of Mine and Troponin Testing SGEM#424: Ooh Ooh I Can’t Wait to Be Admitted to Hospital The original 2014 GED Guidelines were consensus-based and helped establish standards for geriatric emergency departments, including staffing, education, transitions of care, quality improvement, equipment, and protocols. Since then: The evidence base in geriatric EM has expanded. Expectations for clinical practice guideline development have evolved. The GRADE framework has become the international standard for rating the quality of evidence and the strength of recommendations. GED Guidelines 2.0 represent the first EM subspecialty effort to fully adopt the GRADE methodology and provide a transparent, reproducible model for future EM guideline development. This work involved a multidisciplinary collaboration, including experts affiliated with organizations such as the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM), as well as geriatricians, methodologists, and patient representatives. Started with an open call to the Geriatric Emergency Medicine community via SAEM, ACEP, AGS, EUSEM, and ENA. With funding via JAHF. The GED Guideline 2.0 group is planning 14 Systematic Reviews/Meta-analyses, with 6 or 7 Clinical Practice Guidelines. They will all be available on the GEAR 2.0 website Five Questions for Dr. Shenvi I have five key questions to frame our discussion about the GED 2.0 Model for Subspecialty Clinical Practice Guidelines. As a reminder, they are called GUIDElines, not GODlines. This means they are meant to guide our care, not dictate care. 1) Why Update the Original GED Guidelines? The original 2014 GED Guidelines were enormously important because they gave the field its first shared framework for what high-quality emergency care for older adults should look like. But they were developed as consensus-based guidelines at a time when the evidence base in geriatric emergency medicine was much less mature than it is now. Since then, there has been major growth in research, especially through work from GEAR and GEAR 2.0, in areas like delirium, dementia, falls, medication safety, transitions of care, and elder abuse. The update was needed to ensure the guidelines reflected the newer evidence and remained clinically relevant. A second reason is that expectations for guideline development have changed. The paper makes clear that the original guidelines did not include a formal assessment of the quality, quantity, reproducibility, or applicability of the evidence. In today’s environment, clinicians and health systems expect more transparency about how recommendations are made, how strong the evidence is, and how benefits, harms, feasibility, and equity are weighed. GED Guidelines 2.0 was designed to meet those newer standards. A third issue was implementation. The original guidelines had a clear impact, especially through ACEP accreditation, but the paper notes that accredited GEDs still represent a minority of EDs, and many sites have struggled with barriers such as limited resources, competing priorities, and a lack of local champions. So, this update was not just about refreshing content. It was also about making the guidance more usable, transparent, and implementable in both accredited and non-accredited settings. Bottom line, hospitals won’t do things unless there are clear clinical reasons, or financial reasons, or mandates, like CMS measures, which are financial. 2) Why Adopt the GRADE Framework? GRADE stands for: Grades of Recommendation, Assessment, Development, and Evaluation. They provide a systematic, transparent framework for rating the quality of evidence and grading the strength of recommendations in healthcare. The group adopted GRADE because they wanted the updated guidelines to be more rigorous, more transparent, and more trustworthy. According to the paper, GED Guidelines 2.0 is the first emergency medicine subs

Date: March 26, 2026 Dr. Rob Leeper Guest Skeptic: Dr. Robert Leeper is a trauma surgeon at the London Health Sciences Centre and an ATLS instructor who has helped train generations of physicians in trauma care. He has previously joined SGEM for: SGEM #200 – Bloodletting and Alexander Hamilton SGEM #256 – RLQ Pain and Appendectomy SGEM #345 – Non-operative Management of Appendicitis It’s SGEM Xtra time, where we go beyond a single paper and dive into broader topics that impact our daily practice. Now, some of you may remember that back in 2018, we did a Top 10 list for ATLS 10th Edition. Yes, we cranked it up to 10. ATLS 10th Edition: Top 10 Changes But today… We’re not stopping at 10. Because this SGEM episode goes to 11. If you don’t get that reference, go watch This Is Spinal Tap. It’s a mockumentary about a fictional rock band whose amplifiers go to 11 instead of 10. And when asked why they didn’t just make 10 louder, the guitarist replies: “These go to 11.” And that brings us to ATLS, now officially in its 11th edition. For those who don’t know the history of ATLS, here is the brief back story. ATLS was born out of tragedy. In 1976, orthopedic surgeon Dr. James Styner crashed his small plane in rural Nebraska. His wife died at the scene. He and his children survived but were severely injured. When they arrived at a small hospital, the trauma care they received was, by his account, disorganized and inadequate. Styner later said: “When I can provide better care in the field with limited resources than my children and I received at the primary care facility, there is something wrong with the system.” That moment led to the development of a structured approach to trauma, one that could be taught, replicated, and standardized. The first ATLS course was introduced by the American College of Surgeons (ACS) in 1980. It emphasized something radical at the time: a systematic, prioritized assessment of trauma patients, beginning with Airway, Breathing, Circulation, Disability, Exposure (ABCDE). In EM, our alphabet is A-B-CT, send them to the donut of truth. But back to the 1980s, the systematic ABCDE approach wasn’t about memorizing injuries. It was about preventing death from the first thing that kills. Over the decades, ATLS became one of the most widely adopted trauma education programs in the world. It has trained hundreds of thousands of clinicians in over 80 countries. And like any long-running franchise (Star Wars, Mission Impossible, Star Trek and Batman), each new edition tries to improve on the original. So today, instead of a Top 10 list as we did for ATLS 10, we’re going with: The 5 important changes in ATLS 11. Because sometimes less is more. Even if the amplifier goes to 11. Five Changes to the ATLS 11th Edition 1. xABCDE – Hemorrhage Now Comes Before Airway: The most noticeable clinical change in ATLS 11 is the addition of the “x” to ABCDE, making it xABCDE, with the “x” standing for exsanguinating hemorrhage. Massive external bleeding is now formally prioritized before airway management in select patients. While many trauma teams have already internalized the “bleeding kills first” principle, especially after a decade of military-to-civilian trauma translation, ATLS has now codified it. In practical terms, this reinforces early tourniquet use, direct pressure, and hemostatic adjuncts as first-line priorities when appropriate. It’s less of a revolution and more of an official acknowledgment that the trauma world has already turned the volume up on hemorrhage control. But formalizing it in the primary survey does matter, because what gets taught gets practiced. 2. Hemodynamic Optimization Before Intubation: Another subtle but important evolution in the 11th edition is the greater emphasis on resuscitating shock before proceeding with rapid sequence intubation (RSI). ATLS 11 highlights the risk of peri-intubation hypotension and arrest in unstable trauma patients, encouraging clinicians to correct hemodynamics before pushing paralytics. This aligns with growing emergency medicine literature around the dangers of precipitous airway management in the shocked patient. It’s a welcome shift toward physiologic thinking rather than purely procedural thinking. In other words, it reminds us that the airway isn’t just anatomy, it’s physiology. 3. Major Structural Reorganization and Systems Focus: The changes to ATLS 11 aren’t just clinical. This edition reorganizes the manual into three major sections: resuscitation, trauma systems/context, and specific injury patterns. More notably, it introduces full chapters on Trauma Systems, Injury Prevention, Trauma-Informed Care, and Communicating Serious News. This reflects a broader view of trauma care that extends beyond the primary survey. ATLS is no longer just about what happens in the first 15 minutes. It is also about the system in which those 15 minutes occur. For instructors, this may feel like an expansion into public health. Whether that’s evolution or missi

Reference: Wong KH, et al. Improving Use of Oral Antihistamines in a Children’s Hospital. Pediatrics. Feb 2026; Date: March 15, 2026 Dr. Stephanie Kubala Guest Skeptic: Dr. Stephanie Kubala is an attending physician in the Division of Allergy and Immunology at Children’s Hospital of Philadelphia. She is double board-certified in both pediatrics and allergy and immunology. Case: A 5-year-old girl is brought in by her parents for an itchy rash. Her symptoms started last night. The parent reports an itchy, raised red rash on her trunk and extremities. She has not had any fever. She does not have any difficulty breathing, wheezing, vomiting, or diarrhea. On your exam, you note hives on her body but no lip or tongue swelling. Her lungs are clear to auscultation. She intermittently scratches at the rash. Her parents tell you, “We gave her a dose of diphenhydramine last night, and it may have helped a little, but it seems to have worn off. Can you help?” Background: In a lot of emergency departments, “hives = diphenhydramine” is practically muscle memory. It’s familiar, it’s been around forever, and families often expect it because it’s what they already have at home. As with many medical interventions, we must weigh potential harms against potential benefits. The problem is that diphenhydramine and other first-generation antihistamines like hydroxyzine come with a bunch of potential side effects, such as sedation, anticholinergic side effects, and unpredictable behavior changes in some kids. It doesn’t always last very long, which can lead to repeat dosing and frustrated families when symptoms come back a few hours later. On the other hand, second-generation antihistamines like cetirizine target the same H1 receptor for itch and urticaria but tend to be longer-acting and better tolerated, which is why many guidelines and expert groups prefer them for routine allergic symptoms. And there’s a bigger safety angle here, too: first-generation agents show up in dosing errors and misuse/overdose cases. The real issue isn’t whether second-generation antihistamines like cetirizine work. They do. We need to start asking why our systems still nudge clinicians toward the older first-generation antihistamines as a default. The issue is well-suited to a quality improvement (QI) study. Before we dive into the details of the study itself, let’s talk about some basics around QI. QI helps close the gap between best practice and day-to-day care. It starts with a clear, measurable aim (what you want to improve, by how much, by when). This is followed by a simple measurement plan: an outcome measure (the main result you’re trying to change), process measures (the steps that should drive that result), and balancing measures (what might worsen unintentionally). Teams then map the current workflow, identify barriers, and build a key driver diagram that links the aim to the handful of system levers most likely to move the needle. The work is tested and refined using Plan–Do–Study–Act (PDSA) cycles. [2] These are iterative rather than a single big rollout. Data is tracked over time with run/control charts to show whether changes are real and sustained. Clinical Question: Can a bundled QI approach meaningfully reduce first generation antihistamine use and increase cetirizine use among pediatric patients receiving oral antihistamines in the ED and inpatient settings? Reference: Wong KH, et al. Improving Use of Oral Antihistamines in a Children’s Hospital. Pediatrics. Feb 2026; Population: Patients 6 months to 21 years in the pediatric ED and inpatient units at a tertiary academic children’s hospital Excluded: Patients in NICU, PICU, or hematology-oncology units Intervention: There were 3 main drivers: education/awareness, cetirizine availability, and standardization through clinical pathways. Comparison: Pre-intervention baseline prescribing practices Outcome: Primary Outcomes: There are two primary outcomes: The proportion receiving oral FGA and the proportion receiving cetirizine Secondary Outcomes: PED revisits within 48 hours, median LOS, clinicians’ knowledge, frequency of clinical pathway use and monthly antihistamine cost. Type of Study: Quality improvement initiative Authors’ Conclusions: “Using the Model for Improvement, we reduced FGA use and increased cetirizine use in the PED and inpatient setting.” Quality Checklist for Ql Study (adapted from QI-MQCS): Do they clearly state the problem and why it mattered? Yes Do they explain why the intervention should improve the outcome? Yes Are the specific changes described in enough detail that another site could reproduce them? Unsure Do they describe the setting the intervention took place (type of hospital/clinic, size, population)? Yes Do they describe the approach to designing and introducing the program? Yes Is the evaluation approach explicit? Yes Do they describe what they are comparing against? Yes Are data sources clear and is the primary outcome operationally defined? Yes Is th

Date: March 11, 2026 Reference: RENOVATE Investigators and the BRICNet Authors; High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients With Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial. JAMA March 2025 Guest Skeptic: Dr. Rory Spiegel is an emergency medicine and critical care physician known for his work in evidence-based medicine and critical care. He is widely recognized for translating emerging research into practical bedside insights through lectures, writing, and digital medical education. His work focuses on resuscitation science, airway management, and the critical appraisal of medical literature. I’m in Maui at the Centre for Continuing Medical Education Year in Review Course. CCME has been doing courses for almost 40 years. The courses take place at amazing locations in the US, including Maui, Hilton Head, Key West, and NYC. CCME recruits four outstanding educators to review ~260 articles from the past year. It’s a unique course because there are no PowerPoint slides to get in the way of the attendees and the speakers. Two faculty members summarize a few articles on a topic in ½ hour with direct interaction with the speakers. You come to this course…you are up to date on the latest EM literature. Case: A 64-year-old woman with a history of COPD (GOLD stage III) and hypertension presents to the emergency department (ED) with worsening shortness of breath over the past 24 hours. She reports increased sputum production and wheezing. On arrival, she is tachypneic and speaking in short phrases. Her vital signs are heart rate 104 beats per minute, blood pressure 148/86 mm Hg, respiratory rate 30 breaths per minute, and SpO₂ 88% on 4 L nasal cannula. She is using accessory muscles and has diffuse expiratory wheezes on auscultation. An arterial blood gas reveals pH 7.29, PaCO₂ 58 mm Hg, and PaO₂ 62 mm Hg. Chest X-ray shows hyperinflation without focal consolidation. Background: Acute respiratory failure (ARF) is one of the most common serious respiratory problems managed in emergency medicine and critical care. For decades, noninvasive ventilation (NIV) has been a central part of therapy for selected patients. This is particularly true for those with COPD exacerbations and acute cardiogenic pulmonary edema. By delivering positive pressure, NIV reduces the work of breathing, improves oxygenation and ventilation. This intervention has been shown to reduce intubation rates and mortality in specific populations. However, NIV can be poorly tolerated, requires a tight mask seal and monitoring, and is resource-intensive [1-3]. These downsides can become more problematic in disease states that are not readily reversible over the first few hours. High-flow nasal oxygen (HFNO) has emerged over the past decade as an attractive potential alternative. By delivering heated, humidified oxygen at high flow rates, HFNO improves oxygenation, improves ventilator efficiency by reducing dead space, and is often better tolerated than mask-based ventilation. Its physiologic appeal and ease of use have led to widespread adoption, particularly during the COVID-19 pandemic. Yet enthusiasm has at times outpaced evidence, and important clinical questions remain: Is HFNO equivalent/non-inferior to NIV in preventing intubation or death? How does it perform across different types of respiratory failure? And when should clinicians choose one over the other? Clinical Question: Is HFNO noninferior to NIV regarding the rates of endotracheal intubation or death at 7 days across five distinct patient groups with ARF? Reference: RENOVATE Investigators and the BRICNet Authors; High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients With Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial. JAMA March 2025 Population: Hospitalized adults with ARF (hypoxemia plus respiratory effort or tachypnea) classified into 5 groups: Nonimmunocompromised with hypoxemia Immunocompromised with hypoxemia COPD exacerbation with respiratory acidosis Acute cardiogenic pulmonary edema (ACPE) Hypoxemic COVID-19 Exclusions: The main exclusion criteria were if there was an urgent need for endotracheal intubation, hemodynamic instability or contraindications to NIV. Intervention: High-flow nasal oxygen (HFNO) delivered continuously, titrated toward 60 L/min. Comparison: Noninvasive ventilation (NIV) delivered through a face mask. Outcome: Primary Outcome: Endotracheal intubation or death within 7 days. Secondary Outcomes: 28-day and 90-day mortality, mechanical ventilation-free days, and ICU-free days. Type of Study: Multicenter, adaptive, noninferiority randomized clinical trial using a Bayesian hierarchical model with dynamic borrowing across patient groups. Authors’ Conclusions: “Compared with NIV, HFNO met prespecified criteria for noninferiority for the primary outcome of endotracheal intubation or death within 7 days in 4 of the 5 patient groups with ARF. However, the small sample sizes in some patient groups and the

Date: March 5, 2026 Today, we’re not in the studio. We’re not in Canada. We’re not even in North America. We are in Oxford. And not just Oxford, we are recording this SGEM Xtra in a pub. This will be the second-ever SGEM PUBcast. We need to travel back in time to 2012 for the first PUBcast. That happened when I came to Oxford for a mini-fellowship at the Centre for Evidence-Based Medicine (CEBM) on how to teach evidence-based medicine (SGEM#6). I had no idea that experience would change my professional career and open so many doors for me around the world. In that early SGEM episode, we did a structured critical appraisal of a 2011 BMJ article by Subramanian et al. called: Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study. That trial examined the dominant grip strength of male orthopedic surgeons compared with male anesthesiologists. No surprise, they found orthopedic surgeons had significantly greater grip strength. However, they also compared the two specialties using an intelligence score and found that orthopedists scored significantly higher than anesthetists. The SGEM bottom line was that the stereotypical image of male orthopedic surgeons as strong but stupid is unjustified in comparison with their male anesthetist counterparts. Well, the SGEM has grown over the last 14 years, with greater than 85,000 subscribers, has been translated into four other languages, and has more than 600 episodes. Tonight, we are back in Oxford at the historic St. Aldate’s Tavern. We are surrounded by centuries of scholarship, skepticism, and possibly a few pints of beer. Joining me to co-host this SGEM Xtra PUBcast is the wonderful Melanie Golob. She is a DPhil candidate in Evidence-Based Health Care here at Oxford. Melanie is also the HTA Program & FFS Operations Manager in the US. Melanie Golob has been a shining star of the DPhil Program for Evidence-Based Health Care and a real ambassador of Evidence-Based Medicine (EBM). Some of us who are older might say you are the Julie McKoy of the DPhil program. She makes everyone feel welcome and appreciated. Questions for Melanie Golob Listen to the SGEM Xtra podcast on iTunes or Spotify to hear Melanie's responses. Question#1: Why Oxford? What drew you here for your DPhil? Was it the Centre for Evidence-Based Medicine (CEBM) specifically? Is there something “statistically significant” about Oxford’s approach to EBM? Does being in a place with this much academic history change how you think? Responds Question#2: What is Your Research About? What problem are you trying to solve with a Living Evidence Synthesis (LES)? Why does “living” evidence matter? Are we ready for AI-assisted living evidence? Question#3: Advice for Future Oxford Students What advice would you give someone interested in doing a DPhil in Evidence-Based Health Care? What makes someone a good candidate? What’s the hardest and most rewarding part? Questions for DPhil Candidates Layal and Taylor Who are you (name and where are you from), and what brought you to Oxford? What is your area of research? What is the most challenging thing about being at Oxford, and the best thing? That concludes the second SGEM PUBcast. We will be back next episode, trying to cut the knowledge translation window from over 10 years to less than 1 year with the power of social media. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. Note: Other people mentioned on the PUBcast Ross Drain- 4th Year Medical Student at Keble College, University of Oxford Juliana Louw - 5th Year Medicine Student at University of Oxford and President of Oxford Lifestyle Medicine Society Carl Heneghen - Professor of Evidence-Based Medicine, University of Oxford Liam Barrett - Emergency Medicine Trainee pursuing a DPhil in Medical Sciences at the University of Oxford Nicholas De Vito - Postdoctoral researcher at the Bennett Institute for Applied Data Science Layal Bou Harfouch- Drug Policy Analyst at the Reason Foundation, DPhil Candidate at the University of Oxford and Founder of Omniwomyn Taylor Hirschberg - CEO Scientist, AI Healthcare Researcher, Pulitzer and GLAAD nominated, Documentary Film Maker and DPhil candidate at the University of Oxford.

Date: February 26, 2026 Guest Skeptic: Terry O’Reilly is the host of the long-running and popular podcast Under the Influence. He is also an acclaimed storyteller and book writer. However, Terry is not just some radio host talking about marketing; he was an adman on the front lines, working in the trenches for 35 years in the advertising industry. I’ve been a listener of Under the Influence for a long time, and it’s helped me think about how we communicate with emergency clinicians and how we make ideas memorable without overselling them. I see many similarities with Terry. I’m not just some podcaster talking about emergency medicine. I’ve been working in the emergency department (ED), on the front line, for 31 years. I’m not an academic sitting in an Ivory tower opining on how to practice emergency medicine based on the literature. I worked 17 ED shifts in February. I’m walking the walk while I talk the talk. I think that brings a perspective and credibility to the SGEM, similar to the credibility of what Terry does on Under the Influence. Terry and I met in person with my wife, Barb, and 11-year old son, Ethan, around 2009. Terry was promoting his book The Age of Persuasion: How Marketing Ate Our Culture. We pulled Ethan out of school to go to Sarnia for a day and watch him give a talk. Terry even signed a copy of his book for Ethan. Our son was so inspired by the event and went on to pursue an academic career in Marketing. Ethan will be defending his PhD in Marketing from the Ivey School of Business this spring. Today, we are going to talk about Terry's latest book: Against the Grain: Defiant Giants Who Changed the World. It is a collection of stories about people who challenged the status quo and changed what the rest of us thought was possible. It reminded me of Apple's famous commercial, "Think Different." I made a parody video about rural physicians titled “Here’s to the Crazy Ones”. People may be wondering why this matters to emergency physicians. I think the “against the grain” ethos is common in emergency medicine. We have healthy skepticism and often challenge dogma, based on the evidence, when discussing management with other specialties. We also must be good at persuading patients, families, learners, consultants, and administrators that what we are doing is the right thing. Five Questions for Terry O'Reilly 1) What inspired you to write Against the Grain? Was there a single person/story that sparked the project? What’s your definition of defiant? Did you notice a pattern in how these defiant giants resisted the herd/groupthink? 2) What was one of the most surprising stories you uncovered while researching the book? What surprised you: the person’s personality, the risk they took, or how others reacted? Was there a moment in your researching a story where you thought, “No way this is true”, and then it was? 3) There are four medical stories in the book (Chapter 4). Most SGEMers probably know about Ignaz Philipp Semmelweis. Can you briefly tell us the story of Dr. Katalin Karikó Katalin Karikó and Drew Weissman 2023 Nobel Prize in Medicine for their discoveries concerning nucleoside base modifications that enabled the development of effective mRNA vaccines against COVID-19. Do you think healthcare messaging has unique challenges compared with marketing products? In your view, what’s the difference between educating vs persuading in healthcare? We do need to be careful in science and medicine not to commit the Galileo Fallacy. This is when someone assert a is true or should be given more credibility because the person making the claim has been prosecuted or otherwise mocked. This fallacy originates from Galileo Galilei's famous persecution by the Roman Catholic Church for his defence of heliocentrism, when the commonly accepted belief at the time was an earth-centred universe. The truth is independent of whether the person is being mocked/persecuted, as with Semmelweis. What matters is the objective, verifiable evidence and logical arguments. 4) What has the feedback been like on the book tour so far? Which types of readers are connecting most with it? Have any audience questions surprised you? Has anyone pushed back on the idea of celebrating “defiance”? 5) What do you hope the audience learns after reading the book? If you had to boil it down, what should we be more skeptical of? How do we encourage against-the-grain thinking without sliding into cynicism? The SGEM will be back next episode with a structured critical appraisal of a recent publication. Our goal is to reduce the knowledge translation (KT) window from over 10 years to less than 1 year using the power of social media. So, patients get the best care, based on the best evidence. Remember to be skeptical of anything you learn, even if you heard it on The Skeptics’ Guide to Emergency Medicine. Previous SGEM Xtra Book Interviews SGEM Xtra – Brian Goldman: The Power of Kindness SGEM Xtra – Tim Caulfield: Ill

Reference: . Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. Lancet Child & Adolescent Health. July 2025 Dr. Kammeron Brissett Guest Skeptic: Dr. Kammeron Brissett is a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. She completed her pediatrics residency and a chief year at Rainbow Babies and Children’s Hospital in Cleveland, Ohio. Her interests include injury prevention, social determinants of health, and advocacy. Case: A 7-year-old boy with a peanut allergy presents to the emergency department (ED) after eating a cookie at a birthday party. Shortly afterwards, he developed hives and wheezing. His parents gave him an epinephrine auto-injector to improve his symptoms. In the ED, he feels much better. His vital signs are normal, and his lungs are clear. He has no other gastrointestinal or cardiovascular symptoms. The parents tell you, “Unfortunately, we’ve been through this before. It’s not the first time he has accidentally eaten something that may have had some peanuts in it. Last time, we sat in the ED for a few hours before going home. It’s been a long day. Can we just go home now?” Background: Anaphylaxis is a serious, potentially life-threatening systemic allergic reaction with a fast onset. It is a clinical diagnosis that should be considered when: Acute illness with skin/mucosal involvement and either respiratory compromise or reduced blood pressure/end-organ symptoms; or Two or more of the following occurring rapidly after exposure: skin/mucosal involvement, respiratory compromise, reduced blood pressure, or persistent gastrointestinal symptoms; or Reduced blood pressure after exposure to a known allergen for the patient. Early recognition and treatment with intramuscular epinephrine is crucial. Sometimes, even after initial symptom improvement with IM epinephrine, anaphylaxis symptoms can recur even without exposure to the known trigger. This is called a biphasic reaction and can happen up to 72 hours later. The SGEM discussed anaphylaxis and biphasic reactions 13 years ago on SGEM#57. The bottom line was that prolonged observation is likely unnecessary in patients whose symptoms resolve with therapy in the ED. Biphasic reactions are rare and can occur anywhere from 10 minutes up to 6 days. We already have problems with boarding and overcrowding. We can’t keep all patients with anaphylaxis for 6 days. So, when can we send them home? Traditionally, ED observation after anaphylaxis has been around 4 to 6 hours to monitor for biphasic reactions. The Resuscitation Council UK recommends a risk-stratified approach: A patient can be discharged after 2 hours when there’s a good response to a single dose of epinephrine, the symptoms have resolved, the child and family has another epinephrine autoinjector and knows how to use it, and has adequate supervision after discharge. They recommend at least 6 hours of observation if two IM doses of epinephrine were needed or there was a prior biphasic reaction. Finally, they recommend at least 12 hours observation if there was severe respiratory compromise, >2 doses of epinephrine, ongoing allergen absorption, late-night presentation/limited access to care, or difficult access to emergency services. The National Institute for Care and Health Excellence (NICE) is even a bit more conservative, recommending any child under age of 16 with suspected anaphylaxis be admitted. What about in the US? In the United States, the 2023 AAAAI/ACAAI Joint Task Force Practice Parameter (JTFPP) emphasizes individualized, risk-based observation and shared decision-making, noting that risk for biphasic reactions is higher with more severe initial reactions and when >1 dose of epinephrine is required. It also highlights that patients with a prompt, complete, and durable response to epinephrine may not always require activation of EMS or prolonged monitoring, underscoring tailored disposition planning. Clinical Question: Among children treated with epinephrine for anaphylaxis, what is the timing and incidence of repeat epinephrine that could inform safe observation periods? Reference: . Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. Lancet Child & Adolescent Health. July 2025 Population: Children 6 months to 17 years presenting to 31 EDs (30 US, 1 Canada) with an acute allergic reaction treated with epinephrine from 2016 to 2019. Excluded: Transfers from outside facilities, ED medication-induced reactions, missing pre-ED symptom documentation; comorbidities requiring tailored management Intervention: ED observation following the first epinephrine dose and need for additional epinephrine Comparison: Comparisons were made across severity strata (no respiratory/cardiovascular involvement vs respiratory involvement only vs cardiovascular involvement). Outcome: Primary Outcome: Time from first to last epinephrin

Date: February 13, 2026 Reference: Lang et al. Factors associated with emergency department length of stay in Alberta: a study of patient-, visit-, and facility-level factors using administrative health data. CJEM. 2026 Jan 29. Guest Skeptic: Dr. Paul Parks is an emergency physician from Medicine Hat, Alberta. He has been the President of the Alberta Medical Association (AMA) Section of Emergency Medicine for many years, the AMA Board of Directors for 9 years, and the Previous President of the Alberta Medical Association. Paul has won the Canadian Association of Emergency Physicians (CAEP) National Teacher of the Year Award and the CAEP Alan Drummond National Advocacy Award. Case: A 78-year-old man with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) arrives at the emergency department (ED) by ground emergency medical services (EMS) at 15:30 with dyspnea and hypoxia. He’s triaged Canadian Triage and Acuity Scale (CTAS) 2, needs non-invasive ventilation (NIV), diuresis, labs, chest x-ray, and likely admission. The department is packed; multiple admitted patients are boarded in hallway spaces because inpatient beds are unavailable, and nursing assignments are stretched. The patient is placed in the “EMS-PARK” area, which is an extension of the waiting room, and part of a mandatory EMS offload policy. Workup is done while the patient is still technically in the waiting room. The workup and disposition decision happen within a few hours, but transfer to an inpatient bed doesn’t occur until 2-3 days later. Background: ED length of stay (LOS) can be considered a vital sign of ED operations and the broader acute-care system. When LOS rises, it often signals that the ED is no longer functioning as a short-stay diagnostic and stabilization unit but is serving as a buffer for upstream demand and downstream capacity issues. The consequences are not just operational (hallway beds, delayed assessments, delayed analgesia, delayed imaging), but also human. We covered a study that showed for older patients, one overnight stay in the ED waiting for an inpatient bed was associated with a 4% absolute increase in mortality (SGEM#424). In addition, increasing LOS can lead to clinician burnout and moral injury. LOS is also tricky because ED crowding is rarely a single-point failure within the ED. Modern crowding frameworks (often summarized as input–throughput–output) remind us that while ED processes matter, some of the most powerful determinants are output constraints. This is especially true when there is access block and inpatient bed scarcity. In other words, you can run an efficient front-end, but if admitted patients cannot be moved to inpatient beds, the system backs up, and ED LOS climbs. As one concrete example of the output challenges many provinces struggle with, in Alberta, 1/3 of our acute hospital capacity, or about 30%, can be occupied by Alternate Level of Care patients. These alternative level of care (ALC) patients have had their acute care needs met, but they cannot be safely discharged from the hospital without specific continuing care resources – home care, assisted living, or long-term care. We’ve talked about ED crowding on an SGEM Xtra. It covered some of the Zombie Ideas that have been circulating around for decades. The classic one is to blame non-urgent patients for using the ED. They are not responsible for ED crowding. Diverting non-urgent patients away can be dangerous and won’t solve the underlying problem. CAEP published a position statement on emergency department overcrowding in 2013. CAEP argued for nationally standardized performance benchmarks. The statement also called for system-level solutions to improve flow while recognizing that ED optimization alone cannot solve crowding without hospital-wide and community-wide action. While CAEP’s advocacy has influenced awareness, policy discussion, and accountability framing, significant problems continue into 2026. Clinical Question: Across Alberta ED visits, what patient-, visit-, and facility-level factors are associated with longer ED length of stay? Reference: Lang et al. Factors associated with emergency department length of stay in Alberta: a study of patient-, visit-, and facility-level factors using administrative health data. CJEM. 2026 Jan 29. Population: ED visits drawn from linked Alberta Health Services administrative data for 14 ED facilities in Alberta, covering May 2022 to March 2023. Exposures: Factors such as age, deprivation measures, EMS arrival, triage acuity (CTAS), primary care continuity, time/day patterns, and facility-level constraints, including emergency inpatient pressure and hospital occupancy; staffing signals (hours worked per nurse) were also examined. Comparison:Between levels of each exposure, typically relative to a reference category or per-unit change (hospital occupancy, EMS vs non-EMS arrival, different facility types, weekday vs weekend, etc.). Outcomes Primary Outcome:ED tot

Date: January 3, 2026 Reference: Shroyer et al. Accuracy of cath lab activation decisions for STEMI-equivalent and mimic ECGs: Physicians vs. AI (Queen of Hearts by PMcardio). Am J Emerg Med. 2025 Nov. Guest Skeptic: Dr. Amal Mattu has been on the faculty at the University of Maryland since 1996. He has developed an academic niche in emergency cardiology and electrocardiography, and he also enjoys teaching and writing on other topics, including emergency geriatrics, faculty development, and risk management. Amal is currently a tenured professor and Vice Chair of Emergency Medicine at the University of Maryland School of Medicine, and a Distinguished Professor of the University of Maryland-Baltimore. Case: A 58-year-old man with diabetes and hypertension arrives at the emergency department (ED) 30 minutes after the sudden onset of substernal chest pressure radiating to the left arm, now improved to 3/10. His vital signs are BP 146/88, HR 92, RR 18, O2 sat 98% on room air. The initial 12-lead ECG shows RBBB with left anterior fascicular block and subtle anterior ST‑depression with proportionally tall, broad T waves in V2 to V4. This is an appearance that can be seen with Hyper-Acute T Wave Occlusive Myocardial Infarction (HATW‑OMI) or an ST-Elevated Myocardial Infarction (STEMI)‑mimic in conduction disease. A debate ensues between emergency medicine and cardiology on whether to activate the cath lab now or get troponins plus serial ECGs? Background: Emergency physicians need to be experts at interpreting ECGs. For decades, we’ve been taught STEMI criteria, only to learn repeatedly that important exceptions exist (posterior OMI, de Winter, hyperacute T waves, modified Sgarbossa in LBBB, etc.). Those exceptions have evolved into two distinct categories. There are the STEMI‑equivalents (OMI without classic ST‑elevation) and STEMI‑mimics (ST‑elevation without OMI). That expanding exception list increases diagnostic complexity and uncertainty. This is the area where artificial intelligence (AI), utilizing computer vision and machine learning, could provide a benefit. ECG-specific AI models now aim squarely at this problem. The study we are reviewing today evaluated the Queen of Hearts (QoH) AI. It is a deep neural network trained to detect occlusive myocardial infarction (OMI) on 12-lead ECGs. The model is described as “91% accurate” in prior work and is undergoing FDA review as of March 24, 2025, but whether it outperforms practicing clinicians on the hardest cases (STEMI‑equivalents and mimics) remained unclear. ECG diagnostic accuracy is important in emergency medicine because misclassification cuts both ways. Missed OMI delays reperfusion, while overcalls send patients and teams to the cath lab unnecessarily, putting patients at risk and using up valuable resources. A diagnostic aid that catches true positive OMIs while reducing false activations could improve outcomes and team throughput. Clinical Question: Among EM physicians and cardiologists interpreting STEMI‑equivalent and STEMI‑mimic ECGs, how accurate are they compared with a machine‑learning ECG algorithm? Reference: Shroyer et al. Accuracy of cath lab activation decisions for STEMI-equivalent and mimic ECGs: Physicians vs. AI (Queen of Hearts by PMcardio). Am J Emerg Med. 2025 Nov. Population: 53 emergency physicians and 42 cardiologists from a community system. Intervention: Human interpretation and QoH AI algorithm classifying each ECG as OMI requiring immediate CLA vs not Comparison (Reference Standard): OMI Present: Angiographic culprit with ≤TIMI II flow and elevated troponin, or culprit with TIMI III flow and significantly elevated troponin. OMI Absent: No culprit ≥50% stenosis on angiography or, when no angiography, negative serial troponins, no new echo wall‑motion abnormality, and negative clinical follow-up Outcome: Diagnostic accuracy of ECG-based CLA decisions. CLA‑positive was defined a priori for STEMI/STEMI‑equivalents and for “reperfused OMI” (Wellens, transient STEMI). Type of Study: A cross-sectional diagnostic accuracy study using a fixed case‑set, with comparisons to a reference standard. Authors’ Conclusions: “Physicians frequently misinterpret STEMI-equivalent and STEMI-mimic ECGs, potentially impacting CLA decisions. QoH AI demonstrated superior accuracy, suggesting a potential to reduce missed OMIs and unnecessary catheterization laboratory activations. Prospective studies are needed to validate these findings in clinical practice.” Quality Checklist for a Diagnostic Study: The clinical problem is well-defined. Yes The study population represents the target population that would normally be tested for the condition (ie no spectrum bias). No The study population included or focused on those in the ED. No The study participants were recruited consecutively (i.e. no selection bias). No The diagnostic evaluation was sufficiently comprehensive and applied equally to all patients (i.e. no evidence of verification bias). No All diagn

Date: January 6, 2026 Guest Skeptic: Darren McKee is an author and speaker. He has served as a senior policy advisor and policy analyst for over 17 years. Darren hosts the international award-winning podcast, The Reality Check. He is also the author of an excellent, thought-provoking book called Uncontrollable: The Threat of Artificial Superintelligence and the Race to Save the World (2023). The book lays out what AI is, why advanced systems could pose real risks, and what individuals and institutions can do to increase AI safety. We have discussed AI on the SGEM a few times: SGEM Xtra: Rock, Robot Rock – AI for Clinical Research SGEM#459: Domo Arigato Misuta Roboto – Using AI to Assess the Quality of the Medical Literature SGEM#460: Why Do I Feel Like, Somebody’s Watching Me – CHARTWatch to Predict Clinical Deterioration SGEM#472: Together In Electric Dreams – Or Is It Reality? AI already touches the emergency medicine world through triage, documentation (AI scribes), imaging, and patient communications. You argue in the book that we’re in exponential times, AI capabilities may accelerate, and that simple rules won’t reliably constrain advanced systems. All of which has implications for safety, bias, reliability, and public trust in healthcare. The book is divided into three sections. I expanded on that so I could ask Daren questions about five different areas. Listen to the SGEM Xtra podcast to hear his responses: Five Questions for Darren Origin Story & Stakes: The book's introduction contrasts the confident historical skepticism about nuclear power with the speed with which reality overtook it. Give us a brief history of nuclear power. Then the book pivots to today’s AI and uses an analogy of humanity’s "smoke detector " moment. Explain what that is and why you decided now was the time to write this book. Part I: What is Happening? In the first part of the book, you build a narrative from AI to AGI to ASuperI. Can you provide some definitions of those terms and explain why they matter? Can you walk us through how current systems (large language models and image models) work at a high level? Why did emergent capabilities surprise even their builders, and why don’t we fully understand what’s happening under the hood of these machines? Part II: What are the Problems? You outline six core challenges: exponential progress, uncertain timelines (and expert disagreement), the alignment problem, why simple rules (à la “Three Laws”) fail, how control erodes as tech integrates into our lives, and how all this aggregates into societal risk. We are not going to go through all six, but could you explain the alignment problem? The other topic I wanted to expand on was the Three Laws. Part III: What Can We Do? The last two chapters get practical and discuss what institutions can do for safe AI innovation and what individuals can do to increase AI safety. Give us your top 2 or 3 institutional moves (transparency, evaluation, guardrails). How about your top 2 to 3 personal moves that listeners can do? AI in the Emergency Department: Bring it home for us in the emergency department if you can. When an AI-enabled tool is proposed for triage, documentation, or image support, what are the three questions every emergency clinician or leader should ask before adoption? The SGEM will be back next episode with a structured critical appraisal of a recent publication. Our goal is to reduce the knowledge translation (KT) window from over 10 years to less than 1 year using the power of social media. So, patients get the best care, based on the best evidence. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Reference: Aronson PL, et al. Prediction Rule to Identify Febrile Infants 61–90 Days at Low Risk for Invasive Bacterial Infections. Pediatrics. September 2025 Date: January 6, 2026 Dr. Jillian Nickerson Guest Skeptic: Dr. Jillian Nickerson is a pediatric emergency medicine attending at Children’s National Hospital and Assistant Professor of Pediatrics and Emergency Medicine at The George Washington University School of Medicine and Health Sciences in Washington, DC. Prior to completing her PEM fellowship, she completed an emergency medicine residency at Mount Sinai in New York. Now she is also the associate program director for the pediatric emergency medicine fellowship program at Children’s National Hospital. Background: Fever is a common complaint that we encounter in the emergency department. In general, we want to be careful in our counseling and our practice not to perpetuate many of the myths and misconceptions that contribute to fever phobia. But there are certain populations where fever does get us a bit worried. When infants present with fever, we have to think about evaluating for other sources of infection such as bacteremia or meningitis, termed invasive bacterial infections (IBI). Fortunately, the prevalence of IBI tends to be low, but missing one could lead to significant morbidity or mortality. How do we determine whom to test and what tests to perform? We’ve covered multiple clinical decision rules for risk-stratifying febrile infants before on the SGEM: SGEM #171: Step-by-Step Approach to the Febrile Infant SGEM#296: She’s Got the Fever but Does She Need an LP, Antibiotics or an Admission? SGEM#341: Are the AAP Guidelines for the Evaluation and Management of the Well-Appearing Febrile Infant SGEM#387: Lumbar Punctures in Febrile Infants with Positive Urinalysis SGEM #474: Help! Which Clinical Decision Aid Should I Use to Risk Stratify Febrile Infants? Some of these clinical decision rules like Step by Step can be applied to infants up to 90 days. Others like the 2021 American Academy of Pediatrics (AAP) clinical practice guideline and the Pediatric Emergency Care Applied Research Network (PECARN) clinical decision rule, only include infants up to 60 days. Clinical Question: Is there an accurate prediction rule to identify well-appearing febrile infants 61–90 days old who are at low risk for invasive bacterial infection (IBI)? Reference: Aronson PL, et al. Prediction Rule to Identify Febrile Infants 61–90 Days at Low Risk for Invasive Bacterial Infections. Pediatrics. September 2025 Population: Non-ill-appearing febrile infants 61–90 days who had evaluation with both urinalysis/urine dipstick and blood culture Excluded: infants who were critically ill (ESI level 1, intubated, received vasoactive medication), death in the ED, prematurity ≤32 weeks, substantial pre-existing medical or surgical conditions, skin or soft tissue infections, home antibiotic use before ED visit Intervention: Derivation of a clinical prediction rule using urinalysis, temperature, ANC, ± procalcitonin. Comparison: none Outcome: Primary Outcome: Accuracy of the prediction rule to identify infants at low risk for IBI, defined as bacteremia or bacterial meningitis. Secondary Outcomes: none Trial: Retrospective cohort study Dr. Nathan Kuppermann Dr. Paul Aronson Authors: Dr. Paul Aronson is a pediatric emergency medicine attending and Professor of Pediatrics and Emergency Medicine at Yale School of Medicine. He is the Deputy Director of the Pediatric Residency Program and leads the Research Track. Dr. Nathan Kuppermann is executive vice president, chief academic officer of Children's National Hospital and director of the Children's National Research Institute. He also serves as chair of the Department of Pediatrics and associate dean of Pediatric Academic Affairs at the George Washington University School of Medicine and Health Sciences. Dr. Kuppermann is a pediatric emergency medicine physician, clinical epidemiologist and leader in emergency medical services for children. Authors’ Conclusions: We derived two accurate clinical prediction rules to identify febrile infants 61–90 days at low risk for invasive bacterial infections when urine and blood testing are obtained. Prospective validation is needed. Quality Checklist for Clinical Decision Rules: The study population included or focused on those in the ED. Yes Where was the study conducted (external validity). Conducted across 17 EDs in the PECARN Registry over 10 health systems (with many pediatric EDs). The patients were representative of those with the problem. Unsure. All important predictor variables and outcomes were explicitly specified. Yes This is a prospective, multicenter study including a broad spectrum of patients and clinicians (level II). No Clinicians interpret individual predictor variables and score the clinical decision rule reliably and accurately. Yes Is this an impact analysis of a previously validated CDR (level I study)? No For Level

Date: January 17, 2026 Reference: Casey et al. RSI Investigators and the Pragmatic Critical Care Research Group. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. NEJM. 2025 Dec Guest Skeptic: Dr. Scott Weingart is an ED Intensivist from New York. He did fellowships in Trauma, Surgical Critical Care, and ECMO. Scott is best known for talking to himself about Resuscitation and Critical Care on the podcast EMCrit, which has been downloaded more than 50 million times. Scott and I will both be presenting at Incrementum 2026 in Spain. Case: You’re working an evening shift in a busy tertiary-care emergency department (ED). Emergency Medical Services (EMS) rolls in a 62-year-old woman with a history of hypertension and type 2 diabetes. She’s febrile at 39.2°C, tachycardic at 125 beats/min, hypotensive at 86/52 mm Hg despite 2 L of crystalloid and breathing 32/min on a non-rebreather with oxygen saturation of 88%. Chest X-ray shows a right‑lower‑lobe infiltrate; lactate is 5.6 mmol/L. She’s now on a norepinephrine infusion at 0.15 µg/kg/min and still looks exhausted and altered. You decide she needs emergent rapid sequence intubation (RSI) for worsening work of breathing and impending respiratory failure. The respiratory therapist is at the bedside, the pharmacist has arrived with the RSI box, and your resident says: “For induction, should we go with ketamine because she’s septic and hypotensive, or etomidate because we’re worried about pushing her over the edge?” Background: Intubating critically ill patients can be one of those high-stakes, high-adrenaline things we do often in emergency medicine (EM), but the physiology is stacked against us. These patients are often hypoxic, hypotensive, acidotic and catecholamine-depleted before we even reach for the laryngoscope. Emergency airway registries and multicentre cohorts consistently report serious peri-intubation complications (profound hypotension, hypoxemia, cardiac arrest, failed or difficult intubation) in roughly 10% to 20% of critically ill adult intubations in the ED and ICU [1]. Even a single episode of severe hypotension or hypoxemia during intubation is associated with increased mortality and organ failure in the ICU population [2]. So, the choice of induction agent seems to matter. Etomidate became the darling of emergency RSI because it has a rapid onset, short duration, and relatively preserved hemodynamics compared with agents like thiopental or high‑dose propofol [3]. The flip side is adrenal suppression: a single dose transiently inhibits 11‑β hydroxylase and measurably blunts cortisol production for 24–72 hours. Observational studies and post‑hoc analyses in septic shock raised alarms that etomidate might increase mortality by worsening relative adrenal insufficiency, leading some guidelines and regulators to discourage or even remove etomidate in sepsis [4]. But those were mostly non-randomized data, and prior RCTs comparing etomidate with other agents were small and gave conflicting signals about mortality. Ketamine, by contrast, is a dissociative NMDA antagonist with a very different vibe. It provides profound amnesia and analgesia, maintains airway reflexes to some degree, and has sympathomimetic properties that can increase heart rate and blood pressure by catecholamine release [5]. Those properties have made ketamine attractive in shocked patients where we’re worried that propofol or midazolam will “tank the pressure”. However, in catecholamine-depleted septic shock, ketamine’s direct myocardial depressant effects may become more apparent, and registry data suggest its hemodynamic advantage over etomidate is not as clear as many of us were taught on shift. Old concerns that ketamine raises intracranial pressure have largely been debunked in modern neurocritical care literature, further widening its appeal. Other agents are still in the mix. Propofol remains widely used in operating theatre practice and some EDs because of its familiarity and ease of titration, but it predictably causes vasodilation and negative inotropy, making it a frequent offender in peri‑intubation hypotension among critically ill patients [6]. Benzodiazepines (midazolam) have a slower onset, a more variable effect and a longer half‑life, and when used as primary induction agents in shock, they’ve been associated with more hypotension and delirium compared with etomidate or ketamine. Fentanyl and other opioids are often layered on for analgesia or “blunting” the sympathetic surge, but they can also precipitate abrupt hypotension and apnea in the already fragile patient. So for years we’ve been stuck between the theoretical adrenal toxicity of etomidate and the hoped‑for hemodynamic benefits of ketamine, without a large, definitive randomized trial in ED/ICU patients powered for patient‑important outcomes like mortality. Clinical Question: In critically ill adults undergoing emergency tracheal intubation in the ED or ICU, which induction agent is bett

Date: January 5, 2026 Reference: Robblee et al. 2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. Headache 2025 Dec Happy New Year, SGEMers! What better way to start 2026 than with an SGEM Xtra about migraine headaches? We were originally scheduled to record this episode in December, but circumstances changed. This is another SGEM Xtra and not the typical structured critical appraisal with a checklist. It will be a conversation about what we should be doing and should stop doing when treating migraine patients in the ED based on the new American Headache Society (AHS) guidelines. However, you will find a standard SGEM nerdy critical appraisal at the end of this blog post. Migraine is one of the most common causes of headache visits to the ED, representing ~¼ of the 3.5 million annual headache-related visits in the US. Despite prior guidelines, ED practice is still all over the map, and patients sometimes leave without much relief. The AHS has just released the 2025 guideline update on parenteral pharmacotherapies and nerve blocks for adult ED migraine. To help us understand these new guidelines, we are joined by two neurologists who literally wrote the guidelines. Dr. Jennifer Robblee Dr. Jennifer Robblee (lead guideline author) is a Board‑certified neurologist and headache specialist at Barrow Neurological Institute in Phoenix. Her practice focuses on refractory migraine and status migrainosus. She trained at the University of Toronto (MD, neurology residency, MSc) and completed a headache fellowship at the Mayo Clinic Scottsdale. Jennifer is the third eurologist to be on the SGEM. We’ve had Dr. Jeff Saver and Dr. Ravi Garg discuss thrombolytics and stroke. This will be an example that not all of neurology and emergency medicine intersect over stroke care. Dr. Serena Orr Dr. Serena Orr (senior guideline author) is a pediatric neurologist, headache subspecialist, and director of the pediatric headache program at Alberta Children’s Hospital in Calgary. Serena has a strong interest in acute treatment of migraine, tech‑based treatment solutions, and psychosocial factors affecting migraine in kids and teens. The AHS guideline committee uses a 5-year update cycle for guidelines. Since 2016, 26 new RCTs and 20 injectable treatments, including nerve blocks (GONB, SONB, SPG) and eptinezumab. Unfortunately, ED migraine outcomes are still not great. Only ~37% of ED patients achieve headache freedom at discharge. These new guidelines were trying to answer two questions. Which injectable meds are effective in adults with migraine in the ED? Are nerve blocks effective in adults with migraine in the ED? Top 5 things ED should know about the 2025 AHS Migraine Guidelines Listen to the SGEM podcast to hear Jennier and Serena discuss the top five things emergency physicians should know about the 2025 migraine guidelines. 1. Prochlorperazine IV & Greater Occipital Nerve Blocks (GONB) Are Now Level A “Must Offer” IV prochlorperazine and greater occipital nerve blocks (GONB) are Level A - must offer or adults presenting to the ED with a migraine attack requiring parenteral therapy (if no contraindications). Questions: This is a big upgrade from 2016. Why did prochlorperazine and GONB earn Level A status in 2025? Practically, what does that look like in an ED order set? Are you imagining that everyone gets prochlorperazine? For the EM docs who have not been performing occipital nerve blocks, how steep is the learning curve? 2. Hydromorphone Is Level A “Must NOT Offer” Hydromorphone IV: Level A - Must NOT offer for migraine in the ED. Questions: Let’s talk about opioids. Hydromorphone is now ‘must NOT offer’, what tipped the scale to Level A harm/no benefit? “Must NOT offer” seems like a strong statement (thou shalt not), is there not a potential clinical situation where an opioid still should be offered? How do we balance real‑world pressures, patient expectations, throughput, Press Ganey scores with an anti‑opioid, evidence‑based stance? It’s going to impact ED docs and not neurologists. 3. The Level B Recommendations: Level B - “Should offer” for headache requiring parenteral therapy (Dexketoprofen IV, ketorolac IV, metoclopramide IV, subcutaneous sumatriptan, and supraorbital nerve blocks [SONB]). Dexamethasone IV remains Level B “should offer” for recurrence prevention from the 2016 guidance. Questions: If Level A is your starting lineup, who’s on the bench as your Level B ‘should offer’ options, and when do you pull them in? Is there a preferred sequence – dopamine antagonist first, then NSAID, then triptan, or is it more patient‑specific? How should ED clinicians think about dexamethasone? Is it still a routine add‑on, or more selective? 4. Nerve Blocks Are Mainstream GONB: Level A - Must offer. SONB: Level B - May/should offer when GONB is insufficient or not possible. Questions: For a busy ED,

Date: December 23, 2025 Reference: Todd et al. Antihypertensive prescription is associated with improved 30-day outcomes for discharged hypertensive emergency department patients. J Am Coll Emerg Physicians Open. 2024 Guest Skeptic: Dr. Mike Pallaci is a Professor of Emergency Medicine at Northeast Ohio Medical University and a Clinical Professor of Emergency Medicine at Ohio University Heritage College of Osteopathic Medicine. He currently serves as Core Faculty for the USACS EM Residency at Summa Health System in Akron, OH where he is also Medical Director for the Virtual Care Simulation Lab, Director for the Simulation Medicine Fellowship and Vice Chair for Faculty and Resident Development. Over the course of his 24-year career in EM (15 in academics), he has worked in EDs with volumes ranging from 6,000 to 85,000 per year in urban and rural areas, in community and academic institutions, and has served as Program Director for two EM residencies. He has given lectures and published podcasts and articles in all areas of Emergency Medicine, including at the ACOEP Scientific Assembly, on the EM:RAP platform and right here on the SGEM. Prior research has resulted in book chapters, journal publications and presentations at multiple regional, national and international conferences on numerous topics including medical education, chest pain, pain management, gender bias, documentation, wellness, medicolegal issues, emergency ultrasound, hypertension and others. Case: A 47-year-old male presents to the emergency department (ED) with an ankle sprain. Admitting vital signs include a blood pressure of 210/130, which is similar on repeat measurements. He has no complaints except for ankle pain. He is in good health, has no known medical history, and has a primary care doctor whom he hasn't seen in about 6 or 7 years. Background: Hypertension is one of the most common “incidental” findings in the ED. In the US, there are over 900,000 annual ED visits with elevated blood pressure, and that number is climbing each year. Up to a third of these patients have no prior diagnosis of hypertension. Chronic uncontrolled blood pressure is strongly associated with myocardial infarction, stroke, heart failure, renal failure, and death, so these “incidental” readings are not benign. Standard outpatient care focuses on confirming the diagnosis with repeated measurements and then starting long-term therapy (lifestyle plus medications) to reduce cardiovascular events and mortality over the years, with randomized trial and meta-analytic evidence that treating hypertension reduces composite cardiovascular events and death. The ED, however, sits at an awkward intersection between chronic disease and acute care. Many patients we see with elevated blood pressure are asymptomatic or have nonspecific complaints, with no clear end-organ damage. Guidelines generally allow ED physicians considerable discretion about whether to initiate oral antihypertensives at discharge versus simply arranging follow-up. In 2025, the American College of Emergency Physicians (ACEP) published an updated policy regarding patients with asymptomatic markedly elevated blood pressure. They asked whether ED medical intervention reduces rates of adverse outcomes. They provided a Level C Recommendation that said: In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required. In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control. [Consensus recommendation] Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up. [Consensus recommendation] Previous work suggests that starting antihypertensives from the ED is safe and improves short-term blood pressure control in high-risk populations. Still, there has been very little evidence about patient-oriented short-term outcomes (myocardial infarction, stroke, heart failure, death, and ED revisits). Clinical Question: Among adult ED patients discharged with a diagnosis of hypertension and not on antihypertensive therapy, is an ED discharge prescription for an oral antihypertensive medication associated with a lower 30-day risk of severe hypertension-related adverse events, death, or ED revisits? Reference: Todd et al. Antihypertensive prescription is associated with improved 30-day outcomes for discharged hypertensive emergency department patients. J Am Coll Emerg Physicians Open. 2024 Population: Adult patients (≥18 years) seen and discharged from an ED within a single hospital system with a primary or secondary ED discharge diagnosis of essential (primary) hypertension and hypertensive urgency without prior treatment for hypertension during the previous 18 months. Excluded: Patients admitted to the hospital or to ED observation. Those who died in the ED. Patients without documented elevated blood pressure (BP <

Date: November 27, 2025 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: You are looking after a 65-year-old man who appears to be in septic shock. He presented after five days of fever and cough, and is now severely lethargic and hypotensive on arrival. You give him antibiotics and IV fluids immediately, but an hour later, his lactate comes back at 5, and you need to start norepinephrine to keep his MAP above 65. You put in a call to the intensive care unit (ICU) to get him transferred, and the intensivist asks you whether you have started personalized hemodynamic resuscitation targeting capillary refill time. You don’t want to sound dumb, but what the heck is personalized hemodynamic resuscitation protocol targeting capillary refill time? Background: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is the most severe end of that spectrum. Patients with sepsis have persistent hypotension requiring vasopressors to maintain MAP ≥65 mm Hg and a lactate >2 mmol/L despite adequate volume resuscitation (Sepsis‑3). In high-income countries, mortality has fallen but remains substantial. In many settings, mortality can be between 30% to 70%. High-quality ED care requires early recognition, IV antibiotics, source control, hemodynamically directed fluids, and vasopressors. The management of septic shock has changed dramatically since the time that Ken and I started practice. We went through a period in which a very aggressive bundle of care was proposed, based on work by Dr. Emanuel Rivers, published in the NEJM in 2001. Then, we ran big trials on the components of that bundle, and found that none of them helped individually (ARISE, ProCESS & ProMISe). It was clear that these patients benefited from close attention and clinical reassessments, but aside from early antibiotics, the exact interventions needed were unclear. For a while, many people focused on trending lactate levels. We then saw the original ANDROMEDA SHOCK study, which showed that a resuscitation strategy focused on clinical assessments of capillary refill time was at least as good as a strategy focused on trending lactates. We have been left with the question of exactly how to improve capillary refill and which other targets are important. There has been a question about whether a higher MAP target might help (SGEM#90), especially in elderly patients with more baseline hypertension. But the recent OPTRESS study showed worse outcomes with a higher MAP target in elderly septic shock patients. Therefore, aside from the consensus that providing early antibiotics is a good idea, there remain many questions about the ideal initial resuscitation strategy for septic shock patients. Clinical Question: In adult patients with septic shock, can death, duration of vital support, and/or hospital length of stay be improved by a “personalized hemodynamic resuscitation protocol targeting capillary refill time? Reference: Hernandez et al. Personalized Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial. JAMA. 2025 Oct Population: Adults (≥18 y) with septic shock per Sepsis‑3 (vasopressors after ≥1 L IV fluid and lactate >2 mmol/L), within 4 hours of shock onset. Key Exclusions: >4 h from shock onset; anticipated surgery or dialysis within 6 h; expected survival <90 days; refractory shock; DNAR; Child‑Pugh B/C; severe ARDS; active bleeding; pregnancy; inability to assess CRT (peripheral vascular disease, hypothermia, very dark skin tone, Raynaud phenomenon). Intervention: A personalized hemodynamic resuscitation protocol targeting capillary refill time (CRT) using a 6-hour stepwise algorithm (see below). Comparison: Usual care per local protocols/guidelines. Outcome: Primary Outcome: A hierarchical composite tested with a stratified win ratio of: (1) 28-day all-cause mortality, then (2) duration of vital support (time requiring cardiovascular, respiratory, or kidney support) through day 28, then (3) hospital length of stay through day 28. Secondary Outcomes: Secondary outcomes were each of the three components of the primary outcome. Trial: This is a pragmatic, multi-center, open-label, randomized controlled trial. Authors’ Conclusions: “Among patients with early septic shock, a personalized hemodynamic resuscitation protocol targeting capillary refill time was superior to usual care for the primary composite outcome, primarily due to a lower duration of vital support.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias)

Date: Dec 17, 2025 Reference: Pagnini F, et al. Unexpected events and prosocial behavior: the Batman effect. npj Mental Health Research. November 2025 Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine physician at Children’s National in Washington, DC. You may also know him as the host of SGEM Peds. Case: It’s been a dark, cold day in Gotham City. You’re finally on the metro heading home after a long shift. The train is packed, and you’re standing, crammed uncomfortably among all the other citizens eager to get home. Outside, you see the holiday lights and decorations, trying valiantly to shine through the flurries of snow. At the next stop, you see a visibly pregnant passenger board the crowded train car. She shuffles in and stands, holding the rail. No one around her moves. No one gets up to offer their seat. Hardly anyone even notices. You pull your coat a bit tighter around you and wonder: What’s it going to take to nudge people to be a little more helpful? Background: Prosocial behaviour is something we rely on every shift but hardly ever discuss explicitly. Psychologists typically define it as voluntary actions aimed at helping others. Examples include holding a door open, donating money, giving up your seat, or stepping in to assist a stranger. It’s an umbrella term that covers everything from simple everyday kindness to extraordinary acts of altruism. The world just saw an extraordinary example of prosocial behaviour in the Bondi Beach attack ‘hero’, Ahmed Al Ahmed. Motivations vary: empathy and concern for others, a desire to follow social norms, expectations of reciprocity, and even a wish to avoid guilt all influence prosocial behaviour. Prosocial behaviour has traditionally been studied in several primary ways. In the lab, researchers use economic games (such as dictator, ultimatum, and public goods games), staged helping tasks (such as picking up dropped pens or assisting with a “broken” computer), or vignette-based scenarios (“Would you stop to help?”). In real-world settings, classic bystander studies explore whether people intervene when someone seems in need and what situational factors (crowding, diffusion of responsibility, perceived danger) influence their decision to act or remain passive. Throughout all approaches, a key theme is that context plays a crucial role: the same individual may assist in one situation but ignore someone in another. Over the past decade, there has been increasing interest in how subtle environmental cues influence prosocial behaviour. Mindfulness research indicates that when people focus on the present moment, they may be more inclined to notice others’ needs and respond accordingly, although the evidence remains modest and not definitive. Another area of study examines "social primes." For example, images of superheroes can temporarily boost helping intentions and small acts of assistance. A related body of research on the “pique technique” demonstrates that unusual, unexpected events or requests can disrupt automatic “no” responses and increase compliance or helping, likely by pulling people out of autopilot. The “Batman effect” study we explore today extends these ideas into real-world scenarios. Could an unexpected disruption, such as a person dressed as Batman, increase a specific prosocial behaviour? For an emergency physician accustomed to crowded waiting rooms and chaotic departments, it’s an intriguing yet potentially significant question: can small, harmless environmental “shocks” encourage people to do the right thing a little more often without anyone ever having to take a mandatory module on ethics? Clinical Question: Among passengers on a crowded metropolitan subway, does the presence of an unexpected event (a person dressed as Batman) increase the likelihood that someone offers their seat to a pregnant-appearing woman, compared with no Batman present? Reference: Pagnini F, et al. Unexpected events and prosocial behavior: the Batman effect. npj Mental Health Research. November 2025 Population: Passengers in crowded cars on the Milan underground metro. Intervention: Presence of someone dressed as Batman (~3 meters away, no interaction with an experimenter pretending to be a visibly pregnant woman). Comparison: Identical set-up without Batman Outcome: Whether the seated passenger offered their seat to the (pretend) pregnant woman during a single-stop ride Type of Study: Quasi-experimental, non-randomized controlled field study. Both conditions were conducted simultaneously in different train cars and different areas of the platforms. Authors’ Conclusion: “This study suggests that unexpected events can increase prosocial behavior by momentarily disrupting automatic attention patterns and fostering situational awareness. These findings open new avenues for understanding the environmental and cognitive mechanisms underlying prosociality, and suggest potential applications for promoting kindness and cooperation in everyday setti

Reference: Binder ZW et al. “Ultrasound-Guided Nerve Block for Pediatric Femur Fractures in the Emergency Department: A Prospective Multi-Center Study.” Academic Emergency Medicine, 2025. Date: November 24, 2025 Dr. Lauren Westafer Guest Skeptic: Dr. Lauren Westafer is an Associate Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School, Baystate. She is the co-founder of FOAMcast and a researcher in pulmonary embolism and implementation science. Dr. Westafer serves as the research methodology editor for Annals of Emergency Medicine. Case: A 9-year-old boy presents to the emergency department after a trampoline injury. He was at a party with his friends and they were all bouncing together and competing to see who could bounce the highest. The boy fell down on his right leg and a friend accidentally landed on it. On your exam, the boy is in significant pain and has a deformity of his right leg. You do not note any additional injuries. X-rays confirm a mid-shaft femur fracture. You administer some IV morphine, but the boy is still whimpering in pain. One of the other attending physicians on shift who happens to be an ultrasound enthusiast, suggests using an ultrasound-guided nerve block as a way to manage the boy's pain. The boy’s parents ask “What is that?” Background: Femur fractures are one of the most painful injuries in pediatric patients and frequently require hospital admission for definitive treatment, often with long ED stays prior to operative management. Traditional pain management for these injuries relies heavily on IV opioids, which have well-documented side effects including nausea, respiratory depression, and sedation. Increasing public awareness of the opioid crisis has also led to growing parental concern over opioid exposure in children. There is growing interest in opioid-sparing pain control methods. The fascia iliaca compartment nerve block (FICNB) is a regional anesthesia technique that targets the femoral nerve and adjacent sensory nerves to provide localized pain relief. While landmark-based FICNB techniques have been used successfully in adult patients, recent studies suggest that ultrasound guidance improves the accuracy and safety of these procedures. However, evidence on the effectiveness and safety of ultrasound-guided FICNB in pediatric patients, particularly when performed by emergency physicians in real-world ED settings, remains limited. Clinical Question: In children with femur fractures, is ultrasound-guided FICNB more effective at reducing pain compared to systemic analgesia? Reference: Binder ZW et al. “Ultrasound-Guided Nerve Block for Pediatric Femur Fractures in the Emergency Department: A Prospective Multi-Center Study.” Academic Emergency Medicine, 2025. Population: Children aged 4–17 years presenting to the ED with isolated, acute femur fractures. Excluded: Patient with neurovascular compromise, multi-trauma, GCS ≤13, bilateral fractures, allergy to anesthetics, prisoners, pregnancy. Intervention: Ultrasound-guided fascia iliaca compartment nerve block (FICNB) performed with ropivacaine or bupivacaine Comparison: Systemic analgesia administered at discretion of ED treating team Outcome: Primary Outcome: Reduction in pain intensity at 60 minutes using the Faces Pain Scale–Revised (FPS-R). Secondary Outcomes: Reduction in pain at 240 minutes, opioid consumption (oral morphine equivalents per hour), occurrence of adverse events, and emergency department (ED) length of stay. Trial: Prospective multi-center observational study conducted at 12 pediatric emergency departments in the US and Australia. Some sites performed FICNB. Other sites did not. Dr. Zachary Binder Guest Author: Dr. Zachary Binder is a pediatric emergency medicine attending physician at UMass Memorial Health and Associate Professor at UMass Chan Medical School. He is the Director of Point-of-Care Ultrasound for the Department of Pediatrics and the medical school. Authors’ Conclusions: Children who received FICNB had greater reductions in pain intensity and required less opioid medication than those who did not. This is the largest prospective study evaluating the ultrasound-guided FICNB performed on children in the ED, and its findings support the procedure’s use for pediatric femur fracture pain management. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes. Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes. How precise are the results? Fairly precise Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes. Fu