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

Date: December 4, 2025 Guest Skeptic: Dr. Jestin Carlson – Long-time listener, second-time guest. Reference: Reinaud et al. Reporting of Noninferiority Margins on ClinicalTrials.gov: A Systematic Review. JAMA Netw Open. 2025 Case: You are working with a resident who asks you about a new thrombolytic they heard about on the SGEM for acute ischemic stroke. This new treatment was found not to be inferior to the existing thrombolytic, but they are not sure how the paper reached that conclusion. You start to discuss noninferiority margins when the resident asks you, “Are the noninferiority margins reported on ClinicalTrials.gov consistent with the final publications?” Background: A non-inferiority (NI) trial asks whether a new strategy is “not unacceptably worse” than an established, effective strategy by more than a pre-specified amount. The non-inferiority margin (Δ) or delta is the largest loss of effectiveness we would tolerate in exchange for another advantage (lower cost, easier logistics, fewer adverse effects). Regulators and methods groups emphasize that Δ must be clinically justified, pre-specified, and not chosen after seeing the data. The Δ is then tested using a one-sided hypothesis procedure or, equivalently, by checking whether the confidence interval for the treatment difference stays within Δ. For example, a new medicine to treat hypertension lowers patients’ systolic blood pressure by 1 point more than the standard treatment but causes gastrointestinal (GI) upset in 50% of patients. That difference may be statistically significant, but clinically it doesn’t result in a net benefit for the patients since so many of them get GI upset. Ideally, the noninferiority margins should be set up before the trial is conducted to minimize bias. Many modern ED trials rely on NI logic (TNK vs tPA for stroke, non-operative treatment of appendicitis, Simple Aspiration versus Drainage for Complete Pneumothorax, etc). However, prior work suggested poor reporting of noninferiority margins with reporting rates as low as 2.6% for studies published between 2012 and 2014. That was over 10 years ago...hopefully we have improved since then. Clinical Question: What proportion of registered noninferiority randomized trials report the noninferiority margin at registration, and how consistent are margins between ClinicalTrials.gov and corresponding publications? Reference: Reinaud et al. Reporting of Noninferiority Margins on ClinicalTrials.gov: A Systematic Review. JAMA Netw Open. 2025 Population: All registered non‑inferiority trials on ClinicalTrials.gov with primary completion 2010–2015 (Stage 1) and all first‑posted 2022–2023 (Stage 2). Excluded: Nonrandomized, single-arm, phase 1–2/2–3, diagnostic/screening trials where noninferiority was only a secondary outcome. Exposure: Presence of a prespecified noninferiority margin reported on ClinicalTrials.gov (at registration / during enrollment / after primary completion / in posted results). Comparison: Descriptive contrasts across timepoints and between the registry and corresponding publications (consistency). Outcome: Primary Outcome: Proportion reporting the noninferiority margin at registration on ClinicalTrials.gov. Secondary Outcomes: Timing of first reporting (registration, during enrollment, after completion, or in posted results); proportion reporting margin in posted results; proportion reporting margin in the corresponding publication; justification of margin; consistency between registry and publication; reporting of primary analysis population and Type I Error. Type of Study: A systematic review of registered randomized trials’ methods reporting. Authors’ Conclusions: “Reporting of the noninferiority margin on ClinicalTrials.gov was low (3.0% in 2010–2015 sample, 9.2% in 2022-2023 sample). Because margins are central to design and interpretation, mandatory reporting of trial design and the noninferiority margin at registration would improve transparency and reliability of noninferiority trial results.” Quality Checklist for Systematic Review: Was the main question clearly stated? Yes Was the search detailed and exhaustive? Yes Were the inclusion criteria appropriate? Yes Included studies sufficiently valid? Yes Results similar from study to study? Yes Any financial conflicts of interest? Authors do not report any financial conflicts of interest. Results: In the 2010 to 2015 cohort (n=266), 60% were industry‑funded; most evaluated drugs/biologics (~67%); parallel‑arm designs predominated (94%); open‑label was common (49%); adults‑only accounted for 74%; and the median planned sample size was 304 (IQR 63 to 545). The 2022 to 2023 cohort (n=327) showed similar patterns with more adult-only studies (83%) and a median planned sample size 228 (IQR 50 to 406). Key Result: Very few trials pre-specified a Δ at registration, a super majority reported a Δ in their publication and registry‑to‑publication consistency could only be evaluated in a handful of studies. 2010 t

Date: November 26, 2025 Reference: Ray et al. Emergency Department Visit Frequency Among Adults with Chronic Abdominal Pain: Findings From the 2023 US National Health Interview Survey. AEM November 2025. Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine in the UK and an evidence-based medicine advocate. She's a seasoned knowledge translator with her PaperinaPic infographics. Case: You are mid-shift in what feels like the never-ending winter of emergency medicine, and you hear the sigh as your resident picks up the chart of the next patient to be seen. Wondering if the resident requires coffee or support, you ask what is wrong. “I’m good, it’s just this is the third patient with acute worsening of abdominal pain they’ve had for years that I’ve seen this week. What’s going on?” Background: Abdominal pain is a frequent reason for presentation to the emergency department (ED), generating over 13 million visits in the US in 2022. As emergency care providers, we are taught to think of the worst-case diagnoses (aneurysmal, ischaemic, an ectopic pregnancy, appendicitis, etc). Once the “bad stuff” is excluded, it’s tempting to breathe a sigh of relief and “not my concern”. However, there is an estimated population prevalence of chronic abdominal pain of around 22 per 1,000 person-years. According to the International Association for the Study of Pain, this is defined as abdominal pain without a clear diagnostic explanation that lasts for 3 months or more. Often, patients with these symptoms have been diagnosed with “functional” abdominal pain, although more recent terminology uses “Disorders of Gut-Brain Interaction”. Managing patients with acute-on-chronic pain syndromes in the ED can be very challenging, particularly if continuity of care is lacking for their chronic condition. This has been addressed to some extent by the GRACE-2 guidance on managing recurrent low-risk abdominal pain, which de-emphasizes repeated routine imaging and recommends opioid-minimizing strategies for symptom management. Clinical Question: Do people with chronic abdominal pain have higher rates of ED utilization than those without? Reference: Ray et al. Emergency Department Visit Frequency Among Adults with Chronic Abdominal Pain: Findings From the 2023 US National Health Interview Survey. AEM November 2025. Population: Adult respondents to the National Health Interview Survey 2023 who completed the question on demographics, pain, healthcare seeking behaviours, disability, mental health, past medical history and social determinants of health. Exclusion: The entire survey excludes people without a permanent household address, active-duty military personnel or civilians on military bases, and residents of long-term care facilities. For this study, the authors also excluded people reporting a history of cancer, Crohn’s disease and ulcerative colitis and those who were pregnant. Exposure: Chronic abdominal pain (CAP) was defined by the authors as reporting pain “most days” or “every day” over the prior three months, and being “bothered by” abdominal, pelvic or genital pain “somewhere between a little and a lot” or “a lot” over the prior three months. Comparison: Adults without chronic abdominal pain. Outcomes: Primary Outcome: ED visits in the prior 12 months. Secondary Outcomes: Mental health status, physical comorbidities, disability, and social determinants of health. Type of Study: Secondary analysis of a cross-sectional interview study. Dr. Michael Ray This is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Michael Ray is an Assistant Research Professor, Department of Emergency Medicine at George Washington University School of Medicine & Health Sciences. Known as a pain researcher. Clinically practiced as a chiropractor in an outpatient setting, which led to an interest in chronic pain and transition to academia. Authors’ Conclusions: This nationally representative analysis suggests that individuals with CAP have significantly higher ED utilization and face greater burdens of disability, mental health conditions, comorbidities, and SDOH-­related barriers. These findings highlight the potential value of addressing BioPsychoSocial factors to reduce ED reliance and support comprehensive care for CAP patients. 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? Unsure Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Unsure Have the authors identified all important confounding factors? Unsure Was the follow-up of subjects complete enough? N/A How precise are the results? The numbers are large, so they are likely to be reasonably precise, but formal measures of uncertainty, such as credible intervals, aren’t presented in the paper. Do you believe the results? Ye

Date: November 8, 2025 Reference: Millin M, et al., Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries – A NAEMSP Comprehensive Review and Analysis of the Literature, Prehospital Emergency Care, Aug 2025. Guest Skeptic: Clay Odell, BSN, NRP, RN, is a Paramedic Firefighter with Newport (NH) Fire-EMS. He is a past Chief of the NH Bureau of Emergency Medical Services. Previous positions he held are Trauma System Coordinator for the State of NH, Executive Director of Upper Valley Ambulance in Fairlee VT, and a flight crew member at Dartmouth Hitchcock Advanced Response Team. Clay has been a paramedic since 1985 and has been a registered nurse since 1997. Case: Your EMS unit responds to a 911 call for a hunting accident. You arrive to find the patient sitting on the tailgate of his truck. He tells you he fell out of his deer stand, approximately 20 feet, landing on his head. He walked out of the woods about a mile after the fall. His chief complaint is head and neck pain. He has a Glasgow Coma Scale (GCS) score of 15, a hematoma and laceration above his left eye, and he is quite tender over the cervical spine region. You observe your colleagues trying to apply a rigid cervical collar without moving the patient’s neck. It goes about as well as usual, meaning the patient's head is moved a bit. Maybe more than a bit. He then decides he hates the collar and rips it off. He adamantly refuses all attempts to apply a soft collar or improvised towel roll. On arrival at the trauma center, you give a handoff report, and the team leader demands to know why the patient is not in a collar. The patient overhears this and rather profanely informs everyone, "you ain't putting no *F-ing* collar on me". Background: Prehospital care for suspected SCI has two competing imperatives, limiting secondary cord injury while avoiding iatrogenic harm. Historically, EMS prioritized rigid immobilization (long backboard + rigid cervical collar) based on the fear that post-injury movement could precipitate delayed neurologic deterioration. In the last two decades, emergency care has shifted toward selective spinal motion restriction (SMR) and earlier collar removal when appropriate. This reflects a better understanding of risk, test performance, and harms from prolonged immobilization. In the ED, validated decision tools (NEXUS and Canadian C‑spine Rule) help identify very‑low-risk patients who do not need imaging; when imaging is needed, modern multidetector CT outperforms plain radiography for clinically significant cervical spine injury (CSI). A large Western Trauma Association cohort (10,276 patients) found CT sensitivity of 98.5% with a negative predictive value of ~100% for clinically significant injuries. The misses were rare and occurred in patients with focal neurologic deficits, who then warranted an MRI [1]. Prehospital protocols increasingly emphasize minimizing time on a backboard and avoiding prolonged collar use because of pressure injury and other morbidities. A systematic review by the East Association for the Surgery of Trauma (EAST) supports collar removal after a negative high-quality CT in an obtunded adult. They highlight the downstream harm from extended immobilization without added benefit [2]. Pediatrics and geriatrics remain special populations. NEXUS shows high sensitivity in children, though confidence intervals are wider in the very young. Clinicians should have a low threshold for imaging in older adults, who are vulnerable to serious cervical spine injuries from low-energy mechanisms [3]. Clinical Question: In trauma patients with potential SCI, what is the evidence that post‑injury movement causes delayed neurologic deterioration, and what are the benefits and harms of prehospital spinal immobilization and SMR? Reference: Millin M, et al., Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries – A NAEMSP Comprehensive Review and Analysis of the Literature, Prehospital Emergency Care, Aug 2025. Population: Human (and some animals) with potential spinal cord injuries that addressed one of four predefined questions(pathophysiology of delayed neurologic injury, harms of immobilization, effectiveness of immobilization/SMR at limiting movement, and the relationship to delayed neurological injury). Exclusions: Manikin/simulation‑only studies, abstracts without full publication, editorials, other reviews/meta-analyses, guidelines, book chapters, and non-English full manuscripts. Intervention: Prehospital spinal immobilization (long backboard + cervical collar) and SMR (cervical collar ± vacuum splint/ambulance cot) Comparison: No immobilization vs immobilization or alternative immobilization strategies. Outcome: Primary Outcome: Effectiveness of immobilization/SMR at limiting movement and relationship to delayed neurological injury. Secondary Outcomes: Harms of immobilization/SMR (airway/respiratory compromise, raised ICP, pressure ulcers, delays to c

Date: November 12, 2025 Reference: Taccone et al. Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury The TRAIN Randomized Clinical Trial. JAMA 2024 Guest Skeptic: Dr. Alex Weiler is an Emergency Department staff physician in the Peterborough Regional Health Centre and is an associate professor with Queen's University Department of Family Medicine. This podcast was recorded live at the Kawartha EM Conference in beautiful Peterborough, Ontario. Case: A 48-year-old woman presents with a sudden, severe headache and brief loss of consciousness. CT/CTA confirms aneurysmal subarachnoid hemorrhage (SAH). She is coiled and admitted to the intensive care unit (ICU) with an external ventricular drain. On ICU day 3, Hb is 8.4 g/dL (or as we say in Canada 84 g/L), she is not actively bleeding, Glasgow Coma Scale (GCS) of 10 with fluctuating attention, and her expected ICU stay is clearly >72 hours. Background: Acute brain injury (ABI) can occur for a variety of reasons, including aneurysmal SAH (like in this case) or trauma. Anemia is common in patients with ABI and can worsen cerebral hypoxia. For decades, ICU transfusion practice drifted toward “restrictive” triggers (Hb <7 g/dL or <70g/L) based on trials in mixed ICU populations. However, brain-injured patients may not behave like the average ICU patient. The brain is uniquely sensitive to oxygen delivery, and secondary ischemia strongly predicts poor neurological outcomes. Small single-center studies and physiologic work suggested higher hemoglobin could improve brain tissue oxygenation; however, prior randomized evidence has been sparse or inconclusive in discrete ABI subgroups (traumatic brain injury [TBI], SAH), leaving real uncertainty about the optimal transfusion threshold for this population. The TRAIN trial was designed to answer a practical question that matters at the bedside: in adults with ABI who are anemic but not exsanguinating, does a liberal transfusion strategy improve downstream neurological outcomes compared with a restrictive strategy? Clinical Question: In adults with acute brain injury (TBI, aneurysmal SAH, or ICH) who are anemic (Hb <90 g/L), does a liberal RBC transfusion threshold (transfuse when Hb <90 g/L) compared with a restrictive threshold (transfuse when Hb <70 g/L) improve 6-month neurological outcomes? Reference: Taccone et al. Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury The TRAIN Randomized Clinical Trial. JAMA 2024 Population: Adults (18 to 80) in 72 ICUs across 22 countries with TBI, SAH, or ICH. They needed to have an Hb <90 g/L within 10 days of injury and an expected ICU stay of ≥72 hours. Exclusions:Hb >90 g/L, GCS 3 with fixed/dilated pupils, GCS >13 at randomization, active bleeding, expected ICU stay <3 days, prior neurological disease, pregnancy, inability to receive transfusion; others are listed in the flow diagram. Intervention: Liberal strategy (transfuse when Hb <90 g/L for 28 days). Comparison: Restrictive strategy (transfuse when Hb <70 g/L for 28 days). Outcome: Primary Outcome: Unfavourable neurological outcome at 180 days, GOS‑E 1 to 5 (death to severe disability). Secondary Outcomes: 28-day mortality; composite of death or organ failure at day 28; organ failure; ICU/hospital LOS; distribution (“shift”) of GOS‑E; prespecified serious adverse events (cerebral ischemic events, VTE, infections, TRALI, anaphylaxis). Type of Study: A multicenter, pragmatic, parallel group, open-label, RCT Authors’ Conclusions: “Patients with acute brain injury and anemia randomized to a liberal transfusion strategy were less likely to have an unfavorable neurological outcome than those randomized to a restrictive strategy.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the ED. 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. No The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Unsure Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Yes Financial conflicts of interest. Funded by non-profit sources, and the sponsors had no role in design/analysis/reporting. Minor author disclosures unrelated to the intervention were reported. Results: 820 completed the trial, with 806 having the primary outcome (393 liberal; 413 restrictive). Mean age 51 and 46% women. The type of brain injury was ~59% TBI, 23% SAH, 18% ICH overall. GCS at randomization was 6 [IQ

Date: October 17, 2025 Dr. Kristen Panthagani Guest Skeptic: Dr. Kristen Panthagani is an emergency medicine resident and Yale Emergency Scholar at Yale New Haven Hospital. She’s a physician-scientist, having completed her MD/PhD at Baylor College of Medicine. She’s also well known as a science communicator, creator of You Can Know Things which helps explain science in a way everybody can understand, with an emphasis on addressing health rumors and explaining evidence-based medicine. This SGEM Xtra is inspired by piece in the New England Journal of Medicine titled, Training Health Communicators-The Need for a New Approach. It covers the shifting landscape of how and where people are getting health information, specifically social media. It also provides some key competencies to keep in mind as we train healthcare professionals and scientists to communicate in these spaces. The idea of "social media" has existed for a long time. Check out the book Writing on the Wall by Tom Standage to learn more. We last covered the topic of science communication on a SGEM Xtra with Sarah Mojarad where she gave us five tips for science communication. Today we have five themes from your article to discuss. Listen to the SGEM Xtra podcast to hear Dr. Panthagani discuss these themes in detail. Shifting Information Sources People’s habits are changing. They are going to different sources to get health information, and we have to adapt and evolve to stay relevant. The idea of "talk with your doctor if you have questions" is often impractical if people cannot get timely appointments in clinic. Websites for universities and organizations can be reputable sources, but health information is not always presented at the recommended health literacy level. People are not fans of the top-down, “I am the high and mighty institution or organization. Let me tell you what to do” approach anymore. So where are people turning for health information? People are increasingly getting their information from social media. Over half of adults in the US report getting health information from social media. It is unlikely that we can simply tell people to stop using social media for this purpose. Putting a Face to the Message How can we harness social media? The typical dry and stiff presentation with text-heavy slides at a scientific conference is unlikely to grab people’s attention. People gravitate toward authenticity. A more raw, informal style may be resonate more compared to a polished, rehearsed message "Be a real person." These were tips about style of communication. What tips do you have for creating content? If it's boring to you, it's probably boring for your audience. Don't do stuff you hate. If you like writing, don't create reels. Find ways to write articles, commentary, Substack, etc. You don't have to do it all. Bidirectional Communication Traditional health communication has been top-down from institutions/organizations to the consumer. There is a difference between information dissemination versus communication. Information dissemination is one direction. Communication is bi-directional Listen to the audience Be careful that the scientific understanding of a term (ex. "immunity") may not be the colloquial understanding. Data is not enough. Unite over shared values. Bidirectional communication requires time and effort. Don't feel obligated to respond to every comment. Read the comments to gauge understanding and identify points of confusion. Acknowledging Uncertainty This is a sore spot when it comes to the communication that came during the Covid-19 pandemic. We have to acknowledge that this was a really tough time. We confronted a novel disease and pathogen. The language around topics like vaccines, social distancing, masking, did not really acknowledge that these interventions are not perfect. Guidance changed based on new and emerging data. This is difficult and requires balancing the simplicity of the message with the nuance. We did not do a good job communicating nuance and uncertainty in the early data. How will the public receive scientists acknowledging uncertainty when there are other voices (who may lack knowledge or expertise) proclaiming their message loudly and confidently? People may appreciate nuance more than we give them credit for. Sometimes saying, "I don't know" can actually built trust. Be Nice Dr. Panthagani has a Substack article about why criticizing “anti-vaxxers” backfires. In it she brings up a distinction between shame and guilt from research Brene Brown. Guilt focuses on the behavior and the decision. Shame attacks the character of the person. Not surprisingly, making people feel stupid, calling them stupid, or being quick to label them doesn’t really work when it comes to effective science communication. Using shame-based methods makes things worse Find ways to connect over shared values. Keep in mind Graham’s hierarchy o

Date: October 30, 2025 Reference: Boes et al. Prevalence of violence against health care workers among agitated patients in an urban emergency department. October 2025 AEM Guest Skeptic: Dr. Suchismita Datta. She is an Assistant Professor and Director of Research in the Department of Emergency Medicine at the NYU Grossman Long Island Hospital Campus. Case: It's 7:34 pm. You just took a sip of your portable espresso machine coffee from your favourite Batman cup. It's been 34 minutes into your Tuesday overnight shift. Things are a little crazy, but you are proud of yourself for getting your day colleague out on time. Just then, your second-year resident walks briskly towards you and sits down next to you, an air of fluster about her. She is trying to keep her cool, but you can see her hands are trembling as she is putting in orders for the patient she just saw. You ask her what's up, and she responds, "The intoxicated patient in bed 12 just threatened to punch me when I told him I couldn't give him more pain medications. He said pretty awful things about me, called me names, and cursed at me... they called over security... but I still feel a little shook up about it... " She looks down and shakes her head, and then looks back at you and asks, "How often does this actually happen? Violence against us?" Background: Violence toward clinicians is not a rare event in the ED but rather a predictable occupational hazard. The Canadian Association of Emergency Physicians (CAEP) has called ED violence “unacceptable,” urging a system-wide, zero-tolerance culture and coordinated mitigation efforts across hospitals, EMS, and law enforcement. Their formal CAEP Position Statement on violence in the ED summarizes scope, risk factors, and policy recommendations for prevention and reporting [1]. In the US, the American College of Emergency Physicians (ACEP) maintains a consolidated resource hub on ED workplace violence, including policy statements and advocacy for federal legislation (OSHA standards and the SAVE Act) to mandate prevention programs and establish penalties for assaults on healthcare workers. ACEP’s 2022-member poll found 85% of respondents reported violence had increased in their ED over the prior five years, with 45% saying it had greatly increased. The 2024 follow-up highlighted that >90% feared threats or attacks in the prior year. These data align with the day-to-day experience of emergency physicians and underscore persistent underreporting and inadequate institutional responses [2]. Both CAEP and ACEP emphasize practical approaches such as environmental design, staffing and security policies, de-escalation training, standardized reporting, and partnerships with law enforcement. At the same time, they reject the idea that violence is “part of the job.” Clinical Question: Among ED patients with, what is the prevalence of violent events against health care workers, and how does that compare with events formally reported to the hospital? Reference: Boes et al. Prevalence of violence against health care workers among agitated patients in an urban emergency department. October 2025 AEM Population: ED patients from a locked observation unit at Hennepin County Medical Center (Minneapolis, MN). Exclusions: Patients known to be in custody at the time of the encounter were excluded from data collection. Exposure: Agitation, defined as an Altered Mental Status Score (AMSS) ≥ +1 (range from −4 to +4). Observers then recorded whether the encounter included verbal abuse, a threat of violence, or a violent act against a health care worker. Comparison: N/A Outcome: Primary Outcome: Assault against any health care worker, defined by Minnesota state statute as an act with intent to cause fear of immediate bodily harm or death, or intentional infliction/attempt to inflict bodily harm. Secondary Outcomes: Verbal abuse of health care workers by agitated patients (distinct from threats), defined as harsh/insulting/derogatory language or gestures intended to frighten, humiliate, or belittle. Type of Study: A secondary analysis of two prospective, observational studies conducted in the ED setting. This is an SGEMHOP, and we are pleased to have the lead author on the episode, Dr. Brian Driver. He is a faculty emergency physician and Director of Clinical Research in the Department of Emergency Medicine at Hennepin County Medical Center. Authors’ Conclusions: “Verbal abuse, threats of assault, and violent acts occurred frequently in ED patients with agitation and were underreported.” 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? Unsure Was the foll

Reference: Boutin A, et al. Removable Boot vs Casting of Toddler’s Fractures: A Randomized Clinical Trial. JAMA Pediatr. Published April 2025. Date: July 23, 2025 Dr. Andrew Tagg Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder and website lead of Don’t Forget the Bubbles (DFTB). Case: A two-year-old boy presents to your pediatric emergency department (ED) with a limp and refusal to bear weight. His parents aren’t exactly sure what happened. They were at the park and suspected that he might have twisted his leg coming down a slide. On your exam, he does not have a fever. He does not have any swelling or deformity of his bilateral lower extremities. You order X-rays, which confirm a nondisplaced spiral fracture of the distal tibia, a classic toddler’s fracture. After you disclose his diagnosis, his worried parents ask you, “A fracture? Does that mean it’s broken? Will he need to get a cast? He’s such an active little guy, typically.” Background: Toddler’s fractures are subtle, nondisplaced spiral fractures of the tibia. They typically occur in children between the ages of 9 months and 4 years. They often present in children who are just beginning to walk, hence the term “toddler’s fracture.” These kids can come in with inability to bear weight, a limp, or nonspecific pain. Another challenge is that the history you get may or may not help guide you. These injuries usually result from low-energy trauma, such as a twisting injury during a fall. That can happen multiple times a day when you’re learning to walk! The mechanism of injury is so subtle sometimes that parents or caretakers may not recall any inciting event. The findings on X-ray can be quite subtle as well. AP and lateral views may reveal a very small hairline fracture that’s easily missed. In some situations, X-rays will be negative despite clinical exam findings suggestive of a toddler’s fracture. In those situations, repeated X-rays in a week or so can show some evidence of periosteal reaction. The traditional management has included immobilization with a long leg or short leg cast, based on the belief that toddlers are unlikely to limit activity independently and require rigid immobilization to promote healing and pain relief. However, growing concerns about the discomfort, skin breakdown, need for follow-up visits, and potential complications from casting have led to interest in less restrictive treatments. such as removable walking boots. Clinical Question: In children with radiographically confirmed toddler’s fractures, is treatment with a removable walking boot noninferior to a circumferential cast? Reference: Boutin A, et al. Removable Boot vs Casting of Toddler’s Fractures: A Randomized Clinical Trial. JAMA Pediatr. Published April 2025. Population: Children aged 9 months to 4 years with radiograph-visible tibial toddler’s fractures seen in 4 Canadian pediatric emergency departments. Exclusion: Presented more than 5 days after injury or had an increased risk for pathological fracture or delayed healing Intervention: Removable prefabricated walking boot. Parents were told to use the boot for one week, then use it as needed for symptoms for up to three weeks. This was based on caregiver discretion, with no scheduled follow-up. Comparison: Standard circumferential casting. This varied across sites: Two sites did a long-leg splint in the ED, followed by a fiberglass cast. Another site did a short or long leg splint/cast in the ED, followed by a long leg fiberglass cast. The final site placed a short-leg splint in the ED, followed by a short-leg fiberglass cast. The casts were applied within seven days of the ED visit. Two sites had casts that were peelable, meaning they could be removed by caregivers at home. The other two sites had patients return to the clinic for cast removal. Outcome: Primary: Evaluation Enfant Douleur (EVENDOL) pain score at 4 weeks Secondary: Return to activity, complications, caregiver satisfaction, care burden, healthcare utilization. Trial: Pragmatic, multicenter, assessor-masked, noninferiority randomized clinical trial Authors’ Conclusions : In this multicenter randomized clinical trial examining the management of children with TF, a removable boot without physician follow-up was noninferior to circumferential casting with respect to pain recovery. While there was a clinically relevant but not statistically significant trend toward more skin complications in the boot group, there was no difference in caregiver satisfaction, and the boot strategy demonstrated reduced childcare-related challenges Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes 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 co

Date: October 10, 2025 Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department. Case: A 37-year-old man presents to the emergency department (ED) with severe right-sided flank pain. The pain started about eight hours ago as a vague discomfort in his right flank, but it has gotten progressively worse and now is radiating to his groin. Patient reports nausea, an increased urge to urinate and noticing blood in his urine on one occasion. The patient denies prior medical or surgical history. Upon ED arrival, his vital signs are normal. Physical examination revealed a stated age patient in distress due to severe right flank pain, prominent right-sided costovertebral angle tenderness, and absence of abdominal tenderness or guarding. While strongly considering renal colic in differential diagnosis and reaching for the bedside ultrasound, you are wondering if a single dose of a non-steroidal anti-inflammatory (NSAID) will be enough to relieve this patient’s pain, or should you add Magnesium or Lidocaine? Background: Renal colic is a common and extremely painful emergency department (ED) complaint encountered in the ED that frequently recurs. The nonsteroidal anti-inflammatory drugs (NSAIDs) given intravenously or intramuscularly (IM) are frequently used as first-line therapy. However, about 30% of ED patients receiving NSAIDS require rescue analgesia in the form of opioids. Opioid use, though effective, is limited at times due to the potentially dangerous adverse effects. Thus, there might be a role for other non-opioid classes of drugs to be co-administered with NSAIDs for relief of renal colic. Magnesium sulfate (MgSO₄) has been suggested as a possible treatment option. It may blunt ureteral smooth muscle spasm by antagonizing calcium influx in smooth muscle and by N‑methyl‑D‑aspartate (NMDA) receptor antagonism. These are mechanisms that can reduce visceral pain and augment other analgesics. Small ED trials and meta‑analyses suggest MgSO₄ can reduce pain scores and opioid use in renal colic, though the evidence base has been limited and heterogeneous [1]. Another suggested treatment modality for renal colic is intravenous lidocaine. We looked at this treatment on SGEM#202 and were unimpressed with the efficacy. Systemic lidocaine blocks voltage‑gated sodium channels and appears to modulate central sensitization and visceral pain pathways. In ED populations, systematic reviews indicate IV lidocaine offers variable analgesia with a mixed signal for benefit, and renal colic–specific RCTs suggest it may be inferior to ketorolac and best considered (if at all) as part of a multimodal strategy rather than as monotherapy [2]. Clinical Question: In adult ED patients with suspected renal colic receiving IM diclofenac, does adding IV magnesium sulfate or IV lidocaine increase the proportion achieving ≥50% reduction in pain at 30 minutes compared to a saline placebo? Reference: Toumia M, Sassi S, Dhaoui R, et al. Magnesium Sulfate Versus Lidocaine as an Adjunct for Renal Colic in the Emergency Department: A Randomized, Double-Blind Controlled Trial. Ann Emerg Med 2024 Population: The study enrolled adults aged 18 to 65 years with suspected acute renal colic and a pain score of 5 or more on a 10-point numerical rating scale (NRS). Exclusions: Pregnancy/breastfeeding; NSAID, MgSO₄, or lidocaine contraindication or allergy; renal/hepatic dysfunction; analgesic use in prior 6 h; bleeding diathesis or GI hemorrhage; significant CAD/arrhythmia; seizures; peritoneal signs; altered mental status; anticoagulation; hemodynamic instability; morphine allergy. Intervention: All patients received 75 mg IM diclofenac. The intervention groups then received either 1g IV MgSO₄ (10 mL) over 2-4 minutes or 1.5 mg/kg IV lidocaine (10 mL) over 2-4 minutes. Comparison: Placebo(10 mL normal saline) after 75 mg IM diclofenac. Outcome: Primary Outcome: The proportion of participants achieving at least a 50% reduction in the NRS score at 30 minutes after drug administration. Secondary Outcomes: Need for rescue analgesia, time required for 50% pain reduction, proportion of participants with persistent pain (NRS>2) at 90 minutes, frequency of adverse events, and frequency of return visits to the ED for renal colic recurrence. Type of Study: Prospective, multicenter, randomized, double‑blind, placebo‑controlled, 3-arm trial conducted from November 2022 to August 2023 in three academic hospital EDs and one regional hospital ED in Tunisia. Authors’ Conclusions: “Adding intravenous MgSO4, but not lidocaine, to IM diclofenac offered superior pain relief but at levels below accepted thresholds for clinical importance.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequat

Date: October 3, 2025 Reference: Doheim et al. Meta-Analysis of Randomized Controlled Trials on IV Thrombolysis in Patients With Minor Acute Ischemic Stroke. Neurology 2025 Guest Skeptic: Dr. Casey Parker is a Rural Generalist, Evidence-based medicine enthusiast and Ultrasound Nerd. This episode was recorded live, in beautiful Broome, Australia, at the Spring Seminar on Emergency Medicine (SSEM 2025). You can get copies of the slides used in the presentation at this LINK. You can also watch the episode on YouTube. Case: Dani is a recently retired emergency department (ED) doc who has spent the last year travelling the world, playing banjo & sharing time with family and friends. This morning, whilst eating a breakfast of eggs and ham, Dani had a sudden onset of right-hand weakness and difficulty speaking. Dani’s family called 000 (911 in North America), and she was taken to the ED within one hour. On arrival at your medium-sized rural ED, Dani is assessed by the “Stroke Team aka, you” as having mild motor weakness in the right hand and mild dysarthria. Dani is given an NIHSS score of 4. A rapid CT and CTA is quickly reported as “no acute large vessel occlusion” and “No intracranial bleed and no established cortical infarction”. You know that many centers in the city are offering intravenous tPA for patients with acute ischemic stroke. You wonder if Dani should get a dose? Background: Minor ischemic strokes (MIS), often defined by NIHSS ≤5, are very common, with roughly half of all ischemic strokes presenting with mild deficits. Despite the mild presentation, these strokes are not always benign. About 30% of patients with initially minor stroke symptoms end up significantly disabled (unable to walk independently) at 90 days [1]. In short, a small stroke can still have a big impact on a patient’s life if it isn’t effectively treated or if it progresses. Dr. Daniel Fatovich There have been gallons of ink spilled in the discussion of the stroke literature, with much debate on previous SGEM episodes about the relative risks and benefits of IV thrombolytic therapy for acute strokes. Drs. Ken Milne and Danny Fatovich have earned themselves the title of “non-expert EM contrarians” when discussing the literature around acute ischemic stroke management with Neurologists all over the world. IV thrombolysis (tissue plasminogen activator [tPA], or newer Tenecteplase [TNK]) is a well-established therapy for acute ischemic stroke based on some questionable evidence [2-6]. However, its role in mild strokes has been hotly debated. On one hand, treating early might prevent a minor stroke from evolving or causing hidden disability. On the other hand, tPA carries a risk of intracerebral hemorrhage, and many minor stroke patients recover well without aggressive intervention. Guidelines have wrestled with this nuance: current recommendations endorse tPA for mild strokes that have clearly disabling deficits, but advise against tPA for mild non-disabling strokes [7]. The core controversy is whether the potential functional benefit in MIS is worth the bleeding risk if the patient is already doing okay. Things changed 10 years ago after Mr. CLEAN was published. It showed that endovascular interventions (EVT) for acute large vessel occlusions (LVOs) could have impressive results (NNT of 7). However, the role of IV thrombolytics for minor stroke syndromes remains unclear and controversial. Legendary (now-retired) ED Dr. Joe Lex once stated, “If I can kick the syringe outta’ your hand – then don’t give me the tPA!” Was Joe right? Before 2019, practice varied widely. Some neurologists treated almost any stroke within the window, reasoning that “time is brain” even for mild deficits, while others were more conservative. Observational studies yielded mixed signals. Several studies suggested that thrombolysis in mild strokes improves the chance of an excellent outcome at discharge or 90 days, while others showed minimal benefit. The PRISMS trial (2018) was a key randomized study in this area. It compared alteplase vs. aspirin in patients with minor non-disabling strokes (NIHSS ≤5). PRISMS found no difference in 90-day functional outcomes (mRS score 0-1) between the tPA and aspirin groups, but did find an increase in symptomatic intracerebral hemorrhage with tPA [8]. However, that trial was stopped early after only ~1/3 of the planned enrolment (313/948). This was reported due to a lack of funding. There are issues with stopping trials early, which we have discussed on previous SGEM episodes. Stopping PRISMS early meant it lacked the power to definitively settle the question of lysis minor, non-disabling strokes. Consequently, equipoise remained, and actual practice often followed guideline nuance, treating “minor-but-disabling” strokes (for example, isolated aphasia or hemiparesis that significantly limits function) while generally avoiding tPA in trivial or rapidly improving strokes. Viele et al JAMA 2016, Guyatt et al BMJ 2012, Tyson

Reference: George S, et al. Effectiveness of nasal high-flow oxygen during apnoea on hypoxaemia and intubation success in paediatric emergency and ICU settings: a randomised, controlled, open-label trial. Lancet Respir Med. March 2025 Date: July 10, 2025 Guest Skeptic: Dr. Spyridon Karageorgos is a Pediatric Chief Resident at Aghia Sophia Children’s Hospital, Athens, Greece and faculty of the Pediatric Emergency Medicine MSc at Queen Mary University in London. Case: A two-year-old boy presents in the emergency department (ED) with severe respiratory distress and hypoxemia. You attempt to use some non-invasive forms of respiratory support, but he continues to have significant work of breathing and retractions. His mental status begins to decline, and he appears much sleepier than before. The team makes the decision to intubate him. You follow the steps of the pre-intubation checklist and pre-oxygenate him with 100% FiO2. As the sedative and paralytic for intubation are given, the respiratory therapist asks, “Do you also want to use nasal high flow (NHF) for apneic oxygenation during intubation?” Background: Managing hypoxia in pediatric patients in EDs and intensive care units (ICUs) remains a challenge. Hypoxia can arise from various causes, including bronchiolitis, pneumonia, asthma, or undifferentiated respiratory failure. Ensuring timely and effective oxygenation is critical to stabilizing these patients and preventing progression to respiratory failure or cardiac arrest. NHF oxygenation has gained traction as a respiratory support modality in both ED and ICU settings. NHF delivers humidified and heated oxygen at high flow rates, which typically exceed the patient’s inspiratory flow through nasal cannula. This mechanism not only improves oxygenation but can also help reduce the work of breathing by flushing anatomical dead space and providing some degree of positive end-expiratory pressure (PEEP). The use of NHF is considered less invasive than continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) or mechanical ventilation. It is usually better tolerated, especially by children. The use of NHF has expanded into general pediatric practice, especially for treating conditions like bronchiolitis and other forms of acute respiratory distress. But, its comparative efficacy to standard oxygen therapy in various clinical settings and patient populations remains a subject of ongoing investigation. While we would always prefer a controlled intubation, sometimes the patients we see in the ED are unstable and need to be intubated emergently. We often try to pre-oxygenate prior to intubating to maximize oxygen reserves. Previous studies have suggested that the use of NHF may reduce the risk of hypoxemia and improve first-attempt intubation . However, randomized controlled trials evaluating this practice in the pediatric population are limited. Clinical Question: In children requiring emergency intubation, does the use of nasal high-flow oxygen for apneic oxygenation reduce hypoxemia and increase the rate of successful first-attempt intubation compared to standard care? Reference: George S, et al. Effectiveness of nasal high-flow oxygen during apnoea on hypoxaemia and intubation success in paediatric emergency and ICU settings: a randomised, controlled, open-label trial. Lancet Respir Med. March 2025 Population: Children aged 1 month to 15 years with acute hypoxic respiratory failure (SpO₂ <92% on room air) requiring emergency endotracheal intubation in EDs and pediatric and neonatal ICUs across Australia, New Zealand, and Switzerland. Exclusion: Primary nasal intubation, blocked nasal airways, elective endotracheal tube change, intubation required immediately for loss of cardiac output or respiratory arrest, location of intubation outside of ED or ICU, death Intervention: Nasal high-flow oxygen at 2L/kg/min during the apneic phase of intubation. Weight HFNC rate 0-12 kg 2L/kg/min (max 25 L/min) 13-15 kg 30L/min 15-30 kg 35L/min 30-50 kg 40L/min >50 kg 50L/min Comparison: Standard care Outcome: Primary Outcomes: Hypoxemia (SpO2 ≤90% or difference of ≥10% if they were unable to achieve a pre-intubation saturation of 100% or the patient had cyanotic congenital heart disease with a right to left shunt) and first-attempt intubation success without hypoxemia Secondary Outcomes: Total intubation attempts, re-oxygenation needs, duration of ventilation, lowest oxygen saturation throughout intubation period, length of stay, mortality, adverse events. Trial: Randomized controlled, open-label, pragmatic multicenter trial Dr. Shane George Guest Author: Dr. Shane George is a paediatric emergency and critical care physician at Gold Coast University Hospital, Australia. That’s right he’s trained in both emergency medicine and paediatric intensive care. He’s the lead for children’s critical care research for Gold Coast Health which is affiliated with the University of Queensland and Vice Chair o

Date: September 18, 2025 Guest Skeptic: Dr. Neil Dasgupta is an Emergency Medicine (EM) physician and emergency department (ED) intensivist from Long Island, NY. He is the Vice Chair of the ED and Program Director of the EM residency program at Nassau University Medical Center in East Meadow, NY. Reference: Doupnik et al. Impact of telemental health on suicide prevention care in U.S. emergency departments. AEM Sept 2025 Trigger Warning: The following case scenario discusses suicide and self-harm. If you or someone you know is at risk, seek immediate help (dial 911/999/112 as appropriate, or 988 in the US/Canada for suicide & crisis support). Resources: Substance Abuse and Mental Health Services Administration (SAMHSA) National Alliance on Mental Illness (NAMI) American Foundation for Suicide Prevention (AFSP) Case: It’s 23:15 on a Tuesday in a 10-bed rural emergency department (ED) that serves as the community’s sole hospital. A 37-year-old male arrives with a friend after texting that they “can’t do this anymore.” The friend is concerned because he has access to firearms. Triage vitals are stable. The nurse uses the ED’s standard suicide‑risk screen, which is positive. The nurse activates the service’s 24/7 telemental‑health workflow. A video cart is wheeled into the room, and a remote clinician joins the conversation. Background: Delivery of quality mental health care is one of the major difficulties affecting our EDs. Caring for these patients presents a particular kind of challenge, since establishing rapport with the patient, getting a detailed history, gathering collateral information from others, overcoming possible intoxications or toxidromes, requiring staff for continuous observation and treating physical injuries can require substantial levels of time and skills. In addition, suicide remains a leading cause of death, and EDs are a frequent point of contact for people in crisis. Many of these encounters involve complex psychosocial factors, limited outpatient capacity, and time-sensitive safety planning. The stakes are high, and what happens in the ED can shape risk in the hours to days after discharge. As emergency physicians, we balance therapeutic alliance, thorough risk assessment, and efficient disposition in an environment built primarily for acute medical care, not longitudinal mental health follow-up. Frustration often occurs due to limited resources, high volumes, inpatient boarding and overcrowding; it can seem impossible for an ED physician to provide compassionate, nuanced, complete psychiatric care. Patients utilize the ED for mental health care because they often do not have a choice. Sometimes that lack of choice stems from a report of suicidal thoughts, which in most communities represents a lack of capacity to make medical decisions, and EMS systems are required to transport these patients for emergent psychiatric care. In many communities, especially in areas that have less robust access to health care in general, there are profound administrative, financial and systemic barriers to creating or maintaining a functional level of mental health care infrastructure, profoundly overburdening the services that exist and pushing those needs onto the local emergency departments. Telemedicine (particularly telepsychiatry and broader telemental health) has become a pragmatic way to expand access to mental health expertise. This has accelerated with the pandemic-era virtual care. Programs vary widely, with some providing on-demand psychiatric prescribers, while others lean on social work, psychology, or case management. Integration with the ED team and the electronic health record (EHR) can be excellent in some settings and minimal in others. Despite legislative progress in the US, including the Affordable Care Act and the Addiction Equity Act, reimbursements remain poor for the care of such patients, severely limiting access to care. As with many other challenging issues, for lack of a better option, the ED becomes the entryway to any portion of the healthcare system. For rural and critical‑access hospitals, telemedicine can be the difference between no specialist input and round-the-clock access. But the question that matters to front-line EM clinicians is not just “Is telehealth available?” It’s “Does telehealth meaningfully improve the way we deliver suicide‑prevention care in the ED?”And, even if processes improve, do those changes translate into better patient-oriented outcomes (POO) such as reduced attempts, ED revisits, or suicide deaths? Clinical Question: Among US hospital-affiliated EDs, is having access to telemental health associated with greater routine use of recommended suicide‑prevention practices? Reference: Doupnik et al. Impact of telemental health on suicide prevention care in U.S. emergency departments. AEM Sept 2025 Population: 606 EDs in the US associated with a general medical hospital Excluded: EDs in government hospitals (VA/DoD), specialty hospitals (orthoped

Date: Sept 16, 2025 Reference: Prada et al. Evaluation of the evidence on acetaminophen use and neurodevelopmental disorders using the Navigation Guide methodology. Environ Health. August 2025 Guest Skeptic: Dr. Andrew Martin is an emergency physician practicing in Jacksonville, Florida. Case: A 27-year-old at 24 weeks’ gestation presents to the emergency department (ED) with fever (38.6 °C), myalgias, and sore throat. She took 650 mg of acetaminophen (Tylenol) six hours ago with partial relief. She hesitated to repeat the dose after reading online posts about “Tylenol and autism.” She has no abdominal pain, no vaginal bleeding, and normal fetal movement. Vitals otherwise stable; pharynx erythematous, no exudate. She asks, “Is it safe to take another dose, or could this hurt my baby’s brain later?” Background: Acetaminophen (paracetamol) is the most used analgesic–antipyretic in pregnancy. A recent prospective cohort study suggests ~40 to 65% of pregnant people report using it. They are typically using acetaminophen for headache, myalgias, or fever, with most use being short and intermittent. Alternatives, particularly non-steroidal anti-inflammatory drugs (NSAIDs), carry well-described fetal risks in late gestation. This is one of the reasons why acetaminophen remains the default first-line choice [1,2]. Biologically, acetaminophen crosses the placenta and achieves fetal levels like maternal levels, making the developing brain theoretically exposed during critical windows [3]. This has motivated a large observational literature examining whether prenatal exposure is linked to later neurodevelopmental outcomes such as ADHD and autism. Meta-analyses generally report small associations (summary effects around 1.2 to 1.3) and signal stronger effects with longer duration of use, though heterogeneity in exposure measurement and outcome ascertainment is substantial. Professional bodies, including the American College of Obstetricians and Gynecologists (ACOG) and the Society of Obstetricians and Gynecologists of Canada [SOGC], continue to recommend acetaminophen for appropriate indications at the lowest effective dose and shortest duration. At the same time, they do acknowledge ongoing research and the limitations of observational data (including confounding by indication). For emergency clinicians, the practical tension is familiar. The dilemma is that untreated maternal fever and significant pain can themselves harm pregnancy, yet patients are increasingly asking about possible long-term neurodevelopmental potential harms of using acetaminophen. Clinical Question: Is acetaminophen exposure during pregnancy associated with ADHD, ASD, or other neurodevelopmental disorders (NDDs) in children? Reference: Prada et al. Evaluation of the evidence on acetaminophen use and neurodevelopmental disorders using the Navigation Guide methodology. Environ Health. August 2025 Population: Observational studies assessing children of pregnant individuals for neurodevelopmental outcomes. Excluded: Postnatal exposures, non-human studies for the primary analysis, non-original publications, and duplicate reports from the same cohort. Exposure: Prenatal acetaminophen (maternal self-report, biomarkers such as meconium/cord blood, or medical records/prescription registries). Comparison: Children who were not exposed prenatally to acetaminophen, or those exposed to alternative analgesics. Outcome: Primary Outcome: NDDs (particularly ADHD and ASD) and related symptomatology measured by clinical diagnoses, medication use, or validated behavioural scales. Secondary Outcomes: Timing and dose–response patterns, broader cognitive/behavioural domains (language & executive function), and triangulation across design types. Type of Study: Systematic review using the Navigation Guide methodology with a qualitative synthesis (no meta-analysis) due to substantial heterogeneity. Authors’ Conclusions: “Our analyses using the Navigation Guide thus support evidence consistent with an association between acetaminophen exposure during pregnancy and increased incidence of NDDs. Appropriate and immediate steps should be taken to advise pregnant women to limit acetaminophen consumption to protect their offspring’s neurodevelopment.” Quality Checklist for Systematic Review: The main question being addressed should be clearly stated. Yes The search for studies was detailed and exhaustive. Unsure Were the criteria used to select articles for inclusion appropriate? Yes Were the included studies sufficiently valid for the type of question asked? Unsure Were the results similar from study to study? No Were there any financial conflicts of Interest? Yes Result: They searched PubMed (primary) through Feb 25, 2025, with confirmatory checks in Web of Science and Google Scholar. A total of 46 studies were included. The studies consisted of a mix of prospective cohorts, retrospective/historical cohorts, sibling-controlled cohorts, and two case-control studies. Sample s

Date: August 12, 2025. This is an SGEM Xtra, and today, we’re putting on our conference lanyards and boarding passes to talk about one of the most exciting events in the global EM calendar, IncrEMentuM 2026. For those who did not attend IncrEMentuM 2025, it set the bar incredibly high. From the moment delegates walked into the venue in Murcia, Spain, there was a buzz that felt like the early days of SMACC. The conference felt electric, global, and unapologetically fun. The talks were short, sharp, and full of energy, blending the best evidence with stories you’d remember long after the conference ended. On-stage simulations pushed the boundaries of what a medical conference could be, while debates in the concourse were full of healthy skepticism. Between sessions, the networking was amazing. One minute you could be sipping coffee next to EM legend Scott Weingart, and the next minute swapping resuscitation hacks with a new friend from across another continent. And, of course, the Spanish hospitality shone through. Paco, Carmen and the whole Incrementum team made everyone feel welcome, well fed, and everyone left wanting more. Well, you are in luck. Lightning is going to strike again on April 22 to 24, 2026, back in beautiful Murcia. Today, I am joined by three amazing Canadian EM physicians and educators who will be presenting in Murcia. Dr. Sara Gray has been known to run codes with the grace of a symphony conductor. Dr. Chris Hicks is like the Yoda of resuscitation: wise, calm, and occasionally cryptic. And finally, Dr. David Carr, the master of pearls, pitfalls, and the occasional “I-can’t-believe-that-just-happened” story. Having these three superstars on the SGEM reminds me of what a deep bench of medical educators we have in Canada. We are consistently punching above our weight in the #MedEd world. Today's podcast is not about Canada but rather the amazing things Spanish EM educators are doing. Five Questions for the Panellists Listen to the SGEM Xtra podcast to hear Sara, Chris and David respond. What can people expect from IncrEMentuM 2026? How is it different from your typical EM conference with endless PowerPoint karaoke & bad coffee? How does IncrEMentuM compare to the SMACC conferences? What will each of you be bringing to the stage in 2026 in Murcia? Beyond the great talks, why should someone hop on a plane to Murcia, and what are you looking forward to the most? IncrEMentuM 2026: April 22 to 24 in Murcia, Spain. Be prepared or be unprepared. Come for the evidence, stay for the tapas, and leave with new skills, new friends, and maybe a few “you-had-to-be-there” stories. The SGEM will be back with a structured critical appraisal, trying to cut the knowledge translation (KT) window from over ten years to less than one year, using the power of social media, so patients get the best care, based on the best evidence. Recuerda ser escéptico de todo lo que aprendas, incluso si lo escuchaste en The Skeptics’ Guide to Emergency Medicine.

Date: August 12, 2025 Article: FDA Approved and Ineffective by Jeanne Lenzer and Shannon Brownlee. June 5, 2025. The Lever. Jeanne Lenzer Guest Skeptic: Jeanne Lenzer is a long-time medical investigative journalist and returning SGEM guest. Her previous work, including the book The Danger Within Us, explored how conflicts of interest and weak evidence can endanger patient care. In this new project with The Lever, Jeanne analyzes how the FDA approves drugs that often don’t meet basic efficacy standards. I think many people assume that if a treatment is FDA-approved, surely it must work. However, people may be shocked to find out about the FDA’s drug approval process and how ineffective or harmful medications make it to market. Most patients and doctors have no idea that the FDA has quietly flipped the drug approval process on its head by putting most drugs on the market before they are shown to be safe or effective, with the promise that they will do those studies after they are on the market. Studies have shown that once a drug is on the market, patients do not want to enter or remain in clinical trials because they are convinced they’re being deprived of a proven treatment, and failure to enroll sufficient patients is one reason postmarket studies are delayed or never conducted. Once a drug is on the market, the FDA can require postmarket testing, but the due dates are often set so many years in the future that the patent will have run out. Take the controversial new Alzheimer’s drug, Leqembi, which causes brain bleeds, swelling and death. The manufacturer is required to conduct safety studies and report annually to the FDA. However, neither the FDA nor the company will release the safety data until the final report is due. This will be in 2036, 13 years after it’s been on the market. This can be considered a guaranteed win for Pharma and a bad deal for patients. The FDA has fallen so low that the agency introduced a new term, “dangling approvals” for drugs approved before clinical benefit was proved and then allowed to remain on the market even after the post-marketing studies fail. Richard Pazdur, head of oncology at the FDA, defended the agency’s refusal to order certain cancer drugs off the market even after their post-market studies failed, saying “A failed trial, doesn’t mean a failed drug.” Well, true and true, but the idea is that drugs were supposed to be proven to work before they go on the market, not after. And with Pazdur’s and the FDA’s reasoning, any bad drug could remain on the market forever. And a few have. A two-year investigation by Lenzer and Brownlee found 429 FDA approvals (2013–2022) where the majority of drugs were authorized on inadequate evidence of effectiveness, with heavy reliance on surrogate outcomes, frequent lack of replication, and slow/absent confirmatory trials. The highlighted real-world harm and cost and call for regulators and clinicians to re-center on patient-oriented outcomes (POO) before widespread adoption. The article gives a few stories about FDA-approved drugs that turned out to cause harm without any benefit. One example was the drug Elmiron: Elmiron (pentosan polysulfate sodium) was approved in 1996 by the FDA for interstitial cystitis (chronic bladder pain) FDA approval was given without solid evidence of effectiveness FDA allowed approval on the condition that a follow-up study be done to confirm efficacy The follow-up study took 18 years to complete and showed no benefit over placebo Despite this, Elmiron remained on the market Not just a lack of benefit, but there were reported cases of harm Elmiron was associated with cases of a rare eye disease called pigmentary maculopathy that resulted in vision loss or blindness. It was also associated with severe colitis and dozens of deaths Bottom line is a drug with no proven benefit and significant harms stayed on the market for nearly 30 years A cautionary tale of systemic FDA failure to protect patients There were other examples in the articles: Avastin (bevacizumab): Initially approved for metastatic breast cancer via progression-free survival (PFS) surrogate; later trials failed to show survival benefit; approval was withdrawn for that indication, but surrogate-based oncology approvals have continued apace. Copiktra (duvelisib): Approved on surrogates; subsequent data suggested earlier death vs comparator and serious harms; FDA restrictions only years later. ProAmatine (midodrine): Repeatedly rejected; ultimately approved under Subpart H with promised post-market evidence that never convincingly materialized. Special Guest Skeptic: Dr. Jerome Hoffman. He is a longtime friend of the SGEM, a mentor and a true thought leader in evidence-based medicine (EBM). Dr. Hoffman has critically appraised stroke studies, challenged the tPA (alteplase) hype, and now serves as the analytical lead behind this FDA investigation. Four Questions for Jeanne & Jerry Listen to the podcast to hear their answers to these and ot

Reference: Jessen et al. Pharmacological interventions for the acute treatment of hyperkalaemia: A systematic review and meta-analysis. Resuscitation 2025 Date: August 6, 2025 Guest Skeptic: William Toon is a paramedic who, this past May achieved over 50 years of continuous EMS certification. His professional path has taken him from front-line paramedic to national presenter, expert witness, flight medic, EMS program director, and senior training executive with a doctorate in Higher Education. Case: A 65-year-old patient presents to the emergency department (ED) with general weakness, mild abdominal cramping, and nausea over the past 12 hours. The patient has poorly controlled type 2 diabetes, heart failure with reduced ejection fraction, and chronic kidney disease stage 4 on hemodialysis. The patient missed their last dialysis appointment two days ago. The patient takes several medications for kidney disease and blood pressure, including a potassium-sparing diuretic. His ECG shows peaked T-waves. Stat chemistry reveals a serum potassium of 6.5 mmol/L. He is not yet oliguric and is hemodynamically stable. The team must initiate pharmacologic treatment immediately while preparing for possible escalation to dialysis. Background: Hyperkalemia is a potentially life-threatening electrolyte abnormality frequently encountered in the ED. It’s common in patients with chronic kidney disease, diabetes, or those on renin-angiotensin-aldosterone system (RAAS) inhibitors. While treatments like insulin, beta-agonists, and calcium gluconate are well-known, the comparative efficacy and safety of pharmacologic agents used to rapidly reduce serum potassium remain uncertain. Clinicians must balance rapid action with safety when choosing treatment for hyperkalemia. Understanding which pharmacologic interventions work best and how quickly they act is vital to optimizing care. Unfortunately, much of the existing data on hyperkalemia treatment is derived from small or methodologically limited trials. Clinical Question: What is the effectiveness of pharmacological interventions in the acute treatment of hyperkalemia compared to standard care, placebo, or other interventions in adults? Reference: Jessen et al. Pharmacological interventions for the acute treatment of hyperkalaemia: A systematic review and meta-analysis. Resuscitation 2025 Population: Adult patients with hyperkalemia (typically defined as serum potassium ≥5.0 mmol/L). Studies included varied populations such as those with CKD, dialysis patients, and acutely ill inpatients. Exclusions: Patients under 18 and those receiving non-pharmacologic interventions (dialysis) were excluded. Intervention: Any acute pharmacological intervention to mitigate the harmful effects of hyperkalemia or to lower potassium levels. Comparison: Placebo, standard care, or head-to-head comparisons of other pharmacologic interventions. Outcome: Primary Outcome: Change in serum potassium from baseline at specific time points (1, 2, 4, and 6 hours). Secondary Outcomes: Proportion of patients achieving normokalaemia, adverse events (hypoglycaemia), need for rescue therapy (dialysis), and all-cause mortality. Type of study: Systematic review and meta-analysis Authors’ Conclusions: “Evidence supports treatment with insulin in combination with glucose, inhaled or intravenous salbutamol, or the combination. No evidence supporting a clinical effect of calcium or bicarbonate for hyperkalaemia was identified.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. No The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Yes There was low statistical heterogeneity for the primary outcomes. No The treatment effect was large enough and precise enough to be clinically significant. Yes Who funded the trial? No financial support was provided for the study. Did the authors declare any conflicts of interest? No relevant conflicts of interest disclosed. Results: Studies included adult patients with hyperkalemia from EDs, inpatient wards, and dialysis units. Ages ranged widely, with a predominance of patients with chronic kidney disease (CKD) and cardiovascular comorbidities. Key Result: Sodium zirconium cyclosilicate and insulin-glucose regimens were most effective in lowering serum potassium within four hours, while other agents had limited short-term impact. Primary Outcome: At four hours, insulin-glucose reduced potassium by an average of 0.8 mmol/L, and sodium zirconium cyclosilicate by 0.67 mmol/L. SPS (sodium polystyrene sulfonate) and patiromer showed smaller and delayed effects. Secondary Outcomes: Hypoglycemia occurred in 17% of insulin-treated patients. Dialysis was needed in 6.2%. Mortality rates were not significantly different among treatment groups. Substantial Clinical and Methodological Heterogeneity: O

Date: August 11, 2025 Dr. Gillian Schmitz Guest Skeptic: Dr. Gillian Schmitz is a board-certified Emergency Physician practicing at The Naval Medical Center in San Diego. She is also a former President of the American College of Emergency Physicians (ACEP). This SGEM Xtra is inspired by the 1992 film A League of Their Own. Unlike our previous pop culture references like Buffy the Vampire Slayer, Star Trek, Batman, Top Gun, Ted Lasso and Mission: Impossible, this story is based on real events. The All-American Girls Professional Baseball League (AAGPBL) was created in 1943 and lasted until 1954. This league gave over 600 women a chance to play pro baseball. For the SGEMers who may not have seen this movie, here is a summary. A League of Their Own (1992) is a sports drama directed by Penny Marshall that tells the fictionalized story of the real-life All-American Girls Professional Baseball League. It was formed during World War II when many male baseball players were serving overseas. The film follows sisters Dottie Hinson and Kit Keller as they join the Rockford Peaches and navigate the challenges of playing professional baseball in a male-dominated society. With a blend of humour, heart, and historical insight, the film highlights themes of gender roles, perseverance, and the lasting bonds formed through sport. Top 5 Themes from “A League of Their Own” As chosen and interpreted by Dr. Gillian Schmitz. Listen to the SEGM podcast to hear her full description of what the quotes mean to her. “I don’t have ball players. I have girls.” – Jimmy Dugan This quote reflects how society has historically minimized women’s capabilities in professional arenas. Emergency medicine, like baseball in the 1940s, has not always welcomed women without skepticism. Concerns about femininity, perception, and acceptance parallel the gender biases faced by women in emergency medicine leadership today. Even ‘proper’ women had concerns, expressing their worries about the ‘masculinization’ of these pioneer female athletes. Sound familiar? We have done several shows on the SGEM illustrating the gender inequity in the house of medicine. SGEM#352: Amendment – Addressing Gender Inequities in Academic Emergency Medicine SGEM Xtra: From EBM to FBM – Gender Equity in the House of Medicine SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease SGEM#248: She Works Hard for the Money – Time’s Up in Healthcare SGEM Xtra: Money, Money, Money It’s A Rich Man’s World – In the House of Medicine SGEM Xtra: I’m in a FIX State of Mind “Why should you go? To say for once you actually did something… something special.” – Kit to Dottie This line speaks to the deep calling many women in emergency medicine feel. It reminds us of the early emergency medicine pioneers who were often told they were wasting their time. Yet they pressed forward, driven by the belief they could make a real difference. That passion to do something special, despite the challenges, still drives many of us in emergency medicine today. If you want to do something special, despite the challenge, then head over to FemInEM.org led by Drs. Dara Kass, Esther Choo, Jenny Beck-Esmay and the legend of emergency medicine, Dr. Diane Birnmaumer. We also recently did an SGEM Xtra: This is My Fight Song - FeminEM 2.0. They are doing some amazing things, advancing gender equity in emergency medicine, improving reproductive healthcare delivery in emergency departments, mentorship and being champions of change. “You know, if I had your job, I’d kill myself.” – John Lovitz This moment of dry sarcasm reflects the burnout and emotional toll our specialty can bring. But it also highlights that, despite the difficulty, emergency medicine remains the best job in the world for many. I couldn’t imagine doing anything else. Emergency medicine still lights me up. “You gotta go where things happen.” – Marla’s Dad This is the heart of advocacy, leadership, and frontline emergency medicine. Whether it’s in the trauma bay or on Capitol Hill, women in emergency medicine are making things happen and often leading the way. You want to feel fulfilled? Go where things happen… or make them happen. “It’s supposed to be hard. If it wasn’t hard, everyone would do it. The hard is what makes it great.” – Jimmy Dugan This is the quintessential emergency medicine quote. The job is hard. The leadership path is hard. Breaking barriers is hard. But that’s what makes it great and worth doing. It’s that difficulty that shapes us, connects us, and gives meaning to what we do. Some final thoughts on the movie A League of Their Own? The movie reminds us that history is full of stories about women rising to the challenge, creating new paths, and demanding space at the table. Progress has been made, but there is still more work to be done. This includes representation in leadership and issues of gender pay gaps. There’s still much to challenge and change, but also much to celebrate. Emergency medicine has its league of extraordina

Reference: Otterness et al. The Use of TENS for the Treatment of Back Pain in the Emergency Department: A Randomized Controlled Trial. AEM Aug 2025 Date: August 22, 2025 Guest Skeptic: Dr. Lauren Westafer is an Assistant 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 44-year-old man presents to the emergency department (ED) with low back pain after bending to pick up his child. He has pain in his left lower back that is worse when he moves. He has no fever, chills, weakness, or numbness. He has well-controlled hypertension and no history of recent antibiotic use or drug use. The patient has no midline tenderness, is without neurological deficit, and has no red flag features on history and physical exam. He took 500 mg of acetaminophen a few times without significant relief. Background: Back pain is one of the most common reasons patients seek ED care, with an estimated 2.5 million ED visits for back pain each year. After dangerous diagnoses such as spinal epidural abscess, cord compression, and ruptured abdominal aortic aneurysm have been excluded, the next challenge for emergency clinicians is analgesia to improve the patient’s pain and mobility. Unfortunately, there are numerous causes of musculoskeletal low back pain, rendering a single treatment course inconsistently effective for all-comers. Many pharmacological and non-pharmacological therapies have been tried with limited efficacy. Acetaminophen (Williams et al Lancet 2014) Muscle relaxants (Friedman et al JAMA 2015) NSAIDs (Machado et al Ann Rheum Dis 2017) Steroids (Balakrishnamoorthy et al Emerg Med J 2014) Benzodiazepines (Friedman et al Ann Emerg Med 2017) Cognitive Behavioral Therapy and mindfulness (Cherkin et al JAMA 2016) Chiropractic (Paige et al JAMA 2017) Physical therapy (Paolucci et al J Pain Research 2018) Acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013) One treatment that can be very effective but comes with very real potential harms is opioids. The American College of Emergency Physicians (ACEP) has addressed the issue of opioid use in patients being discharged home after an acute episode of pain. They give a Level C Recommendation saying: Do not routinely prescribe, or knowingly cause to be co-prescribed, a simultaneous course of opioids and benzodiazepines (as well as other muscle relaxants/sedative-hypnotics) for treatment of an acute episode of pain in patients discharged from the emergency department (Consensus recommendation). Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological modality that administers low-intensity electrical stimulation to inhibit nociceptive pain signals. The efficacy of TENS devices in acute low back pain is uncertain. Clinical Question: Is transcutaneous electrical nerve stimulation (TENS) more effective at relieving back pain than sham TENS? Reference: Otterness et al. The Use of TENS for the Treatment of Back Pain in the Emergency Department: A Randomized Controlled Trial. AEM Aug 2025 Population: Adult ED patients (≥18 yr) with thoracic or lumbar back pain of at least moderate severity when research assistants were present (Mon–Fri, 8a–8p). Exclusions: Patients with suspected spinal cord injury or infectious etiology, fractures, hemodynamic instability, allergy to standard analgesics, pacemakers, and those with skin conditions precluding TENS application were excluded. Intervention: Two cutaneous TENS adhesive pads above and below the point of maximal tenderness with TENS unit set at a point just below the pain threshold and gradually increased for up to 30 minutes. Comparison: Sham TENS pads applied but no electrical current. Patients were told they might or might not feel pulses. Outcome: Primary Outcome: Absolute reduction in pain (0–10 NRS) from baseline to 30 Secondary Outcomes: Administration of rescue medications, change in pain severity, patient satisfaction with assigned treatment, and whether patients would recommend the same treatment Trial: Single-center randomized controlled trial Dr. Kara Otterness This is an SGEMHOP, and we are pleased to have the lead author on the episode, Dr. Kara Otterness. She is originally from Illinois and graduated from Drexel University College of Medicine and completed her Emergency Medicine residency training at NYU/Bellevue. She joined the Stony Brook EM faculty in 2015. She is passionate about teaching, medical education and currently serves as one of the assistant program directors at Stony Brook. Dr. Otterness has been a guest skeptic on SGEM#96. Authors’ Conclusions: “TENS was more effective than sham TENS at reducing pain severity in adult ED patients with back pain.” Quality Checklist for Randomized Clinical Trials: The study population included or focused

Reference: Othman AA, et al. Combined ketamine and midazolam vs. midazolam alone for initial treatment of pediatric generalized convulsive status epilepticus (Ket-Mid study): A randomized controlled trial. Pediatric Neurology. June 2025 Date: May 27, 2025 Dr. James Chamberlain Guest Skeptic: Dr. James Chamberlain is a pediatric emergency medicine attending physician at Children’s National Hospital in Washington, DC where he is the Director of Data Analytics and Informatics for the Division of Emergency Medicine. He is also a Professor of Emergency Medicine and Pediatrics at George Washington School of Medicine and Health Sciences. He has led or co-led two large national trials of status epilepticus and is starting a third, the Ketamine adjuvant for Established Status Epilepticus Treatment Trial (KESETT). Case: A two-year-old boy with a known seizure disorder is brought to the emergency department (ED) by his family for a seizure at home. The episode is described as generalized tonic-clonic activity which self-resolved after about a minute. He was post-ictal afterwards and has not fully returned to baseline. He has not had any recent fevers or illnesses. During your conversation with his parents, he starts seizing again. You administer two doses of a benzodiazepine, but the seizure continues. You give an additional levetiracetam load, which stops the seizure activity, and he is admitted to the hospital for observation. Afterwards, a medical trainee you are working with says to you, “I read that there’s been interest in other medications like ketamine in the treatment of seizures. Do you think there would have been any benefit in giving ketamine earlier?” Background: We often see children presenting with seizures in the ED. Currently, the standard of care recommends the use of benzodiazepines such as midazolam as first-line treatment. Midazolam, but not the other benzodiazepines, can be given intravenously, intramuscularly, intranasally, or as a buccal paste. Sometimes this works and stops the seizure activity. Sometimes it does not. Seizures that are refractory to treatment are dangerous and can lead to neuronal injury, long-term deficits, or even death. We want to stop seizure activity as quickly as we can. The typical management of seizures is to give a benzodiapene. If that does not work, give a second dose. If that still doesn't stop the seizure, then administer another anti-seizure medication like levetiracetam, fosphenytoin, or valproate. There’s been increasing interest in the use of ketamine for seizures. There are several factors that make ketamine potentially a very powerful drug for status epilepticus. Ketamine is an NMDA receptor antagonist and therefore theoretically should break the vicious cycle of status. There have been dozens of animal studies in at least 4 different species demonstrating efficacy as early treatment of status. In some of these studies, ketamine and other NMDA receptor antagonists are neuroprotective. In humans, ketamine is widely used for super refractory status, when all other medications have failed. Estimates are that it is about 70% effective for this indication. We have a long track record of using ketamine safely in the emergency department setting and growing experience in EMS. Ketamine is well tolerated, short-acting, and preserves protective airway reflexes and ventilation. Even very large accidental overdoses have been well tolerated. The one caveat is that we don’t know if all these safety parameters hold in the condition of status epilepticus, but limited case series have not shown safety problems. Currently, it is not part of conventional therapy for pediatric status epilepticus, but there is thought that it may work synergistically with benzodiazepines in stopping seizures. Clinical Question: Is ketamine combined with midazolam more effective than midazolam alone in the treatment of pediatric generalized convulsive status epilepticus? Reference: Othman AA, et al. Combined ketamine and midazolam vs. midazolam alone for initial treatment of pediatric generalized convulsive status epilepticus (Ket-Mid study): A randomized controlled trial. Pediatric Neurology. June 2025 Population: Children 6 months to 16 years presenting with generalized convulsive status epilepticus without prior treatment with antiseizure medications (ASMs) for the current episode. This was defined as clinically detectable generalized tonic-clonic convulsions that persist or recur without regaining consciousness in between for longer than 5 minutes. Exclusions: Previous treatment with ASM, traumatic brain injury (TBI), conditions associated with increased intracranial pressure, hypertension, glaucoma, hyperthyroidism, pheochromocytoma, end-stage kidney or liver disease, cardiac disease, history of alcohol intake, hypoglycemia, hyperglycemia, inborn errors of metabolism, known allergy or contraindication to study drugs, known or suspected psychiatric disorder, failure to get IV access in f

Date: July 10, 2025 Guest Skeptics: Professor Timothy Caulfield is a Canadian professor of law at the University of Alberta, the Research Director of its Health Law Institute. His area of expertise is in legal, policy and ethical issues in medical research and its commercialization. This is another SGEM Xtra book review. Tim was our guest skeptic a few years ago, discussing his book called Relax, Dammit! A User’s Guide to the Age of Anxiety. He is back on the SGEM to discuss his latest book called The Certainty Illusion: What You Don't Know and Why It Matters. I asked Tim several questions about his book. Please listen to the podcast to hear his responses. Questions for Professor Caulfield The book is structured into three main parts. In Part I: The Science Illusion, you examine how scientific language and imagery are co-opted to confer credibility on dubious claims. You discuss how quantum physics has been misappropriated by the wellness and alternative medicine industries. Why do you think "quantum" has become such a powerful marketing tool? The phrase "It’s Science!" is often used to shut down debate. What are the dangers of weaponizing the language of science? You talk about Zombie Science (ideas that refuse to die despite mountains of evidence). I’ve given a lecture for the Gateway Centre of Excellence in Rural Health on zombie ideas about hospital crowding. What is a good example of zombie science in health and wellness? At the end of Part I, you introduce ‘The Humility Fix" as a potential solution. Can you explain why intellectual humility is a necessary antidote to misinformation? In Part II: The Goodness Illusion, you unpack how concepts of health, sustainability, and morality are manipulated to create a false sense of certainty. You explore things like "health halos," in which terms like "clean," "organic," and "natural" are used to mislead consumers. Can you expand on that concept? You list 12 words in total that you call the "Devious Dozen". These are a set of misleading or overhyped health and wellness claims that exploit public perception and create a false sense of certainty. These terms and concepts are often used in marketing, politics, and public discourse to manipulate consumers and reinforce misinformation. Do you have a couple of favourites? You also talk about how virtue signalling and ideological narratives shape public opinion, often overriding evidence-based reasoning. The idea that our desire to do what’s "right" can be exploited through misleading claims about health, wellness, and even sustainability. What’s an example of this in the medical field, and how can healthcare professionals push back against it? You also discuss the White Hat Bias in this section of the book. It is a phenomenon where research findings are distorted in the service of what is perceived as a noble or righteous cause. This bias leads to the overrepresentation of certain findings, particularly in fields like public health, nutrition, and medicine, where there is strong societal motivation to support outcomes. Who coined the term White Hat Bias? Can you give an example of the White Hat Bias from the COVID-19 pandemic? In Part III of the book, you discuss The Opinion Illusion. This delves into how the digital age has fueled an economy of opinion, where ratings, reviews, and social media influence create misleading perceptions of truth and expertise. How has the “opinion economy” shaped modern decision-making? How has this shift impacted our ability to discern truth from misinformation? You highlight the influence of online reviews and rankings. Why do people trust anonymous reviews more than expert opinions or personal recommendations? What role do algorithms play in distorting our perception of consensus and credibility? The book isn’t all doom and gloom. You do offer some solutions for navigating this chaotic information environment. What would it look like if you could design an ideal system for verifying the credibility of online opinions? How can individuals cultivate a healthier skepticism toward online rankings without becoming entirely cynical? What role do educational institutions and policymakers play in addressing the certainty illusion in digital spaces? You mention that authenticity itself has been commodified. Do you think there is a way to reclaim genuine trust in reviews and expert opinions? What’s the most surprising or unexpected thing you discovered while researching The Certainty Illusion? That’s it for this SGEM Xtra. Remember, the SGEM is about cutting the knowledge translation (KT) window down from over ten years to less than a year, but ultimately, it’s about patients getting 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: Kemal et al. Emergency department utilization by youth before and after firearm injury. AEM July 2025 Date: July 28, 2025 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine in the UK and an evidence-based medicine advocate. She's a seasoned knowledge translator with her wonderful PaperinaPic infographics. Case: Your non-US emergency department (ED) has recently been shaken by the attendance of a teenager with a gunshot injury. Subsequent investigation has found he attended a different hospital in the region six weeks ago with a stab wound. The team wonders if that attendance was an opportunity to intervene. Background: Firearm injuries are now the leading cause of death in youth in the United States, surpassing motor vehicle collisions.[1] While the immediate clinical management of gunshot wounds is well covered in emergency medicine training, there is less clarity around what happens before and after that ED visit. Could we identify these high-risk youth earlier? Do patterns of ED use provide clues for intervention? The ED often serves as the primary healthcare contact point for youth exposed to community violence. Some youth injured by firearms may have prior ED visits for mental health crises or minor injuries, presenting opportunities for preventative strategies. But are we missing these cues? Additionally, once youth survive a firearm injury, they face elevated risk for repeat injury, psychological trauma, and even death. Understanding post-injury healthcare utilization may reveal missed chances for intervention, particularly in general EDs that may lack pediatric-specific resources. Clinical Question: Do youth with firearm injuries have increased emergency department utilization before and after their injury compared to their peers? Reference: Kemal et al. Emergency department utilization by youth before and after firearm injury. AEM July 2025 Population: Youth aged 10 to 19 years who had an index ED visit for a firearm injury in 2019 across eight US states, identified from the Healthcare Cost and Utilization Project database. Exclusion: Youth who lacked the data to assess 90 days before or after the index injury, and those without longitudinal ED visit linkage, injuries from non-power firearms, and recurrent visits with firearm injury. Exposure: Having sustained a firearm injury as indexed by an ED visit. Comparison: ED utilization by the same patients in the 90 days before and after the firearm injury. Outcomes: Primary Outcome: Number and types of ED visits 90 days before and after the index firearm injury. Secondary Outcomes: Types of ED visits and recurrence of trauma. Type of Study: Retrospective cohort study using linked administrative claims data. Dr. Samaa Kemal This is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Samaa Kemal is an early-career pediatric emergency medicine clinician-investigator at Ann & Robert H. Lurie Children's Hospital of Chicago. Her work is primarily focused on the intersection of violence and health equity in children. Her research priorities are focused on developing and implementing novel and effective solutions to prevent violent injuries and subsequent adverse outcomes in children. Authors’ Conclusions: “Youth have high rates of ED utilization before and after firearm injury. Half of firearm-injured youth receive their emergency care exclusively in general EDs. Implementing firearm injury prevention and intervention efforts in all ED settings is critical.” 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? No 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? No Do the results of this study fit with other available evidence? Yes Funding of the Study? Eunice Kennedy Shriver National Institute of Child Health and Human Development Results: The median age was approximately 17 years; predominantly male and from racially minoritized groups. Key Result: Youth frequently used EDs before and after injury, suggesting opportunities for early identification and intervention. Primary Outcome: 12.8% of youth had at least one ED visit in the 90 days before the firearm injury, and 22.1% had at least one in the 90 days after. Secondary Outcomes: Of those with post-injury ED visits, 26% had recurrent trauma; mental health and assault-related visits were common. Listen to the SGEM podcast to hear Samaa answer our five nerdy questions. Confounding by Indication and Unmeasured Covariates: One of the primary threats to internal validity in observ

Reference: Bourke EM, et al. PEAChY-O: Pharmacological Emergency Management of Agitation in Children and Young People: A Randomized Controlled Trial of Oral Medication. Annals of Emergency Medicine. Feb 2025 Date: April 29, 2025 Guest Skeptic: Dr. Brad Sobolewski, is a pediatric emergency medicine physician at Cincinnati Children’s Hospital and Professor of Pediatrics at the University of Cincinnati College of Dr. Brad Sobolewski Medicine. He is the creator of the PEMBlog and host of PEM Currents: The Pediatric Emergency Medicine Podcast. Brad is passionate about using digital media to translate complex clinical concepts into engaging, accessible educational content. His work centers on advancing knowledge sharing through innovative, tech-forward approaches to medical education. Case: A 14-year-old girl with no known medical or psychiatric history presents to the emergency department (ED) with her family for aggression. Her parents tell you that they have been getting into arguments a lot recently. Today, she became so angry that she started punching and kicking the walls at home. You interview the girl and perform your physical examination, and determine that there are likely no medical diagnoses contributing to her aggression, nor that she has sustained any injuries requiring immediate management. After you leave the room and her parents enter, you hear them get into another argument, and she gets more agitated. The staff try a combination of de-escalation techniques, but she continues to be aggressive and starts threatening the staff. A nurse working with you asks, “I don’t think our de-escalation techniques are working. Do you want to give her something to help calm her down? We have olanzapine or diazepam here. Which one do you want to give?” Background: Pediatric agitation can be defined as a clinical state characterized by heightened motor activity, emotional arousal, and often aggressive or disruptive behavior outside of expected developmental norms. It can be triggered by many things like underlying psychiatric disorders, medical conditions (like delirium, hypoxia, or metabolic disturbances), substance intoxication or withdrawal, and situational stressors, such as hospitalization or separation from caregivers​. In the ED setting, pediatric agitation presents unique challenges. Not only can it compromise the safety of the child, caregivers, and medical staff, but it can also delay care and exacerbate underlying conditions​. When a child presents with extreme agitation or aggression, the first step is to take a broad, thoughtful approach. We can’t just assume it’s a psychiatric issue. Medical causes like hypoglycemia, intoxication, or even something like new-onset diabetic ketoacidosis can present this way. Missing these diagnoses could be dangerous. Once we’ve ruled out organic causes, the focus shifts to early recognition and de-escalation. We try to identify the signs that a child is becoming more agitated before they escalate further. The goal is to intervene early and often with non-pharmacologic strategies. This can mean adjusting the environment: dimming the lights, reducing noise, giving the child space, or removing extra staff from the room. Sometimes something as simple as offering a snack, a drink, or a comfort item can make a big difference. Re-direction, distraction, and using calm, supportive language can also go a long way. Of course, there are times when those strategies aren’t enough, and we may need to use physical restraints or medications. But that should never be our starting point. The overarching goal is to approach these situations with empathy and respect. Support the child and their family while protecting everyone’s safety, including our own. There’s no perfect medication for agitation so it really depends on the situation. If the child is cooperative, start with an oral option. It gives the child a bit of control and helps avoid the trauma of restraint or an IM injection. When oral meds aren’t possible and the child poses a risk to themselves or others, IM options may be necessary. In those cases, it’s important to know what medications (dosing, onset, and potential side effects) are available and what local protocols recommend. The choice also depends on why the child is agitated. Antipsychotics, benzodiazepines, antihistamines, or even ketamine all have a role, but each comes with considerations based on the child’s history and the clinical scenario. Whatever we use, the goal is to reduce distress safely and respectfully, while keeping everyone protected. Brad I have actually done a whole podcast series in collaboration with the EMSC innovation and Improvement Center and emDocs on agitation. Clinical Question: Is oral olanzapine or oral diazepam more effective in achieving successful sedation in pediatric patients with acute severe behavioral disturbances? Reference: Bourke EM, et al. PEAChY-O: Pharmacological Emergency Management of Agitation in Children and Young Peopl

Date: July 9, 2025 Guest Skeptics: Dr. Cindy Bitter is an Associate Professor in the Division of Emergency Medicine at Saint Louis University. She has a Master’s in Bioethics, and she is passionate about EM capacity building and physician resilience, especially improving wellness through time in nature. Dr. Amy Bi is a graduate from the SSM Health Saint Louis University Emergency Medicine residency and the University of Missouri School of Medicine. She is interested in continuing medical education, orange theory, and travelling. This is an SGEM Xtra episode, which takes us back to the late '90s to explore the intersection of pop culture and professional practice through the lens of Buffy the Vampire Slayer. It's similar to the episodes we did about Star Trek, Top Gun, Dark Knight, Ted Lasso, and The Pitt. Cindy reached out to me about a presentation she made at the HumanisEM conference. It's an interdisciplinary conference that explores the intersections of the Health Humanities and Emergency Medicine, started in 2023. The presentation at the conference was inspired by a conversation with female residents about why Buffy remains a must-watch show for young professionals, especially in medicine. In the lecture, we explore lessons from the show that resonate with emergency physicians and healthcare professionals. Click on the LINK for a copy of the slides. There may be some people like me who are not familiar with the show. Buffy the Vampire Slayer premiered in 1997 and ran for seven seasons. Its central premise was that the seemingly dumb blonde chick who is the first to get killed in horror movies is trained to fight back. Ultimately, the monsters were symbols of the challenges we face on the way to growing up and creating a meaningful life. The show hid a healthy dose of existential philosophy under the quips, music, and 90s fashion, and continues to gain fans more than 20 years after it ended. Career Advice from Buffy the Vampire Slayer Honour Your Calling Quote: “You talk about slaying like it’s a job, it’s not. It’s who you are”. What’s My Line? Part 2; S2, ep 10. Writer: Marti Noxon Our path in medicine is somewhat different than the “one girl in all the world” who is destined to fight the forces of darkness, but there are analogies. Buffy sometimes struggles with her calling but ultimately accepts her path (Prophecy Girl). And she shows that this is not a single event, but something she chooses every day (What’s My Line, Anne, Amends). We come to medicine with our own set of strengths and skills, choose our path, and actively reaffirm it as we complete years of education and residency training. There are certainly challenges in our healthcare system, but there is also connection and sometimes even joy. Meeting Challenges Quote: “Bottom line is, even if you see 'em coming, you're not ready for the big moments. No one asks for their life to change, not really. But it does. So, what are we, helpless? Puppets? No. The big moments are gonna come. You can't help that. It's what you do afterwards that counts. That's when you find out who you are.” Becoming, part 1; S2, ep 22. Writer: Joss Whedon Quote: “From now on, we won’t just face our worst fears, we will seek them out. There’s only one thing in this world more powerful than evil, and that’s us.” Bring on the Night; S7, ep 10. Writer: Marti Noxon with Douglas Petrie Medical school, residency, and even attending life are filled with learning from students, residents, coworkers, nurses, colleagues, and administrators. We must incorporate new evidence into our practice, learn from mistakes, and improve for future encounters. New situations come at us all the time; it’s how we strategize and confront them that counts. That might mean reading up on disease presentations we do not see often or practicing high-acuity, low-occurrence procedures. Knowing we are prepared for the challenges we see can give us confidence. Work-Life Balance and Leaning into your Humanity Quote: “It’s the 90s, the 1990s in point of fact. I can do both. Clark Kent has a job, I just want to go on a date… If the apocalypse comes, beep me.” Never Kill a Boy on the First Date; S1, ep 5. Writer: Rob Des Hotel & Dean Batali Quote: “You know how you’re always trying to save, oh, every single person in the world? Did it ever occur to you, you are one of them?” You’re Welcome. Angel S5, ep 12. Writer: Joss Whedon, David Greenwalt, David Fury One theme in the early seasons of BtVS is the tension between Buffy’s duties as a Slayer and her desire to have a normal life. This sometimes goes awry, as her efforts to continue her normal high school activities find her hexed (Witch), rendered helpless by a cursed Halloween costume (Halloween), and almost eaten by a lizard demon (Reptile Boy). But eventually, she finds a path that provides her a stable-ish home life and meaningful friendships while being a Slayer. In season five, Buffy cuts herself off from her

Reference: Arnold CG, et al. Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule. Acad Emerg Med. Jan 2025 Date: May 7, 2025 Dr. Sandi Angus Guest Skeptic : Dr. Sandi Angus is a Paediatric and Adult Emergency Medicine Registrar in the Shrewsbury and Telford Hospital NHS Trust. She is passionate about paediatric EM, wellbeing and medical education. Case: A ten-year-old boy presents to your emergency department (ED) after being involved in a motor vehicle collision at high speed. Emergency Medical Service (EMS) tells you that he was properly restrained. His parents were also in the vehicle and are currently being brought to the ED as well. He appeared a bit dazed initially, but he has had a Glasgow Coma Scale (GCS) score of 15 throughout transport. Your primary survey is unremarkable. He complains of some abdominal pain, although you note a soft abdomen on exam and no seatbelt sign. As you complete your secondary survey, he vomits once, which is non-bloody. A medical trainee working with says to you, “He says his stomach hurts and threw up. Do you think we need to CT scan his abdomen?” Background: Intra-abdominal injury (IAI) in children is a significant concern for emergency physicians. This is particularly true in cases of blunt trauma. Although relatively uncommon compared to adults, IAIs in children can be life-threatening. We have to identify them early and manage them appropriately. The organs most frequently injured include the spleen, liver, and kidneys, but any abdominal organ can be affected​. Diagnosing IAIs in pediatric patients poses a unique challenge. Children often present with subtle clinical findings, and the physical examination can be unreliable due to factors such as altered mental status, distracting injuries, or the child’s inability to articulate their symptoms​. Imaging modalities like computed tomography (CT) are the gold standard for diagnosis, but CT use must be balanced against the risks of ionizing radiation. Traditionally, clinicians relied heavily on their clinical gestalt, but this approach can miss injuries or lead to unnecessary imaging. The risks of CT imaging are not inconsequential. Children are more radiosensitive than adults, and for each abdominal or pelvic scan, the lifetime risks of cancer are 1 per 500 scans, irrespective of the age at exposure. However, this is actually very small compared with the background risk of developing cancer in a lifetime, which is 1 in 3, so if your scan is clinically justified, the benefit is likely to outweigh the potential harm [1]. To improve diagnostic accuracy and minimize unnecessary CT scans, clinical decision rules (CDRs) or “tools” have been developed. One such tool, the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rule for intra-abdominal injuries, identifies children at very low risk of clinically important IAIs, aiming to safely reduce CT utilization​ [2-3]. This rule was composed of seven variables, all of which could be collected on history and physical exam. There was no need for labs or imaging in this decision rule. These seven variables were: Evidence of abdominal wall trauma or seat belt sign GCS <14 and blunt abdominal trauma Abdominal tenderness Thoracic wall trauma Complaint of abdominal pain Decreased breath sounds Vomiting If all seven variables were negative, the child was at very low risk of having intra-abdominal injury requiring intervention and the decision rule recommended against a CT scan. Despite the benefits of existing decision rules, the question remains how best to apply these tools when only one or two PECARN criteria are positive—a clinical gray zone not well characterized in earlier validation studies. Understanding the individual performance of PECARN rule components in predicting IAI is crucial for refining decision-making in pediatric trauma care. Clinical Question: What is the risk for intraabdominal injuries requiring acute intervention (IAIAI) in children with one or two positive PECARN intraabdominal injury rule variables? Reference: Arnold CG, et al. Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule. Acad Emerg Med. Jan 2025 Population: Children <18 years with blunt torso trauma Excluded: Injury occurring >24 hours before ED presentation, penetrating trauma, pre-existing neurological disorder preventing reliable abdominal exam, pregnancy, transfer from another hospital with prior abdominal imaging. All patients who were negative for the original PECARN prediction rule or had more than two variables present. Intervention: Application of the PECARN intraabdominal injury prediction rule with one or two positive variables Comparison: None Outcome: Primary Outcome: Intraabdominal injury undergoing acute intervention (death caused by IAI, therapeutic laparotomy, angiographic embol

Reference: Solnick et al. Sex Disparities in Chlamydia and Gonorrhea Treatment in US Adult Emergency Departments: A Systematic Review and Meta-analysis. AEM June 2025 Date: June 24, 2025 Guest Skeptic: Dr. Suchismita Datta. She is an Assistant Professor and Director of Research in the Department of Emergency Medicine at the NYU Grossman Long Island Hospital Campus. Case: A 24-year-old woman presents to the emergency department (ED) with a two-day history of dysuria, lower abdominal discomfort, and abnormal vaginal discharge. She is sexually active with multiple male partners and does not consistently use condoms. A urine nucleic acid amplification test (NAAT) is sent, and the patient is clinically diagnosed with a possible sexually transmitted infection (STI). She is not in acute distress, has no fever, and requests discharge after symptom control. Background: STIs such as chlamydia and gonorrhea remain significant public health concerns in the United States (US), particularly among young adults. EDs are increasingly serving as critical access points for STI screening and treatment. However, emerging evidence suggests that treatment practices may differ by patient sex, raising concerns about potential inequities in care delivery. Women are disproportionately affected by the long-term sequelae of untreated STIs, including pelvic inflammatory disease, ectopic pregnancy, and infertility. Despite this, treatment disparities may exist. Men presenting with STI symptoms often receive expedited care, while women, even when symptomatic or diagnosed, may not receive timely or adequate treatment. Potential explanations include differing clinical presentations, provider bias, and system-level barriers such as follow-up challenges or diagnostic uncertainty. Chlamydia and gonorrhea can present with a range of symptoms or be asymptomatic, which complicates timely diagnosis and treatment. While the Centers for Disease Control and Prevention (CDC) guidelines recommend empiric treatment in cases of high clinical suspicion, especially when patients may be lost to follow-up, the extent to which these guidelines are equitably applied across sexes remains uncertain. Clinical Question: Are there sex-based disparities in the treatment of chlamydia and gonorrhea among adults presenting to US emergency departments? Reference: Solnick et al. Sex Disparities in Chlamydia and Gonorrhea Treatment in US Adult Emergency Departments: A Systematic Review and Meta-analysis. AEM June 2025 Population: Adults (≥18 years) presenting to US EDs with testing for chlamydia or gonorrhea. Exclusions: Pediatric patients, individuals with incomplete demographic or treatment data, and those not diagnosed in the ED. Exposure: Receipt of appropriate antibiotic treatment during the ED visit. Comparison: Male versus female patients. Outcomes: GC/CT positivity, empiric treatment rates, and discordance between treatment and test results stratified by sex. Type of Study: Systematic review and meta-analysis Dr. Rachel Solnick This is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Rachel Solnick is an Assistant Professor of Emergency Medicine at the Icahn School of Medicine at Mount Sinai. Her research focuses on HIV prevention, STI care, and maternal health, with an emphasis on expanding access to high-quality reproductive and sexual healthcare for all emergency department patients. She is the PI of an NIH Career Development Award studying the implementation of HIV pre-exposure prophylaxis (PrEP) for ED patients diagnosed with STIs during telephone callbacks. Authors’ Conclusions: “Significant sex-based disparities exist in ED empiric antibiotic treatment for GC/CT. Females were 3.5 times more likely than males to be potentially under-treated. These findings underscore the need for targeted interventions to reduce disparities and improve treatment accuracy. Interpretation is limited by study heterogeneity and incomplete sex-specific data.” Quality Checklist for Systematic Review: The main question being addressed should be clearly stated. Yes The search for studies was detailed and exhaustive. Yes Were the criteria used to select articles for inclusion appropriate? Yes Were the included studies sufficiently valid for the type of question asked? Yes Were the results similar from study to study? No Were there any financial conflicts of Interest? None reported Results: The included 19 studies comprised 32,592 ED patients who were tested for STIs and analyzed. The heterogeneity of the prevalence estimates had I2 values of 92.6% or higher. Key Result: Female patients were much less likely to receive recommended antibiotic treatment compared to male patients, while males were much more likely to be over-treated compared to females. Among patients with laboratory-confirmed chlamydia or gonorrhea pooled estimate was 3.5 for females being under-treated relative to males. We asked Rachel five nerdy questions. Listen to the SGEM podcast to hear

Reference: Ye et al. Preoxygenation strategies before intubation in patients with acute hypoxic respiratory failure: a network meta-analysis. Frontiers in Medicine. 2025 Feb Date: June 12, 2025 Guest Skeptic: Dr. Aine Yore is an Emergency Physician, practicing in the Seattle, Washington area for over twenty years. She is the former president of the Washington chapter of ACEP, and her career focus outside of clinical practice has been largely devoted to health care policy. Case: A 68-year-old woman presents in acute respiratory distress. She is febrile, hypoxemic, and meets criteria for sepsis. A chest x-ray reveals multilobar pneumonia. After managing her sepsis, her oxygenation remains poor, with saturations in the 88-92% range despite supplemental oxygen via a nonrebreather mask, and she now shows signs of worsening fatigue. You determine she requires endotracheal intubation, but note that she is at high risk for peri-intubation complications or even death, and wonder if there is a strategy you can utilize to reduce this risk? Background: Acute hypoxic respiratory failure (AHRF) represents a life-threatening emergency where pulmonary gas exchange becomes insufficient to maintain adequate oxygenation. It commonly arises from a variety of conditions, including pneumonia, acute respiratory distress syndrome (ARDS), sepsis, and exacerbations of chronic lung disease (ex, chronic obstructive lung disease). In such patients, intubation is often required, but the procedure itself introduces additional risk. Nearly 25% of patients undergoing emergency intubation in the context of AHRF experience profound desaturation (SpO₂ < 80%) during the procedure. Preoxygenation is a cornerstone of airway management, designed to extend the “safe apnea time” by denitrogenating the lungs and optimizing oxygen reservoirs. The aim is to minimize peri-intubation hypoxia, which is a known predictor of morbidity and mortality. Commonly used pre-oxygenation strategies include: Conventional oxygen therapy (COT), such as non-rebreather masks. High-flow nasal cannula (HFNC) provides warmed, humidified oxygen at high flow rates and can generate low levels of positive end-expiratory pressure (PEEP). Non-invasive ventilation (NIV) provides pressure support to enhance alveolar ventilation and decrease the work of breathing. Combinations of strategies like HFNC with NIV or bag-valve mask. Despite the widespread use of these techniques, clinical uncertainty persists regarding the most effective and safest strategy for preoxygenation in AHRF. This knowledge gap has led to multiple randomized controlled trials (RCTs) on the subject. Clinical Question: What is the optimal pre-oxygenation strategy in patients requiring intubation for acute hypoxic respiratory failure? Reference: Ye et al. Preoxygenation strategies before intubation in patients with acute hypoxic respiratory failure: a network meta-analysis. Frontiers in Medicine. 2025 Feb Population: Adults with AHRF defined as a respiratory rate >30/min, FiO₂ requirement ≥50% to maintain SpO₂ ≥90%, or PaO₂/FiO₂ < 300 mmHg within four hours of enrollment. Exclusions: Studies involving reviews, conference abstracts, case reports, or lacking full text. Intervention: Pre-oxygenation with Noninvasive Mechanical Ventilation, High Flow Oxygen via Nasal Cannula, or some combination of the above. Comparison: Conventional oxygen therapy (COT) or other preoxygenation. strategies. Outcome: There was no primary outcome explicitly stated. Outcomes included incidence of desaturation (SpO₂ < 80%) during intubation, lowest SpO2 during intubation, post-intubation complication rate, intensive care unit (ICU) length of stay (LOS) and ICU Mortality Type of Study: Network Meta-Analysis (NMA) Authors’ Conclusions: “Preoxygenation with HFNC appears to be the safest and most effective approach prior to intubation in patients with AHRF compared to other strategies”. Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. Yes The assessment of studies were reproducible. Unsure The outcomes were clinically relevant. No The treatment effect was large enough and precise enough to be clinically significant. Unsure Who funded the trial? Not stated Did the authors declare any conflicts of interest? No conflicts declared Results: Their search found 11 RCTs containing 2,874 patients with average ages ranging from mid-40s to 60s. Key Result: Outcomes: Incidence of Severe Hypoxia (SpO2 <80%): NIV>HFNC>COT, meaningful effect size Lowest SpO2 during intubation: HFNC+NIV>HFNC+COT>NIV>HFNC>COT, effect size not meaningful Post-intubation Complication Rate: HFNC>HFNC+COT>HFNC+NIV>NIV>COT, effect size not statistically significant ICU Length of Stay: HFNC>COT>NFNC+NIV>NIV, effect size not statistically significant ICU Mortal

Date: June 2, 2025 Dr. Andrew Tagg Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder and website lead of Don’t Forget the Bubbles. This is another SGEM Xtra that talks about what we can learn about being physicians from certain pop culture (TV and Movies). Past episodes include: Star Trek Made Me A Better Physician Lead Me On – What I Learned from Top Gun Holding Out for a Hero – Lessons from The Dark Knight Yeah, Might Be All that You Get – How Ted Lasso Made Us Better Doctor, Doctor – Paging Dr. Robby (The Pitt) Five EM Lessons from Mission Impossible Movies Precision Under Pressure: Ethan Hunt doesn’t get extra time or perfect conditions — and neither do we. Whether defusing a bomb or managing a crashing patient, calm execution under pressure saves lives. The Team is Everything: Hunt may be the face, but he’s nothing without Luther, Benji, and the crew. Medicine is no different: the best outcomes happen when we trust our team and play to each other’s strengths. Always Question the Intel: Just because it’s in the mission briefing doesn’t mean it’s true. Skeptical medicine is about challenging the “received wisdom” and verifying it before acting — just like a good IMF agent would Know Your Exit Strategy: Whether escaping a vault or de-escalating a high-stakes family discussion, always have a way out. Good clinicians plan for failure just as much as success — that’s what keeps patients (and careers) safe. Mission Fatigue is Real: Even Ethan looks wrecked sometimes. Adrenaline is not a sustainable fuel. We need to rest, recover, and recalibrate — especially if we want to perform at a high level over decades. The SGEM will return with a structured critical appraisal of a recent publication. We will continue to strive to reduce the Knowledge Translation (KT) window from over ten years to less than one year, leveraging 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.

Date: May 14, 2025 Dr. Ross Prager Guest Skeptic: Dr. Ross Prager is an Intensivist at the London Health Sciences Centre and an adjunct professor at Western University. His expertise in critical care medicine is complemented by his research interests in critical care ultrasound and evidence-based knowledge translation. This is an SGEM Xtra episode. The inspiration was a thread Ross posted on X: Here are 10 lessons they don't teach in medical school (but should) that I've learned the hard way over the years. He shared ten hard-earned lessons from his clinical life that never made it into the standard curriculum. These lessons are rooted in humility, human connection, and the everyday realities of medical practice. 1. Patients Don’t Care How Much You Know, but How You Make Them Feel Sit down with your patients — standing can seem rushed. Recognize emotions: “I imagine this must be stressful.” Be human. It’s OK to say “I don’t know” or admit fallibility. Patients value authenticity over perfection. 2. You’re Remembered by Your Worst Moments When stress hits, your true self emerges — that is what people remember. Grace under pressure matters more than glory during routine. 3. Stop Trying to Impress People with Knowledge Competence is shown, not shouted. The best clinicians are present and kind, not performative. 4. Being Keen Is Not a Crime Passion is a virtue, not a vice. Don’t hide your enthusiasm. It’s a sign you care. 5. Med School and Residency Are Long Job Interviews Every rotation, every shift, every colleague — it all counts. Build your reputation day-by-day with kindness, work ethic, and humility. 6. Absence of Evidence ≠ Evidence of Absence Not everything is backed by RCTs — that doesn’t mean it’s invalid. Clinical observation and physiologic rationale matter (e.g., vasopressors). As always, be skeptical of the lack of evidence, too. 7. Character Is How You Treat People Who Don’t Supervise You It’s easy to be kind to your boss. Your true self shows in how you treat nurses, janitors, and trainees. 8. Focus on Diagnosis First, Treatment Second Most medical harm arises from misdiagnosis, not mismanagement. Think ten times harder about “what’s going on” before “what should we do?” 9. Don’t Postpone Living Until After Residency If you're waiting for life to get better after training, you're doing it wrong. Find joy now. Build habits of balance early — your future self will thank you. 10. Remember the Spark Recall your first patient: the awe, the uncertainty, the honour. When burnout creeps in, revisit that moment. Reconnect with your “why.” Final Thought from Dr. Prager: “Medicine is not just about answers, it’s about presence. Our best tool is our humanity.” The SGEM will be back next episode with a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window from over ten years to less than one 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.

Reference: St Peter, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomized noni-inferiority trial. The Lancet. Jan 2025 Date: March 19, 2025 Dr. Camille Wu Guest Skeptic: Dr. Camille Wu is a paediatric surgeon based at Sydney Children’s Hospital where she is the Head of Department. She is also on the Training Committee of Paediatric Surgery for Australia and New Zealand. Case: A 10-year-old boy presents to the emergency department (ED) with his parents. He started having abdominal pain yesterday and did not want to eat. Today, his abdominal pain worsened, and he developed a fever. On examination, he looks uncomfortable and is tender to palpation in the right lower quadrant. You tell the parents that his examination is concerning for appendicitis. You order an ultrasound that demonstrates a dilated and non-compressible appendix. You consult the surgery team and both of you come to speak with the family. His parents tell you, “His sister was diagnosed with appendicitis during the Covid pandemic. At that time, she was admitted to the hospital but just treated with antibiotics. She was able to go home and has done well since that time. Do you think he needs surgery, or can he be treated with antibiotics as well?” Background: Acute appendicitis is one of the most common pediatric surgical complaints that we encounter in the ED. Traditionally, appendicectomy has been the gold standard for treatment, based on its effectiveness in preventing complications such as perforation, abscess formation, and peritonitis​. This is typically done laparoscopically through a few small incisions. The concept of non-operative treatment of appendicitis (NOTA) with antibiotics has gained interest over the past decade. This has been supported by growing evidence suggesting that some cases of uncomplicated appendicitis may resolve without surgery​. We have covered NOTA before on the SGEM that included some meta-analyses, randomized controlled trials, and observational studies. SGEM #115: Complicated-Non-operative Treatment of Appendicitis (NOTA) SGEM #180: The First Cut is the Deepest- N.O.T. for Paediatric Appendicitis SGEM #256: Doctor Doctor Give Me the News, I Gotta Bad Case of RLQ Pain- Should I have an Appendectomy? SGEM #345: Checking In, Checking Out for Non-Operative Treatment of Appendicitis (APPAC II RCT) SGEM #384: Take Me Out Tonight, I Don’t Want to Perforate My Appendix Alright The results have been mixed. Some of these studies have suggested that antibiotic therapy is non-inferior to surgical management while other studies have suggested antibiotic therapy did not meet criteria for non-inferiority compared to appendectomy. Most of these studies were conducted in the adult population with fewer studies conducted in children. The question remains: To cut or not to cut? Clinical Question: In children with acute uncomplicated appendicitis, is treatment with antibiotics non-inferior to appendicectomy? Reference: St Peter, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomized noni-inferiority trial. The Lancet. Jan 2025 Population: Children aged 5-16 years with suspected non-perforated appendicitis based on clinical diagnosis +/- imaging Excluded: suspicion of perforated appendicitis, appendix mass/phlegmon, previous antibiotic treatment, positive pregnancy test, current treatment for malignancy, comorbid condition altering length of stay Intervention: Antibiotic therapy, initially with IV antibiotics followed by oral antibiotics after clinical improvement Comparison: Laparoscopic appendectomy Outcome: Primary Outcome: Treatment failure within 1 year. Secondary: Complications (adverse events that required interventions without general anesthesia), length of hospital stay, patient-reported outcomes (quality of life and pain scores) and healthcare utilization. Trial: Pragmatic, multicentre, parallel-group, unmasked, randomized, non-inferiority trial Authors’ Conclusions: Based on cumulative failure rates and a 20% non-inferiority margin, antibiotic management of non-perforated appendicitis was inferior to appendicectomy. Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Unsure 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). Unsure The patients in both groups were similar with respect to prognostic factors. Yes. All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No. All groups were treated equally except for the intervention. Unsure Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered.

Reference: Cohen et al; SUSPECT study group. Can we avoid casting for suspected scaphoid fractures? A multicenter randomized controlled trial. J Orthop Traumatol. 2025 Date: May 1, 2025 Guest Skeptic: Dr. Matt Schmitz is an orthopedic surgeon specializing in Adolescent Sports Medicine and Young Adult Hip Preservation. He practices at the Rady Children’s Hospital in San Diego and is Professor of Orthopedics at UC San Diego. Case: A 48-year-old woman presents to the emergency department (ED) with left wrist pain after slipping on a wet pavement while walking into work. It was a FOOSH injury (fall on out-stretched hand). She did not lose consciousness and was able to drive herself to the ED, but she reports increasing wrist pain with movement. She rates the pain as 6/10 and notes it’s worse with lifting or rotating the wrist. She denies numbness, weakness, or swelling of the fingers. No previous wrist fractures or injuries. On inspection, she has no obvious deformity and minimal swelling at the wrist. The examination reveals tenderness in the anatomical snuffbox and over the scaphoid tubercle. Her range of motion is decreased due to pain, especially with radial deviation and wrist extension. Sensation and cap refill intact; radial pulse present. Plain radiographs (PA, lateral, scaphoid view) show no fracture. Background: Scaphoid fractures are a common injury seen in the ED but can represent a challenge to diagnose, even for experienced clinicians. The scaphoid injury is the most frequently fractured carpal bone, typically occurring after a fall onto an outstretched hand (FOOSH) in young, active individuals. The clinical dilemma arises when there is a high suspicion of fracture based on mechanism and physical exam (especially tenderness in the anatomical snuffbox), but the initial radiographs appear normal. An excellent SRMA on the history, physical exam, and imaging for scaphoid fractures was done by Carpenter et al AEM 2014. On SGEM#420, we wanted to know what to do with a patient who presents with a FOOSH injury and has a normal x-ray. Specifically, are there clinical exam findings that can help rule in/rule out a scaphoid fracture? The bottom line was there was no single physical examination maneuver that could reliably rule out an occult scaphoid fracture. Given this dilemma, ED physicians have erred on the side of caution. If a fracture is not radiographically visible, the patient is immobilized and referred for follow-up imaging in 10 to 14 days or orthopedic review. This conservative approach stems from the significant morbidity associated with missed scaphoid fractures, including non-union and avascular necrosis. However, this “cast first, confirm later” philosophy has led to over-treatment in most cases. Studies estimate that only 10–20% of patients with clinical suspicion of a scaphoid fracture and normal initial X-rays have a fracture confirmed on follow-up imaging. With this context, a new wave of research has emerged, questioning whether immediate casting is necessary or whether selective immobilization and early reassessment may be equally safe and more patient-centred. This ongoing debate challenges emergency physicians to balance the risks of under-treatment with the harms of unnecessary immobilization, time off work, and healthcare costs. Clinical Question: Can patients with suspected scaphoid fractures and normal initial radiographs be managed without casting, using a brief period of bandaging and reassessment? Reference: Cohen et al; SUSPECT study group. Can we avoid casting for suspected scaphoid fractures? A multicenter randomized controlled trial. J Orthop Traumatol. 2025 Population: Adults presenting to the ED with a clinical suspicion of scaphoid fracture but normal initial radiographs. Intervention: 3-day bandaging followed by reassessment. Comparison: Traditional 2-week casting with thumb spica. Outcome: Primary Outcome: Functional outcome at 3 months using the Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) score. Secondary Outcomes: Patient-rated wrist evaluation, visual analog scale for pain, wrist range of motion, patient satisfaction, and complications including non-union Type of Study: Multicenter randomized controlled noninferiority trial Authors’ Conclusions: “Casting for suspected scaphoid fractures but normal initial radiographs can be avoided because bandaging seems to be an alternative treatment option when patients are reevaluated after 2 weeks.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Unsure The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, and outcome assessor

Date: May 6, 2025 Guest Skeptic: Actor, producer and director Noah Wyle. Many of us know him as Dr. John Carter from ER, the show that arguably influenced an entire generation of EM physicians. Since that groundbreaking show, he has been busy with multiple movie roles (Pirates of Silicon Valley, Donnie Darko, White Oleander, Shot, and At the Gate) and TV series (The Librarian, Falling Skies, The Red Line and Leverage: Redemption). Noah is back in scrubs again, playing Dr. Robinavitch in The Pitt, a new medical drama that captures one chaotic, fifteen-hour emergency department shift. There will be no spoilers for the one or two SGEM listeners who haven’t streamed The Pitt. A big shout-out to Dr. Mel Herbert, creator of EMRap, for setting up this interview. Mel has been on the SGEM talking about the extraordinary power of being average. Mel is also a medical consultant for The Pitt. Let’s set the scene of how The Pitt starts: Noah is shown walking to work for a day shift, hoodie on, earbuds in, scruffy beard, backpack, Yeti and cargo pants. He nailed the look of a seasoned EM doctor. The hoodie was from a brewery called Beers of the Burgh, and they are selling the hoodie Noah wears for the entire season. Noah's portrayal as Dr. Robby is so believable that I was instantly willing to suspend disbelief and accept him as a legit EM attending. As an EM physician who has been practicing for nearly 30 years, I felt seen. We’ve done previous SGEM Xtra episodes on how pop culture helps us reflect on our practice of EM—Star Trek, Top Gun, Batman, and even Ted Lasso. But ER was perhaps the most formative show for this EM doctor. I started residency in 1995, and identify with the character, Dr. Robby, in The Pitt. This is especially true in today’s healthcare environment. FIVE NERDY QUESTIONS for Noah Wyle Listen to the SGEM Podcast to hear Noah answer the five nerdy questions. 1. Three Decades: It’s been 30 years since ER first aired in 1994. What’s changed in emergency medicine besides the disappearance of white lab coats and ties and the introduction of designer scrubs (Figs) or, in your case, a hoodie from a beer company? 2. Being A Doctor Again: What was the easiest and hardest part about returning to a role as an emergency physician? For me, it’s the incorporation of ultrasound and a drug names that keeps getting harder to pronounce. What was the easiest and hardest part for you stepping into the role of an EM attending decades later? Teamwork is essential in EM. We talk a lot about being on “Team Patient.” The cast, crew, set designers, writers, directors, and producers of The Pitt captured that flow state we strive for on shift. How did you and your team get into the flow? 3. Feedback: The show has resonated widely; dare I say cultural phenomenon. How has the response been from different groups from your perspective: healthcare workers (doctors, nurses, residents, etc), administrators, and patients? I’m watching it with my wife (Barb) while encouraging my friends and colleagues to do the same. It’s the most accurate window into my life as an attending EM physician that I’ve ever seen. 4. Evidence-Based Medicine: I teach EBM, which combines the best available evidence with clinical judgment while asking patient about their values and preferences. This means not following GUIDElines as if they were GODlines. The show reflects EBM beautifully. I hear you had an EM bootcamp to get the cast up to speed on terminology, procedures and other things. What was that like? I also hear you shadowed some real EM docs on shift. Any specific memories from that experience that informed your acting and the show? 5. Tough Topics: The show doesn’t shy away from tough topics like abortion, healthcare worker violence, vaccine hesitancy, miscarriage, organ donation, burnout, mass shootings, substance use among staff, moral injury, and so much more. Why was it important to tackle these head-on? Was there a deliberate choice to “show the hard stuff” and lean into the controversial aspects of EM? Season#2 of The Pitt has been given the green light, with production starting in June. It will be set during a July 4th holiday weekend shift. The American College of Emergency Physicians (ACEP) has also announced that Noah will be their special guest at the Scientific Assembly in September in Salt Lake City. The SGEM will return next episode with a structured critical appraisal of a recent publication. We're using the power of social media to cut the Knowledge Translation window from over ten years to less than one. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.