The Skeptics Guide to Emergency Medicine

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.

Reference: Umana E, et al. Performance of clinical decision aids for the care of young febrile infants: A multicenter prospective cohort study. eClinicalMedicine Lancet December 2024 Date: March 6, 2025 Dr. Demetris Athanasiou Guest Skeptic: Dr. Demetris Athanasiou is a paediatric registrar based in London and enrolled in the PEM MSc program through Queen Mary University in London. Case: A 6-week-old boy is brought by his parents to your emergency department (ED) for fever. His older sister has been sick with upper respiratory symptoms for the past week but seems to be recovering. Today, while his father was feeding him a bottle, he noticed that the baby was feeling warm and took his temperature, which was 38.2°C (100.7 °F). The boy has otherwise been feeding and acting normally. You examine the baby with an astute medical trainee. As you discuss the next steps in management, she asks you, “I know there’s a bunch of guidelines or decision tools to help risk stratify which babies are low risk for bacterial infections, but I can never keep them straight. Is there one you prefer?” Background: Back in the day, we were performing lumbar punctures (LP) on febrile infants up to 3 months of age because there was concern for bacterial infections. We used to lump urinary tract infections, bacteremia, and meningitis under one umbrella term, “serious bacterial infection” or SBI. Recently, we’ve been told to stop using that term and be more specific about what we are referring to. Bacteremia and meningitis have been termed invasive bacterial infections (IBI) and, fortunately, are rare, occurring in 1-4%. There have been several guidelines and clinical decision tools, such as those developed by the National Institute for Health and Care Excellence (NICE), the American Academy of Pediatrics (AAP), and others that offer strategies to identify low-risk infants who might avoid invasive procedures like a lumbar puncture. These clinical decision tools have been developed to stratify febrile infants into high- and low-risk categories to balance the risk of under-treatment and over-treatment. Several of these tools have been reviewed on the SGEM. SGEM #341: AAP Guidelines SGEM #296: PECARN SGEM #171: Step By Step The hot new test is procalcitonin. Unfortunately, it’s expensive, and not all EDs have access to it or can receive the results promptly to help with decision making. Some are still using other inflammatory markers like C-reactive protein (CRP). With ongoing research and evolving guidelines, the clinical utility of these decision tools continues to be refined. Understanding their strengths, limitations, and applicability in various healthcare systems remains a crucial aspect of evidence-based emergency medicine. Clinical Question: How well do various clinical decision aids perform in identifying febrile infants at low risk for invasive bacterial infection? Reference: Umana E, et al. Performance of clinical decision aids for the care of young febrile infants: A multicenter prospective cohort study. eClinicalMedicine Lancet December 2024 Population: Infants from birth to 90 days of age from across 35 paediatric EDs and paediatric assessment units across the UK and Ireland with fever ≥38°C Excluded: Guardians who declined or withdrew consent Intervention: Application of clinical decision aids (CDA) [American Academy of Pediatrics (AAP), British Society Antimicrobial Chemotherapy (BSAC), National Institute for Health and Care Excellence (NICE) NG143, Aronson] Comparison: Against each other and “treat all” approach Outcome: Primary Outcome: Diagnostic accuracy of CDAs Secondary Outcomes: Etiology of IBI, clinical predictors of IBI, and mean cost per patient Trial: Prospective multicenter cohort study Guest Author : Dr. Etimbuk Umana (Timbs) is a consultant in emergency medicine and lead author of the FIDO study. Authors’ Conclusions: “The AAP and BSAC CDAs are highly sensitive at excluding IBI, with a cost saving to hospital services when compared to a treat all approach. The substitution of CRP for PCT made no difference to the performance of the AAP CDA in this cohort and was more costly.” 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? Unsure Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Pretty precise Do you believe the results? Yes Can the results be applied to the local population? Yes, to the UK and Ireland pediatric populations Do the results of this study fit with other available evidence? Yes Funding of the Study: No financial conflicts of interest Results: There were 1,821 infants included with a median age of 46 days, 61% male, 14% had

Reference: Muldowney et al. A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting. Ann Emerg Med. 2025 Date: April 24, 2025 Guest Skeptic: Dr. Howie Mell received his Medical Doctorate (MD) from the University of Illinois at Chicago, College of Medicine at Rockford. Prior to that, he received a Master of Public Health (MPH) degree emphasizing Environmental and Occupational Health from the University of Illinois at Chicago, School of Public Health, while serving as a firefighter/paramedic in the Chicago suburbs. He completed his residency in emergency medicine at the Mayo Graduate School of Medicine, Rochester, Minnesota. Dr. Mell is board-certified by the American Board of Emergency Medicine in both Emergency Medicine (EM) and Emergency Medical Services (EMS) Medicine. He is a Fellow of the American College of Emergency Physicians (FACEP). Dr. Mell serves as an Ambassador Emergency Physician for Vituity (formerly CEP-America), and he is currently assigned to Schneck Medical Center in Seymour, Indiana (John Cougar Mellencamp’s “Small Town”). Case: You’re an experienced paramedic working a busy night shift in an urban EMS system. Dispatch sends you to a call for a 35-year-old male found acting erratically in a public park. Upon arrival, you find him disoriented, agitated, and combative. Bystanders report that he has been using methamphetamine and alcohol. The patient is uncooperative, making verbal de-escalation ineffective. Physical restraint is needed for transport. Your EMS protocol allows for pharmacologic sedation with either midazolam (1 to 5 mg IV/IM, repeat every 2 to 5 minutes as needed) or ketamine (5 mg/kg IM, max 500 mg). The patient is tachycardic (HR 122 bpm), hypertensive (BP 156/96 mmHg), and has a Glasgow Coma Scale (GCS) score of 12. You need to act quickly for scene safety and the patient's well-being. Background: Acutely agitated patients in the pre-hospital setting present a unique challenge for emergency medical services (EMS). Agitation can stem from various underlying conditions, including psychiatric disorders, substance intoxication, metabolic disturbances, traumatic brain injury, or postictal states​. If not managed appropriately, severe agitation can escalate, leading to self-harm, harm to others, or interference with necessary medical care. Initial management emphasizes verbal de-escalation techniques, which should always be attempted first. However, when these strategies fail, pharmacologic sedation may be necessary to ensure the safety of both the patient and pre-hospital providers. The choice of sedative agent is a critical decision. The paramedic must balance the need for rapid sedation with the risk of adverse effects, including respiratory depression and cardiovascular instability​. Benzodiazepines, such as midazolam, have historically been used for pre-hospital sedation due to their anxiolytic and muscle-relaxant properties. However, their use is associated with risks such as respiratory depression and paradoxical agitation. In recent years, ketamine has gained popularity due to its rapid onset, potent dissociative properties, and preservation of airway reflexes​. Despite its advantages, ketamine is not without concerns, including the potential for emergence reactions, increased blood pressure, and the need for airway management in some cases. Current guidelines lack consensus on the optimal pharmacologic approach, leading to significant variation in practice across EMS systems. The ongoing debate surrounding the best sedation strategy highlights the need for robust clinical research to guide evidence-based practice. A newly published study aims to address this knowledge gap by comparing ketamine and midazolam in the out-of-hospital setting, shedding light on their relative efficacy and safety. Clinical Question: In prehospital patients requiring pharmacologic sedation for acute behavioural disturbance, does ketamine or midazolam result in a lower need for emergent airway support? Reference: Muldowney et al. A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting. Ann Emerg Med. 2025 Population: Patients with acute behavioural disturbances treated by an urban EMS system between 2017 and 2021​. Exclusion: Patients simultaneously administered both drugs Exposure: Administration of midazolam Comparison: Administration of ketamine Outcome: Primary Outcome: The need for emergent airway support, defined as endotracheal intubation or supraglottic airway insertion​. Secondary Outcomes: ED intubation rates and overall mortality​. Type of Study: Retrospective cohort study Authors’ Conclusions: "In this cohort study of patients with acute behavioral disturbance, emergent airway support and other outcomes did not differ following out-of-hospital treatment with midazolam or ketamine."​ Quality Checklist for Observational Study: Did the study ad

Reference: Kareemi et al Artificial intelligence-based clinical decision support in the emergency department: a scoping review. AEM April 2025. Date: April 15, 2025 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. Case: It may be April, but as you sit in your departmental meeting with your emergency physician colleagues, you all note that the winter “surge” of patients hasn’t stopped. The decision fatigue at the end of shifts is as present as ever. “Surely AI will be making some of these decisions better than us soon?” says one of your colleagues, only half joking. Another colleague chips in that the medical students at the nearby university have been warned against using ChatGPT to create differential diagnoses and you are left wondering whether AI might be “working” in the ED soon. Background: Emergency departments can be a high-pressure environment. Clinical decisions must be made quickly and accurately, often with incomplete information. Clinical decision support (CDS) tools aim to address this challenge by offering real-time, evidence-informed recommendations that help clinicians make better diagnostic, prognostic, and therapeutic decisions. CDS spans a wide spectrum from traditional paper-based clinical decision rules to smartphone apps (MDCalc) to more integrated systems into electronic health records (EHRs). These tools function by combining patient data with expert-driven algorithms or guidelines to inform care pathways. They can help determine disease likelihood, risk stratify patients and even guide resource utilization such as imaging or admission decisions​. Recent years have seen a growing interest in applying artificial intelligence (AI), particularly machine learning (ML), to CDS. Unlike traditional "knowledge-based" CDS that relies on literature-based thresholds, AI-driven tools derive patterns from large datasets ("big data") to identify associations and make predictions. These "non–knowledge-based" systems promise to augment human decision-making by uncovering insights that might be overlooked by clinicians or static rules​. However, the majority of AI-based CDS (AI-CDS) tools remain in early development. Few have been rigorously tested in the ED, and even fewer have demonstrated improvements in patient outcomes or clinician workflow. Despite FDA clearance for some tools, evidence for real-world impact remains limited​. Emergency physicians are right to approach this technology with skeptical optimism. We will need to balance the transformative potential of AI with a critical eye toward evidence, safety, and usability. Clinical Question: (1) What is the current landscape of AI-CDS tools for prognostic, diagnostic, and treatment decisions for individual patients in the ED? and (2) What phase of development have these AI-CDS tools achieved? Reference: Kareemi et al Artificial intelligence-based clinical decision support in the emergency department: a scoping review. AEM April 2025. Population: Studies involving AI or ML-based clinical decision support tools applied to individual patient care in the ED, published 2010 - 2023. Excluded: Models that assessed a specific test (e.g. imaging) without clinical context, administrative or operational outcomes (e.g. patient census), models involving irrelevant data (e.g. vignettes or data not available following the emergency assessment), length of stay as a primary outcome, studies without full text or abstract in English. Intervention: AI- or ML-based clinical decision support tools used during patient care in the ED. Comparison: Not applicable for a scoping review. However, the review identified whether studies involved any comparison with usual care, clinician judgment, or non-AI tools. Outcomes: The review didn’t focus on a single outcome but instead categorized studies by their targeted clinical decision task—diagnosis, prognosis, disposition, treatment, etc. Outcomes were only included if they were relevant to emergency clinicians’ decision-making, such as predicting ICU admission, mortality, or need for intervention​. Type of Study: Scoping review. Dr. Hashim Kareemi This is an SGEM HOP and we are pleased to have the first author on the show. Dr. Hashim Kareemi is an emergency physician and researcher at Vancouver General Hospital who is exploring ways to improve the development and implementation of artificial intelligence models in emergency medical care. Authors’ Conclusions: “We found a large number of studies involving a variety of clinical applications, patient populations, and artificial intelligence models. Despite an increased rate of publication in recent years, few studies have advanced from preclinical development to later phases of clinical evaluation and implementation.” Quality Checklist for Scoping Reviews: Was the main question being addressed clearly stated? Yes Was the search for studies detailed and exhaustive? Yes Were the criteria used

Reference: Sax DR, et al. Emergency Severity Index Version 4 and Triage of Pediatric Emergency Department Patients. JAMA Pediatrics, October 2024 Date: February 12, 2025 Dr. Brandon Ho Guest Skeptic: Dr. Brandon Ho is a graduating pediatric emergency medicine fellow at Children’s National Hospital in Washington DC and soon to be attending physician at Seattle Children's. His research interests include AI in healthcare, medical education, and social determinants of health. Case: You are approached by the medical director of your emergency department (ED). She has noticed that recently, there has been an increasing number of pediatric cases presenting to your facility. In some of these cases, the children ended up being more sick than initially triaged. As the institution’s evidence-based medicine enthusiast, she asks you, “What do you think of the triage system we’re using now? How accurate is it for children?” Background: Pediatric triage is a fundamental component of emergency medicine, serving as the first critical step in managing acutely ill or injured children in the emergency department (ED). Unlike adult triage, pediatric triage presents unique challenges due to variations in physiology, developmental differences, and communication barriers in younger patients. Accurately assessing the severity of a child’s condition is essential for ensuring timely intervention while avoiding unnecessary resource utilization. The Emergency Severity Index (ESI) is the most widely used triage system in the United States. It classifies patients based on acuity and predicted resource utilization, ranging from ESI Level 1 (requiring immediate, life-saving intervention) to ESI Level 5 (requiring no resources beyond physician evaluation). However, pediatric triage remains particularly challenging due to factors such as age-based vital sign variations, difficulty in obtaining an accurate history, and non-specific presentations of critical illness​. Typically, ESI levels 1 and 2 are used to assess acuity and risk of instability. ESI levels 3, 4, and 5) are determined by expected resource needs. Those resources can be labs, imaging, medications, consultations, etc. Despite its widespread use, it’s imperfect with previous studies reporting mistriage rates as high as 50%. Pediatric patients can either be undertriage (assigning a lower acuity level than warranted) or overtriage (assigning a higher acuity level than necessary). This can have significant consequences when EDs are experiencing prolonged wait times, the boarding of patients, and are chronically short-staffed. Undertriage may lead to delayed care for critically ill children, whereas overtriage can result in unnecessary resource use, increased healthcare costs, and prolonged ED crowding. Studies have shown that pediatric patients are frequently subject to both types of errors, with younger children and those presenting with atypical symptoms being at risk​. Clinical Question: How accurate is ESI version 4 in predicting acuity and resource needs among pediatric ED patients? Reference: Sax DR, et al. Emergency Severity Index Version 4 and Triage of Pediatric Emergency Department Patients. JAMA Pediatrics, October 2024 Population: Pediatric patients (aged 0-18 years) presenting to 21 Kaiser Permanente Northern California ED’s from January 1, 2016, to December 31, 2020. Excluded: Missing ESI, incomplete ED time variables, transferred patients, patients who left against medical advice (AMA) or left without being seen (LWBS). Exposure: Assigned ESI level compared to actual resource utilization and critical interventions. Comparison: Correct triage rates were compared against undertriaged and overtriaged cases to identify patterns of mistriage​. Outcome: Primary Outcome: The rate of mistriage (undertriage or overtriage) of pediatric patients using ESI v4​. Secondary Outcomes: Patient and visit characteristics associated with mistriage, including age, sex, comorbidities, mode of arrival, and race/ethnicity​. Type of Study: Multicenter retrospective cohort study Authors’ Conclusions: “This multicenter retrospective study found that mistriage with ESI version 4 was common in pediatric ED visits. There is an opportunity to improve pediatric ED triage, both in early identification of critically ill patients (limit undertriage) and in more accurate identification of low-acuity patients with low resource needs (limit overtriage). Future research should include assessments based on version 5 of the ESI, which was released after this study was completed.” 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? Unsure Have the authors identified all-important confounding factors? Unsure Was the follow-up of sub

Date: April 1, 2025 This is another SGEM Xtra. I was asked to give a public lecture for the Gateway Centre of Excellence in Rural Health. The topic was the zombie idea that emergency department crowding is due to non-urgent patients. You can click on this LINK and get a PDF copy of my slides. The YouTube video of the presentation with the Q&A session featuring rural physician Dr. Kay Dingwell is available at this LINK. I also created a song to summarize some of the important parts of this issue (LINK). Thank you to Ivey MBA classmate Shirley Ngo, who was a guest skeptic on the SGEM Xtra: If I Had A Million Dollars episode discussing physician finance. She showed me how to make a song using artificial intelligence. The SGEM will return soon with a structured critical appraisal of a recent publication. Using social media, we continue to try to reduce the knowledge translation window from over ten years to less than one year. Ultimately, we want patients to 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. Zombie Dad Jokes:

Date: March 23, 2025 I was honoured to be invited to speak at Incrementum 2025 in Mercia, Spain. Thank you to Paco, Carmen, and the Incrementum team for putting on one of the best conferences ever. They asked me to talk about five important recent papers in 15 minutes. Usually, I do ten papers in ten minutes. However, This was an international audience, with many of the close to 600 attendees having English as their second language. Therefore, I slowed down and covered five papers in 15 minutes. You can click on each image to get the full SGEM critical appraisal. You can also get access to my slides by clicking on this LINK.

Date: February 22, 2025 Guest Skeptic: Nicholas Peoples, who is a medical student at Baylor College of Medicine in Houston, Texas. Nick’s career has been an exciting blend of global health and emergency medicine. In 2015, Nick was part of the first-ever class to study at Duke University’s new campus in China, where he earned a master’s degree in global health. He went on to spend a couple of years working for medical NGOs in Nepal and Malawi before deciding he wanted to become an emergency medicine doctor. Since then, he’s been at the top of his class in medical school – earning induction into the Alpha Omega Alpha and Gold Humanism Honor Societies. He won the prestigious Schwarzman Scholarship. This past year he published as first author in The Lancet, The BMJ, JAMA, and Academic Medicine. In typical EM fashion, he spends his spare time SCUBA diving and battling a crippling caffeine addiction. This is another SGEM Xtra. Today, we are going to take a deep dive into an essential but often overlooked topic: inaccurate citations in biomedical research. Scientific citations are the foundation of modern research, meant to weave a web of knowledge that is accurate, credible, and informative. However, a startling percentage of these citations are flawed. Inaccurate citations can misrepresent studies, propagate errors, and even shape misguided policies and guidelines. Nick and his colleagues recently highlighted this issue in their paper published in BMJ (Burden of proof: combating inaccurate citation in biomedical literature) and a related letter in The Lancet (Defensive scholarship: learning from academia’s plagiarism crisis). Ingelfinger FJ. Seduction by Citation. NEJM 1976: “The pages of any book, tract or article dealing with medicine are apt to be profusely sprinkled with numerical superscripts (or their equivalents) guiding the reader to a reference list. Not only does the liberal presence of such reference numbers impart an aura of scholarship, but their judicious placement after this or that assertion subtly suggests documented validity. But watch out—those little numbers may be no more than the trappings of credibility. The primary sources cited may be misquoted, inapplicable, unreliable and occasionally even imaginary.” Nick was asked five questions about his study. Listen to the SGEM podcast to hear his answers on iTunes or Spotify. FIVE QUESTIONS How prevalent are inaccurate citations, and what types exist? Pavlovic V et al. How accurate are citations of frequently cited papers in biomedical literature? Clin Sci (Lond). 2021 Mar Porrino JA Jr et al. Misquotation of a commonly referenced hand surgery study. J Hand Surg Am. 2008 Greenberg SA. How citation distortions create unfounded authority: analysis of a citation network. BMJ. 2009 Jul SGEM Xtra: Everything You Know is Wrong Charla Viera.Harvard President Claudine Gay Resignation: What it means for the larger academic community? Am J Experts March 2024 Leung PTM et al. A 1980 Letter on the Risk of Opioid Addiction. NEJM. 2017 Jun What are the underlying causes of inaccurate citations? Authors citing papers they haven’t read fully and either citing nonexistent findings or misinterpreting the findings. Copying citations from other studies rather than reading the primary source, and those citations themselves are inaccurate. This can turn into a long rabbit hole in the literature of sources citing other sources, but no evidence for the claim can be found. Bias or coercion in referencing, such as through peer review. Insufficient gatekeeping for miscitation. The academic community does not take miscitation seriously enough. How does the rise of AI tools like ChatGPT influence citation accuracy? AI tools can fabricate sources or generate plausible sounding but inaccurate citations. I think what worries me is that I have been seeing numerous AI programs being marketed to academics / PhD students where they were developed to read and summarize papers so that researchers don’t have to do any reading at all! I think that is anti-science. Efficiency is great in some areas, but in others, it is essential to take our time. You can’t learn a field by creating SparkNotes. At some point, you do have to sit down and read the extant literature, wrestle with figures and scatterplots and bar graphs, and look under the hood of a paper and make sure all the parts are in working order and pass muster. I think we must be vocal about this. All it will take is one generation of scholars who grow up making AI SparkNotes out of everything, and then that will become the norm, and suddenly, there will be no value to an academic paper anymore. We will just be writing for a nonexistent audience. Only machines will be reading academic papers, and for the rest of us, our understanding will be based on what the machines show us (or don’t show us), which is another source of bias. However, I also suggested that AI could also be harnessed to detect citation errors by validating source

Reference: Pessano S, et al. Positioning for lumbar puncture in newborn infants. Cochrane Database Syst Rev. December 2023 Date: February 7, 2025 Dr. Lauren Rosenfeld Guest Skeptic: Dr. Lauren Rosenfeld is a PGY-3 emergency medicine resident at George Washington University. She is also a new podcast host for Emergency Medicine Residents’ Association (EMRA) Cast Series. Case: A five-day-old girl is brought to the emergency department (ED) for fever by her parents. She was born full-term and seemed to be doing very well after the family returned home. Her mother had an uneventful pregnancy and delivery. Today, the parents thought she was feeling warm and took the girl’s temperature, which was 101°F (38.3°C). They called the pediatrician, who told them to go to the ED for more testing and warned them of the likelihood that their baby may need a lumbar puncture. The worried father asks you, “What is a lumbar puncture? Will it hurt?” Her mother asks you, “Is it like when I got an epidural before delivering? Will you sit her up for it? She can’t sit yet.” Background: We have covered the topic of febrile infants and lumbar punctures (LP) before on the SGEM. However, we typically focused on the febrile infant part. Today we’re going to talk more about performing the procedure of a lumbar puncture on babies. In the ED, lumbar punctures are typically performed in infants with fever in the evaluation for invasive bacterial infections including meningitis. There are many thoughts and bits of advice around how to perform an LP including the proper position, when to remove the stylet from the needle, what kind of analgesia to use, etc. There are multiple positions to set up the lumbar puncture. Commonly, patients can be placed on their side in the lateral decubitus, bend the neck so the chin is close to the chest, hunch the back, and bring the knees toward the chest to approximate the fetal position. Alternatively, patients may also sit upright and then bend their head and shoulders forward. When it comes to infants, most of the time, we are relying on someone else to help hold the baby in those positions as we’re performing the LP. Sometimes, these babies can have episodes of oxygen desaturation when they get held in that position for too long. Clinical Question: How does the positioning of infants during lumbar puncture (lateral decubitus vs sitting vs prone) affect success rates and adverse events? Reference: Pessano S, et al. Positioning for lumbar puncture in newborn infants. Cochrane Database Syst Rev. December 2023 Population: preterm and term infants of postmenstrual age up to 46 weeks and 0 days. Age 4.9 hours to 5 weeks Intervention: Infants positioned in a lateral decubitus position. Comparison: Infants positioned in a sitting position or prone position​. Outcome: Primary Outcome(s): Successful lumbar puncture on the first attempt, with < 500 red blood cells/mm3. Total number of lumbar puncture attempts (successful or unsuccessful). Episodes of bradycardia, defined as a decrease in HR of more than 30% below baseline or less than 100bpm for 10 seconds or longer. Secondary Outcomes: Time to perform LP, episodes of desaturation (SpO2 <80%), apnea, need for pain/sedation medication, skin changes at LP site, infection rate related to LP, pain, and parental satisfaction. Type of Study: Systematic Review Meta-analysis Authors’ Conclusions: “When compared to sitting position, lateral decubitus position probably results in little to no difference in successful lumbar puncture procedure at first attempt. None of the included studies reported the total number of lumbar puncture attempts as specified in this review. Furthermore, infants in a sitting position likely experience less episodes of bradycardia and oxygen desaturation than in the lateral decubitus, and there may be little to no difference in episodes of apnea. Lateral decubitus position results in little to no difference in time to perform the lumbar puncture compared to sitting position. Pain intensity during and after the procedure was reported using a pain scale that was not included in our prespecified tools for pain assessment due to its high risk of bias. Most study participants were term newborns, thereby limiting the applicability of these results to preterm babies. When compared to prone position, lateral decubitus position may reduce successful lumbar puncture procedure at first attempt. Only one study reported on this comparison and did not evaluate adverse effects. Further research exploring harms and benefits and the effect on patients' pain experience of different positions during lumbar puncture using validated pain scoring tools may increase the level of confidence in our conclusions.” 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

Reference: Bannelier et al. Failure rate of D-dimer testing in patients with high clinical probability of pulmonary embolism: Ancillary analysis of three European studies. AEM Feb 2025 Date: February 27, 2025 Guest Skeptic: Dr. Lauren Westafer an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for Annals of Emergency Medicine. Case: A 57-year-old woman presents to the emergency department (ED) with pleuritic posterior chest/back pain, shortness of breath, and left leg swelling. Her oxygen saturation is 95% on room air, blood pressure is 125/70, and her heart rate is 106 beats per minute. She has a swollen left leg that is tender but neurovascularly intact, without signs of cellulitis. She is on oral hormone replacement therapy (estrogen), and has a history of hypertension (on lisinopril). Chest x-ray shows no pneumonia or pneumothorax and bedside ultrasound reveals no B-lines or effusion. Background: Pulmonary embolism (PE) is a potentially life-threatening diagnosis that ED physicians must always have on their radar. The challenge, however, lies in balancing the risks of missing a PE with the harms of unnecessary imaging. D-dimer testing has changed how we workup suspected PE patients by serving as a highly sensitive yet non-specific biomarker for venous thromboembolism (VTE). This test has become a crucial component of modern PE diagnostic pathways. There is a need to “right size” testing such that we do not miss clinically important PEs without exposing very low risk patients to risks of imaging (ionizing radiation, contrast, allergic reaction, cost, and misdiagnosis). The principle behind D-dimer testing is its high negative predictive value (NPV) in ruling out PE, particularly in patients with low to moderate pretest probability. Current guidelines suggest that in these groups, a negative D-dimer result (below the defined threshold) can reliably exclude PE without the need for imaging. The Wells Score and Revised Geneva Score (RGS) and YEARS are widely used clinical prediction rules to stratify risk and guide appropriate use of D-dimer testing. However, in high-risk patients, the utility of D-dimer is less clear. The positive predictive value (PPV) of the test is low due to the presence of multiple potential causes of elevated D-dimer. Some of the causes of elevated D-dimers include cancer, infection, trauma, and post-surgical states. Given that a negative D-dimer result is uncommon in high-risk patients and the high prevalence of PE in this group, traditional teaching has recommended skipping the test and proceeding directly to CT pulmonary angiography (CTPA). The CT scanner has been called the "donut of truth" by some physicians. Despite these long-standing recommendations, recent studies have questioned whether a D-dimer–based approach could still be safe in selected high-risk patients. With age-adjusted D-dimer thresholds and Bayesian approaches refining risk stratification, a re-evaluation of the test’s performance in high-probability patients is warranted. Clinical Question: Can an age-adjusted D-dimer strategy safely exclude PE in patients with a high clinical probability of PE? Reference: Bannelier et al. Failure rate of D-dimer testing in patients with high clinical probability of pulmonary embolism: Ancillary analysis of three European studies. AEM Feb 2025 Population: Patients with a high clinical probability of PE (Wells >6 or Revised Geneva Score >10) and underwent D-dimer testing in the ED. Excluded: Patients with missing D-dimer values, missing data elements for the RGS or Wells score, inconclusive CTPA. Intervention: Age-adjusted or standard (<500) cut off for d-dimer Comparison: None Outcome: Primary Outcome: Failure rate of the age-adjusted D-dimer (i.e. a VTE in a patient with a negative D-dimer) at index visit or during 3-month follow up Secondary Outcomes: Failure rate using a fixed 500 ng/mL D-dimer threshold and the failure rate of CTPA (i.e. a VTE in a patient with a negative CTPA) during 3-month follow up Type of Study: This was a post hoc analysis of three European studies (two cluster randomized trials: PROPER, MODIGLIANI and one retrospective study: TRYSPEED) This is an SGEMHOP but we were unable to get in contact with the lead and corresponding author. We hope they will see or hear this episode and respond to our nerdy questions. Authors’ Conclusions: “In this study, ruling out pulmonary embolism in high-risk patients based on D-dimer below the age-adjusted threshold was safe, with no missed pulmonary embolism. However, the sample size was not large enough to draw a definitive conclusion on the safety of this strategy.” Quality Checklist for Observational Study: Did the study address a clearly focused issue?

Reference: Agnello et al. Monocyte distribution width (MDW) as a screening tool for early detecting sepsis: a systematic review and meta-analysis. Clinical Chemistry and Laboratory Medicine 2022; 60(5):786-792 Clin Chem Lab Med. 2022 Date: February 21, 2025 Guest Skeptic: Dr. Aaron Skolnik is an Assistant Professor of Emergency Medicine at the Mayo Clinic Alix School of Medicine and Vice Chair of Critical Care Medicine at Mayo Clinic Arizona. He is board-certified in Emergency Medicine, Medical Toxicology, Addiction Medicine, Internal Medicine-Critical Care, and Neurocritical Care. Aaron is a full-time multidisciplinary intensivist. He is the Medical Director of Respiratory Care for Mayo Clinic Arizona and enjoys serving as medical student clerkship director for critical care. Case: A 62-year-old male presents to the Emergency Department (ED) with fever, confusion, and shortness of breath. His symptoms began two days ago, starting with generalized malaise and chills, followed by progressive dyspnea and mental status changes. The patient also reports decreased urine output over the past day. He has a history of Type 2 diabetes mellitus, hypertension, and chronic kidney disease (stage 3). His home medications include metformin, lisinopril, and amlodipine, though he hasn’t taken his antihypertensives for the last two days. He is tachycardic, tachypneic, and febrile with a BP of 92/58, and an oxygen saturation of 91% on room air. Physical examination reveals diffuse crackles bilaterally and chest x-ray shows bilateral infiltrates consistent with pneumonia. His WBC is elevated at 23,000 with a left shift. Lactate is 3.8 mmol/L and blood cultures are pending. Background: Rapid and accurate diagnosis of sepsis is critical, as early intervention can significantly reduce patient mortality. However, diagnosing sepsis early remains challenging because it presents with nonspecific symptoms. New biomarkers, such as procalcitonin and lactate, offer some utility but are not sufficiently reliable on their own​​. Recently, monocyte distribution width (MDW) has emerged as a promising biomarker in this diagnostic challenge. MDW, an indicator of variability in monocyte size, can be rapidly assessed as part of an automated complete blood count differential and may flag potential sepsis early in patients. This parameter has the advantage of being available very quickly without additional blood draws, which could be helpful in the fast-paced ED setting. Current evidence suggests MDW could be used alongside existing clinical criteria to help screen for sepsis risk and guide further assessment and treatment, even in patients where sepsis is not immediately suspected​​. Clinical Question: What is the diagnostic accuracy of monocyte distribution width for early detection of sepsis? Reference: Agnello et al. Monocyte distribution width (MDW) as a screening tool for early detecting sepsis: a systematic review and meta-analysis. Clinical Chemistry and Laboratory Medicine 2022; 60(5):786-792 Clin Chem Lab Med. 2022 Population: Adults admitted to various clinical settings, particularly the ED, intensive care unit (ICU), and one infectious diseases unit (I don’t have one of those Ken – do you?). Excluded: Pediatric patients, COVID-19 patients, non-diagnostic studies (ie studies evaluating only the prognostic role of MDW), non-English studies and case reports and reviews. Intervention: Monocyte distribution width (MDW) Comparison: Sepsis-2 and Sepsis-3 diagnostic criteria. Sepsis-2 is based on systemic inflammatory response syndrome (SIRS) markers, while Sepsis-3 relies on organ dysfunction as assessed by the sequential organ failure assessment (SOFA) score​. Outcome: Diagnostic accuracy of MDW for early sepsis detection, measured by pooled sensitivity, specificity, and likelihood ratios​. Type of Study: Systematic review and meta-analysis for diagnostic accuracy Authors’ Conclusions: “MDW represents a reliable biomarker for sepsis screening”. Quality Checklist for Systematic Review Diagnostic Studies: The diagnostic question is clinically relevant with an established criterion standard. Yes The search for studies was detailed and exhaustive. No The methodological quality of primary studies were assessed for common forms of diagnostic research bias. No The assessment of studies were reproducible. No There was low heterogeneity for estimates of sensitivity or specificity. No The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. Unsure Funding and COIs: No research funding was declared and the authors reported no conflicts of interest. Results: Ten studies were included in the SRMA with 9,475 patients. There were 1,370 diagnosed with sepsis (742 using Sepsis-2 criteria and 628 with Sepsis-3). Key Result: MDW showed reasonable diagnostic accuracy for detecting sepsis early but with wide confidence intervals and high heterogeneity. Diagnostic Accuracy: Sepsis 2: Pooled sensitivity and

Date: February 11, 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 another SGEM Xtra. On today’s episode, we’re diving into a fascinating and evolving topic—how artificial intelligence (AI) shapes clinical research. AI has the potential to streamline many aspects of medical research, from study design to statistical analysis and even manuscript preparation. But as always, we need to approach these innovations skeptically. There are a lot of promises being laid on the shoulders of AI, and increasingly, it can be difficult to separate the hype from reality. I certainly believe that AI will change what clinical research looks like in the next decade, but at its core, it will be the synergy between researchers and technology that drives innovation, not either in isolation. The easiest way to reflect on how AI might be used in clinical research is to think about the research lifecycle. Layered on top of this are themes like collaboration/team efficiency, security and privacy, and other general administrative efficiencies (accounting + Meeting scheduling + email management). Study inception and design Protocol Generation Ethics application Study Facilitation and Recruitment Data Extraction Data Analysis Manuscript writing Manuscript submission Knowledge Mobilization Eleven Questions on Artifical Intelligence and Clinical Research Listen to the SGEM Podcast to hear Dr. Prager's responses to my eleven questions. 1. Designing a Study with AI – Formulating a PICO Question: Every good clinical study starts with a clear and well-defined research question. AI tools are now being used to help formulate the PICO (Population, Intervention, Control, Outcome). How can AI assist researchers in this first critical step? 2. Identifying Potential Study Participants from EMRs: One of the biggest challenges in research is identifying eligible patients. Traditionally, this has been done manually and has been a very time-intensive process (think medical students). How can AI help streamline this? 3. Determining the Most Important Patient-Oriented Outcome: Research should prioritize outcomes that matter to patients. How can AI help determine the most clinically meaningful and patient-centred outcomes for a study? In other words, can AI help us find the POO? 4. Estimating Effect Size and Sample Size Calculations: To conduct a well-powered study, researchers need to estimate the expected effect size and determine the required sample size. Can AI assist with these calculations? 5. AI for Statistical Analysis and Data Visualization: Once data is collected, the next step is analysis. How can AI assist with statistics and visualizing complex data? 6. AI-Assisted Manuscript Writing and Editing: Writing a research paper is a time-consuming process, especially for non-native English speakers. A friend of mine is a clinical researcher and editor for a major journal. They talk about knowing some brilliant researchers who cannot write/communicate well. Can AI help these people and improve the clarity and readability of their scientific manuscripts? 7. Verifying Citation Accuracy: We will be talking about the issue of inaccurate citations in the medical literature with Dr. Nick Peoples. His research reported that citations are not correct up to 25% of the time (reference). Concerns have been raised about AI hallucinated citations. We want to make things better, not worse, by using AI. How can AI be used to ensure accuracy and prevent misinformation in referencing? 8. AI in Systematic Reviews and Meta-Analyses: Another form of clinical research is performing systematic reviews and meta-analyses. These can be very labour-intensive. Hiring a research librarian can help. How could AI streamline the process while maintaining rigour? 9. Automating Ethics Approval and Journal Submission: Applying for IRB approval and formatting manuscripts for journal submission can be bureaucratic nightmares. See how I’m slipping two questions into one? How can AI help researchers automate these processes? For manuscript formatting, Ross gave a self-plug a platform during the podcast that he has been working on for the past year. His team built a tool called Resub, that automatically formats manuscripts for any journal in minutes. This is a hugely time-consuming, painful, and tedious process. Worldwide, this wastes almost 24 million researcher hours per year on formatting alone. In the next couple of years, the delays from editorial rejections account for almost 43,000 years of delay in new scientific knowledge reaching the bedside. His thought was to create Resub software that is like a reference manager but for the whole paper. This wasn’t possible before the advent of LLMs, because the technology ne

Reference: Leonard JC et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. June 2024. Date: Oct 15, 2024 Dr. Tabitha Cheng Guest Skeptic: Dr. Tabitha Cheng is a Southern California native and board-certified emergency medicine physician and completed an EMS fellowship as well. The learning didn’t end because she then completed another fellowship in pediatric emergency medicine at Harbor UCLA. Case: An 8-year-old girl is brought in by EMS after a car accident. She was seat belted, sitting in the backseat of the family’s car when they were hit from the side by another vehicle that ran a red light. The airbags deployed, and the car spun a few times. When EMS arrived on the scene, they found both parents unconscious and the girl appeared slightly dazed and confused. EMS places her in a cervical collar and brings her to the emergency department (ED). On your examination, you see she is scared but answering questions appropriately. She does have some abrasions from her seatbelt and complains of pain around her ankle. The rest of her exam is unremarkable. After your evaluation, you are informed that her grandmother has arrived to be with the girl as her other family members are being treated. She looks at the contraption on the girl’s neck and asks you, “Is she okay? Is something wrong with her neck? Does she need an X-ray or CT scan?" Background: Pediatric cervical spine (c-spine) injuries are uncommon (1-3% of blunt trauma). These injuries typically result from blunt trauma caused by motor vehicle accidents, falls, sports injuries, or physical abuse. Although C-spine injuries represent a small fraction of pediatric trauma cases, their potential severity makes accurate and timely diagnosis critical. Younger kids tend to have big lollipop heads which makes them more prone to injury in the upper cervical spine compared to adults (their fulcrum is higher). It is also sometimes difficult to get a scared child to give an accurate history or cooperate with an exam. Many of us use CT or X-rays to help detect cervical spine injuries in this population. Clinicians working in EDs must strike a balance between ensuring they do not miss these rare but serious injuries and avoiding unnecessary imaging, particularly computed tomography (CT), which exposes children to ionizing radiation. Given the sensitivity of developing tissues to radiation, especially in younger children, avoiding unnecessary imaging is a high priority in pediatric care. Traditional diagnostic approaches often lead to the overuse of imaging tools, like CT scans and X-rays, even in low-risk children. This has prompted a movement toward more refined, evidence-based methods for identifying pediatric C-spine injuries, particularly through the development of clinical decision rules (CDRs). CDRs are designed to assist clinicians in making more accurate decisions about when imaging is truly necessary by identifying key clinical predictors of serious injuries. The Pediatric Emergency Care Applied Research Network (PECARN) has been instrumental in developing one of the most widely recognized CDRs for pediatric C-spine injuries. Based on large, multicenter studies, this tool identifies critical risk factors that signal the need for imaging, such as altered mental status, focal neurological deficits, and certain mechanisms of injury. The PECARN rule, validated in clinical settings, has demonstrated high sensitivity in detecting C-spine injuries, while also reducing unnecessary imaging. There are multiple CDRs for identifying pediatric c-spine injuries besides PECARN. The SGEM recently covered the Cochrane systematic review on pediatric CDRs on SGEM #441. Clinical Question: Can the new PECARN clinical prediction rule (tool) guide imaging decisions in detecting pediatric cervical spine injuries without missing significant cervical spine injuries (CSI)?​​ Dr. Julie Leonard Reference: Leonard JC et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. June 2024. Population: Children aged 0–17 years with known or suspected blunt trauma presenting to the ED across 18 US hospitals. Exclusions: Patient with penetrating trauma. Intervention: Derivation and validation of the PECARN CDR prediction rule to guide imaging decisions for pediatric c-spine injuries Comparison: None Outcome: Primary Outcome: Identification of cervical spine injuries within 28 days that warranted inpatient observation or surgical intervention. Secondary Outcomes: Reduction in unnecessary imaging, particularly CT and X-ray use​. Type of Study: Prospective observational cohort study Guest Authors Dr. Caleb Ward Dr. Caleb Ward is a pediatric emergency medicine attending and Associate Professor of Pediatrics and

Date: January 9, 2025 Reference: White et al. Evidence of questionable research practices in clinical prediction models. BMC Med 2023 Guest Skeptic: Dr. Jestin Carlson is the Program Director for the AHN-Saint Vincent EM Residency in Erie Pennsylvania. He is the former National Director of Clinical Education for US Acute Care Solutions and an American Red Cross Scientific Advisory Council member. Dr. Richard Bukata We have had the pleasure of both working for the Legend of EM, Dr. Richard Bukata. He is an amazing educator and a great human being. He has been involved in medical education for over 40 years. He helped create the Emergency Medicine and Acute Care course, a ‘year-in-review’ course where the faculty review over 200 articles from the last year in a rapid-fire, tag-team format, meaning one presents one article, the other provides additional commentary, and then they switch. Each article takes about 2-3 minutes. The faculty is amazing, and the course is held in some wonderful locations: Vail, Maui, New York City, New Orleans, Hilton Head, San Diego, and Key West. There is also a self-study option if you are not able to attend in person. Case: You are working with a fourth-year medical student who is an avid listener to the Skeptics Guide to Emergency Medicine podcast. They recently listened to an episode examining a paper that used receiver operating characteristic curves or ROC curves to determine the accuracy of a predictive model by looking at the area under the curve or AUC. The student knows from other SGEM podcasts that there has been evidence of p-hacking in the medical literature and wonders if there have been similar instances with ROC curves. They ask you if there is any evidence of ‘ROC’ or ‘AUC-hacking?’ Background: To answer that young skeptic’s question, they must understand ROC curves. The ROC is a tool used to evaluate the diagnostic performance of a test or prediction model. The curve is graphed with the true positive rate (sensitivity) on the y-axis and the false positive rate (1-specificity) on the x-axis at various threshold levels for classifying a test result as positive or negative. ROC curves help clinicians determine how well a test or model can differentiate between patients with and without a condition. A perfect test would have a point at the top-left corner of the graph (sensitivity = 1, specificity = 1). The area under the curve (AUC) is often used to summarize a prediction model's discriminatory capacity. A result of 1.0 indicates perfect discrimination, while an AUC of 0.5 suggests performance no better than chance—essentially, a coin toss. By comparing the ROC curves of different tests or models, clinicians can identify which performs better in discrimination. Interpretation of the AUC often hinges on thresholds. Values of 0.7, 0.8, and 0.9 are commonly labelled as “fair,” “good,” or “excellent.” These descriptors, while convenient, are arbitrary and lack scientific foundation. Their widespread use introduces a strong temptation for researchers to achieve “better” AUC values. This drive can lead to things like p-hacking, a questionable research practice in which investigators manipulate data or analyses to cross predefined thresholds. P-hacking is not exclusive to AUC but is a well-documented problem in broader research, particularly surrounding the 0.05 p-value significance threshold. In the context of AUC, p-hacking might include selectively reporting favourable results, re-analyzing data multiple times, or even tweaking model parameters to inflate values. Such practices risk misleading clinicians and compromising patient care by promoting overly optimistic models. Understanding the prevalence and mechanisms of AUC-related p-hacking is vital for emergency physicians who often rely on clinical prediction tools for critical decisions. As the use of these models grows, so does the importance of transparent and robust research practices. Clinical Question: Is there evidence of questionable research practices, such as data manipulation or "hacking", in studies developing clinical prediction models? Reference: White et al. Evidence of questionable research practices in clinical prediction models. BMC Med 2023 Population: PubMed abstracts that reported at least one AUC value related to clinical prediction models Excluded: Abstracts with fewer than 10 words, pharmacokinetic studies using AUC for unrelated purposes, meta-analyses or pooled analyses, and tutorial papers lacking original findings​ Exposure: NA Comparison: No explicit comparison group was utilized, but the study benchmarked observed AUC distributions against expected smooth patterns. Primary Outcome: Evidence of irregular distributions, such as excess AUC values just above thresholds (e.g., 0.7, 0.8 or 0.9), that could suggest data manipulation. Type of Study: Observational study based on secondary data analysis. Authors’ Conclusions: “The AUCs for some models are over-inflated, which risks exp

Date: January 7, 2025 Dr. Dara Kass Guest Skeptics: Dr. Dara Kass is an emergency medicine physician, public health leader, and advocate passionate about equity and healthcare reform. She founded FemInEM, promoting gender equity in emergency medicine, and champions organ donation reform after donating part of her liver to her youngest son. Dr. Kass is dedicated to expanding reproductive healthcare access and educating the public on healthcare policy. A mother of three, she combines her commitment to medicine, advocacy, and equity to create meaningful change. SGEM Xtra: FemInEM - Stronger Together SGEM Xtra: FIX19 You Up Dr. Esther Choo Dr. Esther Choo is an emergency physician and professor at the Oregon Health & Science University. She is a popular science communicator who has used social media to talk about racism and sexism in healthcare. She was the president of the Academy of Women in Academic Emergency Medicine and is a member of the American Association of Women Emergency Physicians. SGEM#248: She Works Hard for the Money - Times Up In Healthcare SGEM Xtra: FemInEM - Stronger Together Dr. Jenny Beck-Esmay Dr. Jenny Beck-Esmay is an associate professor of emergency medicine and assistant residency director at Mt. Sinai Morningside and Mt. Sinai West in New York City. She is passionate about emergency medicine education and gender equity in medicine and is proud to have contributed content to numerous resources including FemInEM, REBEL EM and EMDocs. This is the SGEM Xtra, where we bring you special episodes that highlight important topics in emergency medicine. Today, we have invited these three amazing people to discuss the relaunch of the Females in Emergency Medicine (FeminEM) initiative. Make sure you check out the new WEBSITE. The last time we spoke in 2017, FemInEM was making waves by empowering women in emergency medicine and fostering conversations about gender equity. Now, it’s 2025, and FemInEM is back with renewed energy and a clear mission. Five Questions About FemInEM 2.0 The Relaunch of FeminEM: Why the decision to relaunch FemInEM as a non-profit foundation? What inspired this transition, and what are the key changes that come with it? New Mission and Vision: The new mission statement of FemInEM focuses on advancing gender equity in emergency medicine and improving reproductive healthcare delivery in emergency departments. What strategies will FemInEM use to achieve these goals? Addressing Reproductive Healthcare Challenges: One of the standout components of the relaunch is the focus on reproductive healthcare emergencies. Can you elaborate on the evidence-based protocols and resources FemInEM plans to implement and how they will impact patient outcomes? Mentorship and Career Development: Mentorship has always been a cornerstone of FemInEM. How will the new mentorship programs support women in emergency medicine, and what role do they play in addressing issues like burnout and career advancement? Champions of Change: The "Champions of Change" program is an exciting initiative targeting medical students. How do you envision this program shaping the next generation of emergency physicians and advocates for systemic change? Call To Action - Check Out the New FeminEM Website The SGEM will be back next episode with a structured critical appraisal of a recent publication. We continue to try and cut the knowledge translation window down from over ten years to less than one year using the power of social media. Ultimately, we want patients to get the best care, based on the best evidence. Other SGEM Episodes on this Topic: SGEM Xtra: I Am Woman SGEM Xtra: Money, Money, Money It’s A Rich Man’s World – In the House of Medicine SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease SGEM Xtra: From EBM to FBM – Gender Equity in the House of Medicine SGEM#352: Amendment – Addressing Gender Inequities in Academic Emergency Medicine SGEM#442: I’m on the Right Track Baby I Was Born This Way Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Date: December 2o, 2024 Reference: Kotani et al. Positive single-center randomized trials and subsequent multicenter randomized trials in critically ill patients: a systematic review. Crit Care. 2023 Guest Skeptic: Dr. Scott Weingart is an ED Intensivist from New York. He did fellowships in Trauma, Surgical Critical Care, and ECMO. He is a physician coach concentrating on the promotion of eudaimonia and optimal performance. Scott is best known for talking to himself about Resuscitation and Critical Care on a podcast called EMCrit, which has been downloaded more than 50 million times. Case: A 40-year-old male presents to the emergency department (ED) with severe respiratory failure from bilateral pneumonia. After a trial of Non-Invasive Positive Pressure Ventilation (NIPPV), you’ve decided to intubate him. Should your first pass attempt be done with a bougie or a styletted tube? Randomization Background: The role of single-center randomized controlled trials (sRCTs) in advancing medical knowledge is significant, especially in the field of emergency medicine (EM). These trials often serve as the initial foundation for exploring interventions, providing a focused and controlled environment to test hypotheses. However, the applicability of their findings to broader clinical settings can be limited due to their localized context. Multi-center randomized controlled trials (mRCTs) are often seen as a necessary step to validate these findings across diverse patient populations and healthcare settings. This process of validation is critical, as it addresses external validity—a cornerstone of evidence-based practice​​. Historically, the need to move from sRCTs to mRCTs arises from the recognition that different institutions have varied patient demographics, resources, and protocols that might influence outcomes. While sRCTs provide essential insights, their ability to reflect real-world complexities is inherently restricted​​. Emergency physicians, who operate in unpredictable environments, often rely on evidence that is robust across multiple settings to guide clinical decisions effectively. Despite the apparent hierarchical superiority of mRCTs, there are debates about whether they consistently confirm the results of sRCTs. This discussion is pivotal in understanding how findings can be generalized and integrated into clinical guidelines​​. As emergency physicians, evaluating the interplay between sRCTs and mRCTs not only helps in assessing the reliability of evidence but also in shaping the way we approach the implementation of interventions in our practice. Clinical Question: How often are single-centred RCTs of critically ill patients reporting a mortality benefit confirmed in a multi-centred RCT? Reference: Kotani et al. Positive single-center randomized trials and subsequent multicenter randomized trials in critically ill patients: a systematic review. Crit Care. 2023 Population: sRCTs published in high-impact journals (NEJM, JAMA, or Lancet) that reported statistically significant mortality reductions in critically ill patients. Exclusions: Quasi-randomized or non-randomized methodologies, multicentric trials, pediatric populations, and studies lacking mortality data. Intervention: sRCTs Comparison: mRCTs Outcome: Primary Outcome: Mortality assessed at specified time points such as hospital discharge or predefined follow-up periods. Secondary Outcomes: Guideline utilization of sRCT results, subsequent guideline changes based on mRCT Type of Study: Systematic review that followed the PRISMA guidelines and was registered in the PROSPERO International Prospective Register of Systematic Reviews Authors’ Conclusions: “Mortality reduction shown by sRCTs is typically not replicated by mRCTs. The findings of sRCTs should be considered hypothesis-generating and should not contribute to guidelines.” Quality Checklist for Systematic Reviews: Was the main question being addressed clearly stated? Yes Was 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? Unsure Were there any financial conflicts of Interest? No Who funded the study? The review was funded by academic institutions. Results: The review included 19 sRCTs and 24 subsequent mRCTs. Sixteen sRCTs addressed were followed up by mRCTs. The majority of mRCTs found no mortality difference compared to the significant findings of sRCTs​​. Key Result: Single-centred RCTs often do not replicate in multi-centred RCTs. Primary Outcome: Only one out of 16 (6%) sRCT’s findings were confirmed by mRCTs. Secondary Outcomes: 14 sRCTs were referenced at least once in international guidelines. Of those, 43% (6/14) have since been either suggested against or removed in the most recent versions of the guidelines. 1) PRISMA: Kotani et al. adhered to several essential PRISMA checklist ite

Date: December 6, 2024 Guest Skeptic: Akil Dasan is a multifaceted artist renowned for his talents as a rapper, singer, guitarist, and beatboxer. He gained prominence as a member of the British jazz-rap group Us3, contributing to their 2006 album "Schizophonic". This is an SGEM Xtra. We have done a top ten list before on the SGEM. That episode was the Ten Commandments of EBM. This time we are looking at a 1951 article written by Bertrand Russell and published in The New York Times Magazine. The title of his article was “The Best Answer to Fanaticism–Liberalism” Bertrand Russell was one of the most influential philosophers, logicians, and social critics of the 20th century. Russell is known for his groundbreaking work in mathematical logic and analytic philosophy. He was awarded the Nobel Prize in Literature in 1950 for his varied writings championing humanitarian ideals and freedom of thought. Russell’s work spanned a wide range of topics, including philosophy, mathematics, politics, and education, and he was an outspoken advocate for peace and social reform. Russell’s clarity of thought and commitment to rational inquiry continue to inspire and challenge thinkers around the world. Bertrand Russell had many pithy quotes. Here are a few of my favourites: In his 1951 New York Times article, Russell discusses his perspective on the struggle between tyranny and anarchy throughout history, both of which he viewed as dangerous extremes. He argued that liberalism is less a rigid doctrine and more a disposition, valuing the freedom to challenge ideas through reasoned argument rather than suppression. Russell was critical of both blind allegiance to authority and the radical impulse to overthrow authority without regard for the consequences. There is a great quote in the article where Russell says: “The teacher who urges doctrines subversive to existing authority does not, if he is a liberal, advocate the establishment of a new authority even more tyrannical than the old. He advocates certain limits to the exercise of authority, and he wishes these limits to be observed not only when the authority would support a creed with which he disagrees but also when it would support one with which he is in complete agreement. I am, for my part, a believer in democracy, but I do not like a regime which makes belief in democracy compulsory.” The article concludes with Russell’s “Ten Commandments” for a liberal life, which as a teacher, he wished to promulgate. The list emphasizes skepticism, transparency, intellectual courage, and respect for dissent. These principles reflect his belief that a healthy democracy relies on open dialogue, honest inquiry, and the rejection of dogmatic certainty. Bertrand Russell's Ten Commandments Do not feel absolutely certain of anything. Do not think it worthwhile to produce belief by concealing evidence, for the evidence is sure to come to light. Never try to discourage thinking, for you are sure to succeed. When you meet with opposition, even if it should be from your husband or your children, endeavor to overcome it by argument and not by authority, for a victory dependent upon authority is unreal and illusory. Have no respect for the authority of others, for there are always contrary authorities to be found. Do not use power to suppress opinions you think pernicious, for if you do the opinions will suppress you. Do not fear to be eccentric in opinion, for every opinion now accepted was once eccentric. Find more pleasure in intelligent dissent than in passive agreement, for, if you value intelligence as you should, the former implies a deeper agreement than the latter. Be scrupulously truthful, even when truth is inconvenient, for it is more inconvenient when you try to conceal it. Do not feel envious of the happiness of those who live in a fool’s paradise, for only a fool will think that it is happiness. If you are interested in learning more about Bertrand Russell there is an excellent graphic novel called Logicomix - An Epic Search for Truth. “This exceptional graphic novel recounts the spiritual odyssey of philosopher Bertrand Russell. In his agonized search for absolute truth, Russell crosses paths with legendary thinkers like Gottlob Frege, David Hilbert, and Kurt Gödel, and finds a passionate student in the great Ludwig Wittgenstein. But his most ambitious goal-to establish unshakable logical foundations of mathematics-continues to loom before him. Through love and hate, peace and war, Russell persists in the dogged mission that threatens to claim both his career and his personal happiness, finally driving him to the brink of insanity.” The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down 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. Other SGEM Episodes on Philosophy: SGEM Xtra: A Philoso

Date: December 26, 2024 Reference: Steinhauser S et al. Emergency department staff compassion is associated with lower fear of enacted stigma among patients with opioid use disorder. AEM December 2024 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: You and your resident physician have been working hard all day taking care of patients, saving lives, and making a difference. You hear your resident groan. You ask her what’s the matter, and she says: “I just picked up a patient with the chief complaint ‘abdominal pain,’ thinking it would be a simple, bread-and-butter workup, but the patient is on methadone. I don’t feel like dealing with this at the end of my shift.” Your resident looks up at you intently, looking for answers and hoping for wisdom. You wonder what you can say to help motivate your resident the right way and bring your patient back to the center of the encounter. Background: Opioid Use Disorder (OUD) represents a profound public health challenge, impacting millions of individuals worldwide. Defined as a chronic, relapsing condition characterized by a compulsive urge to use opioids despite harmful consequences, OUD transcends demographic boundaries, affecting individuals across all socioeconomic strata and geographies. In the United States alone, the burden is staggering: over six million individuals were estimated to have OUD in 2022. Emergency departments (EDs) are often the first point of contact for patients experiencing opioid-related crises, ranging from overdose to withdrawal. This positions EDs as critical spaces for intervention, offering a chance to initiate treatment, provide education, and connect patients with long-term resources. Despite this, patients with OUD frequently encounter stigma in healthcare settings, including the ED. Stigma in this context refers to the devaluation and discriminatory attitudes directed at individuals due to their condition. Such attitudes can manifest in subtle ways—disparaging comments, undertreatment of pain, or reluctance to initiate evidence-based treatments like medication-assisted therapy (MAT). This stigma not only undermines the patient-provider relationship but also discourages individuals from seeking care, perpetuating cycles of harm and disengagement. The stigma associated with OUD in emergency settings is multifaceted, rooted in misconceptions about addiction as a moral failing rather than a medical condition. Education and empathy-focused interventions have shown promise in mitigating these biases. By fostering an environment of compassion and understanding, healthcare professionals can significantly enhance the quality of care for these patients and potentially reduce the fear of stigma, as suggested by emerging research. Clinical Question: What is the prevalence of the fear of enacted stigma among patients who present to the ED with OUD, and is experiencing greater compassion from the ED staff associated with lowering this fear? Reference: Steinhauser S et al. Emergency department staff compassion is associated with lower fear of enacted stigma among patients with opioid use disorder. AEM December 2024 Population: Adult patients with diagnosed OUD presenting to an academic ED between February and August 2023. Exclusions: Patients unable to consent, non-English speakers, prisoners, acutely psychotic patients, critically ill patients, those suffering from dementia and those without a definitive diagnosis of OUD. Intervention: NA Comparison: NA Primary Outcome: The level of fear of enacted stigma, measured via the 9-item subscale of the Substance Abuse Self-Stigma Scale. The subscale consists of items rated on a 5-point Likert scale. Scores range from 9 to 45, with higher scores indicating greater fear of enacted stigma. Type of Study: Survey-based, observational. This is an SGEMHOP, and we are pleased to have the lead author, Savannah Steinhauser, on the show. Savannah is a 4th-year medical student at Cooper Medical School in Camden, NJ and is applying to internal medicine for residency. She has experience working with people with OUD both during clinical rotations at Cooper Hospital and with clients with the organization she founded called CMSRU Outreach Alliance. It organizes weekly outreaches on the streets in Camden. Authors’ Conclusions: “Among ED patients with OUD, fear of enacted stigma is common. Patient experience of compassion from ED staff is associated with lower fear of enacted stigma. Future research is warranted to test if interventions aimed at increasing compassion from ED staff reduce patient fear of enacted stigma among patients with OUD.” Quality Checklist for Observational Studies: 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? No Was the exposure accurately mea

Date: December 15, 2024 Guest Skeptics: Dr. Chris Carpenter, Vice Chair of Emergency Medicine at Mayo Clinic. Today, we’re sleighing through the holiday season with a special episode filled with statistical cheer, a dash of skepticism, and a hint of eggnog-flavoured nerdiness. This is an SGEM Xtra like the one we did on What I Learned from Top Gun. It’s fun to mix it up and not do a structured critical appraisal of a recent publication and have a more philosophical chat. The inspiration for the SGEM Xtra episode is the BMJ 2022 holiday article called "The 12 Days of Christmas, the Statistician Gave to Me,". The BMJ statistical editors gifted us a publication highlighting common statistical faux pas, laid out in true holiday spirit. We came up with our own SGEM 12 nerdy days. The 12 Days of Christmas the SGEM Gave to Me Day 1: A P Value in a Pear Tree Ah, the P value of frequentists statistics —often misunderstood and frequently abused. The key here is remembering that a P value isn’t proof of the “truth”. We define truth as the best point estimate of an observed effect size with a confidence interval around the point estimate. We should not hang our clinical decisions on a single P value. When do we ever base our care on one data point? Day 2: Two Confidence Intervals Confidence intervals (CIs) tell us the range of plausible values for our estimate. If they’re too wide, it’s like a holiday sweater that’s too loose—unflattering and not very useful. Reconsider that sample size or effect size to get clinically impactful intervals you would want to share with Santa Claus. And remember, CIs don’t mean certainty! Day 3: Three Missing Values Missing data is the Grinch of research. Ignoring it or using improper methods to handle it can bias your results in unpredictable directions. Using methods like multiple imputation or sensitivity analysis can salvage your data without sacrificing rigour. We often forget that missing data extends beyond interventional studies. For example, in diagnostic research like emergency ultrasound indeterminate results are often swept under the rug and either excluded or not reported – even when methods like 3x2 tables exist to improve the transparency of these indeterminate results that reflect real-life when trying to deploy these diagnostics that require technical expertise and subjective interpretation. Day 4: Four Overfit Models Overfitting is like over-decorating your Christmas tree—too many ornaments and it collapses. Overfit models describe the noise, not the signal, making them poor predictors in new datasets. Keeping your models simple and robust can pay downstream dividends for widespread usability and replicability. Day 5: Five Golden Rules Here are the five statistical golden rules for a randomized control trial: Power Calculation: Do an a priori power calculation that defines the expected effect size, choose a significance level (α, commonly 0.05 and two-sided), specify the desired power (commonly 80-90%) and account for anticipated dropouts. Randomization: Use proper randomization techniques (simple, stratified, or block randomization). Ensure allocation concealment to prevent prediction of group assignment. Outcomes: Clearly defined primary and secondary endpoints. Pick patient-oriented outcomes (POO) rather than disease-oriented outcomes (DOOs), surrogate-oriented outcomes (SOOs) or monitor-oriented outcomes (MOOs) Statistical Analysis Plan: Provides a roadmap for how data will be analyzed and reduces the risk of data dredging or p-hacking. Specify which tests will be used, pre-plan subgroup and sensitivity analyses and define how missing data will be handled. Control of Bias and Confounding: Bias and confounding can distort study results and lead to incorrect conclusions. Use blinding (single, double, or triple) to reduce performance and detection biases. Collect baseline characteristics to assess the balance between groups (e.g., multivariable regression). And of course, citing and transparently adhering to applicable EQUATOR Network reporting standards that are appropriate for the research design is a holly-jolly path to fulfilling these five golden rules. Day 6: Six Sensitivity Analyses Sensitivity analyses test the robustness of your results under different assumptions. It’s like asking, “If we change the cut-off for naughty versus nice, does our conclusion hold?” Day 7: Seven Skewed Distributions Skewed distributions can throw off your statistical assumptions, like trying to fit a rectangular present into a circular box. Many common tests assume normality, so when you’re dealing with skewness, consider transformations or non-parametric tests. And always plot your data first—it’s the gift of clarity. Day 8: Eight Non-Significant Findings Non-significant findings are like getting socks for Christmas—not exciting but often useful. They remind us that the absence of evidence isn’t evidence of absence. Report them transparently, as they contribute to the broad

Reference: Sanchez-Pinto, L.N., et al. Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024​​. Guest Skeptic: Prof. Damian Roland is a Consultant at the University of Leicester NHS Trust and Honorary Professor for the University of Leicester’s SAPPHIRE group. He specializes in Paediatric Emergency Medicine and is a passionate believer and advocate of FOAMed. Damian is also part of the Don’t Forget the Bubbles Team. Dr. Damian Roland Case: A 3-year-old boy arrives at the emergency department (ED) with a high fever, rapid breathing, and lethargy. His parents state that he has had a fever and cough for the past three days. He tested positive for influenza two days ago but seems to be getting worse. On exam, he has crackles in his right lung field. His pulse oximeter reads 88% on room air. His heart rate is elevated. He looks sleepy but is clinging to his parents. A medical trainee you are working with asks, “He looks really sick. Is this pneumonia or could this be sepsis?” Background: Pediatric sepsis is a major global health concern, causing an estimated 3.3 million deaths annually. The 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria were established based on expert consensus and used for diagnosis. However, they've been criticized for low specificity and not being adaptable across different resource settings​​. The SGEM has covered sepsis multiple times: SGEM #448: More than a Feeling-Gestalt vs CDT for Predicting Sepsis SGEM #371: All of My Lovit, Vitamin C Won’t Work for You SGEM #346: Sepsis-You were Always on My Mind SGEM Xtra: Petition to Retire the Surviving Sepsis Campaign Guidelines SGEM #207: Ahh (Don’t) Push It- Pre-hospital IV Antibiotics for Sepsis SGEM #174: Don’t Believe the Hype - Vitamin C Cocktail for Sepsis SGEM #168: HYPRESS - Doesn’t got the Power SGEM #92: Arise Up, Arise Up (EGDT vs Usual Care for Sepsis) SGEM #90: Hunting High and Low (Best MAP for Sepsis Patients) SGEM #69: Cry Me a River (Early Goal-Directed Therapy) Process Trial Today we’re covering the newest criteria, the Phoenix Criteria, for the diagnosis of pediatric sepsis and septic shock. It is more evidence-based and incorporates data from high and low-resource settings. Clinical Question: How accurately can a new clinical decision rule (The Phoenix Sepsis Score) diagnose pediatric sepsis and septic shock in hospitalized children within the first 24 hours? Reference: Sanchez-Pinto, L.N., et al. Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024​​. Population: Children less than 18 years of age with suspected sepsis and septic shock who were admitted to one of ten hospitals in five countries. Exclusions: Newborns and children with postconceptional age of <37 weeks Intervention: The Phoenix Criteria, which is a scoring system based on clinical signs, symptoms, and laboratory values. Comparison: International Pediatric Sepsis Consensus Conference (IPSCC) criteria Outcome: Primary Outcome: In-hospital mortality Secondary Outcomes: Composite of early death (within 72 hours of presentation) and requirement for extracorporeal membrane oxygenation (ECMO). For the Phoenix Scoring System, they used the area under the receiver operating characteristic curve (AUROC) and for binary criteria, positive predictive value (PPV) and sensitivity. Trial: Multicenter, retrospective cohort study Dr. Elizabeth Alpern Guest Authors: Dr. Elizabeth Alpern is a Professor of Emergency Medicine and Chief of Emergency Medicine at Lurie Children’s Hospital of Chicago and Vice Chair of Pediatrics at Northwestern University Feinberg School of Medicine. She’s also a clinical epidemiologist and expert in large databases including the PECARN registry. Dr. Halden Scott is an Associate Professor of Pediatrics at the University of Colorado School of Medicine and an attending physician at Children’s Hospital Colorado where she also serves as Director of Research. Her research interest includes the diagnosis and treatment of sepsis across the emergency care continuum. Authors’ Conclusions: “The novel Phoenix sepsis criteria, which were derived and validated using data from higher- and lower-resource settings, had improved performance for the diagnosis of pediatric sepsis and septic shock compared with the existing IPSCC criteria.” Quality Checklist for Clinical Decision Tools: The study population included or focused on those in the ED. Yes and No The patients were representative of those with the problem. Yes 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 and Yes Clinicians interpret individual predictor variables and score the clinical decision rule reliably and accurately. No. This is an impact analysis of a previously validated CDR (level I). No For Level I studies, the impact on clinician beha

Date: November 7, 2024 Guest Skeptics: Shirley Ngo is a Digital Product Director at RBC. She has extensive experience working with top financial organizations such as General Electric, Citibank, and CIBC in both Canada and Singapore. Additionally, she is co-host and producer of the "Make It Shine Money” podcast, which offers a unique perspective that blends financial expertise and creative vision. This is an SGEM Xtra. We have previously discussed physician mental health and burnout on the SGEM. SGEM#178: Mindfulness – It’s not Better to Burnout than it is to Rust SGEM Xtra: On the Edge of Burnout ACEM18 SGEM#289: I Want a Dog to Relieve My Stress in the Emergency Department SGEM Xtra: The Water is Wide SGEM Xtra: Everybody Hurts, Sometime A few episodes have addressed burnout, wellness and moral injury. However, we have not discussed physicians’ financial health. This is an important thing to consider and can contribute to physician well-being. One thing that can contribute to burnout is the gender inequity that has been reported in the House of Medicine. We have discussed this a few times on the SGEM. I suspect there are similar gender biases in the financial world. SGEM Xtra: I’m in a FIX State of Mind 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: From EBM to FBM – Gender Equity in the House of Medicine SGEM#352: Amendment – Addressing Gender Inequities in Academic Emergency Medicine Both Shirley and I are in our final semester of an Executive MBA at the Ivey School of Business, Western University. Before we jump into this podcast, here are five questions about the EMBA. Why did you decide to do an EMBA, specifically at Ivey? What have you enjoyed the most about the program? What has been the hardest part of the program? Is there a specific skill or knowledge from the program that you found most valuable (example)? Would you recommend the Ivey EMBA to others (ie do you think it provides a good ROI)? Disclaimer: This episode of the Skeptics' Guide to Emergency Medicine is intended for informational and educational purposes only. Neither the host nor the guest are licensed financial advisors. We offer education, not prescriptive advice. The information discussed is our opinion and should be taken as such. Any views or opinions represented in this podcast are personal and belong solely to the podcast creator and do not represent those of people, institutions or organizations that the owner may or may not be associated with in a professional or personal capacity unless explicitly stated. Always consult with a qualified financial professional before making any financial decisions. Physicians are super smart in a particular area, the practice of medicine. You don’t get through undergrad, residence and specialty training without acquiring some expertise in clinical medicine. However, what physicians are generally not experts in is finance (planning and investing). The danger many physicians face is to think that because they are experts in one area (medicine) they are also experts in other areas. Doing the EMBA has taught me how much I don’t know in the world of business. Financial Challenges and Solutions by Career Stage Now, let’s break things down into some digestible financial bites. We can frame the financial challenges and solutions physicians face at three stages of their careers. The first stage is a new grad, followed by mid-career physicians and finally, those nearing retirement. I asked Shirley what were the key challenges and key solutions for each stage of their career. Listen to the podcast to hear her responses. This SGEM Xtra ends by asking Shirley her big takeaways, main message, final thoughts and some final questions. The SGEM will be back next episode doing a structured critical appraisal of a recent publication. We continue to try and cut the knowledge translation window down 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. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

Date: November 10, 2024 Reference: Couper et al. The Paramedic 3 Trial: A randomized clinical trial of drug route in out-of-hospital cardiac arrest. October 31, 2024 NEJM Access to the SGEM Podcast episode at this LINK. Guest Skeptic: Missy Carter is a PA currently practicing in critical care after having attended the University of Washington's MEDEX program. An alumnus of Tacoma Community College's paramedic program Missy served as a paramedic for the Bremerton Fire Department for nearly 12 years and has been involved in paramedic education since 2004. Missy has been teaching airway management for over a decade and is the creator of the Prehospital Emergency Airway Course which is taught throughout Washington State. Case: You’re doing a ride along with your local emergency medical service (EMS) crews and responding to an out-of-hospital cardiac arrest (OHCA). After starting cardiopulmonary resuscitation (CPR), you note pulseless electrical activity (PEA) on the monitor. The paramedic is trying to get intravenous (IV) access to give epinephrine per the protocol. She is struggling to find a good vein and she asks you what you think about going straight to intraosseous (IO) access. Background: OHCA remains one of the most challenging and time-sensitive emergencies faced by prehospital and emergency medicine teams. With a survival rate to discharge often below 10% globally, rapid, effective interventions are needed to improve patient outcomes. Epinephrine has long been a cornerstone in the management of OHCA. Multiple studies have demonstrated how the administration of epinephrine can improve short-term outcomes, such as return of spontaneous circulation (ROSC). However, the evidence regarding its impact on long-term survival and neurological outcomes is mixed​​. Studies like PARAMEDIC-2 have raised questions about whether epinephrine's benefits in achieving ROSC are offset by potential adverse effects on neurological recovery (SGEM#238). One critical consideration in prehospital epinephrine administration is the method of vascular access. IV administration has been preferred the preferred route, but securing IV access can be challenging in the field and in patients with compromised vascular systems. Intraosseous (IO) access provides an alternative in challenging clinical scenarios. However, there has been limited research comparing the efficacy of IO versus IV administration of epinephrine in terms of both survival and neurological outcomes in OHCA patients​​. Given these complexities, ongoing research continues to explore the most effective methods of delivering epinephrine to optimize outcomes. Recent randomized trials are now evaluating whether the speed and reliability of IO access provide significant benefits over the traditional IV route. Most EMS providers are choosing the proximal tibial as their go-to IO access. The current evidence has not given a definitive answer as to which type of access is best for OHCAs. Clinical Question: Should we use an IV first or an IO first approach to deliver epinephrine to adult patients with an OHCA? Reference: Couper et al. The Paramedic 3 Trial: A randomized clinical trial of drug route in out-of-hospital cardiac arrest. October 31, 2024 NEJM Population: Adult patients (≥18 years old) who experienced an OHCA and required vascular access for drug administration during cardiopulmonary resuscitation (CPR). Intervention: IO first approach Comparison: IV first approach Outcome: Primary Outcome: Survival at 30 days Secondary Outcomes: ROSC at any time, sustained ROSC, length of stay (LOS) in hospital, survival at discharge, three and six months, neurologic function measured on the modified Rankin Scale (mRS) at discharge, three and six months, and health-related quality of life (assessed using the EQ-5D-5L questionnaire). Trial: Multi-center, non-masked, randomized trial Authors’ Conclusions: “Among adults with out-of-hospital cardiac arrest requiring drug therapy, the use of an intraosseous-first vascular access strategy did not result in higher 30-day survival than an intravenous-first strategy.” 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). Yes 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. Yes 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. Unsure Funding and financial conflicts of interest. Th

Date: November 13, 2024 Reference: Lee WH, et al. Study of Pediatric Appendicitis Scores and Management Strategies: A Prospective Observational Feasibility Study. Academic Emergency Medicine. Dec 2024 Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine physician at Children’s National Hospital in Washington, DC. He’s also the host of SGEMPeds. Case: A 10-year-old boy presents to the community emergency department (ED) with abdominal pain. It started last night but the pain seemed to worsen this morning. He tells you that it hurts right around his belly button. On examination, he looks uncomfortable but lets you examine his stomach. He winces a little as you press around his belly button and right lower quadrant but is not guarding. He has not had any fevers. His mother asks you, “I had something like this happen to me when I was a child. By the time they figured it out, the doctors told me that my appendix had almost burst! Do you think this could be appendicitis?” Background: Pediatric appendicitis is the most common surgical emergency in children, accounting for a significant proportion of ED visits. Appendicitis occurs when the appendix becomes inflamed, often because of a blockage, leading to infection and potentially life-threatening complications such as perforation. Although the condition is more common in children between the ages of 10 and 20, it can present at any age, making accurate diagnosis in younger populations especially challenging [1]. The clinical presentation of pediatric appendicitis can vary widely. Classical symptoms include right lower quadrant abdominal pain, fever, and vomiting, but these can be absent or altered in younger children, making clinical diagnosis difficult. Furthermore, the differential diagnosis is broad, including conditions such as gastroenteritis, urinary tract infections, and other causes of abdominal pain like constipation. In one study, almost half of these pediatric patients (45%) with abdominal pain were discharged home with “non-specific abdominal pain” [2]. Traditionally, diagnosis relies on a good history, followed by a directed physical examination and appropriate use of diagnostic tests (lab and imaging). Ultrasound is commonly used due to its non-invasive nature, while computed tomography (CT) scans, although more definitive, are often avoided in children due to radiation concerns [3]. Some centers are using rapid MRI clinical diagnostic pathways in suspected pediatric appendicitis​ [4,5]. Outcomes of appendicitis largely depend on early recognition and treatment. If left untreated, the appendix may rupture, leading to peritonitis, abscess formation, or sepsis, which significantly increases morbidity. On the other hand, early surgical intervention, typically via laparoscopic appendectomy, results in low complication rates and rapid recovery for most pediatric patients​. Clinical prediction scores (CPS) exist to help diagnose appendicitis in children. They often consider aspects of the history, physical exam and laboratory values. However, these CPSs are not universally used or validated. Three of these CPSs are the Alvarado score [6], Pediatric Appendicitis Score (PAS) [7], and pediatric Appendicitis Risk Calculator for pediatric EDs (pARC-ED) [8]. We also don’t know how they compare to our clinical gestalt. I remember a case I saw as a resident of a young girl who was sent to the ED for belly pain and to be evaluated for appendicitis. Her exam was unremarkable. She didn’t have a fever. She didn’t look sick. I pressed all over her stomach. I had her jump in the air. I looked for the Rosving’s and Psoas's sign. Everything was negative. Her caretaker also told me that her belly pain was like when she had constipation in the past. It was my attending, whose Spidey senses were tingling, ordered an ultrasound...ruptured appendix. Clinical Question: Can pediatric appendicitis clinical prediction scores accurately diagnose appendicitis in children and outperform clinician gestalt? Reference: Lee WH, et al. Study of Pediatric Appendicitis Scores and Management Strategies: A Prospective Observational Feasibility Study. Academic Emergency Medicine. Dec 2024 Population: Children aged 5 to 15 years presenting with right-sided or generalized abdominal pain and suspected appendicitis Excluded: abdominal trauma within 7 days of presentation, history of prior abdominal surgery, chronic illness affecting the abdomen (inflammatory bowel disease, chronic pancreatitis, cystic fibrosis, sickle cell anemia), pregnancy, inability to obtain accurate history. Intervention: Use of clinical prediction scores (Alvarado, PAS, pARC-ED) Comparison: Clinician gestalt Outcome: Diagnostic accuracy (AUC, sensitivity, and specificity) Type of Study: Prospective observational study Dr. Wei Hao Lee This is an #SGEMHOP, and we are pleased to have the lead author, Dr. Wei Hao Lee, on the show. Dr. Lee is a pediatric advanced trainee currently working at Perth Children’s Hospi

Date: October 28, 2024 Reference: Verma et al. Clinical evaluation of a machine learning–based early warning system for patient deterioration. CMAJ September 2024 Guest Skeptic: Michael Page is currently the Director of Artificial Intelligence (AI) Commercialization at Unity Health Toronto. He leads an AI team intending to improve patient outcomes and healthcare system efficiency. Michael is a sessional lecturer within the Ivey Business School’s Executive MBA program, where he teaches a Technology and Innovation course. Previously, he held senior roles at the Vector Institute for AI, and the University of Toronto. Michael has over 15 years of experience building and leading corporate strategies for innovation, social impact, and research and development for various organizations. Case: The Chief of Emergency Medicine (EM) at a large urban hospital recently approached the AI Committee at Unity Health, intrigued by the CMAJ article describing the apparent success of CHARTWatch in detecting early signs of patient deterioration. Their hospital has struggled with a growing number of adverse events that often occur without warning. With emergency department (ED) volumes rising, administrators are eager to explore AI-driven solutions to improve patient safety and reduce staff burnout. They want to know how CHARTWatch integrates with electronic health records (EHRs), whether it can adapt to their patient ED population, and how clinicians respond to using the tool. The Chief of EM wants to be sure that any new system they introduce will enhance workflow and not add to clinicians’ cognitive burden. Background: There are many ways to define artificial intelligence. One definition of AI is a computer system capable of performing tasks that typically require human intelligence, such as pattern recognition, decision-making, and language processing. In recent years, advancements in AI—particularly machine learning and predictive analytics—have opened new frontiers in various industries, including healthcare. In healthcare, AI is being leveraged to enhance clinical decision-making, streamline administrative processes, and improve patient outcomes. Machine learning algorithms, a core component of AI, can process vast amounts of data to identify patterns that might elude human clinicians. This predictive capability is transforming the way hospitals manage patient care, from optimizing staffing levels to providing personalized treatment recommendations. A promising application of AI is the development of early warning systems to detect patient deterioration. These systems use real-time data from electronic health records (EHRs) and other sources to predict which patients are at risk of adverse outcomes, such as cardiac arrest or transfer to an intensive care unit (ICU) [1.2]. By alerting clinicians to potential problems before they become critical, AI-driven systems aim to reduce unplanned ICU transfers and improve survival rates. Despite the potential benefits, integrating AI into clinical workflows presents challenges. Some studies suggest that the effectiveness of early warning systems varies widely [3], with factors such as alarm fatigue [4] and clinician engagement influencing outcomes. Moreover, there are ongoing debates about the balance between algorithmic precision and interpretability. Transparent, evidence-based deployment is essential to build trust and ensure these tools support rather than complicate clinical decision-making​. Clinical Question: Can the implementation of a real-time, machine learning-based early warning system (CHARTWatch) reduce adverse events and mortality in patients in the emergency department? Reference: Verma et al. Clinical evaluation of a machine learning–based early warning system for patient deterioration. CMAJ September 2024 Population: Patients admitted to the General Internal Medicine (GIM) unit of an academic medical center Exclusions: Palliative patients and patients diagnosed with COVID-19 or influenza. Intervention: Implementation of CHARTWatch, a machine learning-based early warning system designed to alert clinicians of patient deterioration. Comparison: Pre-intervention period (Nov 2016 - June 2020) versus post-intervention period (Nov 2020 - June 2022). A control group (patients from cardiology, nephrology, and respirology units who did not receive the intervention) was also used. Outcome: Primary Outcome: In-hospital deaths Secondary Outcomes: Proportion of alerts for high-risk patients and changes in mortality rates among those groups. Type of Study: Observational study Authors' Conclusions: “The implementation of a machine learning–based early warning system was associated with a reduction in non-palliative in-hospital deaths among patients admitted to general internal medicine. This suggests that CHARTWatch could improve outcomes for at-risk patients in similar settings.” Quality Checklist for Observational Studies: Did the study address a clearly focused issue? Yes

Date: October 28, 2024 Reference: Woelfle T et al. Benchmarking Human–AI collaboration for common evidence appraisal tools. J Clin Epi Sept 2024. Guest Skeptic: Dr. Laura Walker is an Associate Professor of Emergency Medicine and the vice chair for digital emergency medicine at the Mayo Clinic. In addition to finding ways to use technology in emergency department (ED) care, she is interested in how health systems work and how patients move through the healthcare system. Previously, she has been an ED medical director, quality chair, and regional hospital director. Case: The Mayo Clinic Department of Emergency Medicine is planning its next journal club. It has recently been boosted by adding Dr. Chris Carpenter to the faculty who created the amazing JC at Washington University. A resident has been assigned to report on the PRISMA quality checklist for the SRMA they will discuss. She has been playing around with ChatGPT 3.5 from OpenAI and wonders if it could do this task quickly and, more importantly, accurately. Background: In recent years, large language models (LLMs), such as GPT-4 and Claude, have shown remarkable potential in automating and improving various aspects of medical research. One intriguing area of exploration is their ability to assist in critical appraisal, a cornerstone of evidence-based medicine (EBM). Critical appraisal involves evaluating the quality, validity, and applicability of studies using structured tools like PRISMA, AMSTAR and PRECIS-2. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses): This is a set of guidelines designed to help authors improve the reporting of systematic reviews and meta-analyses. It includes a checklist of 27 items that focus on the transparency and completeness of the review process, such as the identification, screening, and inclusion of studies, the synthesis of results, and how potential biases are addressed. AMSTAR (A Measurement Tool to Assess Systematic Reviews): This is a tool used to evaluate the methodological quality of systematic reviews of healthcare interventions. It consists of a checklist of 11 items that assess the robustness of a systematic review's design and execution. The tool covers key areas like the use of comprehensive search strategies, inclusion criteria, methods for assessing the risk of bias, and the appropriateness of data synthesis. PRECIS-2 (Pragmatic-Explanatory Continuum Indicator Summary): This is an assessment tool used to evaluate how "pragmatic" or "explanatory" a randomized controlled trial (RCT) is. It is designed to help researchers design trials that better align with their research goals, whether they aim to inform real-world clinical practice (pragmatic) or control for as many variables as possible to test an intervention under ideal conditions (explanatory). The tool uses nine domains (e.g., eligibility criteria, recruitment, primary outcome, etc.) to rate how closely the trial conditions resemble real-world clinical settings. Traditionally, these tasks have been manual, often requiring significant expertise and time to ensure accuracy. However, as LLMs have evolved, their ability to interpret and analyze complex textual data presents a unique opportunity to enhance the efficiency of these appraisals. Research into the accuracy of LLMs, when used for appraising clinical trials and systematic reviews, is still in its early stages but holds promise for the future of automated medical literature assessment​​. Given that assessing the validity and quality of clinical research is essential for ensuring that decisions are based on reliable evidence, this development raises important questions. Can these advanced AI tools perform critical appraisals with the same accuracy and reliability as human experts? More importantly, how can they augment human decision-making in medical research? Clinical Question: Can large language models accurately assess critical appraisal tools when evaluating systematic reviews and randomized controlled trials? Reference: Woelfle T et al. Benchmarking Human–AI collaboration for common evidence appraisal tools. J Clin Epi Sept 2024. Population: Systematic reviews and RCTs that were evaluated by critical appraisal tools (PRISMA, AMSTAR, and PRECIS-2). Intervention: Five different LLMs (Claude-3-Opus, Claude-2, GPT-4, GPT-3.5, Mixtral-8x22B) assessing these studies. Comparison: Comparisons were made against individual human raters, human consensus ratings and human-AI collaboration. Outcome: Accuracy, and identification of potential areas for improving efficiency via human-AI collaboration. Authors’ Conclusions: “Current LLMs alone appraised evidence worse than humans. Humane-AI collaboration may reduce workload for the second human rater for the assessment of reporting (PRISMA) and methodological rigor (AMSTAR) but not for complex tasks such as PRECIS-2.” Quality Checklist for a Diagnostic Study: Is the clinical problem well-defined? Yes Does

Date: October 29, 2024 Reference: Galili et al. Low dose ketamine as an adjunct to morphine: a randomized controlled trial among patients with and without current opioid use. AEM Oct 2024. Guest Skeptic: Dr. Neil Dasgupta is an emergency medicine physician and ED intensivist from Long Island, NY. He is the Vice Chair of the Emergency Department and Program Director of the EM residency program at Nassau University Medical Center in East Meadow, NY, the safety net hospital for Nassau County. Case: You are hitting the zone in your shift, a veritable disposition machine meeting the constant flow of patients through the emergency department (ED). As you finish a note on a complex critically ill patient, you hear howls of pain coming from the EMS triage desk. A 38-year-old male patient in cycling gear is being brought in after colliding with a lamp post with an obvious upper extremity deformity. He explains loudly to the triage nurse that he has chronic back pain from multiple prior cycling accidents, and regularly takes significant doses of extended-release oxycodone. As you walk over to assess the patient, you take note of how distressed he is and consider how to get him comfortable enough to work him up in the ED. Background: Management of acute pain is an important activity of emergency physicians and can be challenging. Patients frequently come to the ED because they are in pain, and our ability to relieve that pain is central to the patient experience. Alternatives to opiate pain medications have significant limitations with analgesic ceilings (NSAIDs) as well as side effects or toxicity potential that limit their use and efficacy. This issue is even more fraught with difficulty in a patient who chronically uses opioid medications and has developed a tolerance. Within the House of Medicine, there has been a significant shift in the use of opioids as we are more fully understanding the patient consequences and societal effects of a previously more liberal pain management strategy. Judicious use of medications became paramount, with physicians becoming wary of the over-aggressive treatment of acute pain, leaving many patients hurting and frustrated. One effective strategy is a multi-modal approach to pain management, including using adjuvant non-opioid medications for better pain control while attempting to minimize the dose of opiates. Enter ketamine. Ketamine is a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist that was most used as a dissociative anesthetic. It provides excellent sedation, analgesia and amnesia while having a favourable hemodynamic profile and preserving airway reflexes. It has become a favourite medication in emergency departments for procedural sedation as well as a useful behavioural takedown medication. More recently, sub-dissociative doses of ketamine have been used to treat acute pain. We have covered the use of ketamine multiple times on the SGEM, and there will be a list of those episodes at the end of this podcast. The most recent episode was SGEM#457 looking at nebulized ketamine. Clinical Question: Is ketamine an effective adjunct agent along with morphine for acute pain control in the ED? Reference: Galili et al. Low dose ketamine as an adjunct to morphine: a randomized controlled trial among patients with and without current opioid use. AEM Oct 2024. Population: Patients over 18 years old in a single center in Denmark presenting to the ED with acute pain rated ≥5 on a numeric rating scale (NRS) from 0–10 that the ED physician decided required intravenous opioids. Intervention: Administration of low-dose ketamine (LDK) 0.1 mg/kg intravenous (IV) bolus in addition to morphine IV dosed by clinical practice guidelines and adjusted if the patient is currently on opioid medication. Comparison: Administration of isotonic saline as placebo with morphine Outcome: Primary Outcome: Pain reduction as measured by patient-reported pain score at 10 minutes after administration of analgesics. Secondary Outcomes: Pain reduction at 20, 30, 45, 60, 90 and 120 minutes after medication administration; need for rescue opioids, adverse effects; patient satisfaction; provider satisfaction. Type of Study: Single-center randomized double-masked placebo-controlled trial. Dr. Stine Galili This is an SGEMHOP, and we are pleased to have the lead author, Dr. Stine Galili, on the show. She is a Medical Doctor from Aarhus University, Denmark, with ten years of experience in emergency medicine and anesthesiology. Dr. Galili is back to being a specialty trainee in anesthesiology at Aarhus University Hospital after finishing PhD fellowship at the Research Center for Emergency Medicine at Aarhus University Hospital. Authors’ Conclusions: “Low dose ketamine may be effective as an adjunct analgesic to morphine for short-term pain relief in treatment of acute pain in the ED for both patients with and without current opioid use.” Quality Checklist for Randomized Clinical Trials: The study population i

Date: October 7, 2024 Reference: Nguyen et al. Comparison of Nebulized Ketamine to Intravenous Subdissociative Dose Ketamine for Treating Acute Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind, Double-Dummy Controlled Trial. Annals of EM 2024. Guest Skeptic: Dr. Brendan Freeman is an emergency medicine physician, assistant professor of emergency medicine, and medical education fellow at Staten Island University Hospital. He completed his residency training at New York Presbyterian Brooklyn Methodist after graduating from medical school at Touro University College of Osteopathic Medicine in California. Case: You’re working your usual day shift in the emergency department (ED) from 9 am to 5 pm on a Tuesday. The next patient you pick up is a 38-year-old male with a history of kidney stones, presenting with severe flank pain radiating to the groin. He has a history of difficult intravenous (IV) access, is hemodynamically stable, and has no signs of infection. His allergies to acetaminophen, non-steroidal anti-inflammatories (NSAIDs), and opioids limit your pain management options. A bedside sonogram shows no significant hydronephrosis. You’re considering ketamine for pain relief but wonder if you should choose IV sub-dissociative ketamine or nebulized ketamine? Background: Ketamine has long been recognized as a versatile drug in emergency medicine, particularly for its role in analgesia and procedural sedation. Initially developed as an anesthetic in the 1960s, ketamine’s unique pharmacological profile makes it particularly suitable for acute care settings. It is a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist, which induces dissociative anesthesia, meaning patients experience analgesia and amnesia without the loss of consciousness typically associated with other anesthetics​​. In recent years, ketamine has gained popularity in the ED, particularly for treating acute pain. It is used at lower doses than those required for anesthesia (0.1–0.3 mg/kg IV) and is called “low-dose” or sub-dissociative ketamine (SDK). These lower doses of ketamine effectively manage pain without producing full dissociation, reducing the likelihood of severe adverse effects​​. This ability to provide analgesia with minimal respiratory depression and hypotension makes ketamine an attractive alternative to opioids, particularly in patients for whom opioid use is problematic​​. Ketamine’s administration is flexible, with several routes available including IV, intranasal (IN), and more recently, nebulized forms. Each method has its advantages, and ongoing research continues to refine the efficacy and safety of these delivery methods in acute pain management in the ED​​. Prior research by this same group has shown ketamine breath-actuated nebulizer (K-BAN) has effective analgesic properties at three different doses 0.75 mg/kg, 1 mg/kg, and 1.5 mg/kg up to 120 minutes. However, no one has compared K-BAN analgesic efficacy to IV-SDK though. Clinical Question: Which ketamine regimen is superior for treating moderate to severe acute pain in the emergency department, 0.75 mg/kg nebulized or 0.3 mg/kg intravenously? Reference: Nguyen et al. Comparison of Nebulized Ketamine to Intravenous Subdissociative Dose Ketamine for Treating Acute Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind, Double-Dummy Controlled Trial. Annals of EM 2024. Population: Adults aged 18 and older presenting to the ED with acute pain numerical rating scale (NRS) pain score of ≥5​ Exclusions: Patients with altered mental status, respiratory distress, hypotension, or known allergy to ketamine​. Intervention: Nebulized ketamine at 0.75 mg/kg via breath-actuated nebulizer (K-BAN) plus IV saline infusion Comparison: IV sub-dissociative dose ketamine (IV-SDK) at 0.3 mg/kg plus nebulized saline Outcome: Primary Outcome: Reduction in pain scores on the NRS at 30 minutes post-administration​ Secondary Outcomes: The need for rescue analgesia, adverse events, and pain reduction at additional time points (15, 60, 90, and 120 minutes) Type of Study: Prospective, randomized, double-masked, double-dummy controlled trial Authors’ Conclusions: “We found no difference between the administration of IV and nebulized ketamine for the short-term treatment of moderate to severe acute pain in the ED, with both treatments providing a clinically meaningful reduction in pain scores at 30 minutes”​. 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 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 assesso

Reference: Ma K et al. A national survey of children’s experiences and needs when attending Canadian pediatric emergency departments. PLoS One. June 2024 Date: Oct 1, 2024 Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder of website lead of Don’t Forget the Bubbles (DFTB). Dr. Andrew Tagg Case: You are working with a medical trainee on her first clinical rotation through the emergency department (ED). One of the first patients she sees is a 12-year-old boy presenting with lower abdominal pain. He is accompanied by his worried parents. Before entering the room, she says to you, “This is the first time I’ve seen a pediatric patient. Do you have any tips for getting the history or performing the physical exam?” Background: Through the course of one emergency department (ED) shift, we have countless interactions with patients from the initial history, examination, assessment, plan, updates on results from laboratory and imaging testing, reassessments, and eventually a final disposition. Working with children in the ED adds another layer of complexity as we are often trying to explain to them and their caregivers what is going to happen during their time in the ED. Dr. Samina Ali Children's healthcare experiences can have a lasting impact on their understanding of health and their comfort in future medical settings. For example, we discussed the importance of pain management with another Peds EM superstar, Dr. Samina Ali, on an SGEM Xtra and learned that poor pain management contributes to avoiding medical care in the future and even vaccine hesitancy. While caregivers often advocate for their children, trying to understand the child's needs and perspectives directly from the child is crucial for optimizing care. Clinical Question: What are children's perspectives on their needs and experiences during visits to Canadian pediatric EDs? Reference: Ma K et al. A national survey of children’s experiences and needs when attending Canadian pediatric emergency departments. PLoS One. June 2024 Population: Children aged 7-17 years and their caregivers who presented to ten Canadian pediatric EDs between 2018 and 2020 Excluded: Children who remained medically unstable during their ED stay, had altered levels of consciousness, were suspected of being abused, or had a caregiver who was not their legal guardian​. The children and caregivers also had to speak either English or French. Intervention: A cross-sectional survey designed for both children and caregivers. The child survey included 24 questions, focusing on emotional, practical, and communication needs, along with satisfaction with care. Comparison: None Outcome: Primary Outcome: Children’s perspectives on their emotional, practical, and general informational needs and experiences. Secondary Outcomes: Compare caregiver vs child perspectives on needs and experiences and relate demographic characteristics and needs within the ED to child’s understanding of their diagnosis and treatment Trial: Descriptive cross-sectional survey Authors’ Conclusions: “While almost all children felt well taken care of and were happy with their visit, close to 1/3 did not understand their diagnosis or its management. Children’s reported satisfaction in the ED should not be equated with understanding of their medical condition. Further, caution should be employed in using caregiver satisfaction as a proxy for children’s satisfaction with their ED visit, as caregiver satisfaction is highly linked to having their own needs being met.” CROSS Quality Checklist for Survey 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 Have the authors identified all-important confounding factors? No Was the follow-up of subjects complete enough? Yes How precise are the results? Unsure 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 Funding of the Study: Women and Children’s Health Research Institute at the University of Alberta. The authors declare no competing interests. Results: They included 514 children and their caregivers. The mean age of children was around 12 years with 56.5% female. Mean age of caregivers was around 43 years and the majority (78%) were mothers. Most (87%) were discharged home and the rest were admitted or transferred. The survey was split into four categories including: emotional, practical, and communication needs, and overall satisfaction with care. Emotional: Close to 80% of children felt there was enough privacy during conversations with healthcare staff and during the examination. While this is not bad, it also means that 1 in 5 kids did not feel like their privacy was respected. Communication: Over 90% of children said that the doctor

Date: October 2, 2024 Reference: Paxton et al. Headpulse measurement can reliably identify large-vessel occlusion stroke in prehospital suspected stroke patients: Results from the EPISODE-PS-COVID study. AEM Sept 2024 Guest Skeptic: Dr. Lauren Westafer an Assistant Professor in the Department of Emergency Medicine at the UMass Chan Medical School – Baystate. She is the co-founder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for the Annals of Emergency Medicine. Case: The family of a 69-year-old woman activated emergency medical services (EMS) for slurred speech that they noticed when she woke up a couple of hours before. The patient has a history of hypertension, diabetes, gastroesophageal reflux disease (GERD), and dyslipidemia and lives alone but speaks with her son daily. The son reported she seemed fine yesterday evening when they went to dinner, perhaps more tired than usual. The patient had some slurred speech but no obvious facial droop or asymmetric limb weakness. Background: Stroke remains a leading cause of morbidity and mortality worldwide, with large vessel occlusion (LVO) strokes representing approximately one-third of all acute ischemic strokes (AIS) in the United States. However, LVO strokes disproportionately contribute to stroke-related disability and death, accounting for nearly two-thirds of post-stroke dependence and over 90% of stroke mortality [1,2]. The SGEM has covered LVO strokes several times (SGEM#137, SGEM#292, SGEM#333 and SGEM#349). Rapid identification and transport to an endovascular thrombectomy (EVT)-capable center are important for improving outcomes in these patients, as EVT is the standard treatment for LVO stroke with moderate to severe symptoms​ [3-5]. Prehospital identification of LVO stroke remains a significant challenge for emergency medical services (EMS) [6]. Traditional stroke scales used in the field, such as the Los Angeles Motor Scale (LAMS) [7], the Cincinnati Stroke Triage Assessment Tool (C-STAT) [8,9], and the Rapid Arterial Occlusion Evaluation (RACE) scale [10], have shown varied effectiveness. These scales generally demonstrate high specificity but low sensitivity, often resulting in false negatives where LVO strokes are missed​ [11-13]. Clinical Question: Can a cranial accelerometry (CA) headset device be used by paramedics in the prehospital setting to accurately detect patients with a large vessel occlusion (LVO) stroke? Reference: Paxton et al. Headpulse measurement can reliably identify large-vessel occlusion stroke in prehospital suspected stroke patients: Results from the EPISODE-PS-COVID study. AEM Sept 2024 Population: Consecutive adult patients suspected of acute ischemic stroke (AIS) by prehospital emergency medical services (EMS) in the United States. Intervention: The Harmony 5000 CA headset device (MindRhythm Inc). Comparison: The Los Angeles Motor Scale (LAMS). Outcome: Primary Outcome: The feasibility of prehospital deployment of the device, defined by the proportion of subjects with acceptable ECG and headset data. Secondary Outcome: The device's diagnostic accuracy in detecting LVO stroke. Type of Study: This was a prospective, multicenter observational diagnostic accuracy study. Dr. James Paxton This is an SGEMHOP, and we are pleased to have the lead author, Dr. James Paxton on the show. Dr. Paxton is in the Department of Emergency Medicine, at Wayne State University School of Medicine. Authors’ Conclusions: "Obtaining adequate recordings with a CA headset is highly feasible in the prehospital environment. Use of the device algorithm incorporating both CA and LAMS data for LVO detection resulted in significantly higher sensitivity without reduced specificity when compared to the use of LAMS alone." 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). Yes The study population included or focused on those in the ED. Yes The study patients 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). Unsure All diagnostic criteria were explicit, valid and reproducible (i.e. no incorporation bias). Yes The reference standard was appropriate (i.e. no imperfect gold-standard bias). Yes All undiagnosed patients underwent sufficiently long and comprehensive follow-up (i.e. no double gold-standard bias). Yes The likelihood ratio(s) of the test(s) in question is presented or can be calculated from the information provided. Yes The precision of the measure of diagnostic performance is satisfactory. Yes Funding and Conflicts of Interest. The study was funded by MindRhythm, Inc. There were multiple COIs with some authors receiving funding fr

Date: September 23, 2024 Reference: Essat et al. Diagnostic Accuracy of D-Dimer for Acute Aortic Syndromes: Systematic Review and Meta-Analysis. Annals of Emergency Medicine, May 2024 Guest Skeptic: Dr. Casey Parker is a Rural Generalist from Australia who is also an ultrasounder. Case: You are working a busy shift in a rural emergency department (ED) and your excellent Family Medicine trainee presents a case of a 63-year-old woman with chest pain and some intermittent radiation into the inter-scapular region. The patient has no specific risk factors for acute coronary syndrome (ACS) or dissection. The history is not overly concerning for dissection - the adjectives “severe”, and “ripping” or “tearing” are not used. Your trainee has done a great work-up and the possibility of an acute aortic dissection (AAD) is included in her differential diagnosis. Because this is a rural ED and the closest Computed tomography angiography (CTA) is a three-hour drive away, we must decide if this will benefit this patient. You accompany your trainee back to the bedside and clarify the nature of the chest pain, re-examine the patient and review all the available clinical data. There are no abnormalities in the blood work, ECG, or chest x-ray. Her pain seems to have settled. In this woman with no specific features of an aortic dissection, can we use a D-dimer assay to rule out this serious diagnosis and avoid a long and costly transfer? Background: Diagnosing acute aortic syndromes (AAS), which encompass life-threatening conditions like aortic dissection, intramural hematoma, and penetrating ulcers, can be challenging in the emergency department. These conditions typically present with nonspecific symptoms such as chest, back, or abdominal pain, and without early identification, they carry high morbidity and mortality. Aortic dissections are known for their rapid progression and the necessity for swift diagnosis and intervention. CTA is often the go-to imaging modality due to its high sensitivity and specificity for detecting AAS, but its routine use comes with risks—exposure to ionizing radiation and increased healthcare costs. In low-prevalence populations, over-reliance on CTA may be unwarranted. Emergency physicians have increasingly turned to the D-dimer test, a readily available blood test, to help rule out AAS and reduce unnecessary imaging. However, the effectiveness of D-dimer for diagnosing AAS remains debated due to variable test performance in different patient populations. The American College of Emergency Physicians (ACEP) has a policy on thoracic aortic dissections. They asked: “In adult patients with suspected acute nontraumatic thoracic aortic dissection, is a negative serum D-dimer sufficient to identify a group of patients at very low risk for the diagnosis of thoracic aortic dissection?” Answer: “In adult patients with suspected nontraumatic thoracic aortic dissection, do not rely on D-dimer alone to exclude the diagnosis of aortic dissection.” Clinical Question: What is the diagnostic accuracy of D-dimer for diagnosing acute aortic syndrome (AAS)? Reference: Essat et al. Diagnostic Accuracy of D-Dimer for Acute Aortic Syndromes: Systematic Review and Meta-Analysis. Annals of Emergency Medicine, May 2024 Population: Patients presenting to the ED with symptoms consistent with acute aortic syndromes, such as new-onset chest, back, or abdominal pain, syncope, or signs of perfusion deficit. Excluded: Patients with AAS following major trauma or as incidental findings, and studies using a case-control design. Intervention: D-dimer assay with variable cut-offs in trials but the primary analysis of trials using < 500 ng/ml. Comparison: The reference standard tests used for comparison included imaging modalities such as computed tomography angiography (CTA), ECG-gated CTA, echocardiography, magnetic resonance angiography, and confirmation through surgery or autopsy. Outcome: Primary Outcome: Diagnostic accuracy of D-dimer for identifying acute aortic syndromes, specifically sensitivity and specificity. Secondary Outcomes: Trials with other cut-off values from 240 ng/ml to 2110 ng/ml. Type of Study: A systematic review and meta-analysis of diagnostic cohort studies including prospective and retrospective data. Authors’ Conclusions: “D-dimer concentration has high sensitivity (96.5%) and moderate specificity (56.2%) for acute aortic syndrome, with some uncertainty around estimates due to risk of bias and heterogeneity.” Quality Checklist for Systematic Review Diagnostic Studies: The diagnostic question is clinically relevant with an established criterion standard. Yes The search for studies was detailed and exhaustive. Yes The methodological quality of primary studies were assessed for common forms of diagnostic research bias. Yes The assessment of studies were reproducible. Yes There was low heterogeneity for estimates of sensitivity or specificity. Yes and No The summary diagnostic accuracy is sufficiently preci

Date: September 18, 2024 Reference: Dillon et al. Naloxone and Patient Outcomes in Out-of-Hospital Cardiac Arrests in California. JAMA Network Open. August 20, 2024 Guest Skeptic: Dr. Chris Root is an emergency medicine and emergency medicine service (EMS) physician at the University of New Mexico, Albuquerque. Before attending medical school, he was a New York City Paramedic. Chris completed his emergency medicine residency and EMS fellowship at UNM. He currently practices emergency medicine in New Mexico in the ED, in the field with EMS and with the UNM Lifeguard Air Emergency Services. Case: You are working as a paramedic, and you respond to a cardiac arrest. On arrival, you find a 35-year-old male, pulseless and apneic with cardio-pulmonary resuscitation (CPR) in progress by a bystander. There is drug paraphernalia scattered around the room. You and your partner initiate high-quality CPR, place a supraglottic airway, establish intra-osseous (IO) access and administer epinephrine. Your partner asks if you want to administer naloxone as well. Background: We’ve discussed out-of-hospital cardiac arrest (OHCA) at least once or twice on the SGEM (see long list at end of blog). Today’s study looks at the role of naloxone in OHCA. Naloxone is a well-established medication used primarily for reversing opioid overdoses. As a competitive opioid antagonist, naloxone binds to opioid receptors in the central nervous system, effectively displacing opioids and reversing their effects, particularly respiratory depression. This makes naloxone an essential tool for emergency responders dealing with opioid-related incidents. Typically administered via intravenous (IV), intramuscular (IM), or intranasal (IN) routes, naloxone acts rapidly, often restoring normal breathing within minutes. Its safety profile is well-tolerated, with the primary adverse effects related to the abrupt reversal of opioid effects, such as acute withdrawal symptoms. Traditionally, naloxone has been used in cases of suspected opioid overdose where patients exhibit signs of severe respiratory depression or loss of consciousness (LOC). However, its role in broader emergency care contexts, such as OHCA, is evolving. Opioid-associated OHCA has become increasingly common due to the ongoing opioid crisis, with opioids contributing to a significant proportion of cardiac arrests [1-4]. In these scenarios, the pathophysiology involves opioid-induced respiratory depression leading to hypoxia, hypotension, and eventually cardiac arrest. Given this progression, naloxone's ability to counteract opioid effects offers a potential intervention point, even in cardiac arrest scenarios. Current guidelines from organizations like the American Heart Association (AHA) suggest considering naloxone in suspected opioid-associated OHCA cases [5]. However, the efficacy of naloxone in improving outcomes in such cardiac arrests remains a topic of ongoing research and debate. While naloxone is not traditionally viewed as a standard treatment in cardiac arrest care, its potential to address underlying opioid toxicity provides a rationale for its use in selected patients. This has led to variability in EMS protocols, with some agencies including naloxone in their cardiac arrest protocols while others do not specifically recommend it, highlighting a gap in definitive guidance [6]. As the landscape of OHCA continues to evolve, understanding the role of naloxone in these critical situations is vital for EMS providers. This discussion sets the stage for exploring naloxone's place in the management of cardiac arrest, particularly as new evidence emerges regarding its impact on outcomes such as return of spontaneous circulation (ROSC) and survival to hospital discharge. Clinical Question: Is naloxone administration in undifferentiated OHCA associated with survival to hospital discharge? Reference: Dillon et al. Naloxone and Patient Outcomes in Out-of-Hospital Cardiac Arrests in California. JAMA Network Open. August 20, 2024 Population: Adult patients (aged 18 or older) who received EMS treatment for nontraumatic OHCA in three Northern California counties between 2015 and 2023. Excluded: Patients under 18 and missing data regarding medication administration Exposure: Naloxone administration during resuscitation. Comparison: No naloxone administration during resuscitation. Outcome: Primary Outcome: Survival to hospital discharge Secondary Outcomes: Sustained ROSC (detectable pulse for at least 20 minutes or at the end of EMS care) Type of Study: Retrospective cohort study Authors’ Conclusions: “In this retrospective cohort of patients with OHCA, EMS-administered naloxone was associated with clinically significant improvements in ROSC and survival to hospital discharge.” 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? Y

Date: September 12, 2024 Reference: Anderson et al. Full dose challenge of moderate, severe and unknown beta-lactam allergies in the emergency department. AEM August 2024. Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. Case: It’s another day, another dollar in the emergency department (ED). The next patient is a 63-year-old woman with a cough and fever. After assessment, you diagnose her with pneumonia. You would normally prescribe ceftriaxone but during your assessment, she told you she had a bad reaction to amoxicillin in her twenties, with widespread hives and some facial swelling. You wonder if she could have an allergy challenge dose of ceftriaxone in the ED. Background: Penicillin allergies are among the most reported drug allergies, with estimates suggesting that up to 10% of the US population claims to have a penicillin allergy. These “allergies” are often poorly documented and could potentially be more accurately described as intolerance [1]. However, once the penicillin allergy gets entered into the Electronic Health Record (EHR) it can last for years, despite up to 80% of penicillin allergies waning over 10 years [2]. In addition, the reliability of self-reported allergy to penicillin is highly questionable, especially in acute care settings where rapid decision-making is essential. A substantial body of evidence indicates that over 90% of individuals who report a penicillin allergy are not truly allergic. The mislabeling of penicillin allergy often leads to the unnecessary use of alternative antibiotics, which can be more expensive, less effective, and contribute to the development of antibiotic resistance. Emergency Physicians frequently encounter ED patients with self-reported penicillin allergies. This scenario presents a unique challenge, as these patients may require immediate antibiotic therapy, and providers often have limited time to verify the accuracy of the reported allergy. Consequently, clinicians may resort to broad-spectrum or second-line antibiotics, which can be less ideal due to higher costs, a broader spectrum of activity, or increased adverse effects. A pivotal study by Raja et al. highlighted that more than 90% of self-reported penicillin allergies in an ED setting were false positives when tested with penicillin skin testing, underscoring the need for reliable allergy verification methods in acute care [3]. Getting labelled as having a penicillin allergy not only restricts the use of penicillin but also limits the use of all beta-lactam antibiotics. Some authorities continue to warn about the potential cross-reactivity and ‘bio-similar sidechains’. However, recent changes in the understanding of beta-lactam allergy suggest that allergy may be driven by the R1 side chain of the antibiotic molecule rather than the beta-lactam ring [4]. It is therefore practical to use a full-dose beta-lactam challenge to support first-line beta-lactam use for antibiotic stewardship [5]. Dr. Eric Macy an allergist from San Diego gives a good historical account of how this myth about cross-reactivity developed [6]. If our American listeners are concerned about their medical-legal exposure of providing a beta-lactam to a patient with a reported penicillin allergy there is a systematic review of legal cases that may decrease the litigation fears of some clinicians [7]. Finally, there is a very good study done at the Kaiser Health system. Dr. Macy’s team removed the automated penicillin-cephalosporin cross-reactivity electronic health record (EHR) warnings in one large region. The result was an increase in cephalosporin use but no significant differences in anaphylaxis, new allergies, treatment failures or all-cause mortality. The use of direct oral challenges has been tried in the intensive care unit (ICU) setting to de-label patients. Koo et al showed that offering amoxicillin oral challenges to ICU patients with low-risk penicillin allergies resulted in successful de-labeling for a significant proportion of patients without triggering severe allergic reactions [8]. However, this oral challenge to de-label beta-lactam patients has not yet been evaluated in an ED setting. This seems strange as we are probably the best equipped and skilled part of a hospital to identify and manage an allergic reaction! With the growing emphasis on antimicrobial stewardship, there is an increased push to accurately assess and, where appropriate, remove penicillin allergy labels, especially in acute and critical care settings. By refining our approach to managing self-reported penicillin allergies, emergency medicine can improve antibiotic selection, reduce unnecessary healthcare costs, and combat the rising challenge of antibiotic resistance. Clinical Question: What are the outcomes of patients with documented moderate, severe or unknown beta-lactam allergies challenged with a full-dose administration of a beta-lactam antibiotic in the ED? Reference: Anders

Date: August 30, 2024 Guest Skeptic: Dr. Mel Herbert is a famous Emergency Medicine Physician, award-winning educator, entrepreneur and philanthropist. Mel founded both EM:RAP which creates and distributes Emergency Medicine education in over 160 countries. He also started a non-profit company called EM:RAP GO. This is an SGEM Xtra to end Season#12. I chatted with Mel about his new book, "The Extraordinary Power of Being Average”. He claims he is average and that realization has been key to his success. It is his secret sauce and superpower that you too can tap into. I've read the book multiple times and listened to the audio version which Mel narrates. It moved me to tears several times. I think this should be a fundamental read for physicians and other healthcare workers. I bought every copy available on Amazon and have given it to friends and students. We discussed the similarities of our backgrounds and how the book resonated with me. Mel grew up in the Australian outback and I grew up on an apple farm in Canada. We both struggled through school until a teacher recognized our potential and gave us an opportunity. The topic of Tall Poppy Syndrome came up during our chat. This has been defined as "the fact that people do not like and often criticize other people who are successful" (Cambridge Dictionary). This syndrome is not unique to Australia and has been described in other countries (Japan, Chile and Scandinavia). Mel also discusses how putting other average people together in a team can do extraordinary things. This is true especially when you add the "G-Factor". You need to listen to the podcast to find out what this means. During the podcast, we mentioned some of our mentors who are Legends of Emergency Medicine. This includes but is not limited to Dr. Jerry Hoffman, Dr. Rick Bukata and Dr. Andrew Worster. Mel and I are friends but I am also a skeptic and asked him if his book was a humblebrag. This can be defined as a "modest or self-deprecating statement whose actual purpose is to draw attention to something of which one is proud." It was interesting to hear his response. WARNING: There may be some things discussed on the podcast or blog that could be upsetting. If you are feeling upset by the content, then please stop listening to the podcast or reading the blog. There will be resources listed for those looking for assistance. The chat did go to some dark places. Mel was very open and transparent about the physical abuse he suffered, his mother's substance use disorder and his struggles with mental illness. He specifically discussed episodes of depression and suicidal ideation. If you are struggling there are various wellness resources and suicide telephone lines and websites. Physician Wellness Resources: Physician Health Program, ACEM Member Wellbeing, ACEP Wellness Section, CAEP Resident Wellness and EMRA Wellness Committee Suicide Telephone and Websites: Prevention Hotline 1-800-273-8255 (SAFE), USA Text HOME to 741741, Canada Text 686868, Suicide Prevention Life Line, American Foundation for Suicide Prevention (AFSP), Suicide Prevention Resource Center and AFSP for Professionals Mel and I are both in the third act of our career. People looking from the outside could get the impression that any success we have achieved has been a straight line from A to B. We need people to realize there are many false starts, "failures", stumbles and mistakes along the way. Residents especially need to hear about the zigs and zags in our lives that got us to where we are today. The SGEM has done some other Xtra episodes that you may enjoy until we start Season#13 next month. SGEM Xtra: Five Tips to Avoid Emergency Medicine Burnout SGEM Xtra: On the Edge of Burnout ACEM18 SGEM Xtra: Star Trek Made Me A Better Physician SGEM Xtra: Everybody Hurts, Sometime SGEM Xtra: Holding Out for a Hero – Lessons from The Dark Knight SGEM Xtra: Yeah, Might Be All that You Get – How Ted Lasso Made Us Better The SGEM will be back next month to start Season#13 with a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down 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. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE. Other Resources: Dr. Lorna Breen Heroes Foundation

Date: August 19, 2024 Reference: Partyka et al. Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management: The SABRE Randomized Clinical Trial. JAMA Surg 2024 Guest Skeptic: Dr. Sean Baldwin is an Emergency Physician practising in Sydney, Australia in both a large tertiary emergency department and a small regional emergency department. Interests include information systems and digital health, research and education. Case: A 67-year-old male presents to your hospital emergency department (ED) after a fall from his bicycle. He has three left-sided rib fractures on imaging without underlying complications. He has severe pain with breathing and asks you what the best way to manage his pain may be. Background: Rib fractures are a common injury, particularly for those over 65. This is partly due to the natural aging process, which often leads to decreased bone density and increased fragility. Older people are more susceptible to fractures from even minor trauma. Rib fractures in this population are especially concerning because they are not only extremely painful but also associated with higher morbidity and mortality rates. The pain from rib fractures can lead to reduced mobility, impaired respiratory function, and an increased risk of complications such as pneumonia, making their management a critical aspect of care in older adults. We have covered rib fractures twice on the SGEM. SGEM episode #324 looked at using spirometry to guide discharging older patients with rib fractures. The evidence was not robust enough back in 2021 to confidently use this potential tool. More recently, the April 2024 SGEMHOP reviewed a trial on how effective and safe an ultrasound-guided erector spinae plane block (ESPB) in adult patients with rib fractures is. The bottom line from that episode was that clinicians with adequate training, ultrasound-guided ESPB can provide safe and effective pain control while achieving lower doses of opioid analgesia requirement for up to two hours after intervention. Serratus anterior plane blocks (SAPBs) have been proposed as another potential effective treatment for pain control in patients with fractured ribs. This procedure involves the administration of a local anesthetic into the plane between the serratus anterior muscle and the rib cage, targeting the thoracic intercostal nerves that supply sensation to the chest wall. By blocking these nerves, SAPB provides substantial analgesia, helping to control pain and improve respiratory function without the systemic side effects associated with opioids. The block is typically performed under ultrasound guidance, which allows for precise placement of the anesthetic and minimizes the risk of complications. For elderly patients, particularly those with multiple rib fractures, SAPB can significantly enhance comfort and facilitate deeper breathing, potentially reducing the risk of pulmonary complications such as atelectasis or pneumonia. Clinical Question: Does the addition of a serratus anterior plane block to a protocolized bundle of care in the emergency department improve pain control? Reference: Partyka et al. Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management: The SABRE Randomized Clinical Trial. JAMA Surg 2024 Population: Patients aged 16 years or older with clinically suspected or radiologically confirmed rib fractures. Exclusions: Patients intubated, pregnant, had received a prehospital SAPB, were transferred for urgent surgical intervention, had a moderate to severe traumatic brain injury, or had a major concomitant non-thoracic injury. Intervention: Serratus anterior plane block (SAPB) using ropivacaine in addition to the usual protocolized rib fracture management. Comparison: Standard protocolized rib fracture care alone without the SAPB. Outcome: Primary Outcome: Composite pain score reduction 4 hours after enrollment, defined as a reduction in the pain score by 2 or more points and an absolute pain score of less than 4 out of 10 points. Secondary Outcomes: Total opioid administration 4, 12, and, 24 hours from study enrollment, median pain scores over the first 24 hours of admission, delirium, pneumonia, subsequent regional anesthesia administered by inpatient pain services, intensive care unit and hospital length of stay (LOS), 30-day mortality, need for noninvasive or invasive mechanical ventilation, local anesthetic systemic toxic effects, and 30-day quality of life assessment Type of Study: Multicenter, open-label, pragmatic randomized clinical trial conducted across eight hospitals in metropolitan and regional New South Wales, Australia Authors’ Conclusions: “This randomized clinical trial found that the addition of an SAPB to standard rib fracture care significantly increased the proportion of patients who experienced a meaningful reduction in their pain score while also reducing in-hospital opioid requirements.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on

Date: August 13, 2024 Guest Skeptics: We have two guest skeptics for this SGEM Xtra episode. Dr. Palma Dr. Francisco Campillo Palma is an Emergency Medicine doctor. He works in prehospital (EMS and HEMS), and at Morales Meseguer Hospital in public medical service in Murcia, Spain. Franciso has postgraduate Master's degrees in emergencies and urgent care, clinical ultrasound, and emergency and disaster management, from the University of Elche, the University of Madrid, and the University of Oviedo. He is also a university expert in Helicopter Emergency Medicine, a teaching member at Emergency Global System (EGS) and Director of the Organizing Committee of IncrEMentuM 2025. Dr. Cano Dr. Carmen María Cano is an Emergency Medicine doctor. She works in Los Arcos del Mar Menor Hospital, in public medical service in Murcia, Spain. Postgraduate master's degrees in emergencies and urgent care, clinical ultrasound, and clinical research from the University of Elche and the University of Madrid. Teaching member at Emergency Global System (EGS) and member of the Organizing Committee of IncrEMentuM 2025. This is an SGEM Xtra episode to discuss the IncrEMentuM conference scheduled for March 12-14, 2025 in Murcia, Spain. Emergency Global System (EGS) is the company behind IncrEMentuM. It is a training company for healthcare professionals. EGS is a small family of people (nurses, physicians and technicians) in the Emergency Medicine field passionate about sharing and delivering the best evidence available differently and more engagingly. IncrEMentuM comes from the Latin word meaning “growth.” This term seeks to reflect the commitment that every physician undertakes from the beginning of their residency until the last day of their career. IncrEMentuM aims to learn from some of the brightest minds in emergency medicine worldwide. We seek to grow as professionals and as educators. Now we want to add something different to what we already have Be skeptical, disruptive, and open-minded to what works in other parts of the world. Always learning, this is the way to grow. That is what IncrEMentuM represents. Five Questions about IncrEMentuM Listen to the podcast to hear Francisco and Carmen answer the five questions. Inspiration: What inspired the theme or focus for IncrEMentuM 2025, and how do you think it aligns with current trends or challenges in emergency medicine? Planning: Can you share any behind-the-scenes insights into the planning process for IncrEMentuM 2025, such as how topics and speakers were selected and what unique perspectives they bring to the conference? Why IncrEMentuM? What do you think sets IncrEMentuM 2025 apart from other emergency medicine conferences? Global EM Challenges: In what ways does the IncrEMentuM address the evolving needs of emergency medicine professionals, especially in the context of global healthcare challenges? Anticipation: What are some of the most anticipated discussions or debates that you expect to spark lively conversations among attendees? Five Things Ken is Looking Forward To at IncrEMentuM Spain: As someone who has never been to Spain, I'm looking forward to the cultural experiences (places to visit, food to try, and drinks to sample). Networking Opportunities: The conference provides a unique platform to connect with peers, thought leaders, and industry professionals from around the world, fostering collaborations that can continue long after the event. I love surrounding myself with smarter people. You have a lot of smart people presenting at this conference and I look forward to networking and learning from them. Hands-On Workshops: There are two complementary pre-conference hands-on workshops. One is called Black Cloud run by Ryan Ernst and Sara Crager and the other is Resus X Spain with Haney Mallemat. Speaking: You were kind enough to ask me to speak at the IncrEMentuM conference. I can’t wait to debate my good friend Salim Razaie on induction agents, five papers with the biggest impact in the last year in evidence-based medicine, and myth musting on contrast-induced nephropathy. FOAMed Friends: Free Open Access to Medical Education (FOAMed) started in 2012 and created a global community. It has been fantastic to interact with these amazing people on social media, but it will be better to see them in real life. I’m looking forward to seeing the wonderful Dr. Manrique Umana from Costa Rica again. He is Pura Vida. The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down 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. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

Date: July 29, 2024 Reference: Connolly SJ et al (ANNEXA-I investigators) Andexanet for Factor Xa Inhibitor–Associated Acute Intracerebral Hemorrhage. NEJM May 2024 Guest Skeptic: Dr. Vasisht Srinivasan is an Emergency Medicine physician and neurointensivist at the University of Washington and Harborview Medical Center in Seattle, WA. He is an assistant professor in Emergency Medicine, Neurology, and Neurosurgery at the School of Medicine at the University of Washington. Case: A 65-year-old man is brought into the emergency department (ED) by emergency medical services (EMS) after his family saw him slump over at the dinner table. He was confused, slurring his speech, and had trouble moving his right side. Initial evaluation by medics revealed right arm weakness, a right facial droop, and decreased responsiveness. When he arrives at your ED, the family tells you he was doing fine until dinner. A code stroke is activated, and a CT head shows a left basal ganglia hemorrhage with no vascular lesions on CT angiography. Vital signs show a blood pressure (BP) of 190/110, heart rate (HR) 117 and irregularly irregular, respiratory rate (RR) 18, SpO2 99% on room air. You ask the patient’s family about any other medical conditions, and they report he has high blood pressure and atrial fibrillation. He takes metoprolol and apixaban and last took his medications that morning about eight hours before. As you begin to lower his blood pressure, you start thinking about reversal agents for his anticoagulation. Background: In hemorrhagic stroke, the ABCs for resuscitation remain the same, but can also be categorized as: Airway Management: This is an important aspect for patients with a poor neurologic exam or those who are not protecting their airways. Blood Pressure Control: There is a lot of debate about the aggressiveness of blood pressure lowering. Numerous trials have attempted to determine the optimal blood pressure target to balance the two goals of minimizing hemorrhage expansion and limiting brain ischemia. INTERACT-2 demonstrated that in patients with ICH, intensive lowering of blood pressure did not result in a significant reduction in the rate of the primary outcome of death or severe disability (SGEM#73). ATACH-2 showed that intensive blood pressure reduction (SBP 110-139 mm Hg) does not provide benefit over standard blood pressure reduction (SBP 140-179 mm Hg) in patients with acute intracerebral hemorrhage (SGEM#172). INTERACT-3 reported the odds of a poor functional outcome were lower in the goal-directed intensive care bundle group compared to usual care (SGEM#413). Coagulopathy Reversal: It makes pathophysiologic sense that patients who take anticoagulants should have the drug rapidly reversed to prevent worsening hemorrhage and poor outcomes. However, the evidence regarding the impact of anticoagulation reversal on patient-oriented outcomes such as decreased mortality or improved neurologic function in patients with acute hemorrhagic stroke is mixed and somewhat limited. Reversal of Warfarin: Freeman et al. (2004) found that recombinant factor VIIa can rapidly reverse warfarin anticoagulation in cases of acute intracranial hemorrhage, but the study did not conclusively demonstrate a reduction in mortality or an improvement in functional outcomes. Direct Oral Anticoagulants (DOACs): Compared to warfarin, DOACs like dabigatran, apixaban, and rivaroxaban have shown lower rates of ICH in randomized controlled trials. However, the management of ICH in the setting of DOAC use remains complex. Hemodialysis can help clear dabigatran, and activated charcoal may be used for recent ingestion. Prothrombin complex concentrate (PCC) may offer some benefit in reversing DOAC-related hemorrhage. The 2022 AHA/ASA guidelines give several recommendations on blood pressure lowering and coagulopathy reversal along with an algorithm. Blood Pressure Lowering: “In patients with spontaneous ICH in whom acute BP lowering is considered, initiating treatment within 2 hours and reaching target within 1 hour can be beneficial to reduce the risk of HE and improve functional outcome” (Class 2a; LoE C-LD) “In patients with spontaneous ICH of mild to moderate severity presenting with SBP between 150 and 220 mmHg, acute lowering of SBP to a target of 140 mmHg with the goal of maintaining in the range of 130 to 150 mmHg is safe and may be reasonable for improving functional outcomes.” (Class 2b; LoE B-RP) “In patients with spontaneous ICH presenting with large or severe ICH or those requiring surgical decompression, the safety and efficacy of intensive BP lowering are not well established.” (Class 2b; LoE C-LD) Reversal: In patients with VKA-associated spontaneous ICH and INR ≥2.0, 4-factor (4-F) prothrombin complex concentrate (PCC) is recommended in preference to fresh-frozen plasma (FFP) to achieve rapid correction of INR and limit HE. (Class I; LoE B-R) In patients with direct factor Xa inhibitor-associated spontaneous ICH, andexanet alf

Date: July 31, 2024 Reference: Gonzales RE, Seeburger EF, Friedman AB, and Agarwal AK. Patient perceptions of behavioral flags in the emergency department: A qualitative analysis. AEM July 2024 Guest Skeptic: Dr. Neil Dasgupta is an emergency medicine physician and ED intensivist from Long Island, NY. He is the Vice Chair of the Emergency Department and Program Director of the EM residency program at Nassau University Medical Center in East Meadow, NY, the safety net hospital for Nassau County. Case: You’re three coffees deep into your night shift when emergency medical services (EMS) bring in a highly agitated 34-year-old male patient with a questionable psychiatric history and possible substance use. He is actively fighting with the police and EMS personnel. The paramedic apologizes to you, saying the patient was picked up while having a loud verbal altercation that was about to turn violent and he was unable to administer any medications or get a story, let alone intravenous (IV) access, even with eight police officers on scene. While you do not recognize the patient, your colleague on the other team comes over and says to you “Oh, I know that guy, he’s a real piece of work. Be careful you don’t get hurt! Don’t you wish we got a heads up about these kinds of patients in the chart?” Background: Violence in emergency departments (EDs) has reached alarming levels, creating significant challenges for healthcare professionals. In an American College of Emergency Physicians (ACEP) survey from August 2022, two-thirds of emergency physicians reported being assaulted in the past year with one-third resulting in injury.[1] This disturbing trend has only been exacerbated by the COVID-19 pandemic, which has intensified stress levels, overcrowding, and labour shortages in hospitals. In a 2024 poll of ACEP members, 91% of emergency physicians said that they, or a colleague, was a victim of violence in the past year. A supermajority (68%) of those emergency physicians said they did not feel their employer’s response was appropriate and half reported nothing was done about the violence.[2] Violence in the ED is not just directed against physicians. A 2024 survey by the Emergency Nurses Association (ENA) found that more than half of its members reported being verbally assaulted, threatened with violence, or physically assaulted in the previous 30 days. Additionally, a Press-Ganey analysis indicated that two nurses are assaulted every hour. It's estimated that up to 80% of workplace violence cases involving nurses go unreported, suggesting that the actual incidence of violence is likely much higher than reported figures.[3] ​The violence faced by emergency healthcare workers has profound impacts, including physical injuries and psychological trauma. Many healthcare workers report experiencing severe stress and burnout due to these violent encounters. Studies indicate that the rate of serious injuries from workplace violence is six times higher for hospital workers than for all other private sector employees in the United States​.[4] In response to this unacceptable violence in the ED, there have been calls for legislative action. The "Workplace Violence Prevention for Health Care and Social Service Workers Act" and the "Safety From Violence for Healthcare Employees Act" (SAVE) are two key pieces of legislation aimed at mitigating workplace violence and establishing federal criminal penalties for assaults on healthcare workers. These efforts are supported by organizations like the ENA, ACEP, and the American Nurses Association (ANA)​.[5] To address the issue of ED violence, various strategies have been recommended, including better training in de-escalation techniques, improved reporting systems, and more robust workplace violence prevention programs. There is also an emphasis on supporting healthcare workers' decisions to refuse care in dangerous situations and ensuring that law enforcement is involved in managing violent incidents​.[6] ED violence is unfortunately not an isolated problem in the USA with other countries facing similar issues. The Canadian Association of Emergency Physicians (CAEP) has a position statement on ED violence.[7] This document highlights the serious problem of workplace violence in EDs, emphasizing the need for enhanced safety measures and support for healthcare providers. These include increased security measures, staff training in de-escalation techniques, and the implementation of policies to protect healthcare workers. The underlying cause for the rise in ED violence is likely multifactorial, including difficulties for patients accessing medical and psychiatric care, increasing burdens on ED with significant overcrowding, a highly stressed and under-resourced health care delivery system and perpetual staffing concerns. Several interventions have been developed to address the issue of ED violence. These have ranged from zero-tolerance policies to engaging with v

Reference: Knack et al. Early Physician Gestalt Versus Usual Screening Tools for the Prediction of Sepsis in Critically Ill Emergency Patients. Ann Emerg Med 2024 Date: July 25, 2024 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: Your hospital is running Morbidity and Mortality (M&M) rounds after a few recent cases in which the diagnosis of sepsis was identified late, and antibiotics were delayed. They are planning on instituting a mandatory screening tool at triage, and one of the main purposes of the meeting is to compare the available tools, such as qSOFA and MEWS. As the local evidence-based medicine (EBM) nerd, they ask for your opinion on the evidence. Background: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It is a medical emergency that requires prompt recognition and treatment to improve patient outcomes. We have covered the topic of sepsis many times on the SGEM (SGEM#69, SGEM#90, SGEM#92, SGEM#113, SGEM#168, SGEM#174, SGEM Xtra, SGEM#346, SGEM#371 and SGEM Peds Xtra). There is a lot of emphasis on identifying sepsis early, with the idea that early intervention will save lives. However, despite a strong push for early antibiotics, the evidence of benefit is mostly lacking. There is observational data that is widely cited to suggest that early completion of sepsis bundles improves outcomes but considering that physicians don’t purposefully delay antibiotics in patients with known sepsis, this data is severely limited by multiple confounders [1]. A randomized control trial (RCT) done in the prehospital setting enrolled 2,698 patients. They were randomized to ceftriaxone 2gm intravenous (IV) in the ambulance or usual cares (fluids and supplementary oxygen) until arrive to the ED. The primary outcome reported was no statistical difference in mortality at 28 days (8% in both groups) despite giving antibiotics 96 minutes earlier [2]. All of the secondary outcomes (mortality at 90 days, misdiagnoses, hospital length of stay, ICU admission rate, ICU length of stay, and quality of life) also did not show a statistical difference between the intervention group and the control group (SGEM#207). Thus, early identification of sepsis might not be as important as sometimes stated in guidelines. However, getting the right diagnosis is clearly important for our patients, and as good as we are, no clinician is perfect. Acknowledging our imperfections, many have suggested that screening tools or decision tools might help increase accuracy when screening for sepsis. Many such tools exist, such as the Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), quick SOFA (qSOFA) and theModified Early Warning (MEWS) score. Unfortunately, the enthusiasm for decision instruments often outstrips the evidence. For a decision instrument to benefit patients, it needs to have more than a high sensitivity. It needs to change physician practice for the better. It needs to be better than current clinical practice, or just plain clinical judgement. There is an article published in AEM, with an author list that includes the who’s who of decision rules – from Jeff Kline to Nathan Kupperman to my BFF Chris Carpenter. That document tells us “Before widespread implementation, CDRs should be compared to clinical judgement.” [3] Unfortunately, most of our rules haven’t cleared this basic evidentiary hurdle. Dave Schriger and colleagues reviewed publications in the Annals of Emergency Medicine from 1998 to 2015 and found that only 11% of the studies compared decision aids to clinical judgement [4]. In those that did compare to clinical judgement, physician judgement was superior in 29% and equivalent or mixed in 46%. The decision aid only outperformed clinical judgement in 10% of papers (or two total trials). A similar review by Sanders et al 2015 concludes that clinical decision rules “are rarely superior to clinical judgement and there is generally a trade-off between the proportion classified as not having disease and the proportion of missed diagnoses.” [5] Therefore, before widespread use of sepsis tools like qSOFA or the MEWS score, we really need to see comparisons to clinical judgment. That brings us to the current study, which aims at comparing a number of these tools to initial clinical judgment in the emergency department. Clinical Question: What is the accuracy of standardized screening tools and a machine learning model to predict a hospital discharge diagnosis of sepsis, compared with physician gestalt in the hyperacute period immediately after patient presentation among undifferentiated patients with critical illness in the emergency department (ED)? Reference: Knack et al. Early Physician Gestalt Versus Usual Screening Tools for the Prediction of Sepsis in Critically Ill Emergency Patients. Ann Emerg Med 2024 Population: Critically ill, adult (18

Reference: Gibbs et al. Noninvasive Ventilation for Preoxygenation during Emergency Intubation (The PREOXI trial). NEJM June 2024. Date: July 17, 2024 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 70-year-old man presents to the emergency department (ED) with an exacerbation of COPD. He is hypoxic on arrival with an oxygen saturation of 80% on room air. Although his oxygenation improves to 92% with supplemental oxygen by nasal cannula, he desaturates with minimal exertion and shows increasing fatigue indicating a need for greater respiratory support. He refuses non-invasive mechanical ventilation, as he has not tolerated it in the past, but is agreeable to intubation. His wife, who has been watching the monitors intently, says she is worried. “His oxygen levels keep dropping. How will you intubate him without them going too low?” Background: Preoxygenation is a critical step in the management of airway interventions, especially in critically ill patients undergoing tracheal intubation. This process involves the administration of supplemental oxygen before the induction of anesthesia to increase the oxygen reserves in the lungs, thereby reducing the risk of hypoxemia. Hypoxemia during intubation can lead to severe complications, including dysrhythmia, cardiovascular collapse, hypoxic brain injury, and death. Therefore, effective preoxygenation is essential to enhance patient safety during this high-risk procedure. Traditionally, preoxygenation has been achieved using an oxygen mask, which can deliver a high fraction of inspired oxygen (FiO2) under ideal conditions. However, oxygen masks have limitations. They do not provide positive pressure or ventilatory support, and the actual FiO2 delivered can be significantly lower than expected if the mask does not fit well. This can be particularly problematic in critically ill patients, who often present with compromised respiratory function and may not tolerate the procedure well. An alternative method of preoxygenation is the use of non-invasive ventilation (NIV), which includes devices like continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). NIV offers several advantages over traditional oxygen masks. It delivers a high FiO2 and provides positive pressure support, which can help maintain airway patency and improve ventilation. This is particularly beneficial for patients who are critically ill, and the risk of desaturation is high. Despite its advantages, the use of NIV for preoxygenation is not without challenges. It requires more time to set up and may increase the risk of aspiration in certain patient populations. Recent studies have explored the efficacy of NIV compared to traditional oxygen masks in critically ill patients. The findings suggest that NIV significantly reduces the incidence of hypoxemia during intubation. These results are promising and may influence future guidelines and clinical practices, emphasizing the importance of optimizing preoxygenation strategies to improve outcomes in critically ill patients. However, the optimal preoxygenation strategy to reduce the risk of hypoxemia and potential harm from it has not yet been determined. Clinical Question: Among critically ill adults undergoing tracheal intubation, will preoxygenation with non-invasive positive pressure ventilation reduce the incidence of hypoxemia between induction to two minutes after tracheal intubation, compared to preoxygenation with facemask oxygen? Reference: Gibbs et al. Noninvasive Ventilation for Preoxygenation during Emergency Intubation (The PREOXI trial). NEJM June 2024. Population: Critically ill adults (18 years and older) undergoing tracheal intubation with a laryngoscope and sedation Exclusions: Pregnant women, prisoners, those already receiving positive-pressure ventilation, and those with conditions precluding NIV (e.g., vomiting, severe agitation, facial fractures). Intervention: Preoxygenation with noninvasive ventilation using a tight-fitting mask connected to either a conventional or dedicated noninvasive ventilator (NIV) for three to five minutes before induction. Comparison: Preoxygenation using an oxygen mask (nonrebreather mask or bag-mask device). Outcome: Primary Outcome: Hypoxemia during intubation, defined as oxygen saturation less than 85% during the interval between induction of anesthesia and 2 minutes after tracheal intubation. Secondary Outcomes: Lowest oxygen saturation during the interval between induction and 2 minutes after tracheal intubation. There were also several exploratory outcomes including outcomes related to procedural complications and clinical outcomes including mortality. There were also outcomes related to patient safety. These are listed in the suppl

Reference: Florin TA, et al. Radiographic pneumonia in young febrile infants presenting to the emergency department: secondary analysis of a prospective cohort study. Emerg Med J. 2023 Date: May 29, 2024 Guest Skeptic: Dr. Christina Lindgren is a Pediatric Emergency Medicine Attending at Children’s National Hospital and Assistant Professor of Pediatrics and Emergency Medicine at the The George Washington University School of Medicine and Health Sciences in Washington, DC. She also serves as the Associate Program Director for the Pediatric Emergency Medicine Fellowship. Dr. Christina Lindgren Guest Author: Dr. Todd Florin is a Pediatric Emergency Medicine Attending at Lurie Children’s Hospital of Chicago where he is also the Director of Research and Associate Professor of Pediatrics and Emergency Medicine at Northwestern University Feinberg School of Medicine. Case: A 6-week-old boy is brought by his family to the emergency department for fever. He was found to have a temperature of 38.4C at home this evening. His parents tell you that he has been congested for the past few days and his cough seems to have worsened. They have been using a bulb suction device at home to help him breathe better, and he is still tolerating breastmilk and formula. There is a school-age sibling at home with cough and congestion as well which she has successfully passed on to the rest of the family. On your physical exam, you note that he has clear nasal secretions, normal oxygen saturation, and appears well. His parents ask you, “He’s so little. Do you think he has pneumonia? His sister had pneumonia in the past and got a chest x-ray. Does he need a chest x-ray as well?” Background: We’ve covered the topics of febrile infants and pediatric pneumonia multiple times on the SGEM: SGEM #171: Step-by-Step Approach SGEM #296: PECARN Clinical Prediction Rule for Low-Risk Febrile Infants SGEM #241: American Academy of Pediatrics (AAP) Guidelines for the Management of Febrile Infants 8-60 days old SGEM #338: SAFER Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia SGEM #359: SCOUT-CAP Short vs Standard-Course Antibiotics for Community-Acquired Pneumonia in Children SGEM #387: Lumbar Punctures in Febrile Infants with Positive Urinalysis Dr. Todd Florin It only makes sense that today, we get to combine both topics in one episode and talk about pneumonia in febrile infants <60 days. Pneumonia is tough to diagnose in this very young population based on just clinical examination alone. This can be particularly challenging because there is a lot of crossovers with bronchiolitis. There is no evidence-based guidance as to who gets a chest X-ray (CXR) and who does not. This leads to a lot of practice variation. Clinical Question: What factors (demographic, clinical, laboratory) are associated with radiographic pneumonia in febrile infants? Reference: Florin TA, et al. Radiographic pneumonia in young febrile infants presenting to the emergency department: secondary analysis of a prospective cohort study. Emerg Med J. 2023 Population: Febrile infants ≤ 60 days with rectal temperature ≥38॰C with CXR performed Excluded: Infants who appeared critically ill, already receiving antibiotics, premature <37 weeks gestation), significant comorbidities, indwelling devices, focal bacterial infections (cellulitis) Intervention: Evaluation of radiographic pneumonia, classified into definite pneumonia, possible pneumonia, and no pneumonia. Comparison: None Outcome: Demographic, clinical, and laboratory factors associated with radiographic pneumonia. Trial: Secondary analysis of data from previous PECARN study conducted from June 2016 to April 2019 Authors’ Conclusions: Radiographic pneumonias were uncommon in febrile infants. Viral detection was common. Pneumonia was associated with respiratory distress, but few other factors. Although ANC and PCT levels were elevated in infants with definite pneumonia, further work is necessary to evaluate the role of blood biomarkers in infant pneumonias. 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? Unsure Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Unsure 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 Were there any conflicts of Interest declared and who funded the study? Dr. Ramilo reported personal fees from Sanofi-Pasteur, Merck, and Pfizer, and grants from Janssen and the Bill & Melinda Gates Foundation, unrelated to this study. No other conflicts were reported. The study was funded by the Euni

Reference: Tjan et al. Conflict in emergency medicine: A systematic review. AEM June 2024 Date: July 5, 2024 Guest Skeptic: Dr. Lauren Westafer an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She co-founded FOAMcast and is a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for the Annals of Emergency Medicine. Case: A 71-year-old patient with a history of hypertension and well-controlled diabetes mellitus without organ involvement presents with left lower abdominal pain, afebrile, blood pressure 138/70 mm Hg, heart rate 82 beats per minute, and oxygen saturation on room air 99%. They are afebrile and tolerate oral intake. The emergency department (ED) evaluation reveals an unremarkable chemistry panel with normal renal function and a white blood cell count of 10,000. An abdominal pelvic CT scan demonstrates uncomplicated left-sided diverticulitis. The patient is feeling well enough to go home and you discharge the patient to home without antibiotics and ask them to follow up with their primary care provider or return if they get worse. In follow-up, the patient’s primary care provider is upset that the patient was not started on antibiotics. Background: We have discussed agitation in the ED on the SGEM several times. This has included the use of haloperidol for agitation due to psychosis (SGEM#45), droperidol for acute agitation (SGEM#328) and the problem with the term “excited delirium” (SGEM#218 and SGEM Xtra). We have also done an episode on rudeness and its impact on medical team performance (SGEM#227) and the prevalence of inter-physician professional weight bias (SGEM#343). One thing we have not specifically discussed is the conflict between clinicians. Conflict in the workplace is defined as a process beginning when individuals or groups perceive differences and opposition regarding interests, beliefs, or values. Workplace conflicts typically involve task issues (disparities in procedures, priorities, or resource allocation) and relationship (socioemotional) issues (breakdowns in interpersonal interactions). In healthcare, conflicts are attributed to factors like incompatible personal motivations, high workload, stress, role ambiguity, and poor leadership. Such conflicts hinder cohesive teamwork and decision-making, potentially compromising patient safety. These conflicts can ultimately lead to moral injury [1,2,3]. Conflicts in the ED often stem from clinical decision-making and actions, leading to potential adverse patient events and exacerbating access block issues. While individual studies have identified various factors contributing to conflict, there has been a lack of comprehensive reviews specific to the ED setting. Understanding the individual, team-level and systemic factors that contribute to conflict among clinicians in the ED may provide insights on ways to help efforts to reduce conflict. Clinical Question: What drives conflict in emergency medicine and are there strategies to reduce conflict? Reference: Tjan et al. Conflict in emergency medicine: A systematic review. AEM June 2024 Population: Empirical, peer-reviewed journal articles written in English about conflict in the ED context that answered one of the identified research questions. Participants included ED physicians, ED nurses, internal medicine (IM) physicians, surgeons, health care technicians, managers, and primary care providers. Excluded: Studies that didn’t focus on the ED context, did not address any specified research questions, nonempirical articles such as commentaries, opinion pieces, letters to the editor, non-English papers Intervention: Strategies and approaches to managing and resolving conflicts in the ED. These included communication training, handover standardization protocols, improving admission guidelines, changes in communication systems, and efforts to improve interpersonal and interdepartmental relationships. Comparison: The strategies for managing conflicts were compared to the usual practices and environments where such strategies were not implemented or where traditional methods were used. Outcomes: What constitutes conflict in the ED? What factors contribute to conflict in the ED? What strategies can be employed to address and resolve conflict in the ED? Type of Study – Systematic review Dr. Lee Wong This is an SGEMHOP episode, and it is my pleasure to introduce Dr. Lee Wong. He is an emergency physician at the Austin Hospital in Melbourne, Australia. He also just got a PhD from Swinburne University, Melbourne, researching Leader Identity Threat in emergency medicine. We also have the lead author, Mr. Timmothy Tjan. He is a final-year medical student at Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia. Authors’ Conclusions: “In emergency medicine, conflict is common and occurs at multiple levels, re

Date: June 29, 2024 Reference: Herbert L. Fred M.D. (1998) Old-Fashioned Doctors, Hospital Practice. This is an SGEM Xtra episode. I was honoured to be invited by Dr. Fernada Bellolio to the Mayo Clinic and present to the Department of Emergency Medicine. They were kind enough to allow me to speak about any topic. I decided to talk about an article Dr. Herbert L Fred published in 1998. You can get a copy of the slides by clicking on this LINK. When I say the term “Old fashioned” what comes to mind? Every generation of adults has been critical of the younger generation. This goes back a very long time. There is a wonderful comedy sketch by Monty Python called Four Yorkshiremen. These successful old men talk about how hard it was when they were growing up. One man complained he “lived for three months in a paper bag in a septic tank. We used to have to get up at six in the morning, clean the paper bag, eat a crust of stale bread, go to work down t' mill, fourteen hours a day, week-in week-out, for sixpence a week, and when we got home our Dad would thrash us to sleep wi' his belt.” This prompts another man to say… “luxury”. If you have never seen the Monty Python skit you check it out on YouTube. There is also a 90-second video that illustrates older generations crapping on the younger generation for thousands of years (The History of Adults Blaming the Younger Generation). Now that we have discussed the concept of being old-fashioned in general, let’s talk about old-fashioned doctors specifically. Isaac and Fitzgerald in the BMJ 1999 described seven alternatives to evidence-based medicine (EBM). One of the alternatives they were suggesting with their tongue firmly in their cheek was an old-fashioned doctor practicing Eminence-Based Medicine (EmBM). “The more senior the colleague. The eminent physician with the white hair and balding patch are called the “halo” effect. They place less importance on the need for anything as mundane as evidence. Experience, it seems, is worth any amount of evidence. These colleagues have a touching faith in clinical experience, which has been defined as ‘‘making the same mistakes with increasing confidence over an impressive number of years.” Dr. Herbert Fred This brings us to the article that this lecture is based on. Dr. Herbert L Fred wrote an opinion piece in the journal Hospital Practice in 1998. Dr. Fred was born in Waco Texas, went to medical school at Johns Hopkins, did his internal medicine at the University of Utah, served in the US Air Force and then went on to teach for nearly 6 decades at Baylor College of Medicine and The University of Texas Health Science Center at Houston. In his article, Dr. Fred commiserated by saying “In the 40 years that I have been a full-time medical educator, much has changed regarding what we teach and how we teach our students and house officers. As a consequence, I now confine myself to teaching basic medical principles-principles that should never change. But even so, today’s trainees tell me that what I say and do is old-fashioned.” It sounds like a little bit of ageism from his students. His article responded with what could be interpreted as some ageism about the students. Reading the article it can come across as condescending and paternalistic giving off a strong "OK Boomer" vibe. After Dr. Fred makes a dozen complaints, he concludes the article with “If so, then I am proud to be old-fashioned. And I believe that if more doctors today practiced medicine the old-fashioned way, our profession might regain some of the nobility and respect it once enjoyed.” I posted this article to social media asking if others considered themselves “old-fashioned”. The vast majority of people responded with positive comments and emojis. However, some pointed out another valid perspective about the condescending tone and ageism expressed in the article by Dr. Fred. I wanted to go through ten of his comments and show how these things are not necessarily old-fashioned or new-fashioned but rather timeless axioms of good medical practice. 1. Time With Patients "Is it because old-fashioned doctors spend whatever time it takes to obtain a good medical history and physical examination?" Seriously, we all would probably like to spend more time with our patients. Back in the 1960’s the emergency room was literally a ROOM. There was no specialty of emergency medicine (EM). The physician could take time and sit at the bedside longer and focus on the one patient in the only room. Things have changed significantly and it is now an emergency DEPARTMENT (ED). There is also the current reality of metrics forcing doctors to move faster, be more “efficient” and “meet ‘em, greet ‘em and street ‘em”. Then there is the dumpster fire of COVID-19 leading to the entire healthcare system seemingly signing out to the ED. We are expected to do primary care, manage post-op complications, be mental health experts, substance use disorder specialists,

Reference: Peters MJ, et al. Conservative versus liberal oxygenation targets in critically ill children (Oxy-picu): a UK multicentre, open, parallel-group, randomised clinical trial. Lancet. December 2023 Guest Skeptic: Dr. Anireddy Reddy is a pediatric intensive care attending physician in the Department of Anesthesiology and Critical Care Medicine at Children’s Hospital of Philadelphia. Dr. Anireddy Reddy Case: A 3-year-old girl presents to the emergency department (ED) with fever and respiratory distress. Her parents tell you that she has been sick for almost a week and her symptoms seem to be getting worse. In the past few days, her appetite has decreased, and she is breathing harder. On your exam, you note that she is very tired and can barely keep her eyes open. Her oxygen saturation is 78% on room air. She is breathing at a rate of 70 breaths per minute with diffuse retractions and nasal flaring. Your ED team quickly intubates her and places her on a ventilator. There is some improvement in her oxygen saturation to 92% and she is drawing adequate tidal volumes. The respiratory therapist asks you whether you want to increase the FiO2 to improve her oxygen saturation while awaiting transport to the pediatric intensive care unit. Background: Oxygen is one of the most prescribed therapies. Sometimes it almost feels like a knee-jerk reaction. We see that pulse ox saturation is low and the first thing we do is apply some form of oxygen. But like many interventions, there are potential harms and benefits. Yes, we purposely use the language of potential harms and benefits rather than risk and benefits. Using the term “risk” implies that a negative outcome may or may not happen. While the term “benefits” implies a positive outcome. It’s unbalanced. Too much oxygen has not been shown to improve outcomes in some conditions and has been associated with harm in others. Our guidelines for the treatment of pediatric acute respiratory distress syndrome also recommend a target saturation of 88-92%. Clinical Question: What is the optimal target for systematic oxygen in critically ill children receiving invasive ventilation? Reference: Peters MJ, et al. Conservative versus liberal oxygenation targets in critically ill children (Oxy-picu): a UK multicentre, open, parallel-group, randomised clinical trial. Lancet. December 2023 Population: Children >38 weeks corrected gestational age and younger than 16 years enrolled within 6 hours of being admitted to the Pediatric Intensive Care Unit (PICU) and receiving invasive mechanical ventilation with supplemental oxygen Excluded: known or suspected congenital cardiac disease or sickle cell disease, known pulmonary hypertension, when brain pathology/injury was the primary reason for admission, not expected to survive ICU admission, receiving long-term invasive mechanical ventilation prior, or have end-of-life care plans with limitations in resuscitation Intervention: Conservative oxygenation, defined as a target peripheral oxygen saturation (SpO2) of 88% to 92%. Comparison: Liberal oxygenation, defined as target SpO2 >94% Outcome: Primary Outcome: Duration of organ support at 30 days. This was a rank-based endpoint scored 1 to 30, and 31 if the patient died. Major components of organ support included respiratory (invasive and non-invasive), cardiovascular (vasoactives and fluid boluses), renal support, analgesia/sedation, transfusion, neurological, and metabolic support. Details can be found in the supplemental material. Secondary Outcomes: Mortality at PICU discharge, time to liberation from invasive mechanical ventilation, duration of organ support, length of PICU and acute hospital stay, functional status at PICU discharge, incremental costs at 30 days Trial: Pragmatic, multicentre, open-label, randomized controlled trial Authors’ Conclusions: “Among invasively ventilated children who were admitted as an emergency to a PICU receiving supplemental oxygen, a conservative oxygenation target resulted in a small, but significant, greater probability of a better outcome in terms of duration of organ support at 30 days or death when compared with a liberal oxygenation target. Widespread adoption of a conservative oxygenation saturation target (SpO2 88–92%) could help improve outcomes and reduce costs for the sickest children admitted to PICUs.” 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). 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 compl

Reference: Jansen et al. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA. 2023 Date: June 10, 2024 Guest Skeptic: Dr. Rob Leeper is an intensivist, trauma surgeon, and general surgeon at Western University where he also serves as the director of the Royal College Surgical Foundations program. He is particularly enthusiastic about medical education and the use of high-fidelity simulation to identify latent threats to patient safety and improve team-based crisis resource management. Case: A 24-year-old patient is involved in a high-speed motor vehicle collision. The patient was the intoxicated driver of a sport utility vehicle that left the road and collided head-on with a traffic light. The driver was ejected from the vehicle. On scene, he has a Glasgow Coma Scale (GCS) score of 14, is tachycardic at 130 beats per minute and hypotensive at 85/50 mmHg. He complains of severe pain in his abdomen and left upper extremity. He has an obvious angulated deformity of his left wrist. Pre-hospital personnel placed the patient in a cervical spine collar, obtained peripheral intravenous (IV) access, administered 250cc of 0.9% saline and provided rapid transport to the local trauma center which is less than 15 minutes away. On arrival at the trauma center, the patient’s vital signs and symptoms remain essentially unchanged from those on scene. You initiate standard, simultaneous assessment and resuscitation following the Advanced Trauma Life Support (ATLS) principles. You are debating the addition of resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to your standard care. You wonder what the evidence is for this additional approach. Background: We covered REBOA on the SGEM 5 years ago with Dr. Robert Edmonds (SGEM#258). That was a review of a retrospective observational study of 593,818 trauma patients of which 140 received REBOA compared to 240 matched controls who did not receive this treatment. The overall mortality was worse with REBOA (35.7% vs. 18.9%, p=0.01). The SGEM bottom line in 2019 was that REBOA is currently an intervention of uncertain benefit. Although it has shown promise in some studies, this investigation leaves its therapeutic potential in question and arguably demonstrates harm. There may be substantial benefits in select groups of trauma patients, but these groups are not yet known. Trauma surgeons are hemorrhage control surgeons. Bleeding is the enemy and patient survival turns tenuously on our ability to identify and staunch hemorrhage in as expedient a fashion as possible. Time is our currency and, for patients with massive hemorrhage, minutes matter. Every strategy that enhances time to hemorrhage control is deserving of examination: Trauma Systems - Enhancing the training and tools for our pre-hospital teams, faster helicopters, more trauma centers, etc. Hemostatic Resuscitation - Permissive hypotension, whole blood and factor ratio resuscitation, warmed products, dynamic coagulation monitoring, etc. Enhanced Operative Strategies - Damage control surgery with truncated interventions, energy devices, hemostatic foams/gels/packs, etc. These approaches hold the possibility of enhancing our ability to save patient’s lives. One approach, which has seen a revival in its interest and utilization, is proximal balloon occlusion of the aorta. The rationale is simple, occluding the aorta above the level of bleeding will de facto reduce blood loss at the site of injury and lead to immediately increased blood pressure and, presumably, perfusion to the zone above the occlusion, typically the upper body, the heart, and the brain. A great variety of medical devices designed for this purpose have come to market over the last 15 years and a relatively heterogeneous collection of retrospective clinical data has been published with conflicting results. There are signals of improvement but also signals of harm with this technique. Given this equipoise, a robust prospective clinical trial was undertaken by a group of international trauma providers and researchers. The UK-REBOA was designed and conducted across 16 English trauma centers from 2017 to 2022 to provide the most evidence-based answer to the question of whether the addition of REBOA to standard care improves survival in massively bleeding trauma patients. Clinical Question: Does the addition of REBOA to standard trauma resuscitation practice improve survival for injured patients presenting to lead trauma centres with massive hemorrhage? Reference: Jansen et al. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA. 2023 Population: Adults aged 16 years or older presenting to 16 major trauma centers in the UK (2017-2022) with confirmed or suspected life-threatening torso hemorrhage am

Reference: Kruse et al. Systematic Review, Quality Assessment, and Synthesis of Guidelines for Emergency Department Care of Transgender and Gender-diverse People Recommendations for Immediate Action to Improve Care. WJEM December 2023 Date: May 30, 2024 Guest Skeptic: Dr. Kay Dingwell is a rural emergency physician working in Prince County, PEI with a special interest in gender-affirming care and improving the care of trans and gender-diverse patients. Case: A 16-year-old nonbinary youth on testosterone blockers and oestrogen has come into your emergency department (ED) having twisted their ankle while playing soccer. You learn they are ordering hormones online as they do not have any gender-affirming primary care. You don’t see a large number of trans patients in your ED and you wonder if there might be specific recommendations that can guide your care of this adolescent. Background: In North America, trans and gender diverse (TGD) people make up 0.3% to 0.6% of the overall population, and up to 4.1% of the adolescent population according to Statistics Canada [1] and The Williams Institute in the US [2]. It has been shown in previous research that TGD individuals have both high ED avoidance due to discrimination, as well as a high need for emergency services due to the impacts of minority stress on this population [3,4]. Trans individuals are at higher risk of experiencing violence, adverse substance use, homelessness, and mental health challenges, among other challenges which may impact their health. These patients often report negative experiences when accessing emergency care, and there is an established lack of research to guide their care in the emergency department. A group of researchers, including members of the queer community, set out to perform a systematic review, quality assessment, and synthesis of clinical practice guidelines and best practice statements on the care of transgender and gender-diverse individuals at any stage of accessing emergency department care. Clinical Question: What clinical practice guidelines (CPGs) exist to inform the care of transgender and gender diverse (TGD) patients in the emergency department? Reference: Kruse et al. Systematic Review, Quality Assessment, and Synthesis of Guidelines for Emergency Department Care of Transgender and Gender-diverse People Recommendations for Immediate Action to Improve Care. WJEM December 2023 Population: Transgender and gender-diverse populations of any age, in any setting, region, or nation. It included both medical and paramedical care within these groups. Exclusions: Not a guideline or best practice statement, or guidelines/BPS not relating to TGD patients or ED care, full text not available, or not in English Intervention: There was no intervention. The study looked at implementing clinical practice guidelines (CPG) and best practice statements (BPS) for the care of TGD individuals in ED. Comparison: The guidelines and statements were assessed against quality standards using the AGREE-II and AGREE-REX criteria, rather than comparing different types of care or interventions against each other. Primary Outcome: The identification and assessment of the quality and applicability of guideline recommendations relevant to ED care of TGD people. Authors’ Conclusions: “This is the most comprehensive review of clinical practice guidelines and best practice statements for ED care of transgender-diverse populations to date and reveals several important actionable recommendations for the care of TGD people in the emergency department.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The search for studies was detailed and exhaustive. No The primary studies were of high methodological quality. Unsure 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. No Conflicts of Interest: There were no financial conflicts of interest or sources of funding to declare. Key Results: The initial search identified 1997 articles, with 291 moving on to full-text review after the application of inclusion criteria, resulting in a further 190 being excluded. Of the remaining studies, seven articles had a total of ten recommendations that were relevant to any stage of emergency care. They analyzed these using the AGREE-II tool to assess the methodological quality, and then the AGREE-REX tool to assess the quality and strength of the ten guideline recommendations, eight of which ended up being recommended for use by the assessors as two had no consensus. The eight recommendations include four on sexual health, one on primary care access, one on training ED staff in culturally competent care of TGD patients, one on substance use, and one on mental health. Primary Outcome: Eight Recommendations Transgender people i

Reference: Tavender E, et al. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev. 2024 Date: May 29, 2024 Guest Skeptic: Dr. Caleb Ward is a pediatric emergency medicine attending and Associate Professor of Pediatrics and Emergency Medicine at Children’s National Hospital and The George Washington School of Medicine and Health Sciences in Washington, DC. His research focuses on the pre-hospital care of children by EMS. He is the principal investigator for EMSC State Partnership in Washington, DC and is also involved in various multi-center EMS studies with the Pediatric Emergency Care Applied Research Network (PECARN). Dr. Caleb Ward Case: A 4-year-old boy is brought to the emergency department (ED) by Emergency Medical Services (EMS) after falling from a tall tree. The fall was witnessed by his family. They tell you that he is going through a Spiderman phase and tries to climb everything. They saw him slip off the tree and landed in the grass below. He did not have any loss of consciousness. EMS placed him in a C-collar and brought him to you. On examination, you only notice a few scrapes, but he is cradling his left arm and complaining that it hurts. There looks to be an obvious deformity of his forearm. The family members ask you, “he seems uncomfortable in the neck collar, can we remove it? Do you think he injured his neck?” Background: Pediatric cervical spine injuries (CSI), though rare, can have devastating consequences if missed. Imaging studies include X-rays, CT scans, and MRIs. Typically, we see the use of X-ray or CT more often in the acute setting. The downside of these methods is exposing children to radiation. Clinical Decision Rules (CDRs) have been developed to help guide decision-making and minimize unnecessary tests and imaging while detecting significant injuries. Because there is no standardized process for identifying children with CSI after blunt trauma, practice varies based on clinician, institution, location, and available resources. We have covered some of these CDRs in pediatrics on the SGEM before: Ankle and Knee Injuries (SGEM#3, SGEM#5) Trauma (SGEM#127) Appendicitis (SGEM#155) Head Trauma (SGEM #412, SGEM #225) Febrile Infants (SGEM#171, SGEM #296) While there are CDRs for cervical spine injury in adults like the Canadian C-spine Rule and NEXUS criteria for C-spine imaging, we do not have a dedicated, accurate CDR for pediatric patients. Clinical Question: Which triage tools or Clinical Decision Rules (CDRs) are most effective for detecting cervical spine injuries in pediatric trauma patients? Reference: Tavender E, et al. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev. 2024. Population: Children (aged 0 to <18 years) who underwent blunt trauma evaluation in emergency departments. (ED) Excluded: Patients with previous cervical spine surgery or congenital cervical spine anomalies Intervention: Application of various CDRs or sets of clinical criteria to evaluate the presence of cervical spine injuries following blunt trauma. Comparison: The CDRs were compared with each other and with reference standards like X-ray, CT, MRI, or clinical clearance/follow-up in low-risk children. Outcome: The primary outcome of interest was the diagnostic accuracy of the CDRs, specifically their sensitivity and specificity in detecting cervical spine injuries. Trial: Systematic review Authors’ Conclusions: “There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.” Quality Checklist for Systematic Review Diagnostic Studies: The diagnostic question is clinically relevant with an established criterion standard. Yes The search for studies was detailed and exhaustive. Yes The methodological quality of primary studies were assessed for common forms of diagnostic research bias. Yes The assessment of studies was reproducible. Yes There was low heterogeneity for estimates of sensitivity or specificity. Unsure The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. No Were there any declared financial conflicts of interest? No financial conflicts of interest Results: The five included studies reported a total of 21,379 children, with age ranges from less than 3 years to under 18 years. Studies were conducted in various countries including the USA, UK, Australia, Canada, and Brazil. The median prevalence of CSI was 0.98% with IQR of 0.5% to

Reference: Borgundvaag et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department. AEM May 2024 Date: May 22, 2024 Dr. Bjug Borgundvaag Guest Skeptic: Dr. Bjug Borgundvaag is the Founding Director of the Schwartz/Reisman Emergency Medicine Institute (SREMI), at Sinai Health System. He is a Professor of Emergency Medicine and a Clinician Scientist in the Department of Family and Community Medicine at U of T. Prior to his medical training, he completed a PhD in Pharmacology at U of T. He has been involved in ED-based clinical research examining ways to improve care for patients with alcohol use disorder in the ED for over two decades. This is an SGEM HOP but with a twist. We are not going to do a structured critical appraisal of GRACE4 but rather turn it into an SGEM Xtra. When we combine SGEMHOP with an SGEM Xtra I hope we get some…AMAZING knowledge translation for GRACE4. "The SAEM GRACE program addresses the best practices for the care of the most common chief complaints that can be seen on the tracking board of any emergency department in the country, based upon research and expert consensus. These guidelines are designed with de-implementation as a guiding principle to reasonably reduce wasteful testing, provide explicit criteria to reduce foreseeable risk, and define sensible and prudent medical care." GRACE1: Recurrent, Low-Risk Chest Pain GRACE2: Recurrent, Low-Risk Abdominal Pain GRACE3: Acute Dizziness & Vertigo For this SGEMHOP Xtra combo episode on GRACE4, we are going to give a case scenario, a little background information, ask a clinical question, provide authors’ conclusions, go through the recommendations and a case resolution. Case 1: A patient presents to the ED with nausea, vomiting and some abdominal pain complaining of alcohol withdrawal. He reports that his last drink was 9 hours ago, and he typically consumes 60 oz of spirits/day. He has had prior hospital admissions for the management of alcohol withdrawal, including seizures and one prior episode of delirium tremens. Management: The patient is initiated on a Clinical Institute Withdrawal Assessment (CIWA) protocol and administered intravenous (IV) doses of diazepam hourly for the next 18 hours. There was a 6-hour delay until the first dose of diazepam was administered. Over those 18 hours, his CIWA stubbornly stays at around 18, and by the 15-hour mark, has increased to 21 despite receiving 20mg of diazepam hourly. By the 18-hour mark, he has had a total of 240 mg of diazepam and is getting worse. Clinical Question 1: Is IV phenobarbital, in addition to diazepam, helpful in managing this case of severe alcohol withdrawal? Authors’ Conclusions: There is limited direct high-quality evidence from clinical trials supporting the use of phenobarbital as an adjunct to benzodiazepines for managing moderate to severe AWS in the ED setting. Although the direct prospective evidence comparing these interventions in ED patient populations is limited, the balance between desirable and undesirable effects favours adjunctive phenobarbital over benzodiazepine alone. This is based, in large part, on indirect evidence illustrating the benefits of adjunctive phenobarbital including, but not limited to, reduction on the need for intubation, decreased hospital length of stay, decreased ICU admission and length of stay. Recommendation 1: In adult ED patients (over the age of 18) with moderate to severe alcohol withdrawal, who are being admitted to the hospital we suggest using phenobarbital in addition to benzodiazepines as compared to using benzodiazepines alone. (Conditional recommendation, FOR) [Low to Very Low certainty of evidence] Good practice statement: All patients treated for alcohol withdrawal should be offered follow-up treatment where such treatment is available. Case 1 Resolution: After receiving 240 mg of diazepam over 18 hours with no improvement, the patient was given phenobarbital 5 mg/kg as an infusion. The patient’s symptoms showed significant improvement, and 1 hour later the patient was given an additional 5 mg/kg dose resulting in complete symptom resolution. Case 2: A female patient presents to the ED with moderate alcohol withdrawal. She has consumed 26 oz of vodka a day, for the last four years. She has no history of being admitted to the hospital for the management of alcohol withdrawal syndrome (AWS). Background 2: The patient is treated with diazepam using a symptom-driven approach including hourly CIWA assessments including long-acting benzodiazepines to manage symptoms according to severity. Her AWS resolves over the next 8 hours, and she is ready to be discharged home by the end of your shift. You make a referral to a local addiction medicine service for her to be seen a few days later. Clinical Question 2: Should this patient be offered anti-craving medication upon discharge? Autho

Date: May 13, 2024 Guest Skeptics: Dr. Rebecca Szabo is an obstetrician/gynecologist and medical educator specializing in simulation from Melbourne, Australia working at The Royal Women’s Hospital and The University of Melbourne. This is her first time as a guest skeptic on the SGEM, she has created FOAMed content through various media, including the MedEd Stuff N Nonsense Podcast. Dr. Dennis Ren is a pediatric emergency medicine physician at Children’s National Hospital in Washington, DC. He is the lead for SGEMPed and has created content for other FOAMed sites like First10EM, Don’t Forget the Bubbles, and PedsRAP. This is an SGEM Xtra episode discussing lessons we learned from watching the show Ted Lasso. We have done other SGEM Xtra episodes looking at how various pop cultures impacted us as physicians and influenced us as people. SGEM Xtra: Star Trek Made Me A Better Physician with kindness mentor Dr. Brian Goldman SGEM Xtra: Lead Me On – What I Learned from Top Gun with my BFF Dr. Chris Carpenter SGEM Xtra: Holding Out for a Hero – Lessons from The Dark Knight with PEM superhero Dr. Dennis Ren Five Questions for the Guest Skeptics Why did you like the show so much? Who is your favourite character? Who do you identify most within the show? What friend do you have that represents the ethos of the show? Who do you think needs to watch the show? Listen to the SGEM podcast on iTunes or Spotify to hear Dennis and Rebecca's answers. Ten Lessons Learned from Watching Ted Lasso Be Curious, Not Judgemental Optimism and Positivity Be a Goldfish Empathy and Compassion Vulnerability Open-mindedness The Importance of Family Learning from Failure Leadership Inclusivity and Respect Listen to the SGEM Xtra podcast on iTunes or Spotify to hear Rebecca and Dennis discuss these lessons. The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down 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. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

Reference: Jain A, et al. Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial. Br J Surg. March 2023 Date: May 7, 2024 Guest Skeptic: Dr. Brian Lee is a pediatric emergency medicine attending at the Children’s Hospital of Philadelphia and Assistant Professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. Dr. Brian Lee Case: A 5-year-old girl comes to the emergency department (ED) after smashing her finger with a hammer. Her mother, who possesses a strong “do-it-yourself” attitude, was busy constructing a bookshelf for her daughter when the girl grabbed a hammer to help and promptly dropped it on her finger. On your exam, the girl is tearful and has a bloody index finger, and the fingernail is almost nearly avulsed. She is otherwise uninjured. Her mother tells you, “I remember this happening to me when I was younger, and they had to remove my fingernail. Is there any way to save the fingernail?” Background: Fingertip and nail bed injuries are some of the most common hand injuries in children. These can range from subungual hematomas to lacerations to partial amputations. Fingers and hands are important for performing daily activities, and we want to ensure that these injuries heal appropriately. That includes considerations for function and cosmesis. Some myths have been perpetuated throughout the years regarding finger injuries. For example, the teaching that if a subungual hematoma is >50% of the nail bed, then the nail should be removed because there is likely an underlying nailbed laceration that needs to be repaired. This is not true because we have learned that if the nail is otherwise intact, we can just trephinate it and be done.[1] Another practice that we’ve encountered in fingertip injuries where the nail is avulsed is replacing the nail during the repair. Reasons for that practice include protecting the repair, splitting the nail fold, and reducing infection. But there is not really high-level evidence to back up those claims, and some centers have even advocated for not replacing the nail given the challenges of adequately cleaning the native nail. [2] Suturing nailbeds and suturing avulsed fingernails back on tend to be a bloody mess. This might be the time for the “don’t just do something, stand there” approach [3]. Clinical Question: Is discarding the fingernail during nail bed repair superior to retaining it? Reference: Jain A, et al. Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial. Br J Surg. March 2023 Population: Children less than 16 years of age with nail bed injury to a single finger occurring within 48 hours of presentation believed to require surgical repair Exclusion: Infected injury, underlying nail disease, deformity to the injured finger, amputation, loss of nail bed requiring reconstruction, multiple nail bed injuries Intervention: Fingernail replacement after debridement and suturing of the nail bed or fingernail substitute like foil. Comparison: No fingernail replacement. Outcome: Primary Outcome: Co-primary outcomes of surgical site infection at 7-10 days and cosmetic appearance of the nail using the Oxford Fingernail Appearance Score (OFNAS) Secondary Outcomes: Quality of life based on the EuroQol Five Dimensions (EQ-5D-Y), pain at first dressing change, surgical site infection by 4 months, parent assessment of nail appearance at 4 months, cost difference Trial: Multicentre, pragmatic two-arm parallel-group superiority randomized controlled trial Authors’ Conclusions: “After nail bed repair, discarding the fingernail was associated with similar rates of infection and cosmesis ratings as replacement of the fingernail, but was cost saving.” 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. No The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). No 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. None. Results: They recruited 451 children presenting to 20 secondary-care hospitals with 224 allocated to the nail-discarded group and 227 in the nail-replaced group. The average age was approximately 5.9 years, about 54% of participants were male and most injuries were due to crush and avulsion of

Reference: Tanner et al, A retrospective comparison of upper and lower extremity intraosseous access during out-of-hospital cardiac arrest resuscitation. Prehospital Emergency Care. February 2024. Date: April 25, 2024 Guest Skeptic: Missy Carter is a PA working in an ICU in the Tacoma area and an adjunct faculty member with the Tacoma Community College paramedic program. She is also the local director of the difficult airway EMS course at Washington State. Case: EMS arrives with a 58-year-old woman who suffered an out-of-hospital cardiac arrest (OOHCA). When emergency department (ED) staff roll her to remove her clothing her humeral intraosseous (IO) is dislodged. Later the medic asks you if she should bother placing an upper extremity IO or just stick with the tried-and-true tibial plateau. Background: We have looked at getting access in the pre-hospital setting on SGEM#231. That episode was a study comparing intravenous (IV) vs IO access for OOHCAs. It was a secondary analysis of an observational study which showed an association between decreased favourable neurologic outcomes in the IO group compared to the IV group. Despite that weak evidence, placement of IO in OOHCA has become a routine procedure for many EMS providers. The classic location for IO placement is the tibial plateau. This is because of the ease of finding anatomic landmarks and their location away from other procedures like defibrillation, CPR, and airway management. Some studies have suggested quicker delivery of medications and fluids through the upper extremity IO route compared to the lower extremity route. Clinical Question: Does upper extremity placement of intraosseous access versus lower extremity placement matter in out-of-hospital cardiac arrest? Reference: Tanner et al, A retrospective comparison of upper and lower extremity intraosseous access during out-of-hospital cardiac arrest resuscitation. Prehospital Emergency Care. February 2024. Population: Adults 18 or greater with an OOHCA Excluded: IV access before IO, DNR, interfacility transfers, and EMS-witnessed arrests Intervention: Upper extremity IO placement (100% humeral) Comparison: Lower extremity IO placement (97.8% tibial & 2.3% femoral) Outcome: Primary Outcome: Return of spontaneous circulation (ROSC) Secondary Outcomes: Survival to hospital discharge and survival to discharge home. Authors’ Conclusions: “In this large prehospital dataset, upper extremity IO access was associated with a small increase in the odds of ROSC in comparison to lower extremity IO access. These data support the need for prospective investigation of the ideal IO access site during OHCA resuscitation.” 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? Unsure How precise are the results? Very 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 and No Results: The study population consisted of 155,884 patients, with 76% receiving lower extremity access and 24% upper extremity access. The median age was 65 years, 61% being male, 81% presumed a cardiac etiology and 54% were witnessed arrests. Key Results: Upper extremity IO access was associated with slightly greater odds of achieving ROSC compared to lower extremity IO access. Primary Outcome: Odds Ratio (OR) for ROSC was 1.11 [95% CI: 1.08 to 1.15] Secondary Outcomes: Survival to discharge OR 1.18 [95% CI; 1.00 to 1.39] Survival to discharge to home OR 1.23 [95% CI; 1.02 to 1.48] 1. Retrospective Observational Study: The study's retrospective observational design could lead to potential biases from unmeasured confounder factors. 2, Upper or Lower: 76% of the IOs which were placed were performed in the lower extremity (98% tibial and 2% femoral). The remaining 24% were all upper (humeral). It would be interesting to know what factors determined the insertion site chosen and if this might affect the outcomes. 3. Loss to Follow-up: There was 17% of patients lost to follow-up. Given the small effect sizes observed in the study, this could have been biased by the results if those patients were systematically different. 4. Subgroup Analysis: Intubated patients with upper extremity IO did worse than intubated patients with lower extremity IO. Is this an outlier or is it possible that doing multiple complex procedures distracts the team from providing meaningful procedures (high-quality CPR and defibrillation) in a timely manner? Another subgroup difference observed was patients with shorter ischemic time (witnessed arrest and/or bystander CPR) and