The Skeptics Guide to Emergency Medicine

Reference: Ramesh S, Ayyan SM, Rath DP, Sadanandan DM. Efficacy and safety of ultrasound-guided erector spinae plane block compared to sham procedure in adult patients with rib fractures presenting to the emergency department: A randomized controlled trial. AEM April 2024 Date: April 19, 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 are doing great things and helping many patients during your shift in the emergency department (ED) when you hear a trauma alert being called overheard. You walk over to the trauma room, and you see a healthy-looking 52-year-old male complaining of chest trauma after being involved in a motor vehicle collision before arrival. His imaging shows mildly displaced rib fractures of ribs four through seven. He is stable but complaining of pain despite initial IV acetaminophen and ketorolac. You offer him some opioids which he says makes him throw up. He’s been texting with his daughter who is an emergency medicine ultrasound fellow, and she mentioned something about using the ultrasound to inject something to decrease his pain. Background: We have covered rib fractures once before on the Skeptics' Guide to Emergency Medicine. This was on SGEM#324 looking 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. We know that rib fractures are associated with an increased risk of morbidity and mortality – specifically related to hypoventilation-related complications [1]. These risks are particularly higher in the elderly [2]. A clinical decision tool called the STUMBL score was derived and validated by Battle et al in 2014 [3]. It risks stratified older patients with blunt trauma. An attempt was made to externally validate this tool in New Zealand by Murkerji et al 2021 [4]. It did not perform as well which is not unusual for a clinical decision instrument [5]. Rib fractures can cause lung splinting and therefore, pain management is a very important part of the management of rib fractures. In addition to coming with a litany of undesired systemic side effects such as a depressed level of consciousness and decreased respiratory drive, opioid pain medications are also short-acting and require frequent redosing. With the 2014 CDC declaration that prescription drug overdose is one of the five top health threats, there has been a movement away from opioids as the mainstay of pain management for rib fractures [6]. There have been some studies that looked at the efficacy of alternative pain management strategies, but very few have looked at the efficacy or safety of ultrasound-guided erector spinae plane block. Clinical Question: How effective and safe is an ultrasound-guided erector spinae plane block in patients with rib fractures? Reference: Ramesh S, Ayyan SM, Rath DP, Sadanandan DM. Efficacy and safety of ultrasound-guided erector spinae plane block compared to sham procedure in adult patients with rib fractures presenting to the emergency department: A randomized controlled trial. AEM April 2024 Population: Adult patients with confirmed rib fractures and a numeric rating score (NRS) greater than 4, despite routine analgesia. Exclusions: Allergies to specific medications, penetrating thoracic trauma, pregnancy, infection or laceration at the injection site, specific health conditions (e.g., systolic BP < 100 mm Hg, subcutaneous emphysema at the block site), chronic pain, chronic analgesic use, substance abuse, immediate surgical need, or inability to give consent. Intervention: Ultrasound-guided erector spinae plane block (ESPB) using a high-frequency linear array transducer. The procedure targeted the transverse process corresponding to the fractured rib, where 0.5% bupivacaine was injected after confirming needle placement with saline. Comparison: A sham procedure involved similar preparations without actual needle insertion or injection. Outcome: Primary Outcome: The reduction in pain intensity, was measured using the 11-point NRS at six time points over 12 hours. Secondary Outcomes: The amount of rescue analgesia in morphine equivalents and the occurrence of adverse events. Type of Study: Randomized control trial, prospective, interventional Dr. Manu Ayyan This is an SGEM Hot Off the Press episode, and it is our pleasure to introduce Dr. Manu Ayyan. He is an Associate Professor at Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Puducherry, India. Dr. Ayyan is a nationally recognized educator and recipient of the 2017 INDUS-EM Emergency Medicine Leadership Award. Authors’ Conclusions: “Ultrasound-guided ESPB resulted in significantly reduced pain intensity over the study period, reduced amount of rescue analgesia, and had no discernible difference in adverse events when compared with a sham.” Qua

Reference: Albers GW et al. TIMELESS Investigators. Tenecteplase for Stroke at 4.5 to 24 Hours with Perfusion-Imaging Selection. NEJM Feb 2024 Date: April 12, 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 70-year-old woman was brought into the emergency department by EMS after her family reported she was having trouble talking. They noticed this earlier in the day and let her rest, but when she had trouble moving her right arm, they called 911. Initial evaluation by medics revealed right hemiplegia, a right facial droop, left gaze deviation, and aphasia. When she arrives in your ED, her family tells you she was last seen normal about 12 hours ago. A code stroke is activated, and the initial CT head shows no signs of hemorrhage or early ischemic changes. A CT angiogram shows a proximal middle cerebral artery occlusion. CT perfusion showed a 10 mL core and 189 mL penumbra. As you speak to your stroke team, the question of thrombolysis comes up, as her core is quite small, and the stroke may still be very early in its time course. Background: The question of thrombolysis for acute ischemic stroke dates back nearly 30 years to the initial NINDS trial published in 1995 [1]. Since that time, numerous studies and analyses have been undertaken to categorize the potential benefits and potential harms associated with thrombolysis in stroke [2-8]. We have discussed this issue multiple times on the SGEM including: SGEM#29: Stroke Me, Stroke Me SGEM#70: The Secret of NINDS SGEM Xtra:Thrombolysis for Acute Stroke SGEM Xtra: Walk of Life SGEM#297: tPA Advocates Be Like – Never Gonna Give You Up With the pentad of thrombectomy trials published in 2015 [9-13] and the extension of the thrombectomy window in 2018 following the publication of DAWN [13] and DEFUSE-3 [15], the standard of care has now shifted to mechanical thrombectomy for large vessel occlusion, though thrombolysis is still used up to 4.5 hours from onset of symptoms. We have looked at the issue of EVT with or without thrombolytics on the SGEM a few times. SGEM#137: A Foggy Day – Endovascular Treatment for Acute Ischemic Stroke SGEM#292: With or Without You – Endovascular Treatment with or without tPA for Large Vessel Occlusions SGEM#297: tPA Advocates Be Like – Never Gonna Give You Up SGEM#333: Do you Gotta Be Starting Something – Like tPA before EVT? SGEM#349: Can tPA Be A Bridge Over Trouble Waters to Mechanical Thrombectomy? There have also been several SRMA on this issue [16-21] a few guidelines published on the topic [22-24] and ACEP is currently working on a clinical policy to address this question of EVT +/- thrombolytics. Following nearly a decade of research into Tenecteplase (TNK), beginning as early as 2012 [25], this agent has supplanted alteplase (tPA)as the preferred thrombolytic agent at both some large stroke centers as well as many community sites designated as primary stroke centers. SGEM#377 covered one of those trials comparing tPA to TNK. The AcT trial was a pragmatic, multicentre, open-label, registry-linked, randomized, controlled, non-inferiority trial [26]. This trial reported that TNK was non-inferior to tPA in stroke patients treated within 4.5 hours of symptom onset. Studies from the UK [27], Australia and New Zealand [28, 29], and several studies from Norway [30, 31] have similarly shown that it is neither superior to alteplase nor is it inferior. Perfusion imaging allows more careful patient selection for therapies as it identifies those patients with salvageable ischemic tissue (penumbra) that can be “rescued” if reperfused versus those who have a large burden of infarct (core) that cannot be recovered with reperfusion. However, this requires advanced software not readily available at most EDs and is generally only found at large, referral centers with comprehensive stroke center designation. The standard criteria for intervention come from the DEFUSE-3 trial [15] and are reflected in the inclusion criteria for this study. Clinical Question: Does giving TNK between 4.5 – 24 hours, using perfusion imaging to select patients, improve outcomes after stroke? Reference: Albers GW et al. TIMELESS Investigators. Tenecteplase for Stroke at 4.5 to 24 Hours with Perfusion-Imaging Selection. NEJM Feb 2024 Population: Adults 18 years of age with independent function (mRS 0 – 2) pre-stroke, with an ischemic stroke and could receive the drug/placebo within 4.5 – 24 hours from last known to be well, with NIHSS at least 5, with ICA and/or MCA occlusion on CTA/MRA. Also, needed core < 70 mL, penumbra ≥ 15 mL, and core:penumbra ratio at least 1.8 (DEFUSE-3 criteria) Fig 1 from the DEFUSE-3 trial Exclusions: There were several exclusions published in a separate document [3

Reference: Drysdale SB et al. Nirsevimab for Prevention of Hospitalizations due to RSV in Infants. N Engl J Med. 2023 Date: March 29, 2024 Guest Skeptic: Dr. Michael Cosimini is a pediatrician in Portland Oregon. He is the designer of Empiric Game, a medical editor and contributor to Pediatrics Reviews and Perspectives (PedsRAP) and the digital media editor at Academic Pediatrics. He is passionate about podcasting and serious games for medical education. Dr. Michael Cosimini Case: A 4-month-old twin girl is brought by her parents to the emergency department (ED) for respiratory distress. She has had congestion, a runny nose, and a cough for the past three days. Her parents think her breathing has been getting worse, and she is breathing faster. On your examination, you see that she is tachypneic with a respiratory rate of 66 breaths per minute. You also note subcostal retractions. Her oxygen saturation on room air is 86%. After nasal suctioning, she remains tachypneic, but her oxygen saturation remains under 90%. A viral swab comes back positive for respiratory syncytial virus (RSV). The decision is made to put her on supplemental oxygen via nasal cannula and admit her to the hospital for close observation. Her parents tell you, “She has a twin brother at home. We heard about this new vaccine for RSV. Does it work?” Background: RSV is a major cause of respiratory illness in young children. It is common in bronchiolitis which leads to symptoms like coughing, wheezing, and difficulty breathing. RSV is a major reason why infants are hospitalized for respiratory issues, especially during the fall and winter months when RSV infections are more prevalent. It's hard to think about RSV without recalling the quote “Don’t just do something, stand there!” Because there have been so many things that we’ve tried for bronchiolitis that really don’t seem to have had much effect including hypertonic saline (SGEM#157), high-flow nasal oxygen (SGEM#228), corticosteroids, bronchodilators, etc (SGEM#167). One thing that has also been tried but not covered on the SGEM is a "vaccine" for RSV. Attempts at developing a vaccine against RSV go back decades. The first significant effort to develop an RSV vaccine occurred in the 1960s. A formalin-inactivated RSV vaccine (FI-RSV) was developed and tested in infants and young children. However, instead of protecting against RSV, the vaccine led to worsened infection in many children resulting in some being hospitalized and two deaths. This tragic outcome slowed the development of an RSV vaccine for years. Over the next three decades, researchers sought to understand the immune response to RSV infections and explore potential vaccine targets other than the inactivated virus. During the 2000s, advances in molecular biology, immunology, and vaccine technology rekindled scientists’ efforts in RSV vaccine development. Researchers began exploring various approaches, including protein subunit vaccines, vectored vaccines, live-attenuated vaccines, and mRNA vaccines. Over the last decade, several RSV vaccine candidates have entered clinical trials. These trials have included vaccines for infants, older children, and at-risk adults, such as the elderly and pregnant women (intending to provide passive immunity to newborns). While some RSV vaccine candidates have shown promise, the challenge has been to find a vaccine that is safe, effective, and can provide long-lasting immunity. In 2022 in the European Union and UK and 2023 in the US and Canada approved Nirsevimab to prevent RSV. This is a monoclonal antibody that is supposed to neutralize RSV. Nirsevimab specifically targets a protein that is critical for the virus’s ability to enter and infect human cells, thereby stopping the disease process in its tracks. This action does not rely on the recipient's immune system to activate or produce antibodies, providing immediate protection. This new vaccine technology represents a shift towards monoclonal antibody (mAb) therapy for RSV prevention. Some have been offering nirsevimab to healthy term kids primarily discussing it with families using data from MELODY [1]. This RCT enrolled 1,490 kids and showed good safety compared to placebo, reduced medically attended lower respiratory tract infections, but was not powered to show reduced hospitalization. Clinical Question: What effect does nirsevimab have on hospitalizations for RSV-associated lower respiratory tract infections in healthy infants? Reference: Drysdale SB et al. Nirsevimab for Prevention of Hospitalizations due to RSV in Infants. N Engl J Med. 2023 Population: Infants <12 months with a gestational age of at least 29 weeks entering first RSV season Exclusions: History of immunocompromise, active RSV or lower respiratory tract infection at the time of enrollment, mother received RSV vaccine, eligible for palivizumab. There was a long list of exclusion criteria. Intervention: Single IM injection of nirsevimab (50 mg or 10

Reference: Harrison et al. Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol. AEM March 2024. Date: March 27, 2024 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. Case: It’s a Friday evening at the end of the academic year in the Paediatric Emergency Department (ED) and you are with the parents of a 15-year-old girl who has been brought in acutely intoxicated from an unofficial “School’s Out” party. Although your patient has recovered and is now fit for discharge, her parents are very worried that this may mean she is at more risk in the future. Background: We know that alcohol is a major cause of mortality and morbidity across the world [1] and that ED attendance due to it is rising [2,3]. We also know that adults who attend ED with alcohol-related problems are at an increased risk of death in the following year [4]– in fact, we discussed exactly that in SGEM#313 where we agreed that increasing frequency of alcohol-associated ED visits was associated with increasing mortality. However, we haven’t previously looked at the effect of alcohol in this specific vulnerable age group. CLINICAL QUESTION: IS A FIRST ED PRESENTATION RELATED TO ALCOHOL ASSOCIATED WITH INCREASED MORTALITY IN ADOLESCENTS AND YOUNG ADULTS? Reference: Harrison et al. Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol. AEM March 2024. Population: Patients aged 12-29 with ≥1 ED visit in Ontario 2009-15. Excluded: Patients not resident in Ontario, those who were not eligible for OHIP 2 years before and 3 years after, and those with an alcohol-related ED visit in the 2 years before study commencement. Intervention: Any visit related to alcohol Comparison: No visits related to alcohol Outcomes: Primary Outcome(s): Mortality at 1 year Secondary Outcomes: Mortality at 3 years, cause of death, predictors of death. Type of Study: Retrospective cohort study. Dr. Daniel Myran This is an SGEM HOP and we are pleased to have the lead author Dr. Daniel Myran on the show. Dr. Myran is the Canada Research Chair, Social Accountability, University of Ottawa Investigator, Assistant Professor, Department of Family Medicine, University of Ottawa, Associate Scientist, Ottawa Hospital Research Institute with a Cross Appointed School of Epidemiology and Public Health, University of Ottawa Authors’ Conclusions: "Incident ED visits due to alcohol in adolescents and young adults are associated with a high risk of 1-year mortality, especially in young adults, those with concurrent mental health or substance use disorders, and those with a more severe initial presentation." Quality Checklist for Observational Cohort 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? 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? No Was the follow-up of subjects complete enough? Yes How precise are the results? The confidence intervals are well away from zero, so precise enough. Do you believe the results? Yes Can the results be applied to the local population? Yes and unsure Do the results of this study fit with other available evidence? Yes Funding? Canadian Institutes of Health Research, Ontario Ministry of Health, Ontario Ministry of Long-Term Care. One author received speaker fees from pharma for unrelated subjects. Results: There were 71,778 alcohol-related attendances out of 2,340,097 total attendances in the study period. Of the alcohol-related attendances, 56% were male, 25% in the lowest income quintile, and 68% related to acute intoxication. KEY RESULT: ED ATTENDANCE WITH AN ALCOHOL-RELATED ISSUE WAS ASSOCIATED WITH AN ODDS RATIO OF 3.07 FOR MORTALITY AT 1 YEAR. Primary Outcome: 1-year mortality was 0.35% in the alcohol group versus 0.1% in the non-alcohol group for an adjusted odds ratio of 3.07 (95% confidence intervals 2.69-3.51). The odds ratio varied across demographics (see Table 2). Secondary Outcomes: Mortality at 3 years, cause of death, predictors of death. Listen to the SGEM podcast to hear Daniel’s response to our five nerdy questions. 1. Retrospective Study: As a retrospective study, you could only explore covariates that were routinely recorded, so there is a risk of missing unknown confounders like chaotic lifestyle or neurodivergence. Do you have any insights into these based on your experience in the field? 2. Inclusion Criteria: You relied on ICD-10 coding to identify alcohol-related attendances. Although this is likely to be accurate for diagnoses like acute intoxication and alcoholic cirrhosis, do you think it risks under-identifying the involvement of alcohol in other situations like intimate partner v

Reference: Marx et al. Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial. Am J Respir Crit Care Med. 2023 Date: March 22, 2024 Guest Skeptic: Dr. Richard Malthaner holds the prestigious position of Chair/Head of the Division of Thoracic Surgery and serves as the Director of the Thoracic Robotic Program at Western University's Schulich School of Medicine and Dentistry. Dr. Malthaner currently serves as the Vice President of the Canadian Association of Thoracic Surgeons and is the founder of the Skeptik Thoracik Journal Club. Case: A 25-year-old female medical student presents with right chest pain and dyspnea. Chest x-ray (CXR) shows a “complete pneumothorax.” Background: The first time we got together to discuss chest tubes was on SGEM#129. That episode had two questions. The first question was in a trauma patient, how clinically useful is a CXR after putting in the chest tube? The answer we came up with was to put the tube on the correct side, within the triangle of safety, and within the pleural space. Continue to obtain a CXR post chest tube knowing it will probably not change management. Be more concerned if the patient is doing poorly or the tube is not draining. The second question we tried to answer was does chest tube location matter? The answer is that the part of the location that matters in these situations is that the chest tube is safely placed on the correct side and in the pleural space. The next time were talking chest tubes was not in trauma patients but rather in patients with their first large spontaneous pneumothorax in SGEM#300. We only had one question asking if they all needed a chest tube. The bottom line for that episode was it's reasonable to provide conservative management in a patient with large first-time spontaneous pneumothoraxes if you can ensure close follow-up. We have looked at other chest-related issues with other guest skeptics. SGEM#339 looked at the optimal anatomical location for needle decompression for tension pneumothorax with Dr. Rob Edmonds. That study did not support the claim that the second intercostal space-midclavicular line is thicker than the fourth/fifth intercostal space-anterior axial line. The most recent time we have explored something involving chest tubes was with guest skeptic Dr. Chris Root (SGEM#355). We wanted to know if the size of the chest tube matters in hemodynamically stable patients with traumatic hemothorax. That was a multicenter, non-inferior, unblinded, randomized, parallel assignment comparison trial that reported small percutaneous catheters were non-inferior to large open chest tubes for traumatic hemothorax. Patients can present with a spontaneous pneumothorax. This is defined as air in the pleural space between the lung and the chest wall with no obvious precipitating factor. It can occur in existing lung disease (secondary spontaneous pneumothorax) or with no known underlying lung pathology (primary spontaneous pneumothorax). Chest tube drainage remains the reference first-line treatment of primary spontaneous pneumothorax, however, complications occur in 9–26% of such cases. A less invasive alternative approach is simple aspiration, which could be an option. The best way to manage a first primary spontaneous pneumothorax episode remains unclear. Clinical Question: Is simple aspiration non-inferior to chest tube drainage for first-line lung expansion in patients with complete primary spontaneous pneumothorax? Reference: Marx et al. Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial. Am J Respir Crit Care Med. 2023 Population: Adults aged 18–50 years with a first episode of a symptomatic completed spontaneous pneumothorax for <48 hours. Complete was defined as total separation of the lung from the chest wall. Exclusions: Tension pneumothorax, traumatic and recurrent pneumothorax, and primary pneumothorax associated with pleural effusion or secondary pneumothorax with underlying lung disease. Pregnant or lactating women; patients not available for follow-up; and those with major incapacitation, unable to give consent, or under trusteeship, guardianship, or judiciary protection were also excluded. Intervention: Simple aspiration using a polyurethane safety catheter mounted on a blunt needle (Turkel Thoracentesis Kit, Cardinal Health) placed in the second intercostal space midclavicular line. Free drainage for 15 minutes then -25 cm suction for 30 minutes. Clamp the tube and then obtain a CXR. If the lung is up the tube is removed. Monitor for 24 hours in the ED and then send the patient home. If the lung is not up, more suction for 30 minutes. If not up, chest tube drainage and the patient admitted. If the lung is up then the tube is removed. Comparison: Chest tube drainage (Vygon Thoracic trocar drain 16 or 20 Fr) with the tube placed in the fourth or fifth intercostal space mid-axillary line. Pleur evac drains of BPDS700 type. CX

Date: March 16, 2024 This is an SGEM Xtra episode. Yes, that is two back-to-back SGEM Xtra episodes. The critical appraisal that was lined up for this week's episode got delayed due to some scheduling problems with clinical responsibilities. You can access all the slides for this episode from this LINK and see the presentation on YouTube. This episode is from a talk I gave a few years ago on social media for knowledge translation. How this technology could make the world a better place. I’ve come to recognize that many SGEMers are not very familiar with the best movie decade of all time, the 1980’s. Therefore, I created this talk using the Matrix as a more contemporary theme from the late 1990’s early 2000’s. The Matrix was a groundbreaking movie created by Lana and Lily Wachowski and released in 1999. It started a movie franchise blending science fiction and action in a visual masterpiece. The first movie introduces us to a dystopian future in which humanity is unknowingly trapped inside the Matrix, a simulated reality created by intelligent machines to distract humans while using their bodies as an energy source or batteries. Thomas Anderson (Mr. Anderson), a computer programmer by day and a hacker named Neo by night, discovers the truth about the Matrix. He is drawn into a rebellion against the machines, led by Morpheus and Trinity. Neo is believed to be "The One," a prophesized hero destined to end the war between humans and machines. The film explores themes of reality, freedom, and control. Like Morpheus in The Matrix, “all I’m offering is the truth, nothing more”. "What if I told you"…Morpheus never says that in The Matrix. Yet “what if I told you” is one of the most well-known Memes. There are many quotes from movies that are wrong/misquoted. Here are three examples of movie misquotes. For a list of the top ten movie misquotes click on the LINK: Play it again Sam (Casablanca 1942): That line is never said in the movie Casablanca. Humphrey Bogart actually says ”You played it for her, you can play it for me. If she can stand it, I can. Play it!". Luke, I am your father (Star Wars V The Empire Strikes Back 1980): The actual line by Darth Vader is “No, I am your father.” If you build it, they will come (Field of Dreams 1989): James Earl Jones says"People will come, Ray." Back to the lecture, Morpheus sitting in the chair wearing cool sunglasses and offering Neo the red and blue pill never said “What if I told you”. In the actual dialogue in the scene, Morpheus says: "Do you want to know what 'it' is?". What it is for today’s lecture is the problem with knowledge translation and how it can be addressed with Social Media. Trinity tells Neo in The Matrix “It's the question that drives us, Neo. It's the question that brought you here. You know the question, just as I did. In the movie, the question was “What is the Matrix”? For this lecture, the question is “How long does it take for high-quality clinically relevant information to reach the patient? There are a few answers to the question of how long knowledge translation takes in medicine. One answer is from Dr. John Jackson who was a British Neurologist. He said, “It takes 50 years to get a wrong idea out of medicine, and 100 years a right one into medicine.” This means it takes decades for knowledge translation. In the age of social media that is way too long. Max Planck Another answer to the question about how long knowledge translation takes in science comes from Dr. Max Planck. He was a famous physicist who said “New scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a die generation grows up that is familiar with it.” In other words, it is not facts, evidence or logical arguments that convince people to change their position on a subject but rather the old advocates had to die first for the new information to take hold and become accepted. It takes a generation for knowledge translation. Morris et al published a paper in the Journal of the Royal Society of Medicine in 2011 trying to put an exact number on how long it takes for high-quality, clinically relevant information to reach patients. They came up with the number, 17 years. This is not for 100% of the clinical information but rather only 14%. Journal of the Royal Society of Medicine While I think that the specific number is not as important as the concept that it can take more than a decade for a minority of clinically relevant evidence to be widely adopted by clinicians. Why does it take so long in medicine? A model has been put together that identifies seven major issues that prevent patients from getting the best care, based on the best evidence. This has been called the Leaky Pipe Model of knowledge translation. The first five leaks are at the level of the clinician and the last two leaks are patient-level problems. So, there is

Date: March 6, 2024 This is an SGEM Xtra created from a lecture I gave for the Rural Ontario Medical Program (ROMP) ICE Camp Retreat in Collingwood, Ontario last month. ROMP helps Ontario medical students & residents arrange core & elective rotations in rural Ontario. An old friend, Dr. Matt De Stefano invited me to give a lecture to the PGY-3 Emergency Medicine Residents. Matt said it could be a talk on anything so I decided to create a new presentation called “A Philosophy of Emergency Medicine” This lecture was inspired by the wonderful Professor Melanie Trecek-King. She is a science educator from the USA and has an amazing website called Thinking is Power. I bought a T-shirt from Melanie that says “Be curious, be skeptical and be humble”. Such great wisdom from an amazing science communicator. For the presentation at ROMP, I made a friendly amendment to Melanie’s three items substituting that last piece of advice “Be Humble” (which is very important) with “Be Teachable” for the audience of PGY3 Emergency Medicine Residents. If you are interested in seeing all the slides they can be downloaded from this LINK or you can watch the episode on YouTube. Be Curious: The lecture started not with a 1980s cultural reference but rather with a recent cultural reference from the TV show Ted Lasso. Be Curious, not judgmental. This was a great show for a variety of reasons and we are planning to do a special SGEM Xtra episode on how the lessons we learned from Ted Lasso made us better. Be Skeptical: This is the second important part of my EM philosophy. Carl Sagan is arguably one of the most famous skeptics ever. He in part inspired this knowledge translation project called the Skeptics’ Guide to Emergency Medicine. Probably one of his most famous quotes was that “extraordinary claims require extraordinary evidence” Be Teachable: The third philosophical point I wanted to make about Emergency Medicine was to encourage you to Be Teachable. This does not just apply to when you are a resident but also when you become an attending physician. You will not always be right. Be Kind: One more super important thing that you should consider as part of your EM philosophy is to be kind. It is something I learned from Dr. Brian Goldman. Brian is the host of the amazing CBC show White Coat Black Art and has authored several great books. One of the best books he wrote was called The Power of Kindness - Why Empathy is Essential in Everyday Life. 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. If you would like a copy of all the slides used in this presentation simply click on the LINK and you can see all the slides on YouTube. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics' Guide to Emergency Medicine.

Reference: Gibbons et al. The sonographic protocol for the emergent evaluation of aortic dissections (SPEED protocol): A multicenter, prospective, observational study. AEM February 2024. Date: February 28, 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 at Nassau University Medical Center in East Meadow, NY, the safety net hospital for Nassau County. Case: A 59-year-old man walks into your community emergency department (ED) complaining of chest pain. It is described as a ripping sensation that radiates to his back. His vital signs are all normal and the ECG done at triage does not show an occlusive myocardial infarction. The chest x-ray is unremarkable, and his troponin is not elevated. You suspect an acute aortic dissection (AoD). However, your CT scanner is offline for two hours of scheduled maintenance. He will need to be transferred to the tertiary care center which is 35 minutes away by ground EMS if it is a dissection. Your Spidey senses are tingling, and you don't want to wait for the CT scanner to be back online to make the diagnosis. Arrangements are made for him to be transferred stat to the tertiary hospital while he is still stable. You wonder if a quick POCUS examination looking for three sonographic findings while waiting for the paramedics could help determine the likelihood of this being an AoD. Background: We recently covered acute aortic syndrome (AAS) on SGEM#430. AAS has been called the lethal triad and includes aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer [1]. It is a rare but deadly condition that can present in atypical ways leading to delays in diagnosis and an associated increase in mortality. This episode is going to focus on acute aortic dissection (AoD) which is classified into two major types according to the Stanford classification system: Type A and Type B. This system is based on the location of the tear and helps guide treatment strategies. Type A dissections Involves the ascending aorta and may extend into the descending aorta. It's more common and more dangerous than Type B, as it can lead to serious complications like rupture into the pericardial space leading to cardiac tamponade, aortic valve insufficiency, or myocardial infarction. Symptoms may include more severe chest pain radiating to the back, loss of consciousness, or symptoms of stroke if the blood supply to the brain is affected. Type A AoDs generally require an emergent trip to the operating room as soon as they are identified to reduce the likelihood of a terrible outcome. Type B dissections occur in the descending aorta only, after it has passed the arteries that supply blood to the arms and head. They are less common than Type A and usually less immediately life-threatening, but still serious and potentially fatal if not treated properly. Symptoms can include sudden onset of pain in the back or abdomen, depending on the exact location and extent of the dissection. The pain is often described as tearing or ripping. Speed is important in making the diagnosis of an AoD due to the associated increase in mortality with delays [2,3]. We know from last week that clinical decision tools (CDTs) are not ready for prime time. This is consistent with the American College of Emergency Physicians (ACEP) which does not recommend the routine use of clinical decision rules in suspected cases of AoD [4]. Clinical Question: What is the diagnostic accuracy of three sonographic findings for acute aortic dissection? Reference: Gibbons et al. The sonographic protocol for the emergent evaluation of aortic dissections (SPEED protocol): A multicenter, prospective, observational study. AEM February 2024. Population: A convenience sample of adult patients with clinically suspected Stanford type A or B AoDs before performing a POCUS or CTA from January 2010 to December 2019 Excluded: Those patients unable to consent, those with a preexisting or traumatic AoD, and individuals who did not receive a POCUS evaluation prior to advanced imaging (CTA, MRA, or TEE). Intervention: POCUS performed by PGY1 to 3 EM residents to identify three sonographic findings consistent with acute aortic dissection. This included (1) the presence of either a pericardial effusion or (2) an intimal flap, or (3) an aortic outflow track (AOFT) diameter greater than 35 mm measured from the inner wall to the inner wall within 20 mm of the aortic annulus during end-diastole. Comparison: CTA of chest-abdomen-pelvis, MRI/MRA, or cardiology-performed TEE Outcome: Primary Outcome: Diagnostic accuracy of identifying a Stanford Type A and B AoDs Secondary Outcomes: Test characteristics of each of the three individual sonographic findings for diagnosing Stanford type A and B AoDs Type of Study: Multicenter, prospective, observational, cohort study of a convenience sample of adult patients. Dr. Ryan Gibbons This is th

Reference: Li, T., & Gal, D. (2023). Consumers prefer natural medicines more when treating psychological than physical conditions. Journal of Consumer Psychology 2023, Date: February 23, 2024 Guest Skeptic: Ethan Milne is a Marketing PhD student at the Ivey Business School (Western University). He researches how moral outrage and status-seeking personalities motivate social media aggression, and how retribution can motivate consumer donations. Case: A 20-year-old male presents to the emergency department with palpitations. After a good history, directed physical examination and appropriate investigations you suspect he is suffering from a major depressive disorder (MDD) with a comorbidity of anxiety. He is not a threat to himself or others and wants assistance. You arrange for him to be followed up by his family physician to discuss possible treatment options which include medications. He expresses concern that taking a synthetic drug to treat his depression wouldn’t allow him to be his authentic self. Background: Major Depressive Disorder, commonly known as depression, is a significant mental health condition. Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease. It affects an estimated 5-10% of the population at any given time, with variations depending on demographic factors such as age and gender. It is generally more common in women than in men and can occur at any age, although it often first appears during late adolescence to mid-20s [1]. The National Institute of Health (NIH) estimates that around 8.3% (21.0 million) of US adults over 18 have experienced a major depressive episode in the last year. Various factors can increase the risk of developing MDD, including genetic predisposition, personal or family history of depression, major life changes, trauma, stress, and certain physical illnesses and medications. Depression has been reported to be most prevalent among young women aged 12-17 (29.2%) [2]. The current diagnostic criteria for MDD are outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR). These criteria serve as a guideline for clinicians to diagnose depression. To be diagnosed with MDD, a person must experience at least one of the two symptoms for at least two weeks: Depressed Mood: Most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). Loss of Interest or Pleasure: Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day. The person must also have five or more of the following symptoms during the same 2-week period, and these symptoms represent a change from previous functioning. Significant Weight Loss or Gain (or decrease or increase in appetite nearly every day) Insomnia or Hypersomnia: Trouble sleeping or sleeping too much nearly every day. Psychomotor Agitation or Retardation: Noticeable by others, not merely subjective feelings of restlessness or being slowed down. Fatigue or Loss of Energy: Nearly every day. Feelings of Worthlessness or Excessive or Inappropriate Guilt: Nearly every day, not merely self-reproach or guilt about being sick. Diminished Ability to Think or Concentrate (or indecisiveness, nearly every day) Recurrent Thoughts of Death: Recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. These symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. They must not be attributable to the physiological effects of a substance or another medical condition. Also, the occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. There are several treatment options for MDD and often patients will do a combination of things. It can be a challenge to treat depression effectively and the evidence to support different treatments varies. Lifestyle and Home Remedies: Regular exercise, maintaining a healthy diet, getting enough sleep, and avoiding alcohol and drugs can help manage symptoms of depression. Psychotherapy: Cognitive Behavioral Therapy (CBT): This is a highly effective form of therapy that focuses on identifying and changing negative thought patterns and behaviours that contribute to depression. Interpersonal Therapy (IPT): IPT focuses on improving interpersonal relationships and communication patterns. Psychodynamic Therapy: This explores how unconscious emotions and past experiences contribute to current feelings and behaviours. Medications: Antidepressants: These are the most commonly prescribed medications for depression, including selective serotonin reuptake inhibitors (SSRIs)

Reference: McLatchie et al and DAShED investigators. Diagnosis of Acute Aortic Syndrome in the Emergency Department (DAShED) study: an observational cohort study of people attending the emergency department with symptoms consistent with acute aortic syndrome. EMJ Nov 2023. Date: February 11, 2024 Guest Skeptic: Nirdosh Ashok Kumar, Emergency Medicine Specialist – Aga Khan University Hospital, Karachi, Pakistan. Case: A 66-year-old female with a history of smoking, hypertension, and type-2 diabetes presents to the emergency department (ED) with syncope while walking her dog. She complains of retrosternal chest pain radiating to her jaw. She is bradycardic, hypotensive, and tachypneic. She is received in the resuscitation room. Monitors have been attached, and intravenous (IV) access has been achieved and IV analgesia has been given. The ECG shows sinus tachycardia with non-specific ST-T changes. The chest x-ray is unremarkable. However, she is still in severe pain. A post-graduate year 2 (PGY-2) resident asks you if it could be a ruptured abdominal aortic aneurysm, aortic dissection, or angina. Background: The diagnosis of acute aortic syndrome (AAS) is commonly delayed or missed in the ED. AAS has been referred to as the “lethal triad” that incorporates aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU) [1]. It is a rare condition with a high mortality rate and can present in atypical ways. It affects approximately 4,000 people per year in the United Kingdom [2] and 43,000 to 47,000 people per year in the USA [3]. The annual incidence rate of AD ranges between 2.9 and 7.2 per 100,000. [4-8] The misdiagnosis rate is estimated to be between 16% and 38%6,[9-19] with a diagnostic delay of up to 24 hours for 25% of cases, and mortality follows a linear increase of 0.5% per hour in the first 48 hours. [20] A retrospective observational study from Canadian researcher, Dr. Robert Ohle was published in CJEM in 2023. This study found that between 2003 and 2018, there were 1,299 cases of AAS in Ontario, the largest province in the country. It reported an overall annual incidence rate of 0.61 per 100,000 people which is much lower than previously reported rates. The study also highlighted the significant mortality rate associated with AAS, with a one-year mortality rate decreasing from 47.4% to 29.1%, and ED mortality at 14.9%​​. [21] When looking specifically at atraumatic chest pain presentations to the ED, it is estimated the incidence of AAS is one in 980. [22] It can be like looking for a needle in a haystack of chest pain patients. The gold standard for diagnosing AAS is to perform a CT aorta angiogram (CTA). However, scanning everyone chest pain patient would have a very low diagnostic yield [23,24], expose many patients to unnecessary ionizing radiation and end up being very costly. It would be great if there was a validated clinical decision tool (CDT) to help clinicians be more selective in using CTA to diagnose AAS. Some CDTs have been devised and tested for diagnosing AAS. [25,26] The Aortic Dissection Detection Risk Score (ADD-RS) is one CDT that has been derived and tested. Four studies with methodologic limitations were included in an SRMA of the ADD-RS and published in AEM 2020. [27] The authors concluded that patients with an ADD-RS score of ≤ 1 with d-dimer < 500 ng/mL have high sensitivity for ruling out AASs. However, it is unclear if it is good enough for clinicians to use, better than clinical gestalt [28,29], and an impact analysis has not been done to determine if it would lead to fewer CTAs and d-dimers being performed. Clinical Questions: What are the characteristics of ED attendances with possible AAS, how effective are existing clinical decision tools (ADD-RS, Canadian Guideline, Sheffield, AORTAs) and the use of CTA in an undifferentiated cohort of ED patients? Reference: McLatchie et al and DAShED investigators. Diagnosis of Acute Aortic Syndrome in the Emergency Department (DAShED) study: an observational cohort study of people attending the emergency department with symptoms consistent with acute aortic syndrome. EMJ Nov 2023. Population: Adult patients 16 years of age or older attending one of 27 EDs in England, Wales, or Scotland with onset of symptoms within the past seven days of possible AAS (chest pain, back pain, abdominal pain, syncope, or symptoms related to mal perfusion). Excluded: Absence of any potential AAS symptoms (chest pain, back pain, abdominal pain, syncope, or symptoms related to mal perfusion). Intervention: Clinical judgment, various clinical decision tools characteristics and performance of existing clinical decision tools (ADD-RS, AORTAs, Canadian and Sheffield AAS CDTs), the D-dimer (evaluated separately and in combination with other tools) and CTA. Comparison: None Outcome: Primary Outcome: Diagnostic accuracy of clinical gestalt, ADD-RS, AORTAs, Canadian and Sheffield AAS clinical decision tools and D-dimer (separately and

Reference: Curry SD, et al. Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma. Laryngoscope. March 2023 Date: January 30, 2024 Guest Skeptic: Dr. Alexandra (Ali) Espinel is an Associate professor of pediatrics and otolaryngology at Children’s National Hospital and George Washington University. She is also the director of the Pediatric Otolaryngology Fellowship at Children’s National Hospital. Case: You’re working the morning shift in the emergency department (ED) when you encounter a 3-year-old boy and his family. His parents tell you that he was getting ready to go off to daycare and brushing his teeth while standing on a step stool by the sink. He slipped and the toothbrush poked him in the back of the mouth. Initially, his parents noticed that he was bleeding from his mouth and saw what looked like a wound towards the back of his throat. The boy cried immediately afterwards but has otherwise been acting like himself. On your exam, you notice a small penetrating intraoral injury just lateral to the soft palate without evidence of continued bleeding. His parents ask you, “Is he going to be, okay? We’re glad he’s not bleeding anymore. Do you think he needs any imaging to see if he hurt anything?” Background: Kids like to put things in their mouths. Kids like to run around. Sometimes, kids may fall while having something in their mouth which may cause damage to their oropharynx. The ensuing damage can vary. It could be blunt trauma or penetrating trauma. We get concerned about injuries to the soft palate because of possible deep space neck infection and the risk of injury to the carotid artery behind it which has been associated with thrombosis, dissection, and cerebral infarctions. These super scary complications have been reported in the literature but seem relatively rare. We have many clinical decision tools for imaging in pediatric head trauma [1] or abdominal trauma [2]. But we do not have any of the same tools for oropharyngeal injury which means that there is wide variation about which imaging studies are ordered. Clinical Question: What is the role of CT angiography (CTA) in the diagnosis and management of pediatric oropharyngeal trauma? Reference: Curry SD, et al. Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma. Laryngoscope. March 2023 Population: Patients <18 years old with trauma to the oropharynx. They included meta-analyses, systematic reviews, randomized control trials (RCTs), case-control and cohort studies, case series and case reports. Excluded: Oropharyngeal trauma combined with other severe head injury or multisystem trauma, not primary research, non-English publication Intervention: CTA Comparison: No CTA Outcome: radiologic and clinical outcomes including infection, injury to vasculature, cerebrovascular injury, and neurologic abnormalities. Type of Study: Systematic Review and Meta-Analysis of diagnostic studies. Authors’ Conclusions: “Imaging with CTA yielded radiological abnormalities in a few instances. These results do not support the routine use of CTA in screening pediatric oropharyngeal trauma when balanced against the risk of radiation, as it rarely resulted in management changes and was not shown to improve outcomes.” 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 was assessed for common forms of diagnostic research bias. Yes. The assessment of studies was reproducible. Yes There was low heterogeneity for the primary outcome. Yes. The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. No. Results: The initial search identified 5,078 papers after duplicates were excluded. Only eight studies were included in the final analysis. All those studies were retrospective cohort studies. Only five of eight studies reported rates of CTA use. Key Results: Routine use of CTA in screening pediatric oropharyngeal trauma is not recommended. These eight studies encompassed a total of 662 patients. Among those patients, 293 underwent CT imaging of some kind, and 255 patients were specified as undergoing CTA. Some patients also underwent carotid angiography (3.4% of patients who underwent CT or CTA) for indications that included free air near the carotid, a bruit on neck exam, hematoma next to the carotid artery, carotid spasm, history of tonsil injury and profuse bleeding, and carotid artery exposure with arterial compression. There were two cases in which CTA showed disruption of the carotid intima without a thrombus. These two patients were treated with aspirin. Some patients were admitted to the hospital for observation. Only six out of the eight studies reported antibiotic treatment. Importantly, no patients were reported to have a cerebrovas

Reference: Wilkinson-Stokes M, Betson J, Sawyer S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emerg Med J. February 2023 Date: January 24, 2024 Guest Skeptic: Dr. Rupinder Sahsi is a fellow EBM enthusiast with academic appointments at McMaster University and Wright State University who works as an emergency physician in Kitchener-Waterloo, Ontario, Canada. He is also an assistant medical director for EMS at the Centre for Paramedic Education and Research in Hamilton, Ontario, Canada. Case: You are an advanced care paramedic dispatched to the scene of a 53-year-old female with chest pain. She developed retrosternal chest discomfort shortly after she came in from using her snowblower. You provide her with two tablets of ASA to chew while your partner acquires an ECG, which ultimately shows clear ST elevation in the inferior leads and some ST changes in V1-V2 that make you wonder if your patient is having an acute myocardial infarction (MI) with right-sided ventricular involvement (RVI). Your patient rates their pain as an 8/10 and looks visibly uncomfortable. Do you give nitroglycerin? Background: You have likely heard the caution to avoid nitrates in acute myocardial infarctions that have right ventricular involvement. What is that based upon? As is often the case, when you go back to the primary literature, you discover we are standing on pillars of salt and sand. The evidence for this recommendation is a single observational study of 40 patients published in 1989 [1]. Yet, the findings in those 40 patients went on to be the evidence commonly cited by the American Heart Association (AHA) [2] and the European Society of Cardiology (ESC) [3] in their recommendation against the use of nitrates in acute MIs if there is right ventricular involvement. The pathophysiologic rationale was that nitrates would cause vasodilation and thus reduce RV preload, decreasing left end diastolic volume, and ultimately resulting in clinically important hypotension. Many times, pathophysiology has been used to explain something in medicine only to be discovered later that the body is much more complicated than we thought. That 40-patient study by Ferguson et al did show a statistically significant increased likelihood of hypotension in RVMI patients who received nitrates, but to me, the study design was just plain weird. This was a retrospective trial that looked at 40 patients with inferior MIs. Twenty of them had hypotension after nitrates and 20 of them were not hypotensive. They looked back and saw that a higher proportion of patients with inferior MI and hypotension had ECG evidence of RV involvement. Sounds okay, but by having equal numbers of hypotensive and non-hypotensive patients, they’ve exaggerated the incidence of hypotension. It’s not 50-50. In all comers with MI, the rate is probably closer to <3%. On top of that, there was no standardization of the nitrate dose or route of administration, so it’s hard to know how to extrapolate the findings to our standard nitrate admin protocols. I was not surprised by this information. Fanaroff et al looked at the ACC/AHA guidelines from 2008-2018 [4]. They found 26 guidelines with 2,930 recommendations. Only 9% were Level A while 50% were Level B and 41% were Level C. Compare that previously mentioned 40-patient study to the 2016 Canadian study by Robichaud et al which was 22 times larger (n=1,004) than the Ferguson study [5]. It looked at the administration of a standardized amount of nitroglycerin in MI patients with various vascular territories involved. It shows no statistical difference in adverse events between patients with and without RVMI – a relative risk of 1.02 (95% CI: 0.49 to 2.15) p-value = 0.95. Clinical Question: Is nitrate administration to patients with right ventricular myocardial infarction (RVMI) associated with increased adverse events compared with nitrate administration to patients with myocardial infarctions only in other regions? Reference: Wilkinson-Stokes M, Betson J, Sawyer S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emerg Med J. February 2023. Population: Adult patients diagnosed with acute MI Exclusions: Patients with coronary vasospasm were specifically excluded. Nitrates are an effective primary treatment for coronary vasospasm, and the inclusion of these patients may skew results toward a finding of increased nitrate safety. Exposure: Receiving nitrates in any dose and by any route. Comparison: Patients with acute right-sided myocardial infarctions to patients with acute MI involving any other anatomic distribution Outcome: Primary Outcome: All forms of adverse outcomes reported in the identified literature. The primary meta-analysis excluded studies of low quality, but a secondary analysis was also performed including identified studies that were deemed of lower meth

Reference: Zaoutis T, et al. Short-course Therapy for Urinary Tract Infections in Children: the SCOUT randomized clinical trial. JAMA Pediatr. Aug 2023 Date: October 30, 2023 Dr. Ellie Hill Guest Skeptic: Dr. Ellie Hill is a pediatric emergency medicine physician at Children’s National Hospital in Washington, DC and Assistant Professor of Pediatrics and Emergency Medicine at George Washington University School of Medicine and Health Sciences. Her research interests include improving the diagnosis of urinary tract infections in children. Case: A 4-year-old girl comes to the emergency department complaining of pain with urination. She has not had any fevers or flank pain. The last time she had these symptoms a year ago, she was diagnosed with a urinary tract infection (UTI) and started on antibiotics. You obtain a urinalysis that demonstrates 43 white blood cells, positive leukocyte esterase, and positive nitrites. You tell the family the results of the urinalysis and let them know that she likely has another UTI, and you plan to prescribe some antibiotics. Her parents reply, “Last time she had to take over a week of antibiotics for her UTI, and she had bad diarrhea. Is it possible that we do a shorter treatment if she needs antibiotics?” Background: Does it seem like antibiotic courses are getting shorter these days? We covered short-course treatment for pediatric pneumonia in the SAFER trial with Dr. Andrew Tagg back on SGEM #338 and the SCOUT-CAP trial on SGEM #359. UTIs are one of the most common bacterial infections in childhood that we see in the emergency department [1]. The American Academy of Pediatrics (AAP) released guidelines for the management of febrile infants and children 2 to 24 months back in 2011 [2]. In those guidelines, they included the statement “The clinician should choose 7 to 14 days as duration of antimicrobial therapy.” However, the optimal antibiotic duration for the treatment of UTI is still uncertain [3]. Clinical Question: What is the efficacy of short-course (5-day) vs standard-course (10-day) antibiotic therapy for children with urinary tract infections? Reference: Zaoutis T, et al. Short-course Therapy for Urinary Tract Infections in Children: the SCOUT randomized clinical trial. JAMA Pediatr. Aug 2023 Population: Children 2 months to 10 years with and without febrile UTI exhibiting clinical improvement after 5 days of antimicrobials Excluded: Second uropathogen (>104 CFU by catheterization or suprapubic aspiration, or >5x104 CFU by clean catch), hospitalization for bacteremia, admission to ICU, urine culture with pathogen resistant to initially prescribed antimicrobial, catheter-associated UTI, history of UTI within 30 days, phenylketonuria, congenital or anatomy abnormality of the GU tract other than grade I to II vesicoureteral reflux, duplicated collecting systems, or hydronephrosis, previous GU surgery, unable to tolerate PO medications, immunocompromise, Type I hypersensitivity or anaphylaxis to study products, gestation <36 weeks for children younger than 2, inability to attend follow up Intervention: Additional 5 days of antimicrobial therapy (10 days total, standard course) Comparison: Additional 5 days of placebo (5 days total, short-course) Outcome: Primary Outcome: Treatment failure is defined as symptomatic UTI at or before the first follow-up visit (day 11 to 14) Secondary Outcomes: UTI after first follow-up visit, asymptomatic bacteriuria, positive urine culture, gastrointestinal colonization with resistant organisms Trial: Multicenter, randomized, double-masked, placebo-controlled noninferiority clinical trial Authors’ Conclusions: “In this randomized clinical trial, children assigned to standard-course therapy had lower rates of treatment failure than children assigned to short-course therapy. However, the low failure rate of short-course therapy suggests that it could be considered as a reasonable option for children exhibiting clinical improvement after 5 days of antimicrobial treatment.” 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. Yes 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 Financial conflicts of interest. A few doctors had grants from pharmaceutical companies but reported that they were not related to this particula

Reference: Snyder BD, Van Dyke MR, Walker RG, et al. Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest. Resuscitation 2023. Date: January 11, 2024 Guest Skeptic: Dr. Chris Root is an EMS fellow in the Department of Emergency Medicine at the University of New Mexico Health Sciences Center in Albuquerque, NM. He is also a flight physician with UNM’s aeromedical service, Lifeguard Air Emergency Services. Prior to earning his MD, he worked as a paramedic in the New York City 911 system. Case: You are dispatched to an out-of-hospital cardiac arrest (OHCA). The patient is a 54-year-old man who collapsed in front of his family after complaining of chest pain for several hours. On your arrival, first responders from the fire department are performing high-quality basic cardiac life support. You continue with compressions and defibrillations and your partner places an advanced airway. Your EMS agency has equipped you with small-volume adult bag-valve masks (BVMs), the first responders have been utilizing a standard adult BVM thus far during the resuscitation. Your partner asks you which of the two BVMs you should use to continue the resuscitation. Background: There is continuing debate regarding the appropriate ventilation strategy for OHCAs. Common commercially available BVMs can deliver volumes that exceed normal tidal volumes. Some have argued in favor of using smaller BVMs to avoid hyperventilation. The issue of BVM ventilation in the context of pre-oxygenation for endotracheal intubation was discussed on SGEM#281. Airway management in OHCA has also been covered in SGEM#247 and SGEM#396. We have looked at OHCA more than a dozen times on the SGEM. For a full list of check out the links below to the SGEM blogs: SGEM#50:Under Pressure Journal Club: Vasopressin, Steroids and Epinephrine in Cardiac Arrest SGEM#54:Baby It’s Cold Outside: Pre-hospital Therapeutic Hypothermia in Out of Hospital Cardiac Arrest SGEM#59:Can I Get a Witness: Family Members Present During CPR SGEM#64:Classic EM Paper: OPALS Study SGEM#107:Can’t Touch This: Hands on Defibrillation SGEM#136:CPR – Man or Machine? SGEM#143:Call Me Maybe for Bystander CPR SGEM#152:Movin’ on Up – Higher Floors, Lower Survival for OHCA SGEM#162:Not Stayin’ Alive More Often with Amiodarone or Lidocaine in OHCA SGEM#189:Bring Me to Life in OHCA SGEM#238:The Epi Don’t Work for OHCA SGEM#247:Supraglottic Airways Gonna Save You for an OHCA? SGEM#275:10th Avenue Freeze Out – Therapeutic Hypothermia after Non-Shockable Cardiac Arrest SGEM#306:Fire Brigade and the Staying Alive APP for OHCAs in Paris SGEM#314:OHCA – Should you Take ‘em on the Run Baby if you Don’t get ROSC? SGEM#329:Will Corticosteroids Help if…I Will Survive a Cardiac Arrest? SGEM#336:You Can’t Always Get What You Want – TTM2 Trial SGEM#344:We Will…We Will Cath You – But should We After an OHCA Without ST Elevations? SGEM#353:At the COCA, COCA for OHCA SGEM#380:OHCAs Happen and you’re head over heels – Head elevated during CPR? SGEM#396: And iGel myself I’m over you, cus I’m the King (tube) of wishful thinking. Clinical Question: Is using a small adult BVM during resuscitation of out of hospital cardiac arrest associated with return of spontaneous circulation? Reference: Snyder BD, Van Dyke MR, Walker RG, et al. Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest. Resuscitation 2023. Population: Adult patients treated with an advanced airway for non-traumatic OHCA in a single urban EMS system in the US between 2015 and 2021 Excluded: "Age <18, received basic life support (BLS) only, termination of resuscitation due to advance directives, ALS interventions prior to EMS arrival, insufficient capnography data, cricothyrotomy, advanced airway placed while patient had spontaneous circulation, airway was managed with BVM only, or did not receive CPR while under EMS ALS care.” Exposure: Small bag ventilation with a Mercury Medical CPR-2 Comparison: Large bag ventilation with unspecified “large” BVM Outcome: Primary Outcome: Return of spontaneous circulation (ROSC) at the end of EMS care. This was defined as the time point when the EMS crew entered the receiving ED or termination of resuscitation in the field. Secondary Outcomes: Ventilation rate and mean end-tidal CO2 (ETCO2) value during CPR Type of Study: Retrospective, observational cohort analysis of two prospectively acquired registries managed by one institution’s quality improvement staff. Authors’ Conclusions: “Use of small adult ventilation bags was associated with a lower likelihood of ROSC at the end of EMS care in non-traumatic, adult OHCA.” 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

Reference: Remick KE, et al. National Assessment of Pediatric Readiness of US Emergency Departments during the Covid-19 Pandemic. JAMA Netw Open. July 2023 Date: Dec 11, 2023 Guest Skeptic: Dr. Rachel Hatcliffe is a pediatric emergency medicine attending at Children's National Hospital in Washington, DC. Her research focuses on prehospital care of children with anaphylaxis. Guest Authors: Dr. Kate Remick Dr. Kate Remick is a pediatric emergency medicine physician and Assistant Professor of Pediatrics at Dell Medical School at the University of Texas at Austin. She is an executive lead for the EMS for Children Innovation and Improvement Center. She has held leadership positions with state and national professional organizations to promote high quality emergency care for children. Dr. Hilary Hewes is a pediatric emergency medicine physician and an Associate Professor of Pediatrics at the University of Utah/Primary Children’s Hospital with interests in prehospital care, pediatric trauma and injury prevention, and disaster medicine and preparedness. She is the co-Principal Investigator for the EMS for Children Data Center. Dr. Hilary Hewes Dr. Marianne Gausche-Hill is a pediatric emergency medicine physician and the interim CEO of the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center. She is also a Professor of Pediatrics and Emergency Medicine at David Geffen School of Medicine at UCLA. She is nationally known for her work as an EMS researcher and educator. Case: After your shift in the emergency department (ED) one day, the medical director pulls you aside. She says that they’ve noticed a slight increase in the number of sick pediatric patients coming in recently and the difficulty in finding a hospital to accept the ones who need admission. As a seasoned clinician, she wants your opinion and asks you, “How prepared do you think we are in handling sick children?” and “Do you have any thoughts about how we can improve?” Dr. Marianne Gausche-Hill Background: Back in August of 2022, we announced the start of #SGEMPeds for SGEM Season 11. One of the key motivations was the recognition that we needed to get out of the ivory towers of academic pediatric emergency medicine centers as most children are cared for outside of academic centers. We wanted to spread the gospel of evidence-based medicine so that children get the best care, based on the best evidence, regardless of where they receive care. But does that always happen? Are general emergency departments ready to care for children? Two previous studies conducted assessing the state of nationwide pediatric readiness were conducted in 2003 and 2013. [1,2] Today we're covering the third study. Pediatric readiness is important because it is associated with decreased mortality in ill and injured children. [3, 4] Conflict of Interest Disclosure: Dennis is an Emergency Medical Services for Children (EMSC) fellow in the Knowledge Management domain. Clinical Question: What was the state of pediatric readiness in emergency departments across the United States during the COVID-19 pandemic? Reference: Remick KE, et al. National Assessment of Pediatric Readiness of US Emergency Departments during the Covid-19 Pandemic. JAMA Netw Open. July 2023 Population: ED leadership across the United States. It included 3,647 readiness assessments performed, representing 14.1 million annual pediatric ED visits. Excluded: EDs that are not open 24 hours a day or 7 days a week. Veterans Affairs and prison hospitals. Intervention: Web-based open assessment questionnaire containing 92 questions. Comparison: Previous pediatric readiness scores. Outcome: Primary Outcome: Weighted pediatric readiness score (WPRS, range 0-100); Adjusted WPRS (exclude points for QI plan and Pediatric Emergency Care Coordinator aka PECC) Secondary Outcomes: Changes in WPRS from 2013 to 2021, evaluate factors associated with pediatric readiness. Authors’ Conclusions:“These data demonstrate improvements in key domains of pediatric readiness despite losses in the healthcare workforce, including pediatric emergency care coordinators, during the COVID-19 pandemic, and suggest organizational changes in EDs to maintain pediatric readiness. This comprehensive assessment found that the presence of PECCs, QI plans for children, and staffing the ED with board-certified EM/PEM physicians were associated with higher pediatric readiness and provides an opportunity for all EDs to initiate organizational changes that can enhance their pediatric capability.” 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? Unsure Have the authors identified all-important confounding factors? Yes. Was the follow up of subjects compl

Reference: Roussel et al. Overnight stay in the emergency department and mortality in older patients, JAMA Intern Med 2023 Date: December 18, 2023 Guest Skeptic: Dr. Chris Carpenter, Vice Chair of Emergency Medicine at Mayo Clinic. Case: An 85-year-old patient (Ms. McG) presents to your emergency department (ED) after being found by family on the ground at her independent living facility. Her family was concerned because she has had multiple recent falls, and she wasn’t answering the telephone that morning. They found her in a pool of blood with a scalp laceration and complaining of left hip pain. Although she had exhibited occasional disorientation and gradually diminishing physical activity over the last 5-years, she was still functionally independent. While your ED evaluation, computed tomography (CT) imaging of her head and spine demonstrated no traumatic injury and an x-ray of her pelvis showed no fracture or dislocation, she was unable to bear weight due to her hip pain, so you ordered a CT to further evaluate for occult fracture. Advanced imaging was unavailable until morning by the time that test was ordered. Suspecting an occult fracture, you consult Orthopedic surgery for admission, but they wanted to wait for the CT the next day. You then consult Internal Medicine/Hospitalist who also want to wait for CT imaging in case the admission is more appropriate on the Orthopedic surgery service. After all these consultant calls it is now after midnight and you are concerned that the patient will be in the ED all night and what the consequences of a preventable episode of overnight ED boarding might have on the patient and the rest of the department since the waiting room still has 20 patients awaiting evaluation. Background: Falling is the most common cause of traumatic injury resulting in older adults presenting to the ED [1]. Approximately 20% of falls result in injuries, and falls are the leading cause of traumatic mortality in this age group [2-4]. Older adults who are admitted to the hospital after a fall will be readmitted to the hospital within one-year in 44% of cases and 33% will die within one-year. Because it is such a serious topic, we have covered it several times on the SGEM: SGEM#89: Preventing Falling to Pieces SGEM Xtra: Don’t Bring Me Down – Preventing Older Adult Falls from the Emergency Department SGEM#351: How to Stop Geriatrics from Free Fallin’ GEMCast: How to Help Prevent the Next Fall in Your Older Patients Geriatric ED Collaborative Falls Resources: Falls and Mobility EDs are becoming more and more crowded. The Canadian Association of Emergency Physicians (CAEP) flagged this issue 10 years ago in 2013. They published a position statement with several suggested solutions. Unfortunately, things have only gotten worse, and it does not seem to be an isolated problem in Canada. The American College of Emergency Physicians (ACEP) held a summit of stakeholders across health care in September of 2023. They got together a wide range of leaders in various organizations to discuss potential solutions to what is called “boarding” of patients. Perhaps we should define the term boarding as we are using it in the context of emergency medicine. It is when patients have been assessed and deemed to need admission to hospital. However, there are no beds available in the hospital and the patient remains in the ED. They can end up waiting for hours, days or even have their entire in-patient hospital care delivered in the ED. The Joint Commission is an organization in the US that sets standards to improve safety in healthcare. They have identified the boarding of patients in the ED as a significant safety risk. In 2012, they said patients should not remain in the ED after the decision to admit to hospital of more than four hours [5]. It has been reported that waiting longer than four hours can result in downstream harms which include but are likely not limited to increased medical errors, compromises to patient privacy, and increased mortality [6]. Kelen et al said boarding is like a canary in a coal mine for the healthcare system and is more likely to happen when hospital occupancy rates exceed 85% to 90% [7]. That comment about the canary reminds me of a tweet by one of my mentors, Dr. Alan Drummond. He has been warning about this problem of overcrowding for years and emphasizes that it is a system problem not just a problem in the ED. Al Drummond posted some sad news on the site formerly known as Twitter saying that "The F-ing canary was dead." There was a study published in the EMJ last year talking about an increased mortality associated with longer wait times in the Nasional Health Service in the UK [8]. They observed an increase in all-cause mortality in the next month for patients who waited more than 5 hours to be admitted. This was not a unique observation and other researchers have published similar findings including our friends Jesse Pines and Peter Viccellio [9-10]. Clinical Q

Date: December 12, 2023 Reference: OCFP News. More Than Four Million Ontarians Will Be Without a Family Doctor by 2026. Nov 7, 2023 Guest Skeptic: Dr. Mahaleh Mekalai Kumanan attended Dalhousie University for her undergraduate studies, Master of Health Administration degree and medical school before completing her residency at the University of Western Ontario. She is currently the President of the Ontario College of Family Medicine (OCFP). This is an SGEM Xtra. I had the opportunity to interview the President of the OCFP about the current state of family medicine and some possible solutions. Please consider listening to the SGEM Podcast and hear what Dr. Kumanan has to say. It has been an interesting couple of months. The College of Family Physicians of Canada (CFPC) in September widely communicated they were going to implement an additional year of training for family medicine residents. There was an outcry from individuals and organizations (SRPC, CFMC, RDC, OMA & Ministers of Health) asking the CFPC to pause and reconsider. This included a statement from the OCFP. To its credit the CFPC listened, reflected, and responded in a very appropriate way. The CFPC President (Dr. Mike Green) apologized and announced they are not implementing an additional year of training. This took a great deal of insight and humility. Well done CFPC. Now it is time to address some immediate issues with Family Practice. Some listeners may be wondering why we are discussing this on an emergency medicine podcast. Well, it is because we are all on Team Patient. Family Medicine is the foundation of healthcare. Without strong primary care patients will eventually end up in the ED. I suspect Ontario is not the only province and Canada is not the only country struggling with these problems. As of September 2022, data by INSPIRE-PHC posted on the Ontario Community Health Profiles Partnership (OCHPP) shows nearly 2.3 million Ontarians are without a family doctor – that’s up from 1.8 million in March 2020, or up from 1.6 million in 2018. INSPIRE-PHC research, led by Dr. Kamila Premji, also shows 1.74 million Ontarian's have a doctor who is nearing retirement. In addition, the number of medical school graduates choosing to pursue family medicine is the lowest it’s been in 15 years. Using updated research, the OCFP now predicts that Ontario will exceed its previous forecast as the crisis in family medicine intensifies. Approximately 1 in 4 Ontarian's – or 4.4 million – will be without a family doctor by 2026. OCFP: Three Solutions to the Crisis Ensure Ontarians have a family doctor working alongside a team, so patients can get the help they need faster. Improve the accessibility of care by increasing the time that family doctors can spend providing direct patient care. Ensure every Ontarian has a family doctor by recruiting and retaining more family doctors within the province. Research shows that patients with access to comprehensive team-based primary care, led by a family doctor, have better health outcomes, fewer visits to the hospital/emergency department/specialty care, and overall are more satisfied with their care. The Ontario government needs to commit to ensuring every family doctor and their patients have access to a team. Ontarians who have family doctors working in teams have far greater access to the care they need because their physicians are supported by nurses, pharmacists, dietitians, social workers and more. Having easy access to a team of health care providers led by a family physician means patients can get the right care from the right provider – and frees up time for family doctors to focus on patients that most need their expertise. Right now, 70 per cent of family doctors and their patients do not have access to team-based support. The second solution the OCFP suggests is to improve the accessibility of care by increasing the time that family doctors can spend providing direct patient care. This has got to be about the mountain of paperwork. Family doctors say they can spend up to 25% of their week on administrative work. This is time that could be spent providing direct patient care. We need to give family doctors more time to spend on direct patient care. There are several policy solutions including EMRs, centralized referrals and minimizing forms. On average, family doctors spend 19 hours a week on administrative tasks such as writing sick notes and filling out lengthy insurance forms. Simple measures such as eliminating sick note requirements and standardizing insurance forms, would mean more time treating patients. The third solution brought forward by the OCFP is to ensure every Ontarian has a family doctor by recruiting and retaining more family doctors within the province. There is an incredible amount of institutional knowledge out there considering walking away from primary care. We need to keep them engaged. 1.3 million Ontarians live without a doctor. And 1-in-5 family physicians plan on r

Reference: Punches et al. Patient Perceptions of Microaggressions and Discrimination Towards Patients During Emergency Department Care. AEM Dec 2023 Date: December 14, 2023 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: A 57-year-old Chinese woman presents to the emergency department (ED) with chest pain. She speaks some English, but it is her second language. It is a very busy day, and you proceed to ask her questions in rapid succession. You roll your eyes when you must repeat yourself and ask in a louder and louder voice in order to get a response. Background: Patient experiences of care are associated with health outcomes and may impact perspectives of ED care and the patient recovery process.(1-5) Perceptions of discrimination in healthcare are linked to delays in seeking medical treatment, nonadherence to clinician recommendations, and mistrust of clinicians and the healthcare system.(6-7) We looked at deaf and hard-of-hearing patients in the ED on SGEM#383. Microaggressions are discriminatory behaviors that may be subtle or unintentional but may disempower affected individuals leading to differential care and worse healthcare outcomes.(7-10) Discrimination, implicit bias and microaggressions are common in healthcare encounters involving persons from marginalized groups.(11-17) Microaggressions and discrimination towards patients have been studied in other healthcare settings, but there has been little research on this topic that specifically investigates EDs.(10-11) The ED is a unique part of the healthcare system due to its inherent chaotic environment, time constraints and lack of prior patient-staff interaction. Clinical Question: How can patient perceptions of microaggressions that occur during an ED visit inform potential interventions and prevent future occurrences? Reference: Punches el al. Patient Perceptions of Microaggressions and Discrimination Towards Patients During Emergency Department Care. AEM Dec 2023. As this is a qualitative study, we will use a modified PICO question (PIC): Population: Adult, English speaking patients visiting one of two urban emergency departments in a Midwest US city. Interest: Exploring patient experiences of discrimination during their ED visit. Context: Improving patient care and reducing microaggressions from ED staff This is an SGEMHOP episode, and it is our pleasure to introduce Dr. Lauren Southerland. She is an Associate Professor in the Department of Emergency Medicine at The Ohio State University. Her research interests include clinical process improvement in the ED and implementation science, and she focuses on the care of vulnerable populations, most often older adults or others lacking capacity or capabilities. This study used a mixed methods sequential explanatory approach whereby the researchers collected quantitative data on experiences of discrimination using the DMS tool, followed by qualitative data through a semi-structured interview. Dr. Lauren Southerland As many of us have over the past four years, we were looking at our emergency care and interested in whether our practice was contributing to disparities. Additionally, many of us in medicine have witnessed or experienced microaggressions, and we wondered if our ED care was contributing to patients feeling discriminated against. So, we looked at the available research and found that no one really had a good answer for our question, and the obvious solution to us was to ask patients about their experiences. The sequential, mixed methods design came about because we didn’t want to do interviews during the ED visit, as that could make patients feel uncomfortable or like they were reporting on their healthcare workers. But we also know that once someone leaves the ED to go home it is often hard to get them to answer the phone or call back for an interview. So, we added in the quick discrimination in medical settings scale so that we could obtain some information about our current care in case we couldn’t get many interviews. It also allowed us to compare the quantitative and the qualitative evidence, which led us to some interesting conclusions. That is also why we have 48 people completing the quantitative portion but only obtained 30 final interviews. We had some expected loss to follow up. Another process that worked well was that we did not randomize people to participation. We did not want an average sample of views. We used purposive sampling, were we specifically looked for a people of different ages, genders, race and ethnicities to provide a breadth of viewpoints. What struck me the most is that I learned more about my own research biases. I went into this study on biases and microaggressions with some preconceived biases. I thought we would hear a lot of stories of gender and racial discrimination. And some of that o

Date: November 20, 2023 Reference: Jones et al. Time to reflect on open-label placebos and their value for clinical practice. PAIN October 2023 Caitlin Jones PhD Guest Skeptic: Dr. Caitlin Jones is a Postdoctoral Research Associate at Sydney University’s institute for Musculoskeletal Health. Her research evaluates the benefits and harms of treatments for musculoskeletal conditions with a particular interest in high-risk treatment options such as opioid medicines and spinal cord stimulators for pain. She has a goal to improve patient outcomes and reduce harm from inappropriate treatments. We have an interesting back story on how we met. Dr. Sergey Motov and I did a structured critical appraisal of the OPAL trial (SGEM#419). You were the lead author on that study. You pointed out we missed some details in our review and provided some additional information. We were happy to hear from you and updated the SGEM episode based upon your comments. Not everyone has been so receptive to your study and your feedback. Thanks for appraising OPAL and for engaging with me about it. There were lots of varied responses to OPAL. Most were positive and interested. Some had opinions that the trial doesn’t reflect their practice or their patients, so it’s not relevant to them (reasonable position). Some are furious that we would even suggest that opioids don't work and they are certain this is part of a corrupt evil agenda (I don’t engage with this stance because nothing I can say will change their minds). I do engage when it’s just a genuine misunderstanding, or someone has missed some details.Everyone is free to make up their own mind about how they will or won’t apply these findings into their clinical practice, but I do feel an obligation to correct misunderstandings when I see them. After our exchange I looked up some of your other publications. One of them caught my eye as being very thought-provoking. It looked at open label placebo being used in clinical trials. The title of the paper was Time to reflect on open-label placebos and their value for clinical practice [1]. What got you interested in that topic? A lot of my research compares treatments for MSK pain to placebo to establish efficacy (how well it works). In my field we often find, sadly, that some of the treatments used for decades in clinical practice don’t show effects above that of the placebo when someone finally tests them properly. There’s been increasing chatter about OLPs with a few editorials written in big journals, and an increase in publications on the topic, so it is clearly gaining traction in the clinical and research community. A lot of my work so far has been about testing treatments that have been used for decades without proper testing, and then when we finally test them, we discover we were doing more harm than good all this time. Open label placebos as a clinical treatment are new enough that there is time to intervene and advocate for some thorough testing before they become common place in clinical care. I don’t want this to be another thing where we realize in 50 years’ time that we were harming not helping. SGEM listeners are probably familiar with the placebo effect, but can you give us a brief definition or description? The placebo effect is the positive effect on outcomes stemming from positive expectations around receiving a treatment, but not the treatment itself. Placebo in a research context is the gold standard comparison in efficacy trials that can provide an estimate of the treatment effect, filtering out all the biases and contextual effects that aren’t directly caused by the treatment of interest, so we are left with an estimate of the direct effects of the treatment itself. Then along came some research which caused some excitement. They reported that you could elicit a placebo effect without deceiving the patients (ie telling them it is a placebo) [2]. Yes, some very interesting research came out that even when you tell people they are getting a placebo, they still seemed to cause some positive effects. That was really appealing to a lot of people who believed in the power of placebo, but felt the main barrier to usage was with unethical element of deception – suddenly no deception seemed necessary. Open Label I love talking nerdy and the methods section is my favourite section of a publication. So, what were the fundamental misunderstandings of the open label placebo (OLP) and research methodology? Mismeasuring / over inflating the placebo effect by confusing response for effect Lack of blinding in trials, plus positive preamble, overinflates OLP group and deflates control group effects. Sampling bias, advertising for mind-body treatments and having participants self-select(only examining people with a pre-existing belief or interest). Not including co-design or input from the people who we think would be most likely to receive this (conditions hard to diagnose and treatg. chronic pain, chronic fatigue) I understand

Reference: Shaikh N, et al. Identifying children likely to benefit from antibiotics for acute sinusitis: a randomized clinical trial. JAMA July 2023 Date: October 17, 2023 Dr. Alasdair Munro Guest Skeptic: Dr. Alasdair Munro is a clinical research fellow specializing in pediatric infectious disease at the University of Southampton. He is currently involved with clinical trials of vaccines and antibiotics. Case: A 4-year-old girl presents to your emergency department (ED) with fever and nasal drainage. Her vaccinations are all up to date. Symptoms have been present for the past 12 days. She initially had some cough and congestion which was diagnosed as a viral upper respiratory infection by her primary care doctor. Her symptoms have persisted and yesterday she developed fever (temperature of 38.3°C) and nasal drainage. On physical examination, she has nasal congestion with yellow-colored nasal discharge. The family says to you, “She’s been sick for almost 2 weeks and the color of her nasal drainage changed to yellow. Does this mean she has a bacterial infection that needs antibiotics?” Background: Distinguishing between sinusitis and viral upper respiratory infections in children is challenging. The symptoms often overlap. The latest clinical practice guidelines from the American Academy of Pediatrics (AAP) on the diagnosis and management of acute bacterial sinusitis in children was published in 2013 [1]. Based on those guidelines, a presumptive diagnosis of bacterial sinusitis can be made when a child with URI symptoms has: persistent illness (nasal discharge, daytime cough) lasting more than 10 days without improvement worsening course (new or worsening nasal discharge, daytime cough, or fever after initial improvement) severe onset (fever ≥39°C, purulent nasal discharge for at least 3 consecutive days) This recommendation only has an evidence quality of B. We don’t routinely perform sinus aspiration on children, but it is thought that the most common pathogens involved in sinusitis include Streptococcus pneumoniae Hemophilus influenzae, or Moraxella catarrhalis. Untreated sinusitis is associated with complications such as pre septal cellulitis, orbital cellulitis. In bad cases, there can be intracranial involvement that includes cavernous venous thrombosis, osteomyelitis, meningitis, or intracranial abscess. However, in the interest of antibiotic stewardship. We also do not want to be prescribing antibiotics for viral illnesses. This issue was covered on SGEM #263. We should be thinking about implementing strategies to reduce the unnecessary prescribing of antibiotics in the emergency department. Clinical Question: What are the potential benefits and harms of antibiotic treatment for children diagnosed with acute sinusitis and does it depend on bacterial pathogen colonization or color of nasal discharge? Population: Children aged 2 to 11 years with persistent or worsening acute sinusitis (as per AAP practice guideline) and symptom score of => 9 on Pediatric Rhinosinusitis Scale (PRSS) [2]. This scale ranges from 0-40 with higher scores representing more severe symptoms. Persistent = nasal symptoms, cough or both for 11 - 30 days without improvement. Worsening = period of improvement followed by worsening nasal symptoms or daytime cough, or new onset fever on days 6 - 10. Exclusion: severe presentation (presence of both colored nasal discharge and fever ≥39°C for 3 or more consecutive days, history of asthma, active wheezing, solely cough, history of allergic rhinitis, immotile cilia syndrome, cystic fibrosis, immunodeficiency, allergy to study medications, concurrent infections, systemic antibiotic use within the previous 15 days, prior sinus surgery, families did not have access to phone or were not English/Spanish speaking Intervention: 10 days of Amoxicillin/Clavulanic acid Comparison: Matching placebo Outcome: Primary Outcome: Symptom burden (PRSS) during first 10 days after diagnosis Secondary Outcome: Treatment failure defined as (1) an increase in PRSS score of greater than 20% from enrollment at any time, (2) a decrease of less than 2 points in the PRSS score from enrollment to day 3, (3) a decrease in PRSS score of less than 20% from enrollment to day 4, (4) a decrease in PRSS score of less than 20% from enrollment on 2 consecutive occasions on days 5 to 11, or (5) a decrease in PRSS score by less than 50% from enrollment to the end-of-study follow-up visit. Acute otitis media (AOM). Receipt of another systemic antibiotic Safety: Non-susceptible pathogen at follow up (S pneumonia or H influenzae). Clinically significant diarrhea (3 or more watery stools for 1 day or 2 watery stools on each of 2 consecutive days). Rash. Other resource utilization. Missed work days. Type of Study: A multi-center, double-blind, placebo-controlled, randomized clinical trial. Authors’ Conclusions: “In children with acute sinusitis, antibiotic treatment had minimal benefit for those without nasopharyngeal bacterial

Date: November 22, 2023 Reference: Stopyra et al. Delayed First Medical Contact to Reperfusion Time Increases Mortality in Rural EMS Patients with STEMI. AEM November 2023. 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 72-year-old man with a history of high blood pressure and diabetes calls emergency medical services (EMS) for chest pressure and dyspnea that started 1 hour ago. Upon EMS arrival, they find the patient is sweaty with normal vital signs. A 12-lead electrocardiogram (ECG) demonstrates ST elevations in leads II, III, and aVF with ST depressions in leads I and aVL and the team begins transport to the nearest percutaneous coronary intervention (PCI) capable hospital. Background: We have covered the issue of heart attacks several times on the SGEM. These include looking at the HEART score, troponin testing and cardiovascular disease in women. One aspect we have not addressed is rural. SGEM#151: Groove is in the HEART Pathway SGEM#160: Oh Baby, You’re Too Sensitive – High Sensitivity Troponin SGEM#280: This Old Heart of Mine and Troponin Testing SGEM#370: Listen to your HEART (Score) SGEM#400: A Little Bit of Heart and Sport and Sports Related Sudden Cardiac Arrest in Women SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease Current guidelines target a time between first medical contact (FMC) like EMS on-scene and stent or balloon deployment (PCI) of 90 minutes or less. If time from FMC to PCI is anticipated to be greater than 120 minutes, the guidelines recommend systemic thrombolysis rather than PCI [1]. I’ve published on this issue with a project we called “barn door-to-needle time” [2]. We looked at 101 STEMI patients from two rural EDs. The median door-to-ECG time was 6 minutes, door-to-physician time was 8 minutes and DTN time was 27 minutes; 58% of patients received thrombolytics within 30 minutes. Regional systems of care have been designed to rapidly recognize patients with STEMI and direct STEMI patients to timely reperfusion. Many hospitals do not provide PCI, prolonging transportation times, which disproportionately affects rural patients. There are several distinct time intervals in the care of patients with STEMI and it is unclear which steps in pre-PCI care of patients contribute to avoidable delays. Clinical Question: Is there an association between in-hospital mortality and time between first medical contact and primary percutaneous coronary intervention in rural patients who present with a STEMI? Reference: Stopyra et al. Delayed First Medical Contact to Reperfusion Time Increases Mortality in Rural EMS Patients with STEMI. AEM November 2023. Population: Patients ≥ 18 years of age who were transported to one of three tertiary care hospitals by a rural EMS agency and received primary percutaneous coronary intervention (PCI) for STEMI. Rural agency was defined by US census codes (2014) Excluded: Patients <18, those who had prehospital cardiac arrest, and those who were transferred between hospitals Exposure: 90-minute first medical contact to PCI goal (defined as time between the time recorded as EMS personnel arrival on scene and the time the angioplasty or stent was deployed Comparison: Greater than 90 minute first medical contact to PCI Outcome: Primary Outcome: All-cause in-hospital mortality during the index hospitalization Secondary Outcomes: Prehospital time intervals stratified by index hospitalization mortality. Type of Study: A retrospective cohort study from eight rural North Carolina EMS agencies between January 2016 to March 2020. Dr. Michael Supples This is an SGEMHOP episode, and it is my pleasure to introduce Dr. Michael Supples. He is an assistant professor of emergency medicine and faculty within the emergency medical services fellowship at Wake Forest School of Medicine in North Carolina. He is double boarded in EM and EMS and focuses on prehospital research. Responds Authors’ Conclusions: “Death among rural patients with STEMI was four times more likely when they did not receive PCI within 90 minutes.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Not very precise. Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with o

Date: November 2, 2023 Reference: Coventry et al. Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies. Emerg Med J. Aug 2023 Guest Skeptic: Dr. Matt Schmitz is an Orthopaedic Surgeon who sub-specializes in adolescent sports and hip preservation. He will soon be transitioning out of the US military after a 20-year career in the Air Force and is soon to be Clinical Professor of Orthopaedics at UC San Diego. DISCLAIMER: THE VIEWS AND OPINIONS OF THIS BLOG AND PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US MILITARY. Case: A 24-year-old manual labourer presents to the emergency department (ED) after drinking a few too many beers, having a disagreement with another beer drinker and gets knocked down. The mechanism was described as a classic FOOSH (fall on outstretched hand) injury. Examination reveals pain along the wrist and in his anatomical snuffbox. However, the x-rays read as “normal” by radiology. Background: Fractures of the scaphoid are the most common carpal fractures presenting to the ED. One of the best systematic reviews and meta-analyses on the topic discussing the diagnostic accuracy of the history, physical examination and imaging is by Carpenter et al from AEM 2014 [1]. We went into some detail on SGEM#385. Many potential scaphoid fractures are immobilized but this can be a detriment to job, school, and activities of daily living. Initial Xray’s pick up only about 17% of fractures [2]. Having patients follow-up in a couple of weeks for repeat x-rays can pick up about 7% more [3]. MRIs have greater diagnostic accuracy [1] but may not be available in some areas and can be expensive and not always readily available. A CT scan is not as accurate as an MRI but does come with a different type of cost, radiation exposure [1]. Clinical Question: What to do with a patient who presents with a FOOSH injury and has a normal x-ray; are there clinical exam findings that can help rule in/rule out a scaphoid fracture? Reference: Coventry et al. Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies. Emerg Med J. Aug 2023 Population: Patients with a clinical suspicion of having a scaphoid fracture but a normal initial x-ray Excluded: Studies that did not have enough information to create a 2x2 table even after contacting study authors. Intervention: Various physical examination maneuvers Comparison: N/A Outcome: Diagnostic accuracy expressed as sensitivities, specificity, and likelihood ratios Authors’ Conclusions: “No single feature satisfactorily excludes an occult scaphoid fracture. Further work should explore whether a combination of clinical features, possibly in conjunction with injury characteristics (such as mechanism) and a normal initial radiograph might exclude fracture. Pain on supination against resistance would benefit from external validation.” 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. No The assessment of studies were reproducible. Yes There was low heterogeneity for estimates of sensitivity or specificity. No 6. The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. No Results: They searched the worlds literature, followed the PRISMA guidelines and found eight studies of which four included a small number of children. There were 1,685 wrist injuries included in the SRMA of which there were 123 (9%) occult scaphoid fractures (normal initial x-rays). Most studies were reported as having an overall low risk of bias. Key Results: There was no physical examination that could rule-out an occult scaphoid fracture with any confidence. Primary Outcome: Diagnostic accuracy The best test for both positive and negative likelihood ratios as the pain on supination against resistance test based upon one small study of only 53 patients with 9 occult fractures (17%) LR+ 45.0 (95% CI; 6.5 to 312.5) LR- 0.1 (95% CI; 0.0 to 0.7) 1) Selection Bias: The authors mention that findings on physical examination contributed to the clinical suspicion of a fracture. This could be a source of selection bias. The definition according to the Centre for Evidence Based Medicine at Oxford University “occurs when individuals or groups in a study differ systematically from the population of interest leading to a systematic error in an association or outcome”. 2) Prevalence: Sensitivity depends on the spectrum of disease, while specificity depends on the spectrum of non-disease. So, you can falsely raise sensitivity if the clinical practice has lots of very sick people (sicker than who you see in the ED). Specificity can look great if you have no sick patients in t

Reference: Roland D, Munro A. Time for paediatrics to screen out sepsis “screening.” BMJ. June 2023 Date: Sept 12, 2023 Guest Skeptic: Dr. 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 Background: For anyone who has ever taken care of a decompensating child with septic shock, it’s unlikely you’ve forgotten the experience. So we have a lot of respect for sepsis and the importance of early recognition to prevent morbidity and mortality. Despite the medical community’s experience with sepsis over the years, there is still much that is unclear about the diagnosis and management of sepsis: How is sepsis diagnosed? What is the optimal fluid to give? How much fluid should be given? When should pressors be started? What pressors should be used? What is the optimal timing of antibiotic therapy? We have covered the topic of sepsis a few times on the SGEM 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 Damian and Dr. Alasdair Munro make the bold claim in an opinion article in the BMJ titled, Time for paediatrics to screen out sepsis “screening.” Despite us being very careful in trying to identify children with sepsis, there is a lot of uncertainty. So, we're diving into some of those controversies and gray areas. Some key topics are highlighted below, but tune into the podcast to listen to all the great conversation and pearls of wisdom from Dr. Roland. Why Sepsis is a Challenge in Children’s Acute/Emergency Care? The definition of "sepsis" is not clear. Sepsis may be more due to the body's response to infection than the infection itself. It's possible to have a pathogen in the bloodstream, but not have sepsis because there is not cardiac dysfunction or capillary leakage Children with sepsis may not have a pathogen isolated, and children with a pathogen isolated may not be "septic." What has been the Approach to Sepsis Recognition and Treatment? Sepsis occurs along a spectrum. Recognizing severe sepsis is not difficult in the child that appears acutely ill. Distinguishing the children in the middle of that spectrum is a challenge. There is variation in screening tools and scoring systems for sepsis across healthcare systems. The principle of evaluating for deranged physiology (abnormal vital signs) in combination with fever and infection risk is more ubiquitous. There are differences in application. Screening tools are imperfect. There are many false positives and false negatives. There is no "holy grail" of screening tools. We spoke about the utility of the following in detecting and ruling out sepsis: lactate inflammatory markers (CRP, ESR, procalcitonin) viral PCR testing height of fever We also spoke some of the evidence behind management strategies for sepsis that included: IV fluids Inotropes Antibiotics Recent Controversies and Evidence Many of us are familiar with the Surviving Sepsis campaign/International guidance. After release a group of doctors expressed some concerns due to: conflicts of interest making strong recommendations based on weak evidence criticism regarding the bundling of care that does not consider clinical judgement Infectious Disease Society of America (IDSA) did not endorse the Surviving Sepsis campaign guidelines due to different interpretation of the major studies that lead to the recommendations. Our guidelines tend to lack sensitivity and specificity. While there are significant consequences of missing a sepsis diagnosis, the incidence of sepsis is relatively rare. Why is "Sepsis Screening" an Incorrect Lexicology? A "sepsis screen" was used to describe a bundle of tests. In the example of a febrile 6-week old, a "sepsis screen" involves blood culture, urine, inflammatory markers, and possibly lumbar puncture. The definition evolved when guidance came in that told us what to do if the child presents with certain parameters to evaluate children with a risk of sepsis. Screening tests should have some key principles: known denominator of condition being treated test should be acceptable test should have good characteristics (clearly identify disease) Sepsis screening does not meet these criteria. What can/should we do? We need to look into the conditions in wh

Date: October 26, 2023 Reference: Jones et al. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial placebo-controlled trial. Lancet July 2023 Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department, specifically the use of ketamine. His twitter handle is @PainFreeED. Case: A 37-year-old man without a significant past medical history presents to the emergency department (ED) with a chief complaint of lower back pain that started three days prior to the ED visit after unloading a truck with furniture. He states that pain is severe (7/10 in intensity), sharp, constant, non-radiating, and is exacerbated by any movement. The patient is unable to go to work due to pain and is experiencing severe limitations in his daily activities. He denies any weakness or numbness of the lower extremities or bowel or bladder dysfunction. You perform a physical examination and note prominent tenderness to palpation at bilateral lumbar paraspinal regions with normal neuro-vascular examination. You engage the patient in shared decision making about his most likely diagnosis (muscle strain) and treatment approach such as a short course of non-steroidal anti-inflammatory drugs (Ibuprofen) and gradual physical activity as tolerated. The patient, however, believes that ibuprofen will not touch his pain and insists on receiving an opioid-containing medication. Background: Low back pain and neck pain are extremely common conditions worldwide [1]. We have covered the issue of back pain several times on the SGEM including: SGEM#87:Let Your Back Bone Slide (Paracetamol for Low-Back Pain) SGEM#173: Diazepam Won’t Get Back Pain Down SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain SGEM#304: Treating Acute Low Back Pain – It’s Tricky, Tricky, Tricky SGEM#366: Relax, Don’t Do It – Skeletal Muscle Relaxants for Low Back Pain Back pain and neck pain are leading causes of disability on a global scale [2,3]. The substantial disability burden imposes enormous costs both directly on healthcare systems, and indirectly through productivity losses [4,5]. Not only are these conditions common and painful they are difficult to treat. Many pharmacologic treatments have been tried with limited efficacy. Acetaminophen (Williams et al Lancet 2014) Muscle relaxants (Friedman et al JAMA 2015) NSAIDs (Machado et al Ann Rheum Dis 2017) Steroids (Balakrishnamoorthy et al Emerg Med J 2014) Benzodiazepines (Friedman et al Ann Emerg Med 2017) Many non-pharmacologic therapies have also been tried with limited efficacy. Cognitive Behavioral Therapy and mindfulness (Cherkin et al JAMA 2016) Chiropractic (Paige et al JAMA 2017) Physical therapy (Paolucci et al J Pain Research 2018) Acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013) One treatment modality, opioids, can be effective but comes with very real potential harms. The American College Physicians (ACP) has a 2017 policy on guidelines for treating non-radicular low back pain (Qaseem et al Annals of Int Med). Their third recommendations states: Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence) The American College of Emergency Physicians (ACEP) has addressed the issue of opioid use in patients being discharged home after an acute episode of pain. They give a Level C Recommendations saying: Do not routinely prescribe, or knowingly cause to be co-prescribed, a simultaneous course of opioids and benzodiazepines (as well as other muscle relaxants/sedative-hypnotics) for treatment of an acute episode of pain in patients discharged from the emergency department (Consensus recommendation). Despite guidelines and policy recommendations for prudent short-term opioid use only after other analgesics fail [6], opioid medications are frequently prescribed as the initial treatment for patients presenting with acute low back pain or neck pain. Estimates suggest up to two-thirds of these patients in Australia may receive opioids first-line [7]. Opioid prescription rates remain high in many countries including the USA. One study reported 43 prescriptions dispensed per 100 people in the US in 2020, though efforts have been made recently to curtail this use [8]. The prevalent use of opioids for acute back and neck pain is concerning given the lack of direct, high-quality evidence supporting efficacy [9]. Clinical Question: Is a short course of an opioid analgesic effective at reducing pain severity and improving function and quality of life in patients with acute non-specific low back pain or nec

Date: October 20, 2023 Reference: Cai et al. Implementation of a Clinical Management Tool for Spinal Epidural Abscess Early Diagnosis. AEM October 2023. Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. Case: You are in your group meeting and have heard about a case at a nearby emergency department (ED) where the diagnosis of a spinal epidural abscess was delayed, and a substantial settlement has been made out of court. Your group director is concerned with avoiding the same thing happening in your department and wants to know if you should implement an evidence-based clinical management tool (CMT) to reduce delays in diagnosis. Background: Spinal epidural abscess (SEA) is a diagnosis which can seem easy to make in retrospect. The majority of time (55%) the diagnosis of SEA often involves an error with a median length of time to diagnosis of 12 days according to one study [1]. Diagnostic delays were found to be present in 75% of SEA patients with only a minority (10-15%) of patients present with the “classic triad” of fever, back pain and neurologic deficit [2]. Another study reported that the 90% of patients misdiagnosed on their first ED visit [3] likely due to the non-specific and variable initial presentation, and the number of patients with back pain of benign origin seen in EDs [4]. SEA is the condition with proportionately the highest misdiagnosis rate in ED per a recent systematic review, and long-term sequelae for patients with associated medico-legal costs are high [5]. However, there is a need for clinicians to not let SEA become the next pulmonary embolism with high rates of over investigation. We’ve looked at back pain on the SGEM before, mostly in terms of treatments. SGEM#366 concluded that we could not recommend the routine use of skeletal muscle relaxants, SGEM#304 agreed that adding acetaminophen to ibuprofen did not improve one-week outcomes, while SGEM#173 concluded the same about diazepam (there’s a theme here!). We’ve also looked at the rational use of imaging on SGEM#283 (the Ottawa subarachnoid haemorrhage rule is highly sensitive but has very poor specificity). In SGEM#181, we were unconvinced of the value of routine use of whole body CT in trauma patients, and right back in 2015 on SGEM#106 discussing the Canadian CT head rule and the New Orleans Criteria. However, we’ve not previously looked at the intersection of non-traumatic back pain and rational investigation. CLINICAL QUESTION: DOES IMPLEMENTATION OF A CLINICAL MANAGEMENT TOOL IMPROVE TIME TO DIAGNOSIS AND CHANGE TESTING RATES FOR SPINAL EPIDURAL ABSCESS? Reference: Cai et al. Implementation of a Clinical Management Tool for Spinal Epidural Abscess Early Diagnosis. AEM October 2023. Population: Adults attending at continuously-staffed EDs in a health network covering 15 states, 2016-19. Excluded: Facilities not collecting radiology or lab order data, facilities without 6 months of data before and after intervention. Intervention: Implementation of a literature-based Clinical Management Tool (CMT). Comparison: Periods before and during the implementation of the CMT. Outcomes: Primary Outcome(s): 1. The proportion of patients with SEA with a potentially related visit in the previous 30 days and 2. For those with a prior visit, number of days from first visit to diagnosis. Secondary Outcomes: Utilization rates for CT, MRI, Xray, ESR and CRP. Type of Study: Implementation study. Dr. Anglea Cai This is an SGEM HOP and we are pleased to have the lead author on the show, Dr. Angela Cai. She is a Clinical Assistant Professor of Emergency Medicine at the University of Pennsylvania. She completed this work during her Innovation Fellowship at US Acute Care Solutions. Prior to that she trained at Kings County EM Residency in Brooklyn and the University of North Carolina Chapel Hill for her medical and business degrees. Authors’ Conclusions: “Back pain CMT implementation was associated with an increased rate of recommended imaging and laboratory testing in back pain. There was no associated reduction in the proportion of SEA cases with a related prior visit or time to SEA diagnosis.” Quality Checklist for Observational Cohort 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? Yes Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Unsure Have the authors identified all-important confounding factors? No Was the follow up of subjects complete enough? Yes How precise are the results? Confidence intervals are relatively broad, from minus 4.5 to plus 6% for the change in primary outcome. Do you believe the results? Yes Can the results be applied to the local population? Yes/No Do the results of this study fit with other available evidence? No Funding? No funding source reported, although one author

Reference: Brennan L et al. Time to change the reference ranges of children’s physiological observations in emergency care? A prospective study. J Paediatr Child Health. March 2023 Date: July 12th, 2023 Guest Skeptic: Dr. Vicki Currie is a paediatric emergency medicine registrar in the West Midlands in the United Kingdom. She is also a member of the Don’t’ Forget the Bubbles team where she serves as the editor for the monthly research round up, Bubble WRAP. Dr, Vicki Currie Case: A 5-year-old boy presents to the emergency department (ED) with his parents for fever and fatigue. He has had three days of high fevers at home. His parents report that he has also had a decreased appetite and does not seem interested in drinking liquids. He is usually a happy, active boy but has been very tired over the past day and the parents are having increasing difficulty getting him to wake up. When his vital signs are taken, he is noted to have a temperature of 40°C, a heart rate (HR) of 142 beats per minute (bpm), respiratory rate (RR) of 32 breaths per minute, and blood pressure of 98/60 mmHg. His capillary refill time is three seconds. His parents look at the monitor and ask you, “Is that heart rate normal for him? It seems awfully high. We have been reading online about something called sepsis that can be deadly. Does he have sepsis?” Background: We have looked at pediatric vital signs on the SGEM back in 2014 with PedEM superhero Dr. Anthony Crocco (SGEM#98). That episode reviewed the 2011 Fleming et al systematic review for the normal ranges of HR and RR in children from birth to 18 years of age. The publication provided useful graphs for clinicians on what is normal. Vital signs can be an important objective measurement while assessing a patient. They are often incorporated into many early warning systems, risk-stratification systems, and treatment protocols. Abnormal vital signs may be indicators of potential decompensation. Specifically, heart rate and respiratory rates are used in early attempts to detect sepsis. Children’s vital signs can differ based on age. However, there remains variation regarding what the “normal” ranges of vital signs can be for pediatric patients. Vital sign ranges from common guidelines such as Pediatric Advanced Life Support (PALS) [1] or Advanced Pediatric Life Support (APLS) [2] can differ. Clinical Question: How does a derived distribution of heart and respiratory rates for children compare to APLS and other national guidance? Reference: Brennan L, Heal C, Brown S, Roland D, Rowland AG. Time to change the reference ranges of children’s physiological observations in emergency care? A prospective study. J Paediatr Child Health. March 2023 Population: Children 0-16 years recruited consecutively from October 2017 to September 2020 from three emergency departments and one urgent care centre in England- serving populations with significant inequalities in health and life expectancty. Excluded: none (although impossible values were excluded- Impossible’ values were HR below 50, and RR below 9 or above 90. This did equate to a significant number of records (>11,000 HR and >10,000 RR) Intervention: Anonymized data for patients’ heart rates and respiratory rates Comparison: Reference standards in Advanced Paediatric Life Support (APLS) Outcome: The authors had three aims with their study Comparison of the distribution of heart and respiratory rates from study to APLS ranges Proportion of patients from this study that would meet “severe” cut-off threshold compared to guidelines from the UK Sepsis Trust [3] and National Institute for Health and Care Excellence (NICE) [4] Comparison of distribution of heart and respiratory rates from study to previously published, large data sets [5-7]. Authors’ Conclusions: This study’s data set suggests normal heart rate ranges proposed by the APLS and others is too low and therefore “abnormal” measurement encompass too large a proportion. The respiratory rate of this data set was more consistent with the guidelines and other published data sets. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Unsure Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? No Was the follow up of subjects complete enough? Unsure 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. No conflicts of interest reported Results: Their initial data set included 235,909 records. After excluding entries with missing or impossible values, there were 191,292 records of HR and 191,147 records of RR included in the final analysis. Median age

Date: September 28, 2023 Reference: Jarman et al. Sex Differences in Guideline-Consistent Diagnostic Testing for Acute Pulmonary Embolism Among Adult Emergency Department Patients Aged 18-49. AEM September 2023 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: During a shift in the emergency department (ED), you see two patients with pleuritic chest pain, one female and one male. Pulmonary embolism (PE) is a diagnosis you are considering for both. After d-dimer testing your female patient, you order a CT scan of the chest for the male patient. One of the nurses on shift asks you why you didn’t order a d-dimer for the male, like you did the female patient. Background: PE is commonly considered during ED workups for chest pain and shortness of breath (1). We have covered the topic of PE more than ten times on the SGEM: SGEM#51: Home (Discharging Patients with Acute Pulmonary Emboli Home from the Emergency Department) SGEM#118: I Hope you Had a Negative D-dimer (ADJUST PE Study) SGEM#126: Take me to the Rivaroxaban – Outpatient treatment of VTE SGEM#163: Shuffle off to Buffalo to Talk Thrombolysis for Acute Pulmonary Embolism SGEM#184: We Weren’t Born to Follow-Up – The PEITHO Long-Term Follow-up Study SGEM#219: Shout, Shout, PERC Rule Them Out SGEM#276: FOCUS on PE in Patients with Abnormal Vital Signs SGEM#277: In the Pregnant YEARS – Diagnosing Pulmonary Embolism SGEM#282: It’s All ‘bout that Bayes, ‘Bout that Bayes- No Trouble – In Diagnosing Pulmonary Embolism SGEM#295: Teacher, Teacher – Tell Me How to Do It (Diagnose a PE) SGEM#323: Mama I’m Comin’ Home – For Outpatient Treatment of a Pulmonary Embolism Many patients may be able to have PE ruled out without imaging, after risk stratification with one of several decision tools (2). A very common clinical decision instrument is the Well’s Criteria. It has seven items with each item having a weighting from 1 to 3. The score is added up and then can be applied in a three-tiered model (low, moderate, or high risk) two-tiered model (PE is unlikely or likely). Another common tool is the revised Geneva Score (rGS). It is an eight-item clinical decision instrument for risk stratification. Each item in this tool also has different weight assigned to the items. Patients are considered low, intermediate, or high-risk depending on their total score. Neither of these two scores considers the sex of the patient for risk stratification. However, sex differences exist in the workup of PE, with females receiving more diagnostic testing, but with a lower diagnostic yield. Female patients are also more likely to undergo diagnostic imaging, and females who undergo imaging are less likely to be diagnosed with PE (3-5). Clinical Question: Are male and female patients equally likely to receive care consistent with guidelines for suspected PE? Reference: Jarman et al. Sex Differences in Guideline-Consistent Diagnostic Testing for Acute Pulmonary Embolism Among Adult Emergency Department Patients Aged 18-49. AEM September 2023 Population: Patients 18-49 years of age presenting with chest pain, shortness of breath, hemoptysis, or syncope alone or in combination Excluded: Pregnancy or incomplete ED visits Exposure: Objective testing for PE Comparison: Sex (male or female) Outcome: Primary Outcome: Receipt of guideline-consistent care based on revised Geneva Score (rGS) Secondary Outcomes: Rates of d-dimer testing, d-dimer positivity, rates of CT-pulmonary artery scanning (CTPA), overall yield of testing. Type of Study: A retrospective cohort study conducted at two U.S. academic tertiary care hospitals Dr. Angela Jarman This is an SGEMHOP episode which means we have the lead author on the show. Dr. Angela Jarman is an Assistant Professor and the Director of Sex & Gender in Emergency Medicine at UC Davis. She joined the faculty there after completing a two-year fellowship in Sex & Gender in Emergency Medicine at Brown University, where she also earned a Master of Public Health degree. Authors’ Conclusions: “In this cohort, females were more likely than males to receive care consistent with current guidelines and less likely to be diagnosed with PE.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes How precise are the results? Seem precise where CIs are provided Do you believe the results? Yes Can the results be applied to the local population? Probably Do the results of this study fit with other available evidence? Yes Funding of the Study. It was supported by three grants (American Hear

Reference: Snelling et al. Ultrasonography or radiography for suspected pediatric distal forearm fractures. New England Journal of Medicine June 2023 Date: July 19, 2023 Guest Skeptic: Dr. Casey Parker is a Rural Generalist that includes in his practice emergency medicine, anesthesia, and critical care. He is also a fully-fledged ultrasonographer. Casey currently splits his time between Broome, a small rural hospital in the remote Kimberley region of Western Australia, and a large tertiary ED in sunny Perth. He has been a guest skeptic on the SGEM multiple times. He is also the creator of the amazing #FOAMed website, Broome Docs. Dr. Casey Parker Case: It is a steady Saturday afternoon in your rural emergency department (ED). The triage nurse calls you to have a look at a child who has arrived with his parents in ED after falling from a bouncy castle at a birthday party. He is six years old and appears to be in pain with his left wrist swaddled in an ice pack. He tells you that he was attempting “a double backflip like Spiderman” when he landed heavily on the outstretched hand - this happened about an hour ago. Clinically there is some swelling and tenderness over the distal radius but no deformity. He has good perfusion and no neurological symptoms in the hand. Because it is a small, rural ED there is no radiographer on site but they can be called in if we would like to get an X-ray…. or there is a portable bedside ultrasound machine in the next room ready to go. The child’s mother tells you that the X-ray tech was also at the party having a great time with her children. So, the question is: should we call in our x-ray tech in and disrupt her party fun or just use the ultrasound machine to diagnose this possible fracture? Background: We have covered pediatric wrist fractures a few times on the SGEM. This includes SGEM#19 way back in 2013 reporting a bandage wrap is a safe alternative to traditional casting for children with greenstick fractures. More recently, the amazing Dr. Tessa Davis covered the FORCE trial on SGEM #372 which looked at buckle fractures and compared immobilization in a cast or splint vs. a soft bandage and they found no difference in pain scores or functional outcomes. The use of bedside ultrasound to diagnose uncomplicated wrist injuries in children has been studied in several diagnostic prospective, observational trials to compare its accuracy to traditional plain film X-rays [1-5]. Most of these trials have shown diagnostic sensitivity and specificity above 90% when compared to X-ray as a gold standard. This same research team from Queensland in Australia have also published a paper describing the learning curve for novices in detection of forearm fractures in kids [6]. In 2022 Mobasseri et al published a review of 9 such diagnostic studies and concluded that from an orthopedic perspective that the accuracy was not acceptable, the lack of a randomized controlled trial meant that there was not enough data to support the use of ultrasound over X-ray as an initial diagnostic test [7]. There have been no randomized trials that have compared the patient-centered, functional outcomes after a wrist injury based upon the choice of initial diagnostic test modality. Clinical Question: In children with non-deformed distal forearm injuries, does the use of ultrasound as an initial diagnostic test result in inferior functional outcomes? Reference: Snelling et al. Ultrasonography or radiography for suspected pediatric distal forearm fractures. New England Journal of Medicine June 2023 Population: Children between 5 and 15 years of age who presented to the ED with an isolated, acute, clinically non-deformed, distal forearm injury for which imaging for a suspected fracture was indicated Excluded: obvious angulation/deformity (soft tissue swelling allowed), injury >48hr prior, external X-rays obtained, known bone disease, concern for non-accidental trauma, additional injuries requiring X-rays, congenital forearm abnormality, no credentialed clinician available, developmental delay or behavior prohibiting clinical assessment Intervention: Bedside ultrasound carried out and interpreted by a trained clinician (doctors, nurse practitioners and physiotherapists) Comparison: X-ray Outcome: Primary Outcome: Functional outcome at four weeks (± 3 days) post injury as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) score Secondary Outcomes: PROMIS scores at 1 week and 8 weeks post injury. They also analyzed the children by age cohorts 5 to 9 years and 10 to 15 years old There was also an analysis of the diagnostic accuracy of the ultrasound vs. X-rays. Satisfaction at 4 and 8 weeks (5-point Likert scale with lower scores indicating greater satisfaction) Pain at 1, 4, and 8 weeks using the FACES pain scale Frequency of complications Frequency of radiography Length of stay and treatment time in the ED Trial: Multicenter, open-label, noninferiority, randomized, controlled tria

Date: August 30, 2023 Reference: Griffey et al. The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics. AEM August 2023 Dr. Suchismita Datta 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. This is the last show for Season#11. It has been a great year with the addition of PedEM SuperHero Dr. Dennis Ren. We have some exciting news to cap off the end of this amazing year. Suchi will be joining the SGEM faculty as part of the Hot Off the Press team. Case: A 28-year-old male with a history of type-1 diabetes mellitus presents to the emergency department (ED) with increase in thirst and light headedness. He is otherwise healthy. Blood glucose in triage is 489 mg/dl (27.2 mmol/L). Venous blood gas (VBG) shows an acidosis with a pH of 7.21. Electrolytes show a gap of 21. The patient’s symptoms begin to improve after initial intravenous (IV) fluid administration of one litre of 0.9% saline. The patient states he has had multiple “diabetic emergencies” in the past and usually ends up in the intensive care unit (ICU) on a drip. He is wondering, “Hey doc, do I have to go back to the ICU strapped to an IV pole?” The flow nurse has similar questions for you and wants to know if she should clear out a bed in the critical care bay so that the patient can have appropriate nursing requirements for an insulin infusion. Your resident is eager to go ahead and sign off on the diabetic ketoacidosis (DKA) insulin order set and the ICU attending’s “Spidey senses” are going off. They are on the phone asking you if you already have another admission for them on this busy day. However, the ICU is full and the patient will likely be boarding in your ED for a bit before coming upstairs. Just as all this is happening, you notice how the waiting room is filling up and you can hear the sirens of approaching ambulances becoming louder. You take a deep breath, and you think to yourself…let the squid games begin. Background: DKA is a common yet potentially fatal condition seen in patients with type 1 diabetes. It accounted for roughly 8.9 ED visits /1000 adults with diabetes [1]. DKA results in over 500,000 annual hospital days with estimated annual hospital costs of over $5 billion [2]. Dr. Nathan Kuppermann Despite how common and expensive the management of DKA can be, we have only looked at it once on the SGEM. That was an episode covering the practice changing randomized control trial published in NEJM by Dr. Nathan Kuppermann from the PECARN Team for pediatric DKA [3]. They reported that the type of intravenous fluids (0.45% NaCl or 0.9% NaCl) or speed of infusion did not appear to make a clinically important difference (SGEM#255). Because of the complexity of care around managing DKA, the typical approach is an insulin drip with ICU level of care for all degrees of severity. Increased resource utilization around this can prolong ED length of stay, especially in the context of a busy hospital or a global pandemic. However, over the past 20 years, there is burgeoning evidence that fast-acting subcutaneous insulin analogs could be a potential treatment option for mild to moderate severity DKA including a 2016 Cochrane SRMA [4]. If proven to be a safe and effective management strategy, this would eliminate the need for an insulin drip and opens new options for management and disposition of DKA patients from the ED. Using fast-acting subcutaneous insulin could streamline care in the ED and decrease the length of stay (LOS) in the department. This reduction in LOS is desirable for many reasons including overcrowding, prolonged wait times, and the availability of ICU beds for other critical patients. Clinical Question: Can a patient with mild to moderate severity DKA be safely managed with subcutaneous fast acting insulin analogs on a non-ICU floor with blood glucose monitoring every two hours, and ultimately decrease ED length of stay? Reference: Griffey et al. The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics. AEM August 2023 Population: Non-pregnant, adults (18 years and older) who are presenting with mild to moderate [MTM] DKA Excluded: Pregnant patients, patient younger than 18, patients with concurrent infections, patients with active co-morbidities [ESRD, CHF, active use of immunosuppressants), concerns for myocardial infarction, altered mental status, need for surgery, or at the discretion of ED team if patient deemed to be too sick for the designated floor [which was an OBS floor run by hospitalist]. Intervention: SQuID protocol – Sub Q insulin and admission to predesignated floor Comparison: MTM patients who receive traditional treatment during intervention period, MTM patients who received traditional treatment pre-intervention period, and MTM patients who received traditional treatment pre-COVID [three t

Date: August 20th, 2023 Reference: Milne WK, Challen K, Young T. Skeptics' Guide to Emergency Medicine Season #10 Book Dr. Kirsty Challen Guest Host: Dr. Kirsty Challen is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). She completed undergrad and postgrad training in North West England, acquiring a History of Medicine BSc, a PhD in Health Services Research, an anesthesiologist husband and four children along the way. She is Chair of the Royal College of Emergency Medicine Women in Emergency Medicine group, and involved with the RCEM Public Health and Informatics groups. Kirsty also produces all those wonderful Paper in a Pic Infographics summarizing each SGEM episode. Dr. Tayler Young Guest Skeptic: Dr. Tayler Young is a second year Family Medicine resident at Queen’s University in Kingston, Ontario, Canada. Her interests are quality improvement, Free Open Access Medical Education (FOAMEd) and point of care ultrasound (POCUS). This is an SGEM Xtra to announce that SGEM Season #10 is now available as a FREE pdf book. The SGEM provided the content and Tayler designed the book. She has designed infographics for the Emergency Medicine Ottawa Blog and has summarized SGEM Season #8 and Season #9 with the Avengers and Batman themes. Tayler chose a Harry Potter theme for Season #10 as she is a huge fan of the films and the books. Her favorite character is Norbert the dragon who was secretly hatched by Hagrid in Book 1. Kirsty's favourite character from the Harry Potter series (being a woman in academic EM, still a male-dominated world – see SGEM #352 on the gender pay gap and our Xtra from October 2021 with the wonderful Dr. Suchi Datta about gender inequity) is Hermione Granger. She is the competent skilled witch who faces pushback for knowing the answers and ostracism for not fitting in. She also confesses to having a soft spot for Neville Longbottom, who is quietly ignored and disregarded until trouble really happens and he comes through with the sword of Gryffindor. SEASON #10 Foreword by Dr. Kirsty Challen Harry Potter arrived in our consciousness in 1997 as an unsupported orphan venturing into the magical world for the first time, facing the ever-present but initially under-appreciated threat of Voldemort with Ron and Hermione. The Skeptics Guide to Emergency Medicine was a few years behind, emerging into the #FOAMEd-o-sphere in 2012, but as Harry and his world developed through the books, so has the SGEM. This 10th Edition arrives as advocates of Evidence-Based Medicine continue to tackle the forces of misinformation and pseudoscience. Like Voldemort rising slowly back to power, many in the Ministry of Magic office of academic medicine failed to spot or believe the level of influence social media would have in the world of 2023. Ken Milne was an early adopter of using social media to narrow the knowledge translation gap and reduce the time it takes for quality research to percolate into clinical practice. This isn’t always easy; as Dumbledore says in the Goblet of Fire “there will be a time when we must choose between what is easy and what is right”. As clinicians it might sometimes seem easier to adopt the line of least resistance; blindly and unthinkingly to follow the “rules” of specialty guidelines or the preferences of consultants. But things are not always what they seem; many initially promising treatments fail to translate to benefit in the longer term and it can be tricky to know which is the Scabbers (apparently benign and well received, eventually found to be treacherous and deadly) and which is the Snape (initially unpleasant but at his core hugely valuable). Dr. Dennis Ren As Harry’s group of friends and allies grew wider through the books, so Ken has grown the SGEM faculty; the rotating cast of the SGEM-HOP has been joined by Dennis Ren leading SGEM-PEDS and an ever-increasing number of guest skeptics from many backgrounds (no exclusion of the mudbloods here) ensuring a clinician- and patient-relevant gaze is cast on the medical literature. The structured critical appraisal provides readers and listeners with a Marauder’s Map to see through the complexity and (sometimes) obfuscation of published articles and reach their own, sometimes surprising, conclusions. Like Voldemort (or Harry) some things never seem to die; this 10th edition features the perennial topics of where, if anywhere, thrombolytic agents should feature in the management of ischemic stroke, plus whether the choice of crystalloid for resuscitation really matters at all. New topics with wider relevance also appear, including the strength of the overall evidence base in Emergency Medicine and Orthopedics, and the persistent gender gap in EM remuneration. Even Ron Weasley recognises “when in doubt, go to the library”. Emergency clinicians are well advised “when in doubt, listen to or read the SGEM”. You too can be a skeptic, Harry! SGEM S

Date: August 14, 2023 Reference: Ma et. al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet 2023 Guest Skeptic: Dr. Mike Pallaci is a Professor of Emergency Medicine (EM) for the Northeast Ohio Medical University, and an Adjunct Clinical Professor of EM for the Ohio University Heritage College of Osteopathic Medicine. He has been program director for two EM residency programs, and is currently a core faculty member for the EM residency at Summa Health System in Akron, OH, where he also serves as the Medical Director of the Virtual Care Simulation Lab. This episode originated because of a thread Mike posted on the social media site formerly known as Twitter. The tweet said: “I am sick and tired of some non-EM docs/specialists slamming EM when we don’t aggressively lower BP in ICH.” It certainly got a lot of attention. It got a lot of attention both on the positive side (mostly from EM docs who share the frustration) and on the negative side from some neurologists who didn’t seem to particularly care for the premise of the tweet or for the generally positive response. It started out with venting on Twitter about an unpleasant interaction with one of Mike's partners and turned into a week-long discussion that culminated in an invitation to be the guest skeptic on the SGEM to critically appraise INTERACT-3. Mike backed up his position on blood pressure (BP) lowering using evidence. Specifically, he pointed out that the evidence behind the guidelines re BP management in intracranial hemorrhage (ICH) is relatively weak. This received a mixed response on Twitter. Most EM physicians shared the frustration and made positive comments. Some neurologists disagreed with the premise of the tweet and challenged it. I responded by posting the 2013 SGEM episode on INTERACT-2 (SGEM#73) which showed no statistical difference between intensive (<140 mmHg) and guideline directed (<180 mmHg). In 2017, the SGEM reviewed the ATACH-2 trial (SGEM#172) which showed similar results. A meme was also posted of Charlton Heston from the classic movie the Ten Commandments. It emphasized that GUIDElines are not GODlines. The literature should inform and guide our care, but it should not dictate our care. This is a core principle of evidence-based medicine (EBM). Often the available evidence on a specific medical question is weak. We still need to apply our clinical judgement and ask the patient about their values and preferences. Case: A 67-year-old male presents to the emergency department obtunded with left hemiplegia. Symptoms began just prior to presentation. His blood pressure (BP) is 194/110 mmHg. CT reveals a hemorrhage in the right internal capsule, suggestive of acute hypertensive hemorrhagic stroke. Should the blood pressure be treated? If yes, what should the target blood pressure be? How quickly do we want to get there? And are there any other physiologic variables we want to be aggressive about controlling in the early treatment window? Background: We have covered the common issue of elevated BP after ICH on SGEM#73 and SGEM#172. The 2022 AHA/ASA guidelines give several recommendations on this topic. The class (strength) of their recommendation is 2a/2b based upon Level B and Level C quality of evidence. It is really important to pay attention to the specific language used in the guidelines. First of all, as we’ve already covered, a guideline is something developed by humans giving their best interpretation of the evidence to serve as a guide, not something given to Moses on Mount Sinai. But that point aside, the basis of this discussion was that the strength of the evidence behind these guidelines and the strength of the recommendations in the guidelines themselves are frequently misunderstood and/or misrepresented by our consultants. The specific language used in the guidelines is as follows: “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” They give this a Class 2a recommendation, “Moderate”: is reasonable, can be beneficial; Level of Evidence C-LD (Limited Data). We would say than it would also be reasonable not to acutely lower the BP “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.” This was a Class 2b recommendation, “Weak”: may be reasonable, may be beneficial, effectiveness not well established; Level of Evidence B-R (Randomized; moderate quality evidence from 1 or more RCTs or meta-analyses of moderate-quality RCTs). Listeners to the SGEM know when the word “may” is used it c

Reference: Easter JS et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Annals of Emergency Medicine 2014. Date: July 10, 2023 Guest Skeptic: Dr. Joe Mullally is a paediatric trainee in the Welsh paediatric training program and interested in Paediatric Emergency Medicine. He is a student in the Paediatric Emergency Medicine Masters Program through Queen Mary University in London in collaboration with the Don’t Forget the Bubbles team. Dr. Joe Mullally Background: Children have big heads proportionally to their body compared to adults which makes them more at risk of traumatic brain injury (TBI). Computerized tomography (CT) is commonly used in the emergency department in the diagnosis of TBI. But we’re always trying to balance the potential harms and potential benefits in medicine. A CT scan does mean radiation to the pediatric brain which can increase the risk of leukemia or brain cancer later [1]. Thankfully, clinically important intracranial injuries are rare in children [2]. So, should we CT scan children with minor head injury? The SGEM covered pediatric concussions and head imaging in SGEM #112 and the NEXUS II Pediatric Head CT Decision Instrument in SGEM #225. Today we’re talking about three other popular clinical decision rules (PECARN, CATCH, and CHALICE). But we also want to know, how do those rules compare to physician judgement? Clinical Question: What is the diagnostic accuracy of clinical decision rules and physician judgment in identifying clinically important traumatic brain injuries (TBI) in children with minor head injury? Reference: Easter JS et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Annals of Emergency Medicine 2014. Population: Children less than 18 years of age presenting with head injury to a level 2 pediatric trauma center in the United States between 2012-2013. These children have to have 1) history of signs of blunt injury to the head 2) GCS scores ≥13, 3) injury within the previous 24 hours prior to presentation, 4) physician concern for potential TBI Excluded: Heightened TBI risk (GCS<13, brain tumors, ventricular shunts, on anticoagulants, or had bleeding disorders), or if they presented >24 hours after injury Intervention: CT vs no CT Comparison: Comparison of PECARN, CHALICE, CATCH, physician judgement, and physician practice Outcomes: Primary Outcome: “Clinically important TBI” defined as death from TBI, need for neurosurgery, need for intubation >24hrs for TBI, or hospital admission >2 nights for TBI. Secondary Outcomes: TBI on scan TBI requiring neurosurgery (craniotomy, elevation of skull fracture, monitoring of intracranial pressure, or intubation for elevated intracranial pressure) Type of Study: Single center prospective cohort study Authors’ Conclusions: “Of the 5 modalities described (PECARN, CATCH, CHALICE, physician judgment and physician practice), only physician practice and PECARN identified all clinically important TBIs, with PECARN being slightly more specific. CHALICE was incompletely sensitive but the most specific of all rules. CATCH was incompletely sensitive and had the poorest specificity of all modalities.” 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? Unsure Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes How precise are the results? Fairly precise Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Funding of the Study. No financial conflicts of interest. Results: During the study period, 1,526 children with head injury presented to the ED, and they enrolled 1,062 (70%). The enrolled group had a median age of 6.1 years and 64% were male with 95% presenting with GCS of 15. In comparison the non-enrolled group had a median age of 5 years, 58% male, and 99% had GCS of 15. In summary, the enrolled group was a little bit older, with slightly higher proportion being male, and a bit fewer having GCS of 15. They ended up excluded another 53 mostly because they presented >24 hours from time of injury ending up with a total of 1,009 children included in the study. Key Results: Only PECARN clinical decision rule and physician practice had 100% sensitivity for detecting clinically important TBI. Fifty-two (5%) had injuries seen on CT scan. The most common were skull fractures but there were a few subarachnoid and subdural hemorrhages as well. Twenty-one (2%) had clinically important TBI. Only four (0.4%) required neurosurgical intervention. Selection

Date: July 21, 2023 Reference: McDonald et al. Patterns of change in prehospital spinal motion restriction: a retrospective database review. AEM July 2023 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: A 42-year-old is struck in the face by a slowly moving I-beam at work. He has a brief loss of consciousness (LOC) and then awakens and is ambulatory on scene. Emergency Medical Services (EMS) is called and on arrival the patient is walking but has obvious facial trauma and is complaining of some neck pain. He has midline neck tenderness but no limb numbness or paresthesia. As an EMS crew member, you are tasked with deciding what method of spinal motion restriction to use. Background: We have covered head injuries including concussions multiple times on the SGEM. This has included looking at the Canadian CT Head Rules/Tools (SGEM#106, SGEM#266, and SGEM#272). We have also covered concussions (SGEM#112, SGEM#331, and SGEM#362). Another core element of emergency department (ED) and pre-hospital care is the assessment for potential spinal injuries [1,2]. Patient care and positioning has evolved over time, previously routine spinal immobilization (SI) was with a cervical spine collar, placement on a long, rigid backboard, and straps or head blocks. Over time this has evolved to spinal motion restriction (SMR) with more variable use of cervical collars, patient positioning, and accessories such as head rolls and tape [3-4]. This has evolved due to recognition of some of the adverse effects of immobilization as well as limitations to its benefits. The role of the cervical collar itself varies by jurisdiction and it is not entirely clear which devices and procedures are most effective at reducing potentially harmful spinal motion [5-11]. Existing research on SMR confirms decreases in the use of long backboards and increases in collar-only treatment [12-14]. Some of this research has observed substantial under-treatment among patients who met criteria for precautions, as well as some patients with confirmed injuries who received no treatment from EMS [15-16]. Other studies have observed no increase in the diagnosis of cervical spine injuries, however, variable practice and the possibility of patients not receiving appropriate treatment remains a concern [17-18]. In order for standards for acute management of spinal injuries to progress, we must optimize patient protection and limit harm [19]. Clinical Question: How has the rate of pre-hospital spinal immobilization/spinal motion restriction changed from 2009 to 2020? Reference: McDonald et al. Patterns of change in prehospital spinal motion restriction: a retrospective database review. AEM July 2023 Population: EMS patients with traumatic injuries Excluded: None Intervention: Spinal immobilization/spinal motion restriction Comparison: This is a retrospective review and includes several changes over time, thus the comparison is the change in rate over time of SMR Important Changes Were: In 2009, selective spinal immobilization using NEXUS criteria was implemented. In July 2012, changing documentation required paramedics to record the indications for SI/SMR in all cases. In November 2014, cases of isolated penetrating trauma were exempted from SMR. In April 2016, treatment guidelines were revised to allow for collar-only treatment in low-risk scenarios (patient ambulatory prior to paramedic arrival) Outcome: Primary Outcome: Rate of spinal immobilization/spinal motion restriction Secondary Outcomes: Rates of splinting and wound care as proxy measures of the incidence of trauma care over time. Patient and practice-related factors associated with potential changes over time. Patient related factors include age, sex, acuity, mechanism of injury and indications for treatment. Practice-related factors included cervical collar size, patient positioning, the proportion of collar only use, rate of treatment of penetrating trauma. Type of Study: Retrospective database review Neil McDonald This is an SGEMHOP and we are pleased to have the lead author on the show. Neil McDonald is an Advanced Care Paramedic in Winnipeg, MB, where he works as a Training Officer and Research Coordinator for the Winnipeg Fire Paramedic Service. He also holds a PhD in Applied Health Sciences and a cross appointment as Lecturer in the Department of Emergency Medicine within the Rady Faculty of Health Sciences at the University of Manitoba. Authors’ Conclusions: “This study shows decreasing SI/SMR treatment and changing patient and practice characteristics. These patterns of care cannot be attributed solely to formal protocol changes. Similar patterns and their possible explanations should be investigated elsewhere.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an app

Date: July 21, 2023 Reference: Prekker et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. NEJM 2023 Guest Skeptic: Dr. Jeff Jarvis is the Chief Medical Officer and System Medical Director for the Metropolitan Area EMS Authority in Fort Worth, Texas, also known as MedStar. He is board certified in both Emergency Medicine and Emergency Medical Services. Jeff discusses the application of research in EMS on his podcast The EMS Lighthouse Project. Case: You are an emergency physician caring for a 65-year-old male with a history of hypertension and diabetes who presented with altered mental status, fever, and labored breathing. You’ve found that he is septic and in respiratory failure and needs intubation. Your assessment is that the patient will likely be a physiologically, but not anatomically, difficult airway. You’ve assured appropriate physiologic optimization and pharmacologic preparation and are ready to intubate. Should you go with video or direct laryngoscope? Background: We have looked at this issue of intubation multiple times on the SGEM. The most recent discussion was about the use of etomidate as an induction agent (SGEM#405). The conclusion from that episode was it’s still uncertain if using etomidate decreases the patient-oriented outcome of survival with good neurologic function in critically ill patients requiring emergent endotracheal intubation. Missy Carter The SGEM has also covered prehospital intubation using supraglottic devices for out-of-hospital cardiac arrests (OCHAs) with PA Missy Carter (SGEM#247 and SGEM#396). The take home message from those two episodes was that the airway is less important in adult OHCAs. We should focus more on high-quality CPR and early defibrillation for shockable rhythms and less on type of supraglottic airway device. Chip Lange PA Using a bougie to increase the first pass success (FPS) rate was discussed on SGEM271. It showed the use of a bougie was associated with an increase in FPS. A hypothesized option of adding point of care ultrasound (POCUS) to our various methods of confirming correct placement of the endotracheal tube was covered on SGEM#249 with PA Chip Lange. We felt transtracheal sonography represents a potential fast and accurate way to help confirm endotracheal tube placement in conjunction with other methods. Intubation FPS is associated with fewer adverse events, most importantly hypoxia, hypotension, and cardiac arrest. Traditionally, intubation was performed using direct laryngoscopes (DL) in which the soft tissues of the airway were physically displaced allowing direct visualization of the larynx, epiglottis, and vocal cords followed by passage of an endotracheal tube. The challenging part of intubation using DL is usually visualization of the laryngeal structures while tube passage is relatively easy. Video laryngoscopes (VL) have been developed to improve the challenging part of DL, ie visualization. Literature and clinical experience demonstrate that visualization is typically improved with VL, however, tube passage can be more challenging because the laryngeal structures are indirectly visualized. The debate of DL vs VL goes back over a decade. We covered the issue with guest skeptic Dr. Steve Carroll on SGEM#75 (Video Killed Direct Laryngoscopy). That was an RCT from Baltimore Shock Trauma center comparing the two modalities. The primary outcome was no statistical difference in survival to hospital discharge between the two groups. The SGEM bottom line at the time was VL leads to the same outcome as DL in trauma patients. VL takes longer to accomplish and may be associated with higher mortality in patients with severe head injuries, however this relationship will require more study to confirm. The literature comparing FPS between DL and VL is mixed with some trials, primarily earlier ones, demonstrated either no improvement with VL or superiority with DL, and others, primarily later ones, demonstrating improvement with VL. As the availability and experience with VL has grown, the question remains… does DL or VL use result in higher FPS. Clinical Question: In adult patients needing intubation in an ED or ICU, is FPS higher with DL or VL? Reference: Prekker et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. NEJM 2023 Population: Adult patients 18-years-old and older seen in one of 17 academic ED or ICU needing endotracheal intubation for any reason. Exclusions: Under 18, pregnant, a prisoner, or there was inadequate time to allow for study randomization and enrollement. They were also excluded if, in the opinion of the treating physician, use of VL or DL is clearly either indicated or contra-indicated. In other words, the physician must feel that there is equipoise between DL and VL meaning that they have substantial uncertainty about whether DL or VL would result in better chances of FPS.Prehospital intubations were not included, nor were intubations performe

Date: 15 June 2023 Guest Skeptic: Dr. Samina Ali is a pediatric emergency medicine physician, clinician scientist, and Professor of Pediatrics and Emergency Medicine at the University of Alberta in Edmonton. Her research focuses on improving assessment and treatment of pain in children. She is an executive member of Pediatric Emergency Research Canada (PERC), pain content advisor for TREKK and faculty member of BEEM. Dr. Samina Ali Background: Pain, a common acute and chronic complaint that we see a lot in the emergency department. Whether it is a broken bone, a laceration, abdominal pain, sickle cell vaso-occlusive pain episode, emergency department physicians are familiar with patients experiencing pain, but do we always do a good job at addressing it? The answer is no, especially in vulnerable groups like the seniors [1], certain ethnicities [2], patients with mental health issues [3], and pediatric patients [4,5]. While addressing pain, we sometimes must perform medical procedures which lead to…more pain. This issue is magnified in children where even placement of an IV can be traumatic and painful for a child who does not understand why they’re getting poked. The emergency department can be a painful place to be… We have covered pediatric pain management on the SGEM multiple times. Peds EM superhero, Dr. Anthony Crocco from McMaster University, did one of his rants on pediatric pain. SGEM#78: Sunny Days (Pediatric Pain Control) SGEM#123: Intranasal Fentanyl – Oh What a Feeling SGEM#242: Pain, Pain, Go Away – IN Ketamine vs. IN Fentanyl for Pediatric Pain Management SGEM#378: Keepin’ It REaL when Treating Pediatric Migraine Patients SGEM Xtra: RANThony#3 - Paediatric Pain It is estimated that 1 in 5 children develop chronic pain before childhood. Pediatric pain is one of the costliest chronic conditions, even more so than asthma and obesity [6]. When admitted, children experience an average of 6.3 painful procedures per day and this goes up to 12 in the ICUs! Although evidence-based best practices for addressing pain in children have been published all over the world, we still often fall short. Some of the most serious consequences of untreated pain in children occur much later than the procedure itself. For example, a child who is scared to get an IV: One might think we can hold the child down, bundle them up, and just quickly get it over with, as they need their antibiotics/iv fluids. On that day, we might hear crying and stress from the child, but they will likely settle down and we have successfully delivered out treatment. But there are consequences to this. Poor pain management contributes to avoiding medical care in the future and even vaccine hesitancy [8,9]. This same child, if unvaccinated, may present with serious vaccine-preventable illnesses, require more time and resources for every fever. There is also psychological trauma for the patient, their families, and the healthcare workers who care for them. Sometimes, healthcare workers think that treating children’s procedural pain takes up precious ED time, like waiting for a topical anesthetic to work. In fact, using pain relief for procedural pain leads to less repeat procedures, better ED flow and shorter lengths of stay. Importantly, children who experience chronic pain are more likely to have mental illness, opioid use, and socioeconomic disparities in adulthood. Canada creates 15% of the world’s pediatric pain research, so it made sense that we would be the first country in the world to create a national standard. This new standard is divided up into four main themes. Make pain matter: creating a framework to provide better pain care and employing continuous Quality Improvement (QI) Make pain understood: education and knowledge sharing Make pain visible: pain assessment Make pain better: individualized care plans & multi-modal pain strategies Tune into the podcast to hear Dr. Ali's answers to my questions below: Working Group and Technical Group Members There were many stakeholders involved in the creation of this standard (emergency medicine, anesthesia, psychologists, and chronic pain physicians, nurses, physical therapists, pharmacists, child life, patients, and families. Working with such a multi-disciplinary group, was there any insight provided by a non-physician member that you found particularly enlightening? Make Pain Matter The framework includes six main points: People-centred care and building trust Policies for pediatric pain management Culture of patient safety and incident reporting Pain education curriculum Variety of validated pain assessment tools Goals and objectives for QI around pediatric pain management. Can you give some examples at your own institution of these practices in action? There are many challenges healthcare is currently facing. How do you convince organizational leaders that pediatric pain management should be a priority? Make Pain Understood This section emphasizes education around health ineq

Date: July 6, 2023 Reference: Hanula R et al. Evaluation of oseltamivir used to prevent hospitalization in outpatients with influenza: a systematic review and meta-analysis. JAMA Int Med 2023. Guest Skeptic: Dr. Anand Swaminathan is an Assistant Professor of Emergency Medicine at Staten Island University Hospital. Managing editor of EM:RAP and Associate Editor at REBEL EM. Case: A 57-year-old woman with hypertension, hyperlipidemia and type-2 diabetes mellitus presents to the emergency department (ED) with fever, cough, myalgias, headache and congestion. It’s flu season and you’ve already seen 15 people with the same symptoms. Her vitals look good: Temperature 38.5C, heart rate 102 beats/minute, blood pressure 143/88 and oxygen saturation of 99% on room air. She is breathing comfortably without any increased work of breathing. You send off COVID and flu swabs and the results come back as positive for influenza. She looks well enough to go home but asks if she should be prescribed oseltamivir (Tamiflu) because some of her friends have been given it recently by their doctors. Background: Oseltamivir was approved by the FDA in 1999 based on evidence from trials funded by the maker of the drug, Roche. Safety issues popped up soon after widespread use of the drug including neuropsychiatric effects as well as the more common adverse effects of nausea and vomiting. The Cochrane collaboration published analyses of the available data in 1999, 2003 and 2006. In 2009, the Cochrane group questioned Roche about the completeness of the data and after four years of requests, finally got access to all the data in 2013 and updated their review in 2014. We covered this SRMA on SGEM#98. The 2014 Cochrane review found an improvement in time to first alleviation of symptoms in adults by about 17 hours coupled with several side effects including nausea, vomiting, headaches, and neuropsychiatric effects. Despite these findings, the World Health Organization (WHO), Infection Disease Society of America (IDSA) and the Center for Disease Control and Prevention (CDC) all continue to recommend use of oseltamivir, particularly in patients at increased risk of hospitalization and bad outcomes. There was a large unblinded RCT of over 3,000 patients published in the Lancet in 2020. It looked at patients presenting to their primary care physician with influenza. The results were those treated with oseltamivir recovered about one day earlier than the control group but experienced more nausea and vomiting. This was critically appraised on SGEM#312. A subgroup analysis of the Lancet RCT showed that older, sicker patients with comorbidities and longer previous symptom duration recovered 2–3 days sooner. While this is interesting it should be considered hypothesis generating. Wallach et al JAMA Intern Med 2017, previously reported that subgroup claims are often not corroborated by subsequent studies and rarely confirmed. Also, Yusuf et al JAMA 1991 stated: “the overall trial result is usually a better guide to the direction of effect in subgroups than the apparent effect observed within a subgroup.” When it comes to children suspected of influenza and ill enough to be admitted to hospital there was an observational study looking at the impact of oseltamivir (JAMA Ped 2022). SGEM Peds expert Dr. Dennis Ren did a structed critical appraisal of that study on SGEM#397. The bottom line from that episode was we do not have high-quality evidence to support the routine use of oseltamivir in the treatment of children admitted to hospital with suspected influenza. Clinical Question: Is oseltamivir effective in preventing hospitalization from influenza in adults and adolescent outpatients? Reference: Hanula R et al. Evaluation of oseltamivir used to prevent hospitalization in outpatients with influenza: a systematic review and meta-analysis. JAMA Int Med 2023. Population: RCTs of outpatients 12 years and older diagnosed with natural influenza infections based on clinical history and laboratory evidence (PCR or 3x increase in antibody titers at 30 days). Exclusions: Observational studies Intervention: Oseltamivir 75 mg BID X 5 days Comparison: Placebo or standard care Outcome: Primary Outcome: Hospitalization during the treatment or follow-up period for any cause or duration (Emergency department visits did not count). Secondary Outcomes None Safety Outcomes: Adverse events including nausea, vomiting, diarrhea, cardiac, psychiatric, neurologic or a composite of any gastrointestinaI symptoms Authors’ Conclusions: “In this systematic review and meta-analysis among influenza-infected outpatients, oseltamivir was not associated with a reduced risk of hospitalization but was associated with increased gastrointestinal adverse events. To justify continued use for this purpose, an adequately powered trial in a suitably high-risk population is justified.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The

Date: July 1, 2023 Reference: PATCH-Trauma Investigators and ANZICS Clinical Trial Group. Prehospital Tranexamic Acid for Severe Trauma. NEJM 2023. Guest Skeptic: Dr. Salim Rezaie is a community emergency physician in San Antonio, TX. He is the Creator and founder of REBEL EM, a free, critical appraisal blog that tries to cut down knowledge translation gaps of research to bedside clinical practice (https://rebelem.com). Case: A 48-year-old man involved in a motor vehicle collision (MVC) is being evaluated by paramedics. He was entrapped in his vehicle for over one hour, had an initial blood pressure of 78/46 mmHg, and appeared to have a seat belt sign with deformities to bilateral lower extremities. His Glasgow Coma Scale (GCS) score is 13 with obvious head trauma as well. Emergency Medical Services (EMS) calls in ahead of time to warn the facility that they are 20 minutes out, to give report about the patient, and ask whether they should give tranexamic acid (TXA) pre-hospital. Background: We have looked at the use of TXA many times on the SGEM. Most of the times the RCTs we critically appraised did not demonstrate superiority for their primary outcome. This has included: Post-Partum Hemorrhage (WOMAN): SGEM#214 Gastrointestinal Bleeding (HALT-IT): SGEM#301 Intracranial hemorrhage (TICH-2 and ULTRA): SGEM#236 and SGEM#322) Isolated Traumatic Brain Injury (CRASH-3): SGEM#270 Pre-Hospital TBI: SGEM#305 Epistaxis (NoPAC): SGEM#321 There is some evidence of efficacy for TXA in epistaxis (SGEM#55, SGEM#210, and SGEM#395). There is also the CRASH-2 trial from 2010 which was reviewed with our good friend Dr. Anand Swaminathan (SGEM#80). That classic practice changing paper showed a 1.5% absolute decrease in death in trauma patients receiving TXA vs placebo (NNT = 66). Despite these results, many clinicians remained skeptical of the benefit of TXA in trauma patients. One of the major criticisms of the CRASH-2 trial was it was performed in under-resourced trauma systems and therefore may not be generalizable to care in advanced trauma systems. Clinical Question: In advanced trauma systems, does the prehospital use of TXA increase the rate of survival with a favorable functional outcome in patients at risk for trauma-induced coagulopathy? Reference: PATCH-Trauma Investigators and ANZICS Clinical Trial Group. Prehospital Tranexamic Acid for Severe Trauma. NEJM 2023. Population: Adults (>18 years of age) with suspected severe traumatic injuries at risk for trauma induced coagulopathy (Assessed using the Coagulopathy of Severe Trauma [COAST] score) that could receive TXA within three hours of injury. Coagulopathy of Severe Trauma (COAST Score) Intervention: TXA 1g intravenous (IV) bolus over 10 minutes followed by 1g over 8 hours Comparison: 9% saline (same volume as TXA) administered as bolus and infusion over 8 hours Outcome: Primary Outcome: Survival with a favorable functional outcome at six months assessed using the Glasgow Outcome Scale – Extended (GOS-E) Secondary Outcomes: Death within 24 hours, 28 days, and 6 months after injury Safety: Risk of thromboembolic phenomenon (deep vein thrombosis, pulmonary embolism, myocardial infarction, or stroke) Glasgow Outcome Scale – Extended (GOS-E) Type of Study: International, randomized, double-blind, placebo-controlled trial Authors’ Conclusions: “Among adults with major trauma and suspected trauma-induced coagulopathy who were being treated in advanced trauma systems, prehospital administration of tranexamic acid followed by an infusion over 8 hours did not result in a greater number of patients surviving with a favorable functional outcome at 6 months than placebo.” 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. Yes 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. No Financial Conflicts of Interest. No Results: They included 1,310 trauma patients. The mean age was 44 years, 70% male, 92% had blunt trauma and the median Injury Severity Score was 29. Key Results: No statistical difference in favourable functional outcome at six months. Primary Outcome: Favorable functional outcome at six months TXA (53.7%) vs Placebo (53.5%); Risk Ratio (RR) 1.00; 95% CI 0.9 to 1.12 Secondary Outcomes: 24 Hour Mortality: TXA (9.7%) vs Placebo (14.1%); RR 0.69; 95% CI 0.51

Date: June 16, 2023 Reference: Reed et al. Pilot Testing Fentanyl Test Strip Distribution in an Emergency Department Setting: Experiences, Lessons Learned, and Suggestions from Staff. AEM June 2023 Guest Skeptic: Dr. Lauren Westafer is an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the 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 27-year-old right hand dominant patient presents to the emergency department (ED) with a 2.5 cm left forearm abscess. They have no fever, chills, or signs of compartment syndrome. You perform an incision and drainage of the abscess with significant improvement in pain. The patient reports injection use of opioids, last use was a few hours ago. The patient currently has no signs of withdrawal and is interested in potentially starting on methadone; however, the patient is not ready to start the medication right now. Background: We have addressed the issue of substance use disorder a few times on the SGEM. This included looking at alcohol misuse and opioid misuse. SGEM#55: Drugs in My Pocket (Opioids in the Emergency Department) SGEM#241: Wake Me Up Before You Go, Go – Using the HOUR Rule SGEM#264: Hooked on a Feeling - Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain SGEM#313: Here Comes a Regular to the ED SGEM#374: Bad Habits – Medications for Opioid Use Disorder in the Emergency Department Rises in opioid overdose deaths have been attributed, at least in part, due to increases in fentanyl contaminating the illicit opioids in the United States. EDs are an important touch point for individuals with opioid use disorder (OUD), given the number of encounters for overdose and complications associated with drug use. Although some patients may be ready for medication such as buprenorphine or methadone, which can be initiated in the ED, some patients may not be ready for either medication. In these cases, harm reduction practices, strategies that mitigate complications from drug use, are critical. Fentanyl test strips (FTS) have been suggested as one harm reduction strategy to reduce opioid overdose deaths. The American College of Emergency Physicians (ACEP) endorses greater harm reduction education for emergency physician . Fentanyl test strips can be used by people who use drugs (PWUD), prior to use, to detect the presence of fentanyl. Individuals can then use that information to decide if or how much of the drug to use. Clinical Question: What are the perspectives of clinicians and other staff distributing fentanyl test strips to people who use drugs in an ED setting? Reference: Reed et al. Pilot Testing Fentanyl Test Strip Distribution in an Emergency Department Setting: Experiences, Lessons Learned, and Suggestions from Staff. AEM June 2023 Study design: This was a qualitative study assessing staff perceptions of a pilot of distribution of fentanyl test strips. Staff meeting inclusion criteria (below) were invited to participate and rec Population: English speaking ED clinician (physician, nurse, advanced practice provider, technician, social worker, certified recovery specialist) distributing fentanyl test strips through the pilot program. Intervention: Interviews at two points in time, three weeks and three months after distribution of FTSs began Comparison: Not applicable Megan Reed PhD This is an SGEMHOP episode, and it is my pleasure to introduce Dr. Megan Reed. She is a PhD with a Master’s in Public Health. Megan currently works at the College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA. Authors’ Conclusions: “Implementing FTS distribution may improve patient rapport while providing patients with tools to avoid a fentanyl overdose. Participants generally reported positive experiences distributing FTS within the ED but the barriers they identified limited opportunities to make distribution more integrated into their workflow. EDs considering this intervention should train staff on FTS, how to identify and train patients, and explore mechanisms to routinize distribution in the ED environment.” Quality Checklist for Randomized Clinical Trials: Was there a clear statement of the aims of the research? Yes Is a qualitative methodology appropriate? Yes Was the research design appropriate to address the aims of the research? Yes Was the recruitment strategy appropriate to the aims of the research? Yes Was the data collected in a way that addressed the research issue? Yes Has the relationship between researcher and participants been adequately considered? No Have ethical issues been taken into consideration? Yes Was the data analysis sufficiently rigorous? Unsure Is there a clear statement of findings? Yes How valuable is the research? Valuable Funding/COI: Funding from Bloomberg P

Date: June 15, 2023 Reference: Rees CA et al. Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso-occlusive pain: A multicenter pediatric emergency medicine perspective. American Journal of Hematology Jan 2023 Guest Skeptic: Dr. Amy Drendel is a pediatric emergency medicine physician and physician scientist at Children’s Wisconsin. She is a Professor of Pediatrics and Interim Chief of the Section of Pediatric Emergency Medicine at the Medical College of Wisconsin. Her research interests include optimizing pain treatment in children. She has been a principal investigator and co-investigator on multiple collaborative grants evaluating effectiveness of analgesic regimens for children. Dr. Amy Drendel Case: A 14-year-old male with sickle cell disease (SCD) presents to your emergency department (ED) with a vaso-occlusive pain episode (VOE) of his bilateral legs and back. He tells you that he has had similar pain from previous VOEs, but his sister is graduating from high school tomorrow, and he really hopes he can go home so he can attend her graduation. He denies any fever or difficulty breathing. On exam, he appears uncomfortable with tenderness to palpation of the bilateral shins and lower back. The rest of his exam is unremarkable. As you begin ordering bloodwork and a dose of intravenous (IV) morphine, his nurse says to you, “He looks very uncomfortable. Do you want to give him a dose of intranasal (IN) fentanyl while we’re waiting for an IV?” Background: Children feel pain but are often under-treated. There are many options available to treat pediatric pain both pharmacologically (analgesics, NSAIDS, nerve blocks, sub-dissociative dose ketamine, and opioids) and non-pharmacologically (distraction, music, and splinting). [1-6] Children with SCD presenting to the ED with VOE require timely and effective pain control. Opioids are the primary therapy. The National Heart, Lung, and Blood Institute (NHLBI) released an expert panel report in 2014 with evidence-based guidelines for management of sickle cell disease recommending timely administration of parenteral opioids for VOE. [7] However, multiple barriers including ED crowding, boarding, and staffing shortage contribute to delays in care. IN fentanyl has been safely used to treat pain in pediatric patients. It offers a way to deliver analgesia without IV access. We have covered the use of IN fentanyl in children before in SGEM #123 and SGEM #242. Clinical Question: How does intranasal fentanyl for the treatment of vaso-occlusive pain episodes in children with sickle cell disease impact disposition? Reference: Rees CA et al. Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso-occlusive pain: A multicenter pediatric emergency medicine perspective. American Journal of Hematology Jan 2023 Population: Children aged 3-21 years old, with sickle cell disease (Hemoglobin SS disease or Hemoglobin Sβ Thalassemia) who presented with vaso-occlusive pain episodes to Excluded: Children with upper respiratory infection, concern for stroke or altered mental status, or head injury, acute chest Intervention: Intranasal fentanyl (50 mcg/mL) delivered via atomizer with maximum of 100 mcg Comparison: No intranasal fentanyl administration Outcome: Primary Outcome: Discharge home from the emergency department Secondary Outcomes: Dose and route of opioids administered, the time of opioid administration, non-steroidal anti-inflammatory drug administration, use of IV fluid, time of ED or triage arrival to first opioid administration, time of day patient presented to the ED Type of Study: Secondary analysis of a cross-sectional study from 20 academic pediatric emergency departments in the United States and Canada Authors’ Conclusions: “Children with sickle cell disease who received intranasal fentanyl for vaso-occlusive pain episodes had greater odds of being discharged from the emergency department than those who did not receive it.” 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? Unsure Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Unsure Do you believe the results? Unsure 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: No financial conflicts of interest Results: They included 400 patients with 54% being female. The median age was 14.6 years [IQR 9.8, 17.6]. Most patients (92%) had hemoglobin SS disease while the other 8% had Hemoglobin β Thalassemia. The overall rate of admission was 67%

Date: June 6th, 2023 Reference: Pines, Raja, Bellollo and Carpenter. Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules 3rd Edition Dr. Jesse Pines Guest Skeptic: Dr. Jesse Pines is the Chief Clinical Innovation at US Acute Care Solutions and a Clinical Professor and George Washington University and Professor of Emergency Medicine at Drexel University. In this role, he focuses on developing and implementing new care models including telemedicine, alternative payment models, and clinical programs involving new technology at USACS. Jesse has been on the SGEM before including these two episodes: SGEM#308: Taking Care of Patients Everyday with Physician Assistants and Nurse Practitioners SGEM#316: What A Difference An A.P.P. Makes? Diagnostic Testing Differences Between A.P.P.s and Physicians Please consider listening to the SGEM Xtra podcast with Jesse discussing the 3rd edition of Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules. I was honoured to be asked to write the foreword to this latest edition. Foreword Emergency physicians are many things but one of the most important things we try to be is great diagnosticians. Every shift we use limited information in a busy, chaotic environment to make decisions. Sometimes those decisions can mean life or death and need to be made quickly. We strive to be the best at exercising this important responsibility. This is the book that can help clinicians achieve that goal. The first and second edition of Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules is a resource I have used regularly through my career. It has made me a better diagnostician and better physician. Questions come up on every shift as to what evidence supports our actions. This fantastic book provides answers to those questions in a brief and helpful way. I am often accessing it for my own needs and as an educational resource for students. The third edition contains the foundational elements of providing excellent evidence-based medicine (EBM) care. The authors start by discussing diagnostic testing in the emergency department (ED). They explain the epidemiology and statistics behind diagnostic testing. They appropriately emphasize that clinical decision instruments are tools to guide care, not rules to dictate care. They touch upon the additional responsibility of being good stewards given the realities of limited resources. They also provide a chapter to help clinicians understand the direction of bias in diagnostic research. The third edition covers dozens of common and deadly conditions clinicians are faced with in the ED. This includes chapters on pediatrics, geriatrics, cardiac, neurological, surgical, trauma, infectious disease, and other conditions. There are four new chapters in the latest edition of the book: Skin and Soft Tissue Infection, Shared Decision Making, Cognitive Bias and Telemedicine Diagnosis. There are all wonderful additions to the book. My favourite new chapter is the one discussing Shared Decision Making (SDM). SDM goes beyond informed consent and recognizes the autonomy and agency of patients. We are making important decisions that must consider patients values and preferences. This is one of the three pillars of EBM. While we may be the experts at clinical medicine, patients are experts of their own personal experience. There are many examples of where SDM can be utilized in the ED with my clinical experience to enrich the therapeutic patient-physician alliance. If you want to provide patients the best care, based on contemporary evidence then this is your book. Previous Books Highlighted on the SGEM SGEM Xtra: Message in a Book by the SGU SGEM Xtra: Don’t Give Up – The Power of Kindness with Brian Goldman SGEM Xtra: The Danger Within Us SGEM Xtra: Relax – Damm It! SGEM Xtra: Season 1 to 10 PDF Books 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. Further Reading: SGEM#3: To X-ray or not to X-ray (Ottawa Ankle Rule) SGEM#5: Does Johnny “kneed” an X-ray? (Ottawa Knee Rule) SGEM#48: Thunderstruck (Subarachnoid Hemorrhage) SGEM#88: Shock Through the Heart (Ottawa Aggressive Atrial Fibrillation Protocol) SGEM#106: O Canada- Canadian CT Head Rule for Patients with Minor Head Injury SGEM#170: Don’t Go Breaking My Heart – Ottawa Heart Failure Risk Scale SGEM#201: It’s in the Way That You Use It – Ottawa SAH Tool SGEM#266: Old Man Take a Look at the Canadian CT Head Rule I’m a Lot Like You Were SGEM Xtra: Ian Stiell – Legend of Emergency Medicine Kohn MA, Carpenter CR, Newman TB. Understanding the direction of bias in studies of diagnostic test accuracy. A

Date: June3, 2023 Reference: Kotani et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. Journal of Critical Care April 2023 Guest Skeptic: Dr. Amber Gombash is an emergency physician in Concord, NC. Case: You have a critically ill patient that you are preparing to intubate and wonder if the use of etomidate as your induction agent increases mortality. Missy Carter Background: Intubation is something we have a covered a few times on the SGEM. There was an episode with Physician Assistant (PA) Chip Lange on the use of POCUS to confirm tube placement (SGEM#249). This got some feedback from our friend Scott Weingart over at EMcrit. Our usual go to guest skeptic for airway has been paramedic and PA Missy Carter (SGEM#247, SGEM#271 and SGEM#396). One aspect that has not been well covered on the SGEM is the choice of induction agent when intubating patients. There was an episode 10 years ago looking at the use of etomidate in septic patients (SGEM#44). It was a SRMA reporting an associated increase in adrenal insufficiency and all-cause mortality with the use of etomidate to intubate septic patients. A more recent SGEM episode looked at an unblinded single centre randomized trial comparing etomidate vs ketamine in adult patients requiring emergency endotracheal intubation (SGEM#356). The primary outcome was an 8% absolute increase in all-cause mortality at seven days for patients allocated to the etomidate group. This outcome was no longer statistically different at 28 days. There were multiple issues with this trial including a lack of masking (blinding), selection bias and the primary outcome measure of all-cause mortality at 7 days. Etomidate is often used as the induction agent in critically ill patients due to its fast onset and hemodynamically neutral nature. However, it is hypothesized that etomidate may increase the risk of organ dysfunction and death by the suppression of cortisol production through inhibition of 11-beta-hydroxylase. This goes back to at least 2009 the Ketased study. That trial found that in a critical care setting there was an increase adrenal insufficiency in the group receiving etomidate. There are now multiple randomized trials studying the effect of etomidate as an induction agent on adrenal function and mortality. These studies have reported mixed results—with some finding a statistically significant increase in mortality. There was a SRMA in 2021 that reported an associated increase in adrenal suppression and mortality with etomidate. However, this review combined high-level studies (five randomized controlled trials) with low-level studies (nine post hoc and 15 retrospective studies). Clinical Question: Does etomidate used as an induction agent cause an increased mortality in critically ill adults? Reference: Kotani et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. Journal of Critical Care April 2023 Population: Critically ill adults undergoing emergency endotracheal intubation for critical illness Exclusions: Pediatric patients < 15 years old, etomidate as an infusion (rather than induction/bolus dose), non-randomized trials, systemic reviews, commentaries/editorials and literature reviews, studies not addressing the review question Intervention: Etomidate Comparison: Any other induction agent Ketamine (4 studies), midazolam (4 studies), thiopental (1 study), ketamine + midazolam (1 study), ketamine + propofol admixture (1 study) Outcome: Primary Outcome: Mortality at the main timepoint defined by trial authors Timepoint: Intensive care unit (1 study), Hospital (5 studies), 24 hours (1 study), 7 days (1 study), 28 days (2 studies), 30 days (1 study) Secondary Outcome: Development of adrenal insufficiency Authors’ Conclusions: “This meta-analysis found a high probability that etomidate increases mortality when used as an induction agent in critically ill patients with a number needed to harm of 31.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. No The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Yes There was low statistical heterogeneity for the primary outcomes. Yes The treatment effect was large enough and precise enough to be clinically significant. Unsure Results: The authors identified eleven randomized trials that fulfilled their inclusion and exclusion criteria. These trials include a total of 2,704 patients. Of the eleven studies, the comparator was ketamine in four studies, midazolam in four studies, thiopental in one study, ketamine + midazolam in one study, and ketamine + propofol mixture in one study. Key Result: There is a high probability that etomidate increases mortality when used as an ind

Date: May 10, 2023 Reference: Harhay MO, et al. A bayesian interpretation of a pediatric cardiac arrest trial (THAPCA-OH). NEJM Evidence. 2023. Guest Skeptic: Dr. Kat Priddis is a paediatric emergency medicine consultant and trauma director at Watford General Hospital. She is part of the Don’t Forget the Bubbles team and faculty at Queen Mary University in London where she teaches part of the Paediatric Emergency Medicine MSc. Dr. Kat Priddis Case: You are working at the community emergency department (ED) when you receive a call from the local Emergency Medicine Service (EMS) team that they are bringing a 2-year-old boy who had a cardiac arrest at home. He had been having some upper respiratory symptoms in the previous days. Parents found him in bed that morning blue and unresponsive. They started cardiopulmonary resuscitation (CPR) until EMS arrived. Upon arrival at the ED, your team promptly begins high quality CPR and manages to obtain return of spontaneous circulation. As you are mentally running through your checklist for post-arrest care and preparing to transfer the patient, a team member tells you that there are potentially two hospitals in the area who may be able to accept the patient. One of the hospitals has a pediatric intensive care unit (PICU) that has the capability to perform therapeutic hypothermia but it’s further away. Which hospital should you transfer the patient to? Background: Therapeutic hypothermia in cardiac arrest has been covered on the SGEM multiple times, all the way back to SGEM #21 and SGEM #54 and most recently in SGEM #391. Ken and Justin Morgenstern of First10EM provided a very nice summary of the history of therapeutic hypothermia that you can check out, so we won’t belabor the point. Other therapeutic hypothermia trials included Target Temperature Management or TTM trial (SGEM #82), HYPERION (SGEM #275), TTM2 (SGEM #336). However, we have not covered the Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest (OHCA) in Children or THAPCA-OH published in the New England Journal of Medicine in 2015. We’re adding on a second paper looking at the Bayesian interpretation of the original study. Clinical Question: Does therapeutic hypothermia provide any benefit in neurobehavioral outcomes and survival in out-of-hospital pediatric cardiac arrest? Original trial: Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Engl J Med. 2015. Reference: Harhay MO, et al. A bayesian interpretation of a pediatric cardiac arrest trial(THAPCA-OH). NEJM Evidence. 2023. Population: 295 pediatric patients (ages greater than two days to less than 18 years) hospitalized in PICUs at 38 children’s hospitals, who were admitted after OHCA. Excluded: Inability to randomize within 6 hours of ROSC, Glasgow Coma Scale (GCS) motor score of 5 or 6, decision to withhold aggressive treatment by clinical team, traumatic arrest Intervention: Therapeutic hypothermia (target temperature 33°C). Comparison: Therapeutic normothermia (target temperature 36.8°C) Outcome: Primary Outcome: Survival with good neurobehavioral outcome at 12 months. Outcome defined by Vineland Adaptive Behavior Scales (VABS-II) of 70 or higher (this is a scale from 20 to 160 with higher scores associated with better function) Secondary Outcomes: Survival at 12 months and change in neurobehavioral function Other Outcomes: Global cognitive score, blood product use, infection, serious arrhythmias through 7 days, 28-day mortality Trial: Multinational unmasked randomized clinical trial Authors’ Conclusions Original Paper: “In comatose children who survive out-of-hospital cardiac arrest, therapeutic hypothermia, as compared to therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year.” Authors’ Conclusions Bayesian Interpretation Paper: “There is a high probability that hypothermia provides a modest benefit in neurobehavioral outcome and survival at 1 year.” 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). 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. Unsure. Financial conflicts of interest. Some investigators reported consulting fees from biomedical companies, but it did not seem there were obvious

Date: April 12, 2023 Reference: Edlow et al.Guidelines for Reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. AEM May 2023 Guest Skeptic: Dr. Jonathon Edlow has practiced emergency medicine for nearly 40 years and is a Professor of Emergency Medicine at Harvard Medical School. His academic interest is avoiding the misdiagnosis of patients with neurological emergencies. This is an SGEM Xtra and #SGEMHOP combined. We have reviewed the previous two GRACE guidelines published by the Society for Academic Emergency Medicine (SAEM). GRACE stands for Guidelines for Reasonable and Appropriate Care in the Emergency Department. This is the third GRACE project. GRACE-1 tackled the common issue of recurrent low risk chest pain (SGEM#337). This contrasts with other guidelines that only looked at a single emergency department presentation for chest pain. And GRACE-2 was about low-risk recurrent abdominal pain (SGEM#367). Now we come to GRACE-3. This time it was not a recurrent condition like chest pain or abdominal pain but rather acute vertigo or dizziness. The objective of the GRACE-3 guideline is to provide an evidence-based framework intended to support patients, clinicians, and other health-care professionals in their decisions about the evaluation and management of adult ED patients with acute dizziness who do not have an obvious central cause with frank neurological findings or an obvious general medical one. The population covered by these guidelines are adult patients presenting to the ED with acute dizziness or vertigo of less than two weeks. Let us clarify some terms because it is often not clear when what people mean by dizziness and vertigo. I tend to describe dizziness as light-headedness, unsteadiness, motion intolerance, imbalance, floating, or a tilting sensation. Dizziness in GRACE-3 was defined as the sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion (Barany Society). Vertigo in GRACE-3 was defined as the sensation of self-motion (of head or body) when no self-motion is occurring, or the sensation of distorted self-motion during an otherwise normal head movement. The problem is that research shows that patients often use multiple descriptors simultaneously or change their main descriptor if asked again less than 10 minutes later. So, although your concept is exactly what has been taught for decades, data from the last decade and a half show that it’s simply not true. The author group came up with 15 evidence-based recommendations based on the timing and triggers of the dizziness. Let’s go through those recommendations with the first one being an overarching one. 15 Recommendations from GRACE-3 Recommendation 1: Emergency clinicians should receive training in bedside physical examination techniques for patients with the AVS (HINTS) and diagnostic and therapeutic maneuvers for BPPV (Dix-Hallpike test and Epley maneuver), since untrained ED physicians do not reliably apply or accurately interpret results of this bedside eye movement examination. [Ungraded Good Practice Statement] HINTS stands for Head Impulse, Nystagmus, and Test of Skew. It was initially touted as a highly sensitive, specific marker for cerebellar stroke in the ED. However, study results have been mixed and there is ongoing debate about how to train for and utilize this examination in the acute care setting. A 2021 study [1] reported that EM physicians could be trained on the HINTS and it gave a sensitivity of 97% for central vertigo (SGEM#376). However, a SRMA [2] that included EM physicians showed less impressive results with a sensitivity of 83. The authors of the review felt the use of HINTS by EM physicians had “not been shown to be sufficiently accurate to rule out a stroke.” (SGEM#310). There is a clear disconnect between what is possible for emergency physicians to do and what we currently do in real life. It is possible that emergency physicians can learn to use these techniques (not only the HINTS exam, but also bedside maneuvers to diagnose and treat BPPV). This is consistent with my own anecdotal experience. What is equally clear is that without some sort of training or intentional activity to learn it, we do a pretty bad job in routine practice. Dr. Peter Johns has some great videos on YouTube to show clinicians how to do the HINTS exam. I don’t know this for sure, but I suspect that Peter, like me, picked this up by active learning, not by attending a training session. GRACE-3 goes on to help distinguish central from peripheral causes in patients with the acute vestibular syndrome (AVS). AVS is a clinical syndrome of acute-onset continuous dizziness lasting days to weeks and generally includes features suggestive of new, ongoing vestibular system dysfunction (e.g., nausea and vomiting, nystagmus, and postural instability). In the ED, patients are symptomatic even at rest, and exacerbation from head

Date: April 25, 2023 Reference: Walsh et al. Revisiting “Excited Delirium”: Does the Diagnosis Reflect and Promote Racial Bias? WJEM 2023 Dr. Brooks Walsh Guest Skeptic: Dr. Brooks Walsh is a former paramedic, and is currently an emergency physician in the Bridgeport Hospital, Yale-New Haven Health in Connecticut. This is an SGEM Xtra episode. Brooks reached out to me recently to see if we could revisit the issue of excited delirium. We had done a show on the topic five years ago on SGEM#218. At that time, we recognized there was no universally accepted definition of excited delirium. Please have a listen to the SGEM podcast to hear Brooks discuss the history of this issue and his recent publication. The American College of Emergency Physicians (ACEP) defined the term in 2009 as “acute delirium (not linked to dementia or preexisting pathologies) associated with extreme physical and psychomotor agitation”. The history of this issue goes back almost 200 years. Dr. Luther Bell described extreme agitation observed while he was the superintendent of the McLean Asylum for the Insane. The condition was named “Bell’s Mania” when published in the American Journal of Insanity (now American Journal of Psychiatry) in October, 1849 [1]. The term excited delirium syndrome (ExDS) was coined in the 1980s, after a flurry of deaths of individuals in custody or during arrests following extreme agitation [2]. ExDS usually involved men in their 30s after cocaine, methamphetamine, or ecstasy abuse [3-5]. Fast forward to 2008 when an ACEP resolution called for a group to study “excited delirium,” and to disseminate the paper to Emergency Medical Services (EMS) and law enforcement. The task force came up with a paper that was presented and accepted by the ACEP board in 2009. It was never published in a peer reviewed journal but it has been widely disseminated and cited. There is increasing awareness of the evidence that black men receive the diagnosis of ExDS more often than White men. Those black men who are labeled as having ExDS have a higher mortality than white men. Most recently, a report released by Physicians for Human Rights in March 2022 highlighted these concerns, attracting coverage from national new media. In emergency medicine, we try to be the physician who will treat anyone for anything at any time (hopefully without judgment). There has been an increased recognition of implicit and explicit biases in the house of medicine. This includes but is not limited to race, gender, age, and socioeconomic status. ACEP has made the equitable treatment of patients a priority, including recognition of the role that implicit bias exerts in EM [6]. A statement from ACEP described the death of George Floyd as a manifestation of a “public health emergency,” [7] and affirmed that “ACEP’s mission includes the promotion of health equity within the communities we serve.” Revisiting “Excited Delirium”: Does the Diagnosis Reflect and Promote Racial Bias? This brings us to the 2022 article called Revisiting "Excited Delirium": Does the Diagnosis Reflect and Promote Racial Bias? WJEM 2023 There were five key points raised in the article: Continuing lack of a clear definition for excited delirium Excited delirium is a health issue Excited delirium Is a health equity issue Racialized criteria for diagnosis “Just semantics?” Four actions were suggested in the article: Emergency medicine should avoid the concept of “excited delirium” Clinicians Should Use Established Medical Diagnoses ACEP Should “Retire” the 2009 Report Consider Greater Professional and Racial Diversity in Future Panels ACEP Task Force Report on Hyperactive Delirium with Severe Agitation in Emergency Settings 2021 ACEP published a task force report in April 2021 on Hyperactive Delirium with Severe Agitation in Emergency Settings. It said that “explicit discussion of ‘Excited Delirium Syndrome’ will only occur in the context of evidence surrounding its existence as a distinct pathophysiologic phenomenon”. It went on to say; “While the authors of this paper were informed by the 2009 paper, this work is de novo and not to be construed as an update or refutation of the 2009 paper”. National Association of Medical Examiners (NAME) 2023 NAME came out with a statement on this issue in March 2023. “Although the terms “Excited Delirium” or “Excited Delirium Syndrome” have been used by forensic pathologists as a cause of death in the past, these terms are not endorsed by NAME or recognized in renewed classifications of the WHO, ICD-10, and DSM-V. Instead, NAME endorses that the underlying cause, natural or unnatural (to include trauma), for the delirious state be determined (if possible) and used for death certification.” There was also a recent CBC story titled: Canadian coroners starting to reject excited delirium as cause of police-related deaths. ACEP Position Statement On Hyperactive Delirium 2023 Dr. Jeffrey Goodloe We have some other exciting news. ACEP has come out wi

Date: April 26, 2023 Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You are moonlighting at the Veterans Administration emergency department (ED) and are caring for an Iraq veteran complaining of post-traumatic stress disorder (PTSD) and severe anxiety. You desire a psychiatric consult and learn that you don’t have in-person consult availability at this facility, but instead use telehealth services. You wonder about how this compares to an in-person consult. Background: Mental health and behavioral complaints are common in the ED, but a shortage of mental health providers results in high numbers of patients requiring transfer, some of whom may have been appropriate for discharge. Telemental health (TMH) has been shown in settings outside the Veterans Administration (VA) to increase access to mental health providers, increase the proportion of patients discharged home, and decrease the number of patients transferred. However, what’s not well studied is the effect of TMH on post-evaluation utilization and processes of care such as medication changes, disposition, length of stay, involuntary holds, and use of chemical or physical restraints. Clinical Question: What is the effect of TMH, versus in-person consult, on 30-day outcomes and processes of care during the visit? Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023 Population: Veterans presenting to VA medical center (VAMC) EDs and urgent care centers (UCC) Intervention: Telemental health consult administered via iPad and Apple FaceTime software Comparison: In-person mental health consultation Outcome: Primary Outcome: Composite of 30- day return ED visits, 30-day return hospitalization after the index ED visit, and death from any cause. Secondary Outcomes: Number of medications changed, disposition, length of stay, involuntary hold, use of parenteral benzodiazepines or haloperidol, and use of physical restraints or seclusion Type of Study: Exploratory retrospective cohort study Dr. Jin Han This is an SGEMHOP episode which means we have the lead author on the show. Dr. Jin Han is an emergency physician with Vanderbilt University Medical Center in Nashville TN, and a researcher with the Geriatric Research, Education, and Clinical Center at the Tennessee Valley VA Healthcare System. Authors’ Conclusions: “TMH was not significantly associated with the 30-day composite outcome of return ED/UCC visits, rehospitalizations, and death compared with traditional in-person mental health evaluations. TMH was significantly associated with increased ED/UCC length of stay and decreased odds of placing an involuntary psychiatric hold. Future studies are required to confirm these findings and, if confirmed, explore the potential mechanisms for these associations.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results/is the estimate of risk? Fairly narrow CIs Do you believe the results? Yes Can the results be applied to the local population? No Do the results of this study fit with other available evidence? Yes Funding/COI: Grant from the Office of Rural Health of the Veterans Health Administration and National Center for Advancing Translational Sciences. There were no declared COIs. Results: They identified 496 veterans that met inclusion criteria. The mean age was 55, almost 90% were male and 27% were rural. High-risk chief complaint (suicidal ideation, homicidal ideation, agitation, or psychosis) was 29%. Of the cohort, 70% received TMH and 30% received in-person mental health evaluations. Key Results: No statistical difference in the primary outcome between TMH and in-person mental health evaluation. Primary Outcome: Composite 30-day return visits, rehospitalizations, deaths 4% TMH vs 17.3% In-Person: aOR 1.47 (95% CI; 0.87 to 2.49) Listen to the SGEM podcast to hear Jin answer our five nerdy questions. 1. External Validity: As with most VA studies, the cohort consisted mostly of middle-aged men. How much do you think this limits the external validity to other populations outside of the VA? 2. Baseline Demographics: There were several demographic differences between patients who received TMH and those who received an in-person consult. Do you have any thought

Date: April 20, 2023 Reference: Franklin D, et al. Effect of early high-flow nasal oxygen vs standard oxygen therapy on length of hospital stay in hospitalized children with acute hypoxemic respiratory failure: the PARIS-2 randomized clinical trial. JAMA 2023 Guest Skeptic: Dr. Michael Falk is a Pediatric Emergency Medicine attending at Mount Sinai Medical Center and Associate Professor of Emergency Medicine at the Icahn School of Medicine in New York. He is interested in simulation and medical education. Dr. Michael Falk Case: A 14-month-old boy presents to the emergency department (ED) with two days of upper respiratory symptoms and respiratory distress. He has a cough, fever of 38.5°C, runny nose and increased work of breathing that started today. He is breathing at rate of 48 breaths per minutes with intercostal retractions and oxygen saturation of 88%. His lung exam reveals bilateral wheezing, rhonchi but no focal findings. He is drinking well, and parents report normal urine output. He is suctioned and given trial of Beta agonist because has a history of eczema and a sibling with asthma with no change. Despite your interventions, he continues to breathe rapidly with an oxygen saturation of 89% on room air. You are working with an eager medical student, and she asks, “Should we start high flow nasal cannula (HFNC) at 2L/kg/min and admit the patient?” Background: Respiratory illnesses remain one of the most frequent causes of admission for children less than 5 years. Some of these illnesses result in acute hypoxemic respiratory failure. Historically, there were not many treatments for these children, and they were admitted for observation or intubated and started on mechanical ventilation. High flow nasal cannula (HFNC) started gaining popularity in the early 2000s as an option of noninvasive ventilation. We have covered the use of HFNC in pediatrics a few times on the SGEM including SGEM #228 and SGEM #379. Previous research has shown that HFNC can lower the rate of escalation of care but showed no impact on admission to the intensive care unit (ICU) or length of stay [1]. Clinical Question: Does the early use of HFNC reduce the length of hospital stay in pediatric patients with acute hypoxemic respiratory failure compared with standard oxygen therapy? Reference: Franklin D, et al. Effect of early high-flow nasal oxygen vs standard oxygen therapy on length of hospital stay in hospitalized children with acute hypoxemic respiratory failure: the PARIS-2 randomized clinical trial. JAMA 2023 Population: Children aged 1 to 4 years of age who presented across 14 emergency departments in Australia and New Zealand requiring hospital admission for acute hypoxemic respiratory failure Exclusion: There was a long list of exclusion criteria that you can find in the supplemental material, but these included craniofacial abnormalities, upper airway obstruction, cyanotic heart disease, tracheostomies, apneas, immediate high-level care in the ICU or required noninvasive or invasive mechanical ventilation. Intervention: HFNC at differing rates depending on weight Comparison: Oxygen via nasal cannula at 2L/min or by face mask up to 8L/min Outcome: Primary Outcome: Length of hospital stay defined as time from randomization to time of hospital discharge/death. Secondary Outcomes: Length of oxygen therapy from the time of randomization Length of hospital stay starting from arrival in the ED Proportion of children requiring a change in therapy on the general ward Proportion of children that required ICU admission or transfer to hospital with a pediatric ICU Proportion of children that required escalation of care to noninvasive or invasive ventilation Adverse events Tolerance of intervention Clinical triggers that warranted a change in that child’s care Type of Study: Multicenter, randomized clinical trial Authors’ Conclusions: “Nasal high-flow oxygen used as the initial primary therapy in children aged 1 to 4 years with acute hypoxemic respiratory failure did not significantly reduce the length of hospital stay compared to standard oxygen therapy.” 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. 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. Many of the authors had received

Date: April 12, 2023 Reference: Weizmann et al. Incidence of Cardiac Arrest During Sports Among Women in the European Union. JACC November 2022 Guest Skeptic: Dr. Susanne (Susy) DeMeester is an Emergency Physician practicing at St Charles Medical Center in Bend, Oregon. She has been very involved with EMRAP’s CorePendium as the cardiovascular section editor. Last time Susy was on the SGEM it was for an SGEM Xtra episode discussing gender issues related to cardiovascular disease. Here are five of the highlights from that episode: The leading cause for morbidity and mortality in both males and females is cardiovascular disease (CVD) Females are often excluded from being subjects in medical research, included CVD research Most male and female patients with myocardial infarctions still present with chest pain. However, women are more likely to have atypical presentations compared to men (shortness of breath, weakness, and fatigue). In addition to the usual cardiac risk factors, females also have other things that increase risk like pregnancy, hormone replacement therapy and autoimmune diseases Females diagnosed with acute coronary syndrome are less likely to receive timely therapies Case: You are reading through your social media feed and see a story that jumps out at you. It is a report of a seemingly invincible athlete who collapses on the field and dies of sudden cardiac death. It reminds you of the recent case of football player Damar Hamlin, who has thankfully recovered well. This story makes you wonder: when was the last time you heard of a sudden cardiac death in the female athlete? Background: Sudden cardiac arrest (SCA) is a rare but serious event that can occur in athletes during training or competition. While it can occur in both male and female athletes, the incidence is reported to be higher in male athletes. There are several reasons why SCA may be more common in male athletes than in female athletes. One reason is that male athletes tend to participate in sports that involve more physical contact and higher levels of exertion, which can put more strain on the heart. Additionally, male athletes are more likely to have certain genetic predispositions to heart conditions that can increase their risk of SCA. However, it is important to note that SCA can occur in female athletes as well, and it should not be ignored or overlooked. Females who participate in high-intensity sports should undergo appropriate cardiovascular screening to identify any underlying heart conditions that could increase their risk of SCA. Females are increasingly competing in recreational and professional sports. Little seems to be heard about SCA in these athletes. In fact, not surprisingly, there is a paucity of data on the subject. However, currently available evidence suggests we can improve our understanding of SCA in all athletes by examining sex-based differences. Clinical Question: What are the sex-based differences in sports related SCA? Reference: Weizmann et al. Incidence of Cardiac Arrest During Sports Among Women in the European Union. JACC November 2022 Population: Three large European registries that prospectively collect data on every case of SCA between 2006-2017. Sports-related (Sr) SCA was defined as occurring <=1 hour after ending a sports activity. Excluded: Patients not referred to registry and patients with SCA greater than one hour after cessation of sport. Intervention: There was no intervention as this was a prospective data analysis Comparison: Sr-SCA in men vs women Outcome: Incidence, characteristics, and outcomes in women vs men after episode of Sr-SCA Type of Study: Prospective observational registry study Authors’ Conclusions: “These findings emphasize the dramatically lower risk of Sr-SCA in women compared with men, despite similar subject characteristics. This should be considered in designing preparticipation screening strategies in the future.” 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? Fairly precise Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Funding of the Study: Funded by variety of scientific grants. There was also grant money from companies ie, Boston scientific, Medtronic, and Zoll, though authors did not have any relationships to disclose. Results: They were 34,826 cases of SCD between 2006-2017 in the three registries. A total of 760 (2.2%) were classified at as Sr-SCD. Of those cases, 54 women (7.1%) and 706 men (92.9%). Key Results

Date: April 4th, 2023 Reference: Vaughan and Browne. Reconfiguring emergency and acute services: time to pause and reflect. BMJ Qual Saf. 2023 Apr Guest Skeptics: Dr. Louella Vaugh is an internist practising as a hospitalist physician at an academic centre in London, UK with a special interest in smaller, rural and remote healthcare. Her main job is working for a think tank. John Brown PhD is a Professor of Health Services Research in Ireland who has been studying rural healthcare issues since 2012. This is an SGEM Xtra episode. There have been many “temporary” rural emergency department closures during the past last year. In Ontario alone there have been approximately 160 emergency departments (ED) temporarily closed since the beginning of 2022. This is something that has only happened once since 2006 (Ottawa Citizen March 28, 2023) The study referred to in the editorial looks at the experience in Denmark with a reconfiguration of their emergency healthcare services (Flojstrup et al 2023). The objective of that study was the following: To investigate how the’ natural experiment’ of reconfiguring the emergency healthcare system in Denmark affected in-hospital and 30-day mortality on a national level. The reconfiguration included the centralisation of hospitals and the establishment of emergency departments with specialists present around the clock. It was a stepped-wedge reconfiguration of the entire Danish emergency healthcare system. The main outcome was the adjusted odds ratio for in-hospital mortality and hazard ratio for 30-day mortality with some pre-specified subgroups. They found no statistical difference for in-hospital mortality but slightly increased 30-day mortality. The pre-specified subgroup analyses showed a decrease in in-hospital or 30-day mortality for myocardial infarction, stroke, aortic aneurysm, and major trauma but not for pneumonia, bowel perforation or hip fractures. This was not the only study to come out of the Danish reconfiguration initiative. The dataset also reported increasing admissions, mixed results on length of stay, increasing readmission rates, increasing COPD deaths if transported by ambulance, and expected productivity benefits were not realized. The SGEM advocated for having the evidence to inform/guide our decisions. Here is what the evidence say about the centralization of emergency healthcare services from the Danish study: some possible benefits for small groups of patients (myocardial infarction, stroke, aortic aneurysm, major trauma), there was no overall improvement in the in-hospital mortality trend and a slight worsening of the 30-day mortality trend. Five Assumptions Made about Emergency Healthcare Centralization Listen to the SGEM podcast to hear Louella and John discuss the five assumptions. Listed are the assumptions and some of the points we touched upon. Assumption#1: There is a problem with the quality of EM care that needs to be fixed Boarded patients length of stay (LOS) in the ED increases mortality Canary in the coal mine (fix the mine not the canary) COVID19 and staffing It’s about a system problem not a small hospital problem Assumption#2: Smaller hospitals provide worse care than their larger counterparts Myocardial infarction, stroke, and major trauma account for 1% of ED attendance Other skilled time-sensitive interventions (abdominal, vascular, obstetrical, and intracranial surgeries) still only amount to a total of 5% of ED attendance Little or no evidence that care in small hospitals is worse for 95% of cases Assumption#3: Reconfiguration produces better outcomes While studies of centralisation of care for individual services show better outcomes for specific patient groups, the population-level evidence for whole-scale reconfiguration through changes to ED services tells a different story. Two European studies and several studies in the USA. Renee Hsia has been looking at the impact of rounds of closures in California for nearly 20 years. At least 2 other national studies were conducted in the USA. There is also good evidence relating to the impact of service closure especially on maternity services Other studies have demonstrated that hospital closures affect socioeconomic, geographical and ethnic groups differently, with the burden of closures falling most heavily on the more vulnerable Assumption#4: Remaining organizations are minimally affected by reconfiguration Evidence suggests that the remaining hospitals often suffer from substantial negative ‘spillover effects’, with overall mortality actually rising for their emergency patients ED overcrowding with consequent increases in waiting times on trollies, increases in the pressures on ambulances services (time on the road, incidents and various other forms of ‘operational strain’. The biggest problems currently facing acute and emergency services internationally are rising admissions and overcrowding; These studies strongly suggest that removing any capacity from an already overstretc

Date: March 28, 2023 Reference: Fowler et al. Objective assessment of sleep and fatigue risk in emergency medicine physicians. AEM March 2023 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: You arrive at 7am to relieve your colleague after a night shift. You find her at the desk, asleep with her face on the keyboard, patient documentation half finished. As she tries to wipe the drool out of the keyboard, you ask how she has been sleeping recently. She confides that she is worried that fatigue might be impacting her care of patients. Background: This might come as a surprise to some listeners, but emergency physicians are frequently tired. Realistically, this episode may not require a background section. All emergency physicians are intimately aware of the impacts of shift work and the resultant poor sleep. However, as we struggle to cope with our constant exhaustion, we may lose track of the many detrimental effects of poor sleep. Our sleep schedules impact our overall health. Shift work is associated with increased rates of cancer, cardiovascular disease, and accidents. (Knutsson 2003) I imagine many of us know of a doctor who has been in a car accident when driving home from work. However, for most clinicians, it isn’t the personal risk that bothers us. The big concern is that fatigue impacts the care we provide for our patients. Even moderate levels of fatigue can impact performance similarly to being intoxicated with alcohol. (Dawson 1997) Industrial studies indicate errors increase by as much as 30-50% on night shifts. (Akerstedt 2010) Evidence is somewhat limited in medicine. We have mostly studied residents and how badly we treat them, while ignoring the plight of staff physicians. But there are numerous studies tying fatigue to clinical errors, impaired cognition, reduced empathy, and increased interpersonal conflict. Clinical Question: What is the percentage of time that emergency physicians spend in a fatigued state? Reference: Fowler et al. Objective assessment of sleep and fatigue risk in emergency medicine physicians. AEM March 2023 Population: A convenience sample of emergency physicians from a single academic emergency department. Intervention: Sleep periods were recorded with actigraphy, using a commercially available device that measures wrist movement. Comparison: None Outcome: A “Readiscore” fatigue score was measured before and during clinical shifts. This score consists of 3 factors: sleep quality, sleep duration, and sleep efficiency (total sleep time divided by total time in bed). This is an SGEMHOP and we are pleased to have two of the author on the show. Lauren Fowler PhD Dr. Lauren Fowler is a Professor of Neuroscience at Wake Forest University School of Medicine who teaches medical students not to be afraid of the Neuroscience module. Much of her work focuses on physiological variables related to circadian desynchronization and how fatigue affects healthcare worker cognition, empathy, burnout, and perceptions. She is also studying sleep, fatigue and cognition in cancer survivors (breast and prostate), with the aim of improving cancer survivor sleep to minimize detrimental effects of sleep loss on cognition, pain perception, and quality of life. Dr. Emily Hirsh Our other guest is Dr. Emily Hirsh. She is an Associate Professor of Emergency Medicine at the University of South Carolina School of Medicine Greenville. She also serves as the Director for Faculty Wellbeing in the Department of Emergency Medicine. She survived severe burnout, left academic medicine for a while, completed a two-year fellowship in Integrative Medicine, and then realized that she wanted to help transform the health care system into one that truly cares about the people that work within it, so that they can live their unique, noble desire to care for patients and be able to do so sustainably and happily for many, many years. Authors’ Conclusions: “Fatigue is an issue for many EPs. The present study addressed the percentage of time EPs are in a fatigued state when on shift over an extended duration of time. More research is needed to examine system-level interventions for reducing fatigue in EPs.” 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? Unsure Was the cohort recruited in an acceptable way? No Was the exposure accurately measured to minimize bias? NA Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? No Was the follow up of subjects complete enough? Yes How precise are the results/is the estimate of risk? Unsure Do you believe the results? Yes Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Funding? Prisma Health Sciences Center seed grant Results: Of 131 emergency

Date: March 22, 2023 Reference: Hilsden et al. Point of care biliary ultrasound in the emergency department (BUSED) predicts final surgical management decisions. Trauma Surg Acute Care Open 2022 Guest Skeptic: Dr. Casey Parker is a Rural Generalist that includes in his practice emergency medicine, anesthesia, and critical care. He is also now a fully-fledged “sonologist”. Casey currently splits his time between Broome, a small rural hospital in the remote Kimberley region of Western Australia, and a large tertiary ED in sunny Perth. He has been on the SGEM#369, SGEM#326 and SGEM#217. Case: A forty-year-old woman presents to the emergency department (ED) complaining of epigastric pain and nausea for 24 hours. The junior doctor has performed physical examination and blood work. She has some right upper quadrant (RUQ) tenderness on palpation and an elevated C-reactive protein (CRP) of 42. Her white blood cell count and liver function tests are normal. The very efficient junior doctor has arranged for a formal ultrasound, but this will be done later this afternoon, after six hours fasting. As luck would have it the admitting surgeon is currently in the ED seeing another patient. The supervising ED physician has been to a few training courses and is keen to try out his new sono-skills. This seems like a good case to try and decide if this patient has significant biliary disease such as acute cholecystitis or an impacted gallstone. A focused Biliary US in the ED (BUSED) may be all that is required to guide the surgeon’s decision-making for this patient. Do they need surgery, an ERCP or just analgesia and non-operative care? Background: The SGEM has reviewed the use of point of care ultrasound (POCUS) for a variety of conditions in the ED. This includes using ultrasound for small bowel obstructions (SGEM#373), shoulder dislocations (SGEM#288), appendicitis (SGEM#274), endotracheal tube placement (SGEM#249), retinal detachments (SGEM#245), skull fractures (SGEM#124), acute heart failure (SGEM#119), renal colic (SGEM#97), acute abdominal aneurysms (SGEM#94) and lumbar punctures (SGEM#41). One use of POCUS we have not covered yet is for diagnosing acute biliary disease. Ultrasound is usually the first line imaging modality for diagnosing acute biliary disease. As demonstrated in the list of SGEM episodes, ED clinician performed POCUS has been increasing in popularity over the years. Many small trials have compared the accuracy of POCUS to the “gold standard” of “Radiology-performed ultrasound”. The literature on POCUS for diagnosing acute biliary disease tends to compare the diagnostic accuracy of the sonography in each department. However, little is known about the actual decision-making process after POCUS evaluation. Clinical Question: When compared to point-of-care ultrasound, what is the value of formal radiology-performed ultrasound in terms of the surgical decision-making in acute biliary disease? Reference: Hilsden et al. Point of care biliary ultrasound in the emergency department (BUSED) predicts final surgical management decisions. Trauma Surg Acute Care Open 2022 Population: Adult ED patients 18 years of age or older with abdominal pain who the EM physician felt they had biliary disease after performing a history, physical examination, and POCUS Excluded: If surgery was completed prior to formal ultrasound imaging, failure to gain consent or age less than 18 years. Intervention: Surgical decision (offer surgery, ERCP/MRCP or no surgery) based upon the clinical, laboratory and POCUS data. The BUSED scans were performed by one of 11 specifically trained ED physicians. There were 20 surgeons 3 acute care, 4 colorectal, 4 hepatobiliary, 3 surgical oncology and 3 MIS/bariatric. Comparison: Surgical decision made after formal radiology ultrasound (RUS). Outcome: Primary Outcome: The primary outcome was the percentage of patients in which the management changed after RUS was performed. Secondary Outcomes: Clinical decisions based on surgeon subspecialty, biochemical markers, vital signs, and patient demographics. Type of Study: Observational, prospective cohort study performed at a tertiary care centre study in London, Ontario, Canada Authors’ Conclusions: "This prospective study has shown that in the vast majority of cases the additional information afforded by formal RUS does not alter clinical management. Point of care biliary ultrasound has been demonstrated to be reliable in the diagnosis of acute biliary disease and offers a safe and efficient diagnostic pathway for patients presenting in the emergency room.” 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? Un