The Skeptics Guide to Emergency Medicine

Date: February 27, 2023 Reference: Walsh PS, Schnadower D, Zhang Y, Ramgopal S, Shah SS, Wilson PM. Association of early oseltamivir with improved outcomes in hospitalized children with influenza, 2007-2020. JAMA Pediatr. 2022. Guest Skeptic: Dr. Marisu Rueda-Altez is a pediatric infectious disease fellow at Children’s National Hospital in Washington, DC. She is also the President of the Junior Section of the Society for Pediatric Research. Dr. Marisu Rueda-Altez Case: A 5-year-old child presents to the emergency department in the midst of flu season with three days of fever, upper respiratory symptoms, and malaise. His parents also report that he has lost his appetite and refusing to drink liquids. Nasopharyngeal PCR testing is positive for Influenza A. On physical exam, he is tired appearing and showing signs of respiratory distress with tachypnea and accessory muscle use. His lips look dry and cracked. His oxygen saturation is hovering around 88-90%. His chest radiograph does not demonstrate any focal opacities. After a discussion with his parents, you all agree that it is best for him to be admitted to the for IV hydration and close monitoring. His parents ask you, “A few years ago when we had the flu, we took a medication that helped reduce the length of our symptoms. Would he benefit from that too?” Background: Oseltamivir is recommended by the American Academy of Pediatrics, Infectious Diseases Society of America and Center for Disease Control and Prevention for the treatment of influenza in both adults and children. [1-3] Possible benefits include reduction in duration of symptoms and improvement of outcomes in hospitalized patients. Most of these recommendations are based on data from adult studies during the H1N1 pandemic with limited pediatric data. The SGEM has covered the use of oseltamivir for influenza on SGEM #98 and SGEM #312. Despite the recommendations from these various organizations, there remains some controversy (and skepticism) about the use of oseltamivir due to unpublished trial data, lack of access to the research data by the authors, and ghost-written papers. The BMJ was involved in a long legal battle with the manufacturer that you can read about here. Suffice it to say, that there were more harms than originally reported (including nausea and vomiting, neuropsychiatric events, headaches), and it is possible that the potential benefits were exaggerated.[4] Clinical Question: Will early administration of oseltamivir reduce length of hospitalization and complications of influenza infection? Reference: Walsh PS, Schnadower D, Zhang Y, Ramgopal S, Shah SS, Wilson PM. Association of early oseltamivir with improved outcomes in hospitalized children with influenza, 2007-2020. JAMA Pediatr. 2022. Population: Children <18 year from Pediatric Health Information System (PHIS) database hospitalized with Influenza from 2007-2020. Excluded: Transfers to other hospitals, repeated encounters (if >7 days between encounters, picked one at random; if <7 days, picked the first one), death/ECMO on day 0 or 1 to avoid immortal time bias. Exposure: Early administration of oseltamivir (HD 0 or 1) Comparison: Late administration of oseltamivir (HD 2 or later) or none. Outcome: Primary Outcome: Hospital length of stay (LOS) Secondary Outcomes: 7-day hospital readmission, late ICU transfer (on or after hospital day 2 after being admitted to general ward), composite outcome of in-hospital death or ECMO use. Authors’ Conclusions: "Early use of oseltamivir is associated with shorter hospital stay and lower odds of 7-day readmission, ICU transfer, ECMO use and death." 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? Unsure Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Unsure How precise are the results? 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 of the Study: None Results: There were 55,799 patients were included, who were diagnosed with influenza by ICD 9/10 coding. Of those, 56% were male, and mean age was 3.6 years. 33,207 (59.5%) received early oseltamivir. 4,098 (7%) received oseltamivir on day 2 or later, and 18,494 (33%) were untreated. Key Result: Children treated with early oseltamivir was associated with a shorter length of stays and lower odds of 7-day readmission, late ICU transfer, ECMO use, and death. Primary Outcome Length of Stay Secondary Outcomes The Diagnosis of Influenza: The diagnosis of influenza for this study was determined by review of ICD-9 and 10 codes. The authors do cite previous rese

Date: March 8, 2023 Reference: Smida et al. A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation. Prehospital Emergency Care 2023 Guest Skeptic: Dr. Chris Root is a third-year resident physician 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 air medical service, Lifeguard. He is a former New York City paramedic and this summer will be starting fellowship training in EMS medicine at UNM. Case: A paramedic crew responds to a 54-year-old male in cardiac arrest at a private residence. A fire company is on scene providing high-quality cardiopulmonary resuscitation (CPR) and has defibrillated twice with an automated external defibrillator (AED). The fire-based crew has basic life support (BLS) airway supplies including the King Laryngeal Tube, the paramedic crew carries iGel supraglottic airways (SGAs) in addition to their intubation equipment. They plan to use a supraglottic airway as their initial airway strategy during the arrest, but they wonder if either of these two devices is superior. Background: Airway management strategies for out of hospital cardiac arrest (OHCA) have been hotly debated since the dawn of CPR. Two large trials, PART by Wang et al and AIRWAYS-2 by Benger et al recently evaluated the King-LT and the iGel respectively as alternatives to endotracheal intubation (ETI) in cardiac arrest. Given the difficulty associated with intra-arrest endotracheal intubation, use of supraglottic airways in the prehospital setting is becoming more common. This was discussed with paramedic and physician assistant (PA), Missy Carter when critically appraising the AIRWAYS-2 trial regarding the use of the iGel in OHCA on SGEM #247 Clinical Question: Which supraglottic airway is associated with better patient outcomes, the iGel or the King-LT in patients with an out-of-hospital cardiac arrest. Reference: Smida et al. A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation. Prehospital Emergency Care 2023 Population: Adult OHCA patients treated by EMS contained within the ESO database from 2018-2021 who received prehospital iGel or King-LT supraglottic airway insertion. Excluded: Patients who were less than 18 years of age, pregnant, had do not resuscitate or other physician orders for life sustaining treatment, achieved ROSC after bystander CPR only, or experienced OHCA due to trauma or hemorrhage were excluded from downstream analyses Exposure: iGel Comparison: King-LT Outcome: Primary Outcome: Survival to hospital discharge home Secondary Outcomes: First-pass success, return of spontaneous circulation (ROSC), prehospital rearrest, Intrarrest ETCO2 values Type of Study: Retrospective observational Authors’ Conclusions: “In this dataset, use of the iGel during adult OHCA resuscitation was associated overall with better outcomes compared to use of the King-LT. Subgroup analyses suggested that use of the iGel was associated with greater odds of achieving the primary outcome than the King-LT when used as a rescue device but not when used as the primary airway management device.” 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? Unsure Was the follow up of subjects complete enough? No How precise are the results? Adequately 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 external funding sources Results: The assessed 286,192 OHCA cases for eligibility and were able to include 93,866 patients treated by 1,613 EMS agencies. iGels were inserted in 54,189 (58%) cases, and King- LTs were inserted in 39,677 (42%) cases. The average age of patients in this dataset was 63 years and 37% were female. Just over half (52%) of the 93,866 patients were transported to an emergency department. Of those transported to hospital (49,302), only 19% (9,456) had available disposition data. This means we have data on 10% of the original 93,866 patients. Among the 10% of patients that disposition data was available: 7% were discharged to home or self-care 84% died after arrival at a hospital 4% were discharged to hospice 3% were discharged to skilled nursing 7% were discharged to long-term acute care Key Result: No statistical difference in discharge home between the two devices when a supraglottic airway was employed as the initial airway management strategy. Primary Ou

Date: March 3, 2023 Reference: Hosseinialhashemi et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Ann Emerg Med. 2022 Guest Skeptic: Dr. Dominique Trudel is a CCFP-EM resident in Ottawa, Ontario. Her interest is serving French minority communities delivering care at the Montfort Hospital in Ottawa. Case: Jim is a 50-year-old male who presents to the emergency department with anterior epistaxis. He reported it started last night in his bedroom where he used a space heater. He denies nose picking. He tried applying pressure, but it didn’t work. Vitals are stable and he is not on any anticoagulants. Background: We have covered the topic of epistaxis several times on the SGEM. The first episode was SGEM#53: Sunday Bloody Sunday. This trial looked at 216 adult patients with anterior epistaxis and randomized them to topical TXA (500mg in 5ml) compared to anterior nasal packing. The results were impressive for stopping bleeding in <10min, discharge <2hrs, rebleeding <24hrs, and patient satisfaction. TXA is a synthetic derivative of lysine that inhibits fibrinolysis and thus stabilizes clots that are formed. It has been tried in several medical conditions and been reviewed on the SGEM. There is also a short YouTube video discussing the evidence for TXA. Trauma (CRASH-2): 1.5% absolute mortality benefit (SGEM#80) Isolated TBI (CRASH-3): No statistical difference in mortality (SGEM#270) Post-Partum Hemorrhage (WOMAN): No statistical difference in primary outcome (SGEM#214) Gastrointestinal Bleeding (HALT-It): No statistical difference in primary outcome (SGEM#301) Intracranial Hemorrhage (TICH-2 & ULTRA): No superiority for good neuro outcome (SGEM#236 and SGEM#322) That first SGEM episode on using TXA for epistaxis showing favorable results also discussed eleven questions concerning epistaxis. It’s a good overview on the management of epistaxis. The episode included the Dundee protocol for adult epistaxis management from 2012. A second RCT from the same group looked at TXA for adults with anterior epistaxis who were also taking antiplatelet medications. This too showed impressive results claiming superiority of TXA(SGEM#210). When the NoPAC trial was published, it curbed some of the enthusiasm for TXA in epistaxis (SGEM#321). It was the largest double-blinded RCT (N=496), and found no reduction in the need for anterior packing with the use of intranasal TXA. However, this trial included patients who had already failed 10 min of pressure and 10 min of packing with a topical vasoconstrictor. They also used a lower dose of TXA in the noPAC study. Another issue was that 65% of the patients were taking anticoagulants. Lastly, the primary outcome was different than the previous two RCTs claiming efficacy. These conflicting results have led to uncertainty regarding the use of TXA in patients with epistaxis. Hosseinialhashemi et al sought to provide some clarity with their trial looking at TXA in uncomplicated anterior epistaxis. Clinical Question: Should we use TXA for uncomplicated anterior epistaxis? Reference: Hosseinialhashemi et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Ann Emerg Med. 2022 Population: 18-year-old and older, stable patients with atraumatic anterior epistaxis, without bleeding disorders or anticoagulation. Excluded: Posterior bleeds, hemodynamically unstable, allergic to TXA; known nasopharyngeal, nasal cavity, or paranasal malignancy; pregnancy; the experience of out-of-hospital nasal packing; and epistaxis caused by trauma, known bleeding disorders, recent use of anticoagulation drugs or clopidogrel and patients who were prisoners. Intervention: Cotton pledgets soaked in TXA 500mg, phenylephrine 0.05g and lidocaine 10% x five sprays. Packing was removed after 15 minutes Comparison: Cotton pledgets without TXA but still soaked in phenylephrine 0.05g and lidocaine 10% x five sprays Outcome: Primary Outcome: Need for anterior nasal packing Secondary Outcomes: ED length more than 2h, needing electrical cauterization, rebleeding within 24h, rebleeding within 1-7 days. Type of Study: Single-center, double-blind RCT in a specialized ENT ED in Iran. Authors’ Conclusions: “Intranasal topical application of tranexamic acid is associated with a lower rate of need for anterior nasal packing and a shortened stay in the ED; it may be considered a part of the treatment for atraumatic anterior epistaxis.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Yes The patients in both groups were similar with respect to progn

Reference: Cashen K, Reeder RW, Ahmed T, et al. Sodium bicarbonate use during pediatric cardiopulmonary resuscitation: a secondary analysis of the icu-resuscitation project trial. Pediatric Crit Care Med. 2022 Date: February 15, 2023 Guest Skeptic: Dr. Carlie Myers is Pediatric Critical Care Attending at Cincinnati Children’s Hospital Medical Center. Dr. Carlie Myers Case: A 6-month-old boy presents to the emergency department (ED) with three days of worsening cough, cold symptoms, and fever. Parents note that he has been progressively more tired and difficult to arouse. He is found to be in hypoxic respiratory failure and septic shock. Intravenous (IV) access is obtained. He is quickly intubated. Despite multiple fluid boluses, he remains hypotensive and is started on vasoactive support. His blood gas reveals a mixed respiratory and metabolic acidosis with a lactate of 5.0. Despite your best efforts, he has an episode of agitation leading to hypoxia and subsequent cardiac arrest. Your team begins high quality cardiopulmonary resuscitation (CPR). An arterial blood gas is obtained demonstrates a pH of 7.0, PaCO2 of 70, PaO2 of 28, HCO3- of 7, Base Deficit of -10, and Lactate 10.0. A team member asks if you want to administer some sodium bicarbonate (1mEq/kg). Background: We often manage patients in cardiac arrest in the ED or the intensive care unit (ICU). Apart from high-quality CPR and early defibrillation, many other interventions we try lack a strong evidence base. But that does not stop us from trying to save the patient’s life and may represent some intervention bias.[1] The SGEM has covered the use of epinephrine, vasopressin, methylprednisolone, and calcium for cardiac arrest in SGEM#238, SGEM#350, and SGEM#353. Today we are focusing on sodium bicarbonate. Sodium bicarbonate has historically been used during CPR with the goal of alkalizing blood pH and treating metabolic acidosis. There are a few key assumptions about the use of sodium bicarbonate. Low pH decreases cardiac function and responsiveness to catecholamines. Sodium bicarbonate administration will increase the pH. The increase in pH will lead to improved responsiveness to catecholamines and cardiac function. But it’s not that straightforward. Many of the studies supporting these claims were conducted on animal models or in vitro. [2] It is unclear if we see the same effects of acidosis and sodium bicarbonate in vivo. HCO3- + H+ ↔ H2O + CO2 Rapid bicarbonate infusion can cause an imbalance in CO2 across the cell membrane. HCO3- + H+ converts to H2CO3 and then to CO2 +H20. Extracellular CO2 rises rapidly, it diffuses across cell membranes and the reverse reaction occurs H2O + CO2→ HCO3- + H+; therefore, creating intracellular acidosis. There was a lack of evidence about the benefits and potential harm from using sodium bicarbonate in cardiac arrest [3], so it was removed from the American Heart Association’s (AHA) guidelines. The latest guidelines from the AHA in 2020 state, “clinical trials and observational studies since the 2010 guidelines have yielded no new evidence that routine administration of sodium bicarbonate improves outcomes from undifferentiated cardiac arrest and evidence suggests that it may worsen survival and neurological recovery.” [4] This association seems to hold true in the pediatric literature as well. [5-6] Clinical Question: What is the association between sodium bicarbonate use and pediatric in-hospital cardiac arrest mortality and morbidity? Reference: Cashen K, Reeder RW, Ahmed T, et al. Sodium bicarbonate use during pediatric cardiopulmonary resuscitation: a secondary analysis of the icu-resuscitation project trial. Pediatric Crit Care Med. 2022 Population: Pediatric patients 37 weeks to 18 years of age who received chest compressions across 18 pediatric intensive care units (PICU) or pediatric cardiac intensive care units (PCICU) from Oct 2016 to March 2021. Excluded: Children were excluded if prior to the arrest, they had terminal disease and were not expected to survive, documented lack of commitment to aggressive ICU therapies, brain death, and out of hospital cardiac arrests. Additionally, in the secondary analysis patients on extracorporeal membrane oxygenation (ECMO) at the time of CPR were excluded. Intervention: Sodium Bicarbonate administration during CPR Comparison: No sodium Bicarbonate administered during CPR Outcome: Primary Outcome: Survival to hospital discharge Secondary Outcomes: Return of spontaneous circulation (ROSC), survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category [PCPC] of 1), functional status at the time of discharge using the Functional Status Scale (FSS), and presence of a new morbidity defined as worsening from baseline FSS by 3 or more points. Authors’ Conclusions: “Sodium bicarbonate use was common and associated with lower rates of survival to hospital discharge.” Quality Checklist for Observational Study: Did the study addre

Date: February 17, 2023 Reference: Gettel et al. Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019. AEM Feb 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: You are an administrator responsible for staffing emergency departments (EDs) in a health care system comprising both urban and rural locales. The hiring pool includes emergency medicine trained physicians, non-emergency trained physicians, and advanced practice providers (physician assistants and nurse practitioners). Prior to your hiring search, you wonder how many patient encounters are being seen by each type of physician or advanced practice provider. You also wonder the breakdown of visit acuity being seen by the different provider types. Background: Advanced practice providers (APPs), primarily physician assistants (PAs) and nurse practitioners (NPs), make up more of the emergency medicine (EM) workforce each year (1-4). While APPs have traditionally focused on low-acuity patient encounters, as ED visit volumes and physician shortages increase, APPs are seeing more complex, high-acuity patients (5-6). In the United States, policies have been implemented to permit more independent APP practice, with or without direct physician support. This increase in independent service provision by APPs and change in practice pattern to more high-acuity patients has not been formally assessed (7-8). There is concern regarding the expanding practice pattern of APPs, and a March 2022 Guideline by the American College of Emergency Physicians (ACEP) stated that PAs and NPs should not perform independent, unsupervised care in the ED setting (9). Given current workforce limitations, it is not feasible to continue current 24/7 staffing models in certain EDs and communities without APPs (1,3). Similarly, many rural Canadian emergency departments have reduced their open hours or closed over recent years due to inadequate staffing (MacLean's Magazine - Dr. Alan Drummond) There are both NPs and PAs working in Canadian EDs currently and we could see their role increase in the future should staffing shortages increase. The SGEM has done two previous podcasts on APPs in the ED. These focused on productivity, safety and diagnostic testing differences between emergency physicians and APPs (SGEM#308 and SGEM#316). Clinical Question: How has the role of APPs in the provision of emergency care changed in recent years? Reference: Gettel et al. Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019. AEM Feb 2023 Population: Emergency care providers including emergency physicians, non-EM physicians and APPs (Physician assistants, nurse practitioners, certified nurse midwives, certified registered nurse anesthetists) who provided fee-for-service Medicare in the United States emergency departments from 2013 to 2019. Exclusion Criteria: Providers who received less than 50 total reimbursements within a study year for evaluation services reflecting typical emergency critical care codes. Exposure: Patient encounters by APPs Comparison: Patient encounters by Physicians Outcome: Primary Outcome: Proportion of high acuity encounters independently billed by different emergency clinician types over time. Secondary Outcomes: Variation in clinicians seeing high acuity encounters based on geography (urban vs. rural). Proportion of Evaluation Management services provided by each clinician that were high, moderate or low acuity in comparison to the total number of cases seen. Type of Study: Observational study using a repeated cross-sectional analysis of emergency clinicians using the Centers for Medicare & Medicaid Services (CMS) Provider Utilization and Payment Data Practitioners Public Use File (PUF), Dr. Cameron Gettel This is an SGEMHOP and we are pleased to have the lead author on the show. Dr. Cameron Gettel is an Assistant Professor in the Department of Emergency Medicine and a Clinical Investigator at the Yale Center for Outcomes Research and Evaluation. In these roles, he primarily conducts geriatric-related and health services research Authors’ Conclusions: “In 2019, APPs billed independent services for approximately 1 in 6 high acuity EDencounters in rural geographies and 1 in 11 high acuity ED encounters in urban geographies, and well over one-third of the average APPs’ encounters were for high acuity E/M services. Given differences in training and reimbursement between clinician types, these estimates suggest further work is needed evaluating emergency care staffing decision-making.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Y

Date: February 7, 2023 Reference: Cheskes et al. Defibrillation Strategies for Refractory Ventricular Fibrillation. NEJM 2022 Guest Skeptic: Dr. Sean Moore is an emergency physician working in Kenora Ontario, where he is Chief of Staff at Lake of the Woods District Hospital, Northern Medical Director for the Ornge air medical transport program and associate medical director with CritiCall Ontario. Research interests include simulation-based assessment, transport medicine, and critical care analgesia. He is an assistant professor at the Northern Ontario School of Medicine University and is passionate about health equity for rural and indigenous populations. He has been an ACLS instructor for close to 30 years and notably his first publication focused on out-of-hospital defibrillation. Case: A 60-year-old health professional suffers a cardiac arrest while working at a clinic outside the hospital. An anesthetist is working with him for the procedures. He confirms pulselessness, initiates CPR, gets a colleague to call 911, and intubates the patient on the floor. He is found to be in ventricular fibrillation and receives two defibrillation attempts with an automatic external defibrillator (AED) at the clinic, and subsequently three more with a primary care ambulance crew enroute to the hospital. He arrives at the hospital 18 minutes into his arrest and his monitor shows persistent ventricular fibrillation. Background: Out-of-hospital cardiac arrest (OHCA) is something we have covered extensively on the SGEM over the years. This has included things like therapeutic hypothermia (SGEM#54, SGEM#82, SGEM#183 and SGEM#275), supraglottic devices (SGEM#247), crowd sourcing CPR (SGEM#143 and SGEM#306), epinephrine (SGEM#238) and IO vs IV (SGEM#231 and SGEM#340). One issue that has not been covered on the SGEM is pad placement and double sequential external defibrillation. Clinical Question: Does refractory ventricular fibrillation respond better to standard defibrillation, vector-change defibrillation, or double sequential external defibrillation? Reference: Cheskes et al. Defibrillation Strategies for Refractory Ventricular Fibrillation. NEJM 2022 Population: Ontario patients who were at least 18 years of age and had an OHCA and refractory ventricular fibrillation. Intervention: Vector Change Defibrillation: Pads are placed in an anterior-posterior pad placement after standard anterior-anterior configuration following the third shock with standard defibrillation. Double Sequential External Defibrillation: Pads are placed in both the anterior-anterior and the anterior-posterior pad placements following the third shock with standard defibrillation. Comparison: Standard defibrillation with pads placed in anterior-anterior configuration Outcome: Primary Outcome: Survival to hospital discharge Secondary Outcomes: Termination of ventricular fibrillation, return of spontaneous circulation (ROSC), good Neurologic outcome (modified Rankin scale [mRS] score <3) Trial: Unblinded, cluster-randomized trial with crossover among six paramedic services in rural and urban Canada Authors’ Conclusions: “Among patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED defibrillation or VC defibrillation then among those who received standard defibrillation.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Yes The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Yes Financial conflicts of interest. Disclosure was complete and there were no significant conflicts of interest for any of the authors that would be perceived as potentially influences the submitted work. Results: They enrolled 405 patients into the study. The mean age was 64 years, over 84% were male, 68% were witnessed arrests, 58% had bystander CPR performed, and median response time was 8 minutes. Key Result: Greater survival with vector change and double sequence defibrillation compared to standard treatment. Primary Outcome: Vector Change vs standard group 21.7% vs. 13.3%; relative risk 1.71 (95% CI, 1.01 to 2.88). DSED 30.4% vs. standard 13.3%; relative risk 2.21 (95% CI, 1.33 to 3.67) Secondary Outcomes: DSED but not VC defibrillation was associated with a higher percentage of patients having

Date: February 1, 2023 Reference: Wolfrum et al. Temperature Control After In-Hospital Cardiac Arrest: A Randomized Clinical Trial. Circulation. September 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: You are working an overnight shift at a small rural hospital. You are tidying your things in anticipation of the arrival of the dayshift when a code blue is called. A 50-year-old man who was admitted to the hospital with a non-ST elevated myocardial infarction (NSTEMI) overnight was found unconscious and without a pulse. The nurses started CPR immediately and place pads before you even arrived. The patient is in ventricular fibrillation, and you achieve return of spontaneous circulation (ROSC) on the second shock. The patient is still unconscious. A post-arrest ECG doesn’t show any signs of STEMI. At this point, the dayshift doc walks into the room and asks, “I can’t keep up with all the evidence. Are we supposed to be starting hypothermia?” Background: “Therapeutic” hypothermia took the critical care world by storm in 2002, with the simultaneous publication of two randomized control trials (RCTs) in the same issue of the New England Journal of Medicine – the Hypothermia after Cardiac Arrest (HACA) study and the Bernard study. As a very brief recap, the HACA study randomized 275 comatose adult patients with ROSC after a witnessed cardiac arrest with a shockable rhythm, a presumed cardiac origin of arrest, and a short downtime. The hypothermia group was cooled using an external device to a target temperature between 32 and 34 degrees Celsius and maintained there for 24 hours. The primary outcome was a good neurologic outcome within six months and occurred in 55% of the hypothermia group and 39% of the normothermia group (p=0.009, RR 1.40, 95% CI 1.08-1.81). This translated into an impressive NNT of 6. The six-month mortality was also improved in the hypothermia group (41% vs 55%, p=0.02) NNT 7. Key issues with this study were possible selection bias, early stopping without a clear endpoint, and a subjective outcome in a trial that was only partially blinded. The Bernard study included 77 patients with an initial cardiac rhythm of ventricular fibrillation who had achieved ROSC but were persistently comatose. It was not randomized to individual patients, but rather based on the day of the week. It was also not blinded. The primary outcome, patients with neurologic function good enough to be sent home or to a rehabilitation facility, occurred in 49% of the hypothermia group and 26% of the normothermia group (p=0.046, although when you plug the numbers into a fragility index calculator, you get a fragility index of 0 and a p value of 0.06). This give a very impressive NNT of 4. There was an NNT of 6 for mortality (51% vs 68%, p=0.16) but it was not statistically significant. For more information on the fragility index (FI) click on this LINK. Therefore, therapeutic hypothermia was introduced into clinical practice based on two small trials with multiple sources of bias. Since 2002, we have seen several larger trials that have raised questions about the value of hypothermia. We have covered the issue of cooling patients post OHCA sever times on the SGEM including the original Targeted Temperature Management (TTM) trial (SGEM#82). TTM was a multicentre RCT from 36 intensive care units (ICUs) in Europe and Australia, which enrolled 950 comatose adult patients on arrival to hospital after out of hospital cardiac arrest, regardless of the presenting rhythm. Patients all had their temperatures controlled, but they were randomized to a target of either 33 or 36 degrees Celsius. There were no statistical differences between the groups in mortality, Cerebral Performance Category (CPC), modified Rankin Score (mRS) or mortality at 180 days. The TTM2 trial was covered on SGEM#336. It was another multicenter RCT, and that time hypothermia was compared to normothermia (a goal of keeping temperatures less than 37.5). Once again, there was no statistical difference in outcomes between the two groups in all-cause mortality or neurologic function at six months. On the other hand, the HYPERION trial, which was covered in SGEM#275, was an RCT which include both OHCAs (73%) and IHCAs (27%). The trial comparing hypothermia (33 degrees) to normothermia. In that trial, there was a statistically significant improvement in their primary outcome of neurologically intact survival (10.2% TTM vs. 5.7% usual Care (absolute difference 4.5%), p=0.047 which gives an NNT of 22). The fragility index was 1 and the trial was unblinded, leaving us with significant uncertainty. Therapeutic hypothermia has also been trialed in the prehospital environment and not been found to be superior to usual care (SGEM#21 and SGEM#54). Therefore, there remains significant uncertainty about the value of therapeutic hypothermia after cardiac arrest, especially in the inpatient

Date: January 22, 2022 Reference: Samuels-Kalow M et al. Post-Roe Emergency Medicine: Policy, clinical, training, and individual implications for emergency clinicians. AEM Dec 2022 Guest Skeptic: Dr. Michelle Lin is an emergency physician and health services researcher whose goal is to transform acute care delivery to best meet the needs of those who experience the greatest barriers to accessing health care. This is an SGEM Xtra episode. The ruling of the US Supreme Court on June 24, 2022 in Dobbs v Jackson Women’s Health Organization overturned Roe v Wade and allowed individual US states to determine their own restrictions on abortion. There was a recent tweet about allyship and advocacy by an orthopaedic surgeon, Dr. Simon Fleming. He encouraged people to shut up and listen. To amplify other voices and transfer your privilege. I interpreted that to mean, at times, men should talk less and listen more. Dr. Kirsty Challen This is one of those times. Therefore, Dr. Kirsty Challen will be hosting this SGEM Xtra episode. Academic Emergency Medicine published a special contribution in December 2022 exploring the implications of this for providers of emergency healthcare. This episode was recorded one day after the 50th Anniversary of the Roe v Wade on January 22, 1973. Although the SGEM is based in Canada and Dr. Challen is British we felt this was an issue of such importance that we wanted to invite the authors to discuss it further with us. TRIGGER WARNING: AS A WARNING TO THOSE LISTENING TO THE PODCAST OR READING THE BLOG POST, THERE MAY BE SOME THINGS DISCUSSED ABOUT ABORTION THAT COULD BE UPSETTING. THE SGEM IS FREE AND OPEN ACCESS TRYING TO CUT THE KNOWLEDGE TRANSLATION DOWN TO LESS THAN ONE YEAR. IT IS INTENDED FOR CLINICIANS PROVIDING CARE TO EMERGENCY PATIENTS, SO THEY GET THE BEST CARE, BASED ON THE BEST EVIDENCE. SOME OF THE ABORTION MATERIAL WE ARE GOING TO BE TALKING ABOUT ON THE SHOW COULD TRIGGER SOME STRONG EMOTIONS. IF YOU ARE FEELING UPSET BY THE CONTENT, THEN PLEASE STOP LISTENING OR READING. THERE WILL BE RESOURCES LISTED AT THE END OF THE BLOG FOR THOSE LOOKING FOR ASSISTANCE. QUESTIONS FOR DR. MICHELLE LIN Dr. Michelle Lin was asked several questions about the implications of the Dobbs v Jackson Women’s Health Organization decision. Please listen to the SGEM Xtra podcast on iTunes to hear her answers and for more details. Dr. Michelle Lin Why does Emergency Medicine need to know? After all, we aren’t abortion providers, or even Obstetrician/Gynaecologists. The paper talks about the unequal implications of this decision – surely the law is the law everywhere? Can you tell us more? What are the legal implications for Emergency Physicians caring for patients who may be miscarrying spontaneously, have an ectopic pregnancy, or present with the complications of an abortion which is illegal in that state? You said something specifically about documentation as well? And what about the pregnant or potentially pregnant Emergency Physician? Is this going to impact on us as a workforce too? You’ve mentioned that one of the policy actions for emergency physicians could be to use EMTALA to pre-empt state restrictions. Can you explain how that would work practically for those of us outside the US who don’t have an EMTALA-like system? Is there anything else you would like to say about this issue? 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 upon the best evidence. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE. Additional Resources: College of Family Physicians of Canada (CFPC) Abortion National Health Services (NHS) Abortions Center for Reproductive Rights Planned Parenthood

Reference: Babl et al. Efficacy of prednisolone for bell palsy in children: a randomized, double-blind, placebo-controlled, multicenter trial (BellPIC). Neurology 2022 Date: January 3, 2023 Guest Skeptic: Dr. Jennifer Harmon is an MD, Ph.D at Children’s National Hospital in Washington, DC. She is a board-certified pediatric neurologist and completing another fellowship in medical genetics. Dr. Jennifer Harmon Case: A 9-year-old girl shows up at your emergency department (ED) with unilateral facial paralysis. Her parents noticed that one side of her face looked abnormal when she woke up in the morning. She has no other medical conditions and has not had any recent fevers, ear pain, or trauma. On exam, she is alert and active, but you note that the entire left side of her face does not move when you ask her to smile or raise her eyebrows. The remainder of her exam is unremarkable. You make a clinical diagnosis of Bell palsy, and the parents ask you, “Is there anything you can give her to help her recover faster?” Background: Bell palsy is a common cause of unilateral facial 7th nerve palsy in children. The differential diagnoses for this presentation can include trauma, otitis media, viral infections (herpes, varicella, CMV, EBV, etc), brain lesions or stroke, and acute leukemia. If the 7th nerve palsy is known to be caused by the herpes virus it is called Ramsay Hunt syndrome (herpes zoster oticus) [1]. It is important to perform a careful history and physical before ultimately arriving at the diagnosis of Bell palsy. While many children spontaneously recover, the clinical manifestations of Bell palsy may significantly impact a child functionally and emotionally. There have been studies in adults regarding the treatment of Bell palsy that have demonstrated that treatment with corticosteroids provide significant benefit (NNT 10) [2]. The SGEM covered the use of steroids and antivirals for Bell Palsy in SGEM#14. Unfortunately, the data for the use of steroids in treatment of pediatric Bell Palsy is still lacking [3]. Clinical Question: Does prednisolone improve the proportion of children with Bell palsy with complete recovery at one month? Reference: Babl et al. Efficacy of prednisolone for bell palsy in children: a randomized, double-blind, placebo-controlled, multicenter trial (BellPIC). Neurology 2022 Population: Children 6 months to 18 years presenting to multiple emergency departments in Australia with Bell Palsy diagnosed by a senior clinician with onset of symptoms less than 72 hours prior to evaluation. Excluded: There were a lot of exclusion criteria that we will list in the show notes. Contraindication to prednisolone (active/latent tuberculosis, systemic fungal infection, hypersensitivity, diminished cardiac function, diabetes mellitus, peptic ulcer disease, chronic renal failure, multiple sclerosis, recent active herpes zoster or chickenpox) Use of any systemic or inhaled steroid within 2 weeks prior to onset of symptoms Current or past oncological diagnosis Pregnant or breastfeeding Receiving concomitant medications in which prednisolone is contraindicated Immunization with a live vaccine within previous one month Requirement for live vaccine within 6 weeks of first dose of study drug Signs of upper motor VII nerve weakness Acute otitis media concurrently or within 1 week prior to onset of symptoms Vesicles at ear suggestive of Ramsay-Hunt syndrome Known facial trauma within 1 week prior to symptom onset Any other condition at risk of being influence by the study treatment or might affect completion of study Any concern about ability to comply with the study protocol Prior episode of Bell palsy Intervention: Prednisolone 1 mg/kg (max 50 mg) for 10 days, with no taper. Comparison: Placebo Outcome: Primary Outcome: Complete recovery of facial function at 1 month defined by a House-Brackmann score of 1. This is a scale of 1 to 6 with 1 being completely normal function and 6 being complete paralysis. Secondary Outcomes: Recovery of facial function (House-Brackmann score = 1) at 3 and 6 months Recovery of facial function (Sunnybrook scale score = 100) at 1, 3 and 6 months. This is a scale of 1 to 100 with 0 being completely normal function complete paralysis and 100 being normal function. Self-reported (or parent-reported) pain at 1, 3 and 6 months Presence of synkinesis or autonomic dysfunction at 1, 3 and 6 months using the Synkinesis Assessment Questionnaire (SAQ) Ongoing palsy symptoms Date of resolution of facial weakness Emotional and functional wellbeing at 1, 3 and 6 months using the Pediatric Quality of Life Inventory (PedsQL) and Child Healht Utility 9D (CHU9D) Adverse Outcomes Trial: Double-blind, placebo-controlled, randomized, superiority trial Authors’ Conclusions: “In children with Bell palsy, prednisolone does not significantly change recovery of complete facial function at one month. However, the study lacked the precision to exclude an important harm or benefit from prednisolone.” Qua

Date: January 13, 2023 Reference: Razi et al. Dexamethasone and ketorolac compare with ketorolac alone in acute renal colic: A randomized clinical trial. AJEM 2022 Dr. Kevan Sternberg Guest Skeptic: Dr. Kevan Sternberg is a urologist/endourologist. His focus is on the medical and surgical management of kidney stone disease. Dr. Sternberg did his medical school and residency training at the University of Buffalo (SUNY) and endourology fellowship at the University of Pittsburgh Medical Center. Kevan was on the SGEM Xtra episode three years ago that brought together Emergency Medicine, Radiologists and Urologists to discuss ultrasound vs CT scans for suspected renal colic. You can listen to the SGEM podcast to hear what he thinks the impact of this initiative has been. Case: A 38-year-old female presents to the emergency department (ED) with a five-hour history of acute onset left flank pain. The pain comes in waves, radiates into her left groin and is associated with nausea and vomiting. She noticed darkening of her urine, but does not have dysuria, fever, or vaginal discharge. Background: We have looked at many different therapies to treat renal colic on the SGEM. That has included things like fluid bolus or diuretics (SGEM#32), tamsulosin (SGEM#4, #71, #154, #230), acupuncture (SGEM#220) and lidocaine (SGEM#202). The SGEM bottom line to these different treatment options: You don’t need to push fluids (oral/IV) or use diuretics to pass kidney stones. Medical expulsive therapy with tamsulosin is unnecessary for stones < 5mm. If a benefit does exist for Tamsulosin it's with distal ureteral stones > 5 mm. Acupuncture is not superior to morphine for renal colic. The evidence doesn’t support the use of lidocaine for renal colic. Glucocorticoids (steroids) act as anti-inflammatories, immunosuppressants, antiproliferative drugs, and have vasoconstrictive effects. It has been hypothesized that adding a long-acting glucocorticoid like dexamethasone may help with pain and vomiting associated with passing a kidney stone and decrease opioid use. Clinical Question: Should we be adding a dexamethasone to NSAIDs for the management of suspected acute renal colic? Reference: Razi et al. Dexamethasone and ketorolac compare with ketorolac alone in acute renal colic: A randomized clinical trial. AJEM 2022 Population: Patients presenting to the ED with flank pain and presumed renal colic Exclusions: Pregnancy (confirmed or possible), analgesic therapy during six hours before admitted to the emergency unit, near history of hemorrhagic diathesis, addiction or recent methadone use, use of warfarin and other anticoagulants, acute abdomen, fever, BP ≥ 180/100 mmHg; any contra- indication for ketorolac including hypersensitivity to aspirin or other NSAIDs, active or history of peptic ulcer disease, a recent history of GI bleeding or perforation or suspected or confirmed cerebrovascular bleeding, advanced hepatic or renal disease, patients at risk for renal failure, hyperkalemia, and uncontrolled severe heart failure; and any contraindications for the use of dexamethasone Intervention: Ketorolac 30mg IV plus dexamethasone 8mg IV Comparison: Ketorolac 30mg IV Outcome: Primary Outcome: Change in pain on a 10-cm visual analog scale (VAS) at 30 minutes and 60 minutes Secondary Outcomes: Grade of vomiting and the need for antiemetics and need for opioids Type of Trial: Single-centered, triple-blind, randomized clinical trial from Iran Authors’ Conclusions: “In comparison with the patients who just received ketorolac, adding dexamethasone provided improved pain control after 30 min of 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. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Yes The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. Unsure 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. No The treatment effect was large enough and precise enough to be clinically significant. No Financial conflicts of interest. No Results: They recruited 120 participants (60 in each group), the mean age was 37.6 years of age, 70% were male and 42% reported some vomiting. Key Result: Dexamethasone plus ketorolac was statistically superior to ketorolac alone for pain control at 30 minutes but not at 60 minutes in adults with suspected acute renal colic. Primary Outcome: Change in pain from baseline using VAS 30 Minutes: -5 intervention vs -3 control, p=0.014 60 Minutes: -7 intervention vs -5 control, p=0.07 Secondary O

Date: January 4th, 2023 Reference: Hasbrouck et al. Acute management of atrial fibrillation in congestive heart failure with reduced ejection fraction in the emergency department. AJEM 2022 Guest Skeptics: Dr. Timlin Glaser currently a fourth-year resident in emergency medicine at Lehigh Valley Health Network and future medical toxicology fellow at the University of Arizona College of Medicine - Phoenix. Dr. Matt Murphy is currently a third-year resident in emergency medicine at Lehigh Valley Health Network. He has interests in FOAMEd and is currently following the EBM track in his residency. Welcome to the SGEM Matt. This episode is recorded live as an SGEM journal club. There are five rules to journal club 1) You Must Talk/Tweet about SGEM-JC: The SGEM is a knowledge translation project. We know that it can take over ten years for high-quality, clinically relevant information to reach the patient. As Sir Mark Walport famously said: “science is not finished until it’s communicated.” 2) The EBM Answer Is "It All Depends": This rule was learned this from my EBM mentor Dr. Andrew Worster. There are lots of nuances to the application of the literature. It requires critical appraisal skills, clinical judgment and asking the patient about their values and preferences. 3) Don’t Panic – Even Your Faculty Is Not Sure of Some of the Answers: It is hard to stay up on all the relevant medical literature. There is a tsunami of new information being published every day. It can be overwhelming at times. Don’t panic. As Professor Feynman said…It’s ok to say: “I don’t know”. 4) It’s All About the Methods: The method section is the most important section of the paper. We just said there is so much research being published every day. It can be like drinking from a fire hose making it difficult to find the signal in all the noise. As Professor Altman said in the BMJ back in 1994; “we need less research, better research and research done for the right reasons.” This means we need to be asking the right questions that have patient-oriented outcomes and use proper high-quality methods to answer those questions. 5) Be Skeptical of Anything you Learn, Even If You Heard It On the SGEM Journal Club: Skepticism is such an important concept to understand the medical literature and navigate through life. Aristotle advocated for this thousands of years ago and encouraged people to “be a free thinker and don’t accept everything you hear as truth. Be critical and evaluate what you believe in.” Case: A 62-year-old male with a past medical history of heart failure with reduced ejection fraction presents to your emergency department (ED) via ambulance for palpitations and shortness of breath that started earlier that day. He arrives with an irregular heart rate of 142 beats per minute (bpm). The remainder of his vital signs are unremarkable. On physical exam, you notice three plus pitting edema of both lower extremities and bibasilar rales when auscultating his lungs. He takes multiple medications at home, including a beta-blocker, an angiotensin converting enzyme inhibitor (ACEi), and a loop diuretic. You order an ECG and confirm the patient has atrial fibrillation (AF) with rapid ventricular response (RVR). The patient is very symptomatic, and you need to decide which pharmacologic agent you will use to treat his current condition. Background: Atrial fibrillation is a common dysrhythmia seen on a regular basis by emergency physicians. We have covered this topic several times on the SGEM including: SGEM#88: Shock Through the Heart (Ottawa Aggressive Atrial Fibrillation Protocol) SGEM#133: Just Beat It (Atrial Fibrillation) with Diltiazem or Metoprolol? SGEM#222: Rhythm is Gonna Get You – Into an Atrial Fibrillation Pathway SGEM#260: Quit Playing Games with My Heart – Early or Delayed Cardioversion for Recent Onset Atrial Fibrillation? SGEM#267: AFib of the Night – Chemical vs. Electrical First Cardioversion As discussed in SGEM#133, clinicians routinely employ beta blockers or calcium channel blockers (CCBs) for rate control in patients with AF. Multiple studies have demonstrated that both agents are effective in decreasing ventricular rate to an acceptable range, and current AHA guidelines approve their use in uncomplicated AF. However, the use of beta blockers and non-dihydropyridine calcium channel blockers for rate control in patients with AF with RVR and concurrent decompensated heart failure with reduced ejection fraction (HFrEF) remains controversial. Current guidelines specifically recommend against the use of CCBs (1) despite limited evidence (Level C). For the ED clinician, such a scenario poses a conundrum, as both the disease process and the intervention can worsen heart failure and contribute to cardiogenic shock. Clinical Question: In patients with HFrEF presenting to the ED in AF with RVR, are there significant differences in adverse outcomes for patients treated with IV diltiazem vs IV metoprolol? Reference: Hasbro

Date: Dec 15, 2022 Reference: Mahajan et al. Serious bacterial infections in young febrile infants with positive urinalysis results. Pediatrics. October 2022 Dr. Brian Lee Guest Skeptic: Dr. Brian Lee is a pediatric emergency medicine attending at the Children’s Hospital of Philadelphia and Assistant Professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. Guest Authors: Dr. Prashant Mahajan Dr. Prashant Mahajan is a Professor of Emergency Medicine and Pediatrics at the University of Michigan Department of Emergency Medicine in Ann Arbor, Michigan. He is the Vice-Chair for the Department of Emergency medicine and Section chief for Pediatric Emergency Medicine in CS Mott Children’s Hospital. Currently, he is the founding chair of Emergency Medicine Education and Research by Global Experts (EMERGE), a global emergency research network across 17 countries and 23 emergency departments. Dr. Nathan Kuppermann is a Distinguished Professor of Emergency Medicine and Pediatrics, and the Bo Tomas Brofeldt Endowed Chair of the Department of Emergency Medicine at UC Davis and Associate Dean for Global Health at UC Davis Health. He chaired the first US research network in Pediatric Emergency Medicine (the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics) then became founding chair of the Pediatric Emergency Care Applied Research Network (PECARN). He also recently completed a term as Chair of the Executive Committee of the global Pediatric Emergency Research Network (PERN). Dr. Nathan Kuppermann Both of our guests have received federal funding for their research and played huge roles in establishing multicenter research networks dedicated to improving the care of children across the world. Case: A 6-week-old girl is brought into the emergency department (ED) for fever of 38.5°C that started four hours prior to presentation. Her parents noted that she has been fussier today and has had feeding a little less than normal, but she’s had no other symptoms. She is otherwise healthy, full-term female who had no pre- or postnatal complications. On exam she is well-appearing, and there are no focal signs of infection. You decide to start by obtaining blood and catheterized urine for testing. The urinalysis shows 15 WBCs, 2+ leukocyte esterase and positive nitrites. While waiting for the results of the blood tests, you tell the family the news that their child likely has a urinary tract infection. The family asks you, “does this mean we found the source of her fever? Our son also had a fever when he was very young, and he had to get a lumbar puncture? Do we need to do a lumbar puncture for her today?” Background: Febrile infants ≤ 60 days are at higher risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. While UTIs tend to be the most common, we really do not want to miss those infants with bacteremia and meningitis, termed invasive bacterial infections (IBI). Multiple groups have worked to risk stratify these infants and have listed positive urinalysis as a risk factor for IBI. The SGEM covered the Step-by-Step Approach on SGEM #171 and PECARN Clinical Prediction Rule for Low Risk Febrile Infants on SGEM #296. Recently, the American Academy of Pediatrics (AAP) published guidelines for the management of febrile infants 8-60 days old covered in SGEM #241. In infants 22 days and older, the AAP guidelines state that lumbar puncture may be performed (rather than should) in those with positive urinalysis but normal inflammatory markers. There is wide practice variability in evaluation febrile infants [1-2]. Prior studies have demonstrated low prevalence of meningitis in infants with positive urinalysis [3,4]. Infants between 29-60 days of age are at a comparatively lower risk, with studies estimating their risk to be 0.2% in those with a positive urinalysis [5-6]. These studies, and others, have also highlighted risks to indiscriminate lumbar puncture, stemming from the relatively high rates of sterile pleocytosis in these infants, occurring in 18-24% of these infants [7,8]. Not surprisingly, these infants undergo longer hospitalizations with more IV antibiotics. Clinical Question: In a febrile infant ≤60 days with an abnormal urinalysis suggesting a UTI, do they really need a lumbar puncture or blood work? Reference: Mahajan et al. Serious bacterial infections in young febrile infants with positive urinalysis results. Pediatrics. October 2022 Population: Infants ≤ 60 days of age presenting to 26 emergency departments in the PECARN network between March 2011 and April 2019 with temperature ≥38°C who had urine, blood, and cerebrospinal fluid (CSF) testing at the time of visit Excluded: Prematurity (<37 weeks), significant comorbidities, antibiotic use in the preceding 48 hours, and those critically ill (requiring intubation or vasoactive infusions), UA was nor obtained, CSF not obtained a

Date: December 11th, 2022 Dr. Dennis Ren Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine physician at Children’s National in Washington, DC. You may also know him as the host of this season’s SGEM Peds. This is an SGEM Xtra for the holidays. We have done previous shows on what we have learned from Star Trek and Top Gun. It is hard to believe that we have not done an SGEM Xtra about what Batman has taught us about medicine and life. The release of Season#9 of the SGEM as a PDF book seemed like an excellent opportunity to discuss Batman. This is because the book has a DC comic theme. Some people might find that a bit dark. However, this edition arrives at a time of uncertainty. We have been navigating our way through a pandemic, understaffing, emergency department closures, boarding crises, astronomical wait times sometimes barely keep our heads above water and struggling to do everything we can to care for the patients who depend on us. Despite the challenges we face, I hope the SGEM has been a beacon in the darkness, a bat signal, to remind us that the application of the principles of evidence-based medicine is more important than ever. We discussed this early in the pandemic with Dr. Simon Carley from St. Emlyn’s. Before we start talking nerdy about Batman, I think it is important we give a shout out to Dr. Tayler Young. She is a first year Family Medicine resident at Queen’s University. Her interests are quality improvement and Free Open Access to Medical Education (FOAMed). Tayler did Season#8 book with an Avengers theme. SGEM Season#9 contains the an introduction by Dr. Chris Carpenter. He takes us back to 1934 and the start of DC comics. Batman first appears in 1939. The first page for each chapter has the clinical question, the SGEM bottom line and introduces the guest skeptic. Next comes the case presentation and some background material. This is followed by the PICO with each letter looking like the superman symbol. Each episode has the authors’ conclusions and the appropriate quality checklist to probe the study for its validity. The key results are listed. The Talk Nerdy To Me section has a Green Lantern theme. This is followed by the clinical application, what do I tell the patients and a case resolution section. Each chapter ends with any other FOAMed resources, twitter poll results and the Paper in a Picture infographic by Kirsty Challen You can listen to the SGEM podcast and hear Tayler discuss the layout of SGEM Season#9. You can also download all the previous SGEM books clicking on this LINK. Batman and How it Relates to Medicine and Life We discuss eleven ways that Batman relates to emergency medicine and life. You can listen to the entire discussion on the SGEM podcast available on iTunes. 1. Emergency Medicine is Batman If I were to pick one superhero that embodies the practice of emergency medicine, it must be Batman. He is a detective, a tactician, strategist. He is truly a jack of all trades. He has knowledge of criminal justice, psychology, forensics, chemistry, just to name a few. Sounds very similar to emergency medicine where we act as primary care providers, pediatricians, intensivists, cardiologists, neurologists, psychiatrists, often during one shift. Batman also has a lot of cool gadgets just like we have many tools in our arsenal when practicing emergency medicine. I think some of us might even carry a fanny pack (utility belt) on shift. 2. Vulnerability One of the things that sets Batman apart from other superheroes is that ultimately, he is human. He can get fatigued. He can be hurt. This quality makes me appreciate him more. Dr. Tim Graham shared his powerful story of burnout on SGEM Xtra: Everybody Hurts, Sometimes. We have witnessed people working in emergency medicine perform heroic acts every day, but it’s important take a moment to check in on each other. The pressure and stress can build up and it is ok not to be ok, to be vulnerable. I am fortunate to work at an institution where colleagues commonly check on one another after a difficult patient encounter or bad outcome. I have also had colleagues and friends check on me when I have been going through difficult personal circumstances. This supportive community does not only have to be at your own institution but can extend through social media. Let’s normalize looking out for one another. 3. Batman Won’t Give Up “Maybe that’s what Batman is about. Not winning, but failing, and getting back up. Knowing he’ll fail, fail a thousand times, but still won’t give up.” (Batman-Zero Year) I don’t know about you, but I can’t imagine shouldering the responsibility and burden of being Batman. He is doing his day job of running Wayne Enterprises and no matter how great or poorly his day or how much he got hurt or injured in the previous night, Batman always suits up and goes out on patrol. You just must admire that discipline and tenacity. Our emergency medicine colleagues also exhibit this “won’t give up” attitud

Date: December 16th, 2022 Reference: Hohle et al. Massive Blood Transfusion Following Older Adult Trauma: the Effect of Blood Ratios on Mortality. AEM December 2022 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. She is also the wonderful educator that creates the Paper in a Pic infographics summarizing each SGEM episode. Case: A 71-year-old man is brought to your emergency department (ED) by emergency medical serviced (EMS) having fallen two steps at home. EMS have already splinted an obvious mid-shaft femoral fracture, but he continues to be tachycardic and hypotensive. After a bedside ultrasound shows fluid in the right hemithorax, you insert an intercostal drain which immediately fills with one litre of blood. Noting with some relief that at least he isn’t anticoagulated, you activate the hospital massive transfusion protocol. The transfusion tech calls to remind you that your protocol is currently under review, and asks if would you like the 1:1 or the 1:3 version of fresh-frozen plasma (FFP) to packed red blood cells (pRBC)? Background: Major trauma in older patients is increasing in frequency (1), with the median age of major trauma patients in the UK from 2012-2017 being 63.6 years (2). Falling is the most common cause of traumatic injury resulting in older adults presenting to the ED [4]. Approximately 20% of falls result in injuries, and falls are the leading cause of traumatic mortality in this age group [5,6,7]. Over the last few years there has been increasing concern that the practice of transfusing only PRBC might worsen traumatic coagulopathy. Although a number of trials have attempted to find optimal ratios for transfusion components and the Eastern Association for the Surgery of Trauma practice guidelines suggest a “high” ratio, little of the literature has addressed how this might be applied in an older population. We looked at the PROPPR trial on SGEM#109 when it came out in 2015 and concluded then that a 1:1:1 transfusion strategy was a reasonable approach to massive transfusion and that it seemed to achieve more hemostasis and less death from exsanguination at 24 hours. We’ve also looked at trauma in older patients in SGEM#324 (we don’t yet want to use spirometry to aid discharge decisions in patients with rib fractures), SGEM#212 (increasing age, more rib fractures, more underlying disease and poor oxygenation are risk factors for poor outcome in older patients with chest trauma) and in SGEM#89 in 2014 when we first concluded that identifying older patients at risk of falls is really tricky. CLINICAL QUESTION: DOES FFP:PRBC RATIO IN MASSIVE TRANSFUSION FOR TRAUMA AFFECT SURVIVAL IN OLDER ADULTS? Reference: Hohle et al. Massive Blood Transfusion Following Older Adult Trauma: the Effect of Blood Ratios on Mortality. AEM December 2022 Population: Patients aged 65 or older receiving massive blood transfusion from American College of Surgeons Trauma Quality Improvement Programme National Trauma Data Bank 2013-2017. Massive transfusion was defined as >=10 units of pRBCs in 24 hours or >=5 units within 4 hours of ED admission. Excluded: Patients who were dead on arrival at ED, patients who received no plasma, and those who received more plasma than red cells. Intervention: 1:1 ratio of FFP to pRBC Comparison: 1:2 or lower ratio of FFP to pRBC Outcomes: Primary Outcome(s): 24-hour and 30-day mortality Secondary Outcomes: Hospital and ICU length of stay, ventilator days, complications and need for emergency surgery for haemorrhage control. Type of Study: Observational cohort study Dr. Rae Hohle This is an SGEM HOP and we are pleased to have the lead author on the show. Dr. Rae Hohle is a PGY1 in Emergency Medicine at Regions Hospital in St. Paul, MN. She has a background in computer science and with the support of her program has been able to continue to work on research projects in residency. Authors’ Conclusions: “Compared to all other ratios, the 1:1 FFP:pRBC ratio had the lowest 24-hour and 30-day mortality following older adult trauma consistent with findings in the younger adult population.” 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? 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? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Confidence intervals are relatively broad, from 1.25-2.06 for the largest comparator group. 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/Conflicts of Interest? None Results: In this cohort of over 3,000 patients the odds of mortality

Date: November 30th, 2022 Reference: Johnson et al. One-year outcome of surgery compared with immobilization in a cast for adults with an undisplaced or minimally displaced scaphoid fracture: A meta-analysis of randomized controlled trials. Bone Joint J 2022 Guest Skeptic: Dr.Matt Schmitz is an Orthopaedic Surgeon specializing in Adolescent Sports Medicine and Young Adult Hip Preservation. DISCLAIMER: THE VIEWS AND OPINIONS OF THIS BLOG AND PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US MILITARY. Case: A 32-year-old male construction worker presents to the emergency department (ED) after falling on his right dominant hand. He has swelling in his distal radius, snuffbox tenderness, decreased range of motion and is neurovascularly intact distal to the injury. X-rays demonstrate a minimally displaced midwaist fracture of the scaphoid. He’s got a big job coming up in a couple of months and can’t work with a cast. He asks if surgery would be a better option? Background: Fractures of the scaphoid are the most common carpal fractures presenting to the emergency department (ED). Initial x-rays pick up 17% with only 7% more being identified on follow-up x-rays (1,2). The classic history for a scaphoid fracture is a fall on outstretched hand (FOOSH). Clinicians need to be careful in taking the history because other mechanisms that hyperextend the wrist like a motor vehicle collision while holding the steering wheel can also apply enough force to fracture the scaphoid. Physical examination of patients with a FOOSH injury include palpating for snuff box tenderness. In a systematic review and meta-analysis (SRMA) by Carpenter et al they were only able to find six studies with a total of 170 patients found in the world’s literature looking at snuff box tenderness. The evidence had a substantial amount of heterogeneity (3). The LR- to rule out a scaphoid fracture was 0.15 for snuffbox tenderness which is moderate evidence. However, it had a very wide 95% confidence interval around the point estimate (95% CI; 0.05 to 0.43). There are many other physical exam maneuvers like thumb compression, vibration pain, clamp sign, ulnar deviation pain, radial deviation pain, scaphoid tubercle pain, and resisted supination pronation. None of these have a LR- low enough (<0.1) to reliably rule out a scaphoid fracture. We mentioned x-rays were unreliable as well to rule-out a scaphoid injury. Other imaging modalities like bone scan, ultrasound and CT scan have been used but found to be lacking in accuracy. The best imaging test is an MRI. Initial X-ray 0.24 (0.07–0.79) Follow-up X-ray 0.67 (0.50–0.89) Bond Scan 0.11 (0.05–0.23) Ultrasound 0.27 (0.13–0.56) CT Scan 0.23 (0.16–0.34) MRI 0.09 (0.04–0.19) Emergency physicians can use clinical decision instruments to help in diagnosing certain conditions. There are many validated instruments for fractures such as the Ottawa Ankle Rule (SGEM#3), Ottawa Knee Rule (SGEM#5) and the Canadian C-Spine Rules (SGEM#232). There is no validated clinical decision instrument to help ED physicians accurately rule in or out a scaphoid fracture (4,5). There is not a diagnostic dilemma in this case. The question is does the scaphoid fracture need to be treated operatively or non-operatively. The vast majority (90%) of scaphoid fractures are non-displaced and treated with cast immobilization (6). Displaced fractures increase the risk of non-union from 14% to 50% (7,8,9). If left with a non-union, they almost always result in secondary osteoarthritis of the wrist (10). Also, delayed unions and nonunions are more difficult to treat (i.e. bigger surgery) so there is a trend in orthopedics to perform urgent surgical fixation of scaphoid fractures as opposed to the traditional casting. Whether someone undergoes surgery is an informed decision made between the patient and the surgeon. However, emergency department patients often ask the EM physician if they need surgery. It is good to stay up on the literature so we can prepare the patient for the conversation with the surgeon. We have seen this recently with the non-operative treatment of acute appendicitis (NOTA) and covered this on the SGEM (SGEM#115, SGEM#256, and SGEM#345) Clinical Question: What is the effectiveness of operative vs nonoperative management of un-displaced and minimally displaced (≤ 2 mm) scaphoid fractures? Reference: Johnson et al. One-year outcome of surgery compared with immobilization in a cast for adults with an undisplaced or minimally displaced scaphoid fracture: A meta-analysis of randomized controlled trials. Bone Joint J 2022 Population: Adult patients older than 16 years of age with a un-displaced or minimally displaced (≤ 2 mm) fracture of the waist of the scaphoid. Exclusions: Non-RCTs, children, displaced >2 mm Intervention: Operative management Comparison: Non-operative management Outcome: Primary Outcome: Patient-reported outcome measure (PROM) of wrist function at 12 months Secondary Outcomes: Pain, grip s

Date: November 16th, 2022 Reference: Lipsett SC, Monuteaux MC, Shanahan KH, et al. Nonoperative Management of Uncomplicated Appendicitis. Pediatrics 2022 Dr. Angelica DesPain Guest Skeptic: Dr. Angelica DesPain is an Assistant Professor of Pediatrics and a pediatric emergency medicine physician at the Baylor College of Medicine Children’s Hospital of San Antonio in San Antonio, TX. Case: A 10-year-old boy comes into the emergency department (ED) with right lower quadrant (RLQ) pain for the past two days. He also has had nausea, vomiting, loss of appetite but no fevers. You order an ultrasound and find that he has acute appendicitis without evidence of perforation or appendicolith. His white blood cell count is 11,000 and his C reactive protein (CRP) is mildly elevated. After you tell the family the news, the parents express concern about their child having surgery. They ask you and the surgeon, “Does he absolutely need surgery, or can we treat this medication alone?” Background: The SGEM has covered diagnosing appendicitis using speed bumps (SGEM#23), a clinical decision instrument (SGEM#155) and point of care ultrasound (SGEM#274). The current standard of care for nonperforated acute appendicitis is immediate laparoscopic appendectomy. However, over the last decade nonoperative treatment of appendicitis (NOTA) with antibiotics alone has become an alternative treatment option for non-perforated acute appendicitis. These authors call this alternative nonoperative management of uncomplicated acute appendicitis (NOM). The SGEM has looked at the evidence for NOTA/NOM in adults a few times including SGEM#115, SGEM#256 and SGEM#345. We have also looked at it specifically in children with pediatric general surgeon and rock star Dr. Ross Fisher with an episode called: The First Cut is the Deepest (SGEM#180). In adults, randomized control trials suggest that nonoperative management with antibiotics alone may be a reasonable treatment approach for individuals without appendicolith [1-3]. Although, up to 39% of patients may experience failure by the five-year mark [4]. In children, there have been two randomized and several nonrandomized prospective trials. Most recently, the two prospective pediatric studies published their 5-year data and observed a similar five-year failure rate of nonoperative management of 30-40% [5-6]. The shift from immediate operative management to now up to 3 in 10 cases being treated with IV antibiotics leaves a lot of questions as to whether nonoperative management is an appropriate option for nonperforated pediatric acute appendicitis. Clinical Question: How do the risks and complications compare between nonoperative management vs immediate operative intervention for acute nonperforated appendicitis? There are actually four questions these authors are trying to address with this paper. What are the trends in NOM of nonperforated acute appendicitis? What are the early and late treatment failure rates with NOM? How does subsequent healthcare utilization compare between children undergoing immediate operative management and those undergoing NOM? How do the rates of perforated appendicitis and postsurgical complications compare between children undergoing immediate operative management and those who experience failure of NOM? Reference: Lipsett SC, Monuteaux MC, Shanahan KH, et al. Nonoperative Management of Uncomplicated Appendicitis. Pediatrics 2022 Population: <19 years of age seen across 47 EDs in the Pediatric Health Information System (PHIS) database from January 2011 through March 2020 who were ascribed a primary diagnosis of appendicitis based on ICD-9 and 10 codes. To increase the specificity of the case definition, the study only included patients who either underwent appendectomy or received a parenteral antibiotic during the index visit. Excluded: complex chronic condition and those with a previous visit with a diagnosis of appendicitis or a procedure code for an appendectomy (these would exclude prior cases of nonoperative management) Intervention: Nonoperative management (NOM) of nonperforated acute appendicitis Comparison: Appendectomy for nonperforated acute appendicitis Outcomes: Because they had four questions they were trying to answer, we are not actually sure what their primary versus secondary outcomes were. They were all just…outcomes. Trends in NOM Treatment failure rate for NOM, divided into early (≤14 days) vs late (>14 days); 1, 2, 5-year failure rates Subsequent healthcare utilization for NOM vs immediate management Rates of perforated appendicitis and postsurgical complications between children undergoing immediate operative management versus those who opted for NOM Type of Study: Retrospective cohort study using data obtained from the Pediatric Health Information System (PHIS), Authors’ Conclusions: Nonoperative management of nonperforated pediatric appendicitis is increasing. Although the majority of children who undergo NOM remain recurrence-free years lat

Date: November 26th, 2022 Reference: James et al. Emergency Department Condition Acuity, Length of Stay, and Revisits Among Deaf and Hard-of-Hearing Patients: A Retrospective Chart Review. AEM November 2022 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Click on the LINK for a transcript of the podcast Case: One night you grab the next patient on the board, and upon entering the room introduce yourself as you normally would. The patient waves at you and gestures to a friend in the room, who explains that the patient is deaf and needs a sign language interpreter. You know from your brief look at the triage report that the patient’s vitals are stable and their chief complaint isn’t likely to be immediately life threatening, so you politely explain you’ll be back, and go find the charge nurse to obtain interpreter services. Background: The emergency department sees anyone at anytime for anything. This includes some patients who have difficulty accessing the healthcare system due to social determinants of health, race, gender, mental health, substance use disorder, and physical difficulties. Deaf and hard-of-hearing (DHH) experience disparities in social outcomes as well as health inequities (1), likely due to audism, which creates privilege for non-DHH people in our society (2). DHH patients are more likely to use the ED than non-DHH patients, but little research has been done to compare ED-focused outcomes for these groups of patients (1, 3-4). DHH patients are heterogenous, with adult-onset DHH patients being less likely to use American Sign Language (ASL) with proficiency (5). DHH ASL users may have delays due to interpreter availability, potentially resulting in care discrepancies (1, 6). Clinical Question: How do deaf and hard-of-hearing (DHH) American Sign Language speakers and DHH English speakers utilize the ED, specifically regarding acuity of complaints and pain, what is their ED length of stay and what is the prevalence of acute revisits? Reference: James et al. Emergency Department Condition Acuity, Length of Stay, and Revisits Among Deaf and Hard-of-Hearing Patients: A Retrospective Chart Review, AEM November 2022 Population: All DHH-American Sign Language, DHH-English speakers, non-DHH English speakers users who had used a single academic center for care Excluded: Patients who had not had an ED visit during the time period Intervention: None Comparison: Non-DHH English speakers were compared to DHH ASL-users and DHH English speakers Outcomes: Primary Outcome: Emergency Severity Index (ESI), triage pain score, ED length of stay (LOS), and acute ED revisit (defined as within 9 days) Type of Study: Retrospective chart review of a single health care system Dr. Tyler James This is an SGEMHOP episode which means we have the lead author on the show Dr. Tyler James. Dr. James is a Postdoctoral Research Fellow in the Department of Family Medicine at the University of Michigan Medical School. His research focuses on healthcare access, utilization, and delivery for people with disabilities, with specific interest in working with people with sensory disabilities. He is also a mixed methods research methodologist, and serves as Associate Editor for Media Reviews of the Journal of Mixed Methods Research. Authors’ Conclusions: Our study identified that DHH ASL-users have longer ED LOS than non-DHH English-speakers. Additional research is needed to further explain the association between DHH status and ED care outcomes (including ED LOS, and acute revisit), which may be used to identify intervention targets to improve health equity. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all important confounding factors? Yes Was the follow up of subjects complete enough? Yes How precise are the results? Fairly precise Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Funding of the Study: Agency for Healthcare Research and Quality, and the National Center for Advancing Translational Sciences of the National Institutes of Health under University of Florida Clinical and Translational Science Results: The sample included 100% of DHH-ASL people (n=277). This was compared to 1,000 randomly sampled DHH English speakers, and 1,000 randomly sampled non-DHH English speakers. Of this total sample, 39%, 36% and 30% had an ED visit during the study time frame and were analyzed. The Mean age was mid to late 40’s, ~55% were women and about two-thirds identified as white. Key Result: There were no statistical differences in ESI,

Date: November 19th, 2022 Reference: Khatib N, and Sampsel K. CAEP Position Statement Executive Summary: Where is the love? Intimate partner violence (IPV) in the Emergency Department (ED). CJE.M 2022 Nov Dr. Nour Khatib Guest Skeptics: Dr. Nour Khatib is an emergency physician in Toronto working in community sites Markham Stouffville Hospital and Lakeridge health. Dr. Khatib also works in remote Northern communities in the Northwest Territories and Nunavut. She is currently the professional development and education lead at Lakeridge Health and lead preceptor for Lakeridge Health learners. She is the VP of Finance of a not-for-profit emergency education organization creating educational events for community emergency doctors. Prior to her career in medicine, she was a financial analyst for Pratt & Whitney Canada and has a background in Finance and an MBA. Her unique work and life experiences have fueled her passion for leadership, patient education, and quality improvement. Dr. Kari Sampsel Dr. Kari Sampsel is a staff Emergency Physician and Medical Director of the Sexual Assault and Partner Abuse Care Program at the Ottawa Hospital and an Assistant Professor at the University of Ottawa. She has been active in the fields of forensic medicine and medical education, with multiple international conference presentations, publications and committee work. She has been honored with a number of national awards in recognition of her commitment to education and awareness. She has founded a technology/consultancy company to assist organizations in policy development, staff training, investigation and prevention of sexual harassment and assault. She is also an avid CrossFitter and believes that strength and advocacy are the way to a better world. This is an SGEM Xtra episode. The Canadian Association of Emergency Physicians (CAEP) put out a position statement on intimate partner violence (IPV) on November 2, 2022. CAEP has several position statements including homelessness, violence in the ED, gender equity, opioid use disorder and other topics. We did an SGEM Xtra episode covering the CAEP position statement on Access to Dental Care. The key message is that CAEP believes that every Canadian should have affordable, timely, and equitable access to dental care. TRIGGER WARNING: As a warning to those listening to the podcast or reading the blog post, there may be some things discussed about IPV that could be upsetting. The SGEM is free and open access trying to cut the knowledge translation down to less than one year. It is intended for clinicians providing care to emergency patients, so they get the best care, based on the best evidence. Some of the IPV material we are going to be talking about on the show could trigger some strong emotions. If you are feeling upset by the content, then please stop listening or reading. There will be resources listed at the end of the blog for those looking for assistance. The rate of women murdered by a current or ex-partner in Canada has increased from 1 in every 6 days, to one in every 36 hours in 2022. Canada’s Emergency Departments are where survivors of violence most often seek care, and where the violence against them is not always recognized. A new position statement from the Canadian Association of Emergency Physicians, published in November 2022, during Domestic Violence Awareness Month, aims to guide Emergency Department staff in the recognition and care of survivors of violence. This statement helps guide clinicians and emergency departments on how to implement processes to identify, treat and keep survivors of intimate partner violence safe. Questions for Dr. Khatib and Dr. Sampsel Nour and Kari were asked a number of questions about IPV and the CAEP Position Statement. Please listen to the SGEM Xtra podcast on iTunes to hear their answers and for more details. How do you define IPV? IPV refers to any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship. This is often an issue of power and control and could be in current or past relationships. Why did CAEP decide to put out a position statement on IPV? IPV patients are being seen daily in our EDs and CAEP saw the value in ensuring that this vulnerable trauma population was recognized and received good care when they came to see us. Why did you two decide to take the lead on this issue? Nour had presented an award-winning Grand Rounds on IPV where she noted that CAEP didn’t have a statement yet on this, despite IPV patients being seen most often in an ED setting. In my experience working in this field, I noticed that emerg docs were really comfortable with caring for trauma patients, but were less comfortable with this subset of trauma. So we decided to write a document to help our colleagues across the country. How prevalent is IPV and what impact does it have on those exposed to IPV World Health Organization (WHO) estimates the prevalence to be 1 in 3

Date: November 10th, 2022 Reference: de-Madaria E et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis (WATERFALL). NEJM 2022. Guest Skeptic: Dr. Salim R. Rezaie completed his medical school training at Texas A&M Health Science Center and continued his medical education with a combined Emergency Medicine/Internal Medicine residency at East Carolina University. Currently, Salim works as a community emergency physician at Greater San Antonio Emergency Physicians (GSEP), where he is the director of clinical education. Salim is also the creator and founder of REBEL EM and REBEL Cast, a free, critical appraisal blog and podcast that try to cut down knowledge translation gaps of research to bedside clinical practice. Case: A 38-year-old male presents to the emergency department (ED) with acute mid epigastric abdominal pain with nausea and vomiting. As part of the patient’s workup, he has an elevated lipase, and a CT abdomen and pelvis ultimately shows the patient to have acute pancreatitis. You remember a new trial was just published on whether to use aggressive versus nonaggressive goal-directed fluid resuscitation in the early phase of acute pancreatitis and wonder which would be better for this patient. Background: It’s interesting to see how fluid resuscitation has been debated over the years. This includes fluid type and rate for things like renal colic (SGEM#32), pediatric diabetic ketoacidosis (SGEM#255), hyponatremia (SGEM#326), trauma (SGEM#369), and critically ill adults (SGEM#347 and SGEM#368). Standard management of acute pancreatitis has focused mainly on hydration, analgesia, and investigation for an underlying cause. Recent evidence has challenged the routine use of aggressive large volume fluid resuscitation with the potential to increase the severity of pancreatitis as well as fluid overload. High-quality evidence demonstrating harms of aggressive fluid resuscitation in acute pancreatitis have been lacking. Clinical Question: Does the use of a moderate fluid resuscitation strategy in acute pancreatitis decrease the rate of progression to moderate/severe pancreatitis in comparison to aggressive fluid resuscitation? Reference: de-Madaria E et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis (WATERFALL). NEJM 2022. Population: Adult patients (≥18 years of age) diagnosed with acute pancreatitis based on the Revised Atlanta Classification (Requires 2 of 3: Typical abdominal pain, serum amylase or lipase level higher than three times the upper limit of normal, or signs of acute pancreatitis on imaging) that presented within 24 hours of pain onset Exclusions: Patients who met the criteria for moderately severe or severe disease at baseline (shock, respiratory failure, and renal failure) or who had baseline heart failure (NYHA II, III, or IV), uncontrolled arterial hypertension, electrolyte disturbances (hypernatremia, hyponatremia, hyperkalemia, hypercalcemia), an estimated life expectancy of <1 year, chronic pancreatitis, chronic renal failure, or decompensated cirrhosis Intervention: Moderate fluid resuscitation (bolus of 10 cc/kg lactated Ringer’s [LR] over two hours in patients with hypovolemia or no bolus in those with normovolemia followed by 1.5 cc/kg/hour of LR) Comparison: Aggressive fluid resuscitation (bolus of 20 cc/kg LR over two hours regardless of fluid status followed by 3.0 cc/kg/hour of LR) Outcome: Primary Outcome: Progression to moderately severe or severe acute pancreatitis (according to the Revised Atlanta Classification). Secondary Outcomes: Organ failure, local complications, persistent organ failure, respiratory Failure, hospital length of stay (LOS), ICU admission, and ICU LOS Safety Endpoint: Fluid Overload defined by 2 of the following 3: Criterion 1: Non-invasive evidence of heart failure (ie echo), radiographic evidence of pulmonary congestion, invasive cardiac Cath suggesting heart failure. Criterion 2: Dyspnea Criterion 3: Heart failure signs: peripheral edema, pulmonary rales, increased jugular venous pressure (JVP) or hepatojugular reflex Type of Study: Multicenter, multinational, open-label, parallel-group, randomized, controlled, superiority trial at 18 centers across four countries (India, Italy, Mexico, and Spain) Authors’ Conclusions: “In this randomized trial involving patients with acute pancreatitis, early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Yes The patients in both groups were similar with respect to prognostic factors. No All participants (patients, clinicians, ou

Date: October 24, 2022 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 Pediatric 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 I sent Damian a message on Twitter after he posted about his pre-print paper, “Concomitant infection of COVID19 & Serious Bacterial infection in Infants <90 Days Old during Omicron Surge.” It was a rapid evaluation under the remit of the Public Health/Disease Control so did not require review by a Research Ethics Committee (REC). Unfortunately, journals, do not typically accept this and want to see ethics derogation. This led to a conversation about research ethics and governance. It is important to acknowledge that historically, the medical community has not always conducted research ethically. We took advantage of vulnerable and minority populations as evidenced by Nazi medical experimentation in the concentration camps, the Tuskegee Syphilis Study, or the HeLa cells of Henrietta Lacks. We recognize the importance of research oversight and ethical research, but our world is changing… How have emerging pandemics, technology, and social media impacted the way we conduct and disseminate research? We covered five topics: Ethics of Research in Pandemics Maintaining Research Quality Deferred Consent Big Data Sharing Research on Social Media Ethics of Research in Pandemics Many processes that govern research were scaled back to enable rapid translation of ideas. Some of this was good (ex. steroids in Covid, vaccines) but some had some potentially detrimental consequences (think pre-prints) [1]. It was much easier (in the UK) to access national data sets, and this enabled real-time research to take place. During pandemics, we need to be nimble but governed when conducting research. For example, when a new disease process (ex. PIMS TS or MIS-C) is of such a public health importance that we need to understand it as fast as possible, it is difficult to do so under stringent ethics and governance practices. For the next pandemic, we need to have systems in place for research studies to be pre-approved and ready to go as soon as a pandemic hits. Maintaining Research Quality At one point there were over 100 articles being published per day about COVID-19 [2]. Not all of them were useful or high quality. Keep in mind the words of Professor Altman, “we need less research, better research, and research done for the right reasons.”[3] It is possible to have well-governed research that is poor quality but finds itself through poor review, disseminated widely in a high-quality journal. Conversely, there can be well-governed research that is high-quality, but journals disagree, and that research has less impact because it is not perceived by journals to be good. The issue of ethical review should be separate from quality and governance. Does ethical review encompass the standard or quality of research or the mechanism of ensuring that the research is ethically performed? A randomized control trial is always going to have ethical review whereas an observational study may not. Should research that is well thought out and robust but lacking ethical approval be excluded from journals because editors perceive it does not meet the standard for high-quality research? We separated 1) the governance of conducting research 2) the process of research, and 3) the publication of research and 4) the application of research findings. There are many factors that come into in play when making clinical decisions while facing the pressures of a novel pandemic. Dr. Simon Carley on SGEM Xtra: EBM and the Changingman discussed his publication, Evidence-based medicine and COVID-19: what to believe and when to change. [4] Deferred Consent This is not a new concept but has been historically difficult to get through an ethics committee. We have seen this with seizure studies such as Emergency treatment with Levetiracetam or Phenytoin in Status Epilepticus in children (EcLiPSE)[5] and Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT)[6]. Parents did not want to have the burden of consenting to a study during a stressful time, so these patients were randomized and consent was obtained later. Most of the hesitation about this approach did not come from the patients or parents but the clinicians. These studies are now a couple of years old, but deferred consent is being increasingly used in a variety of pediatric studies. Should deferred consent become the standard? Some still think that consent should be obtained prior, if possible, out of respect for patient autonomy and principle of respect for persons. Maybe there are exceptional circumstances when deferred consent is appropriate such as situations where there is clinical equipo

Date: October 27th, 2022 Reference: Hayashi et al. Comparative efficacy of sedation or analgesia methods for reduction of anterior shoulder dislocation: A systematic review and network meta-analysis. AEM October 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com Case: A 19-year-old man presents to the emergency department (ED) with his first time anterior should dislocation after trying to recreate one of his favourite scenes in the movie Lethal Weapon. He is in significant pain, but your charge nurse informs us that, like most days since the pandemic started, the department is completely full of admitted patients, and there is nowhere safe to perform a procedural sedation, let alone have the staff to do it. The patient asks, through clenched teeth, whether there are any other options to get his shoulder back in. Background: We have covered shoulder issues a few times on the SGEM. There was an episode looking at diagnosing rotator cuff injuries (SGEM#74), the best position post-dislocation immobilization (SGEM#121) and using point of care ultrasound (POCUS) to diagnose shoulder dislocations (SGEM#288). The shoulder joint has the widest range of motion of any joint in the human body. This makes it very useful and very susceptible being dislocated. The vast majority of shoulder dislocations are anterior. Young active men are at greatest risk for dislocating their shoulder. There is also a wide range of options to diagnose shoulder dislocations (clinically, POCUS, x-ray) and dozens of reduction techniques. Some clinicians perform reductions without any analgesics at all, while others choose from a variety of options, including peripheral nerve blocks, intra-articular anesthesia, and full procedural sedation. Procedural sedation might represent one of the greatest advancements for the practice of emergency medicine, allowing us to perform a large variety of necessary but painful procedures without causing our patients pain. Although minor adverse events, such as brief apnea or hypoxia, are common, significant adverse events are very rare, and the benefits are clear (Bellolio 2016). However, for most departments, procedural sedation represents a logistical challenge that can increase a patient’s length of stay. Peripheral nerve blocks (PNBs) can be very effective at controlling pain, but require a degree of practitioner skill. The use of ultrasound to guide these procedures has increased their popularity in recent years. There have been a few randomized control trials (RCTs) of peripheral nerve blocks for shoulder dislocation, but without definitive results (Raeyat Doost 2017; Blaivas 2011). Intra-articular anesthetic (IAA) injections are another option, and seem like they should be incredibly easy, considering that the humeral head is not sitting in the glenoid fossa, and so the joint is wide open and supposedly easy to access. Intra-articular injection has been compared with procedural sedation (PS) for shoulder dislocation, with some potential benefits (Wakai 2011). However, in one study, emergency physicians missed the joint space almost half the time when performing landmark-based shoulder injections (Omer 2021). Therefore, uncertainty remains about the ideal technique to provide analgesia and/or sedation for the reduction of anterior shoulder dislocations. Clinical Question: What is the safety and efficacy of intravenous sedation, intra-articular injection, and peripheral nerve block for the reduction of anterior shoulder dislocations. Reference: Hayashi et al. Comparative efficacy of sedation or analgesia methods for reduction of anterior shoulder dislocation: A systematic review and network meta-analysis. AEM October 2022 Population: RCTs that assessed sedation of analgesia methods for the reduction of anterior shoulder dislocations diagnosed on either physical exam or x-ray in patients older than 15 years of age. Exclusions: Allergies to study medications, multiple traumas, fractures (except Hill-Sachs and Bankart lesions), hemodynamic instability, or respiratory distress. Intervention: Intravenous (IV) sedation, intra-articular anesthetic (IAA) injection, and peripheral nerve blocks (PNB). Comparison: Patients who received either a placebo or no sedation. Outcome: Primary Outcome: There were three primary outcomes - Immediate success rate, patient satisfaction, and ED length of stay (LOS) Secondary Outcomes: Adverse events, pain score, time required for reduction, number of reduction attempts, and total success rate of the reduction. This is an SGEMHOP episode. Normally we have one of the authors on the show. This time we have the corresponding author who is an orthopedic trauma surgeon in Japan. Dr. Yamamoto was kind enough to give a shout out to his co-investigators and send responses to our ten nerdy questions. I can understand how hard it would be to talk nerdy in another language. Dr. Yamamoto's co-authors incliuded

Date: October 18th, 2022 Reference: Moore et al. Head and thorax elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival. Resuscitation 2022 Guest Skeptic: Clay Odell is a Paramedic, Firefighter, and registered nurse (RN). Case: You are the Chief of your local Fire and EMS Department, and an individual contacts you saying he saw a piece on TV about a “Heads Up” CPR device, and he wants to donate half the cost and has his checkbook out. Background: We have covered Out of Hospital Cardiac Arrests (OHCAs) many, many times on the SGEM. This includes epinephrine for OHCA, target temperature management, mechanical CPR, supraglottic airways, steroids, hands on defibrillation and many more topics. 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 Overall, the success rate of resuscitation of out of hospital cardiac arrest – or OHCA’s – is pretty dismal and efforts to improve resuscitation rates are absolutely vital. Animal research has suggested that elevating the head during CPR improves success rates. The proposed physiology includes decreased intracranial pressure and improved return of venous blood from the head and neck to the thorax. Pathophysiology has been used to justify practice many times in medicine. There are examples of medical reversal when properly conducted studies are performed to confirm the hypotheses. The time to accept a claim is when there is sufficient evidence. This study is an attempt to confirm (or refute) the pathophysiology and the animal research into human subjects. Clinical Question: Does the rapid use of an automated head up device as part of a CPR bundle improve survival from OHCA? Reference: Moore et al. Head and thorax elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival. Resuscitation 2022 Population: Adults 18 years of age and older with OHCA (ventricular fibrillation [VF] or ventricular tachycardia [VT], pulseless electrical activity [PEA], or asystole; routine and consistent treatment with ACE-CPR within the participating pre-hospital system; and routine and consistent recording of the 911 call receipt to placement of the APPD [automated controlled head and thorax patient positioning device] time interval. Excluded: Children, prisoners, women known to be pregnant, patients >175kg and patients without documentation of 911 call to start of EMS CPR time interval. Intervention: Automated controlled elevation of the head and thorax CPR (ACE-CPR) with an impedance threshold device (ITD) and active compression decompression (ACD-CPR) or LUCAS manual compression device Comparison: Conventional CPR (C-CPR) with or without ITD Outcome: Primary Outcome: Survival to hospital discharge Secondary Outcomes: Return of spontaneous circulation (ROSC) at any time, “favorable neurological function” defined as a Cerebral Performance Category (CPC) of 1 or 2 or “neurologically favorable function” defined as a modified Rankin Scale (mRS) score ≤ 3 Type of Study: Multi-centre, prospective observational study Authors’ Conclusions: “Compared with C-CPR controls, rapid initiation of ACE-CPR was associated with a higher likelihood of survival to hospital discharge after 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 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 Do you believe the results? Unsure Can the results be applied to the local population? Unsure Do the result

Date: October 5th, 2022 Reference: Top Gun 1986 Guest Skeptic: Dr. Chris Carpenter is Professor of Emergency Medicine in the Department of Emergency Medicine at Washington University in St. Louis and co-wrote the book on "Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules". Chris will be moving to Rochester, Minnesota soon to become the Vice Chair of Implementation and Innovation at the Mayo Clinic. This is an SGEM Xtra episode about what we learned from the 1986 movie Top Gun. It is similar to the episode with kindness guru, Dr. Brian Goldman, on how Star Trek made us better physicians. When Top Gun Maverick was released on Memorial Day Weekend May 27th, 2022, I hosted a weekend extravaganza. This involved watching the original movie, playing beach volleyball and then seeing Top Gun Maverick. It was an epic weekend with friends from around the world. Chris Bond from Standing on the Corner Minding My Own Business (SOCMOB) and I even stood up and sang She’s Lost that Lovin’ Feeling at the local movie theatre. You can click on this LINK to see the performance. Chris Carpenter was booked to attend the Top Gun long weekend but COVID had other ideas. He tested positive a few days before the extravaganza. Chris did not want to become a citizen of Canada for two-weeks in isolation, so he stayed home and missed the fun. We were back together again at ACEP22 in San Francisco. Each year we co-present at the Rural Section meeting. This year we reviewed ten recent publications, provided some critical appraisal of the studies and then discussed if the evidence would be applied differently in a rural or critical access hospital compared to a tertiary or urban centre. You can download a copy of our slides at this LINK. Being together again for the first time since 2019 was a great opportunity to record the Top Gun SGEM Xtra episode. There are so many different lessons/takeaways from the movie and we covered eleven (my second favourite number). Lessons Learned from Top Gun 1) Be Prepared To Fail: Lieutenant Pete Mitchell (Maverick) takes risks and sometimes they work and sometimes they do not work. He dropped below the hard deck to get the kill shot during a training session but was reprimanded. Maverick also took a chance in the bar and tried to sing She’s Lost that Loving Feeling. Lieutenant Commander Rick Heatherly (Jester): "That was some of the best flying I've seen to date — right up to the part where you got killed." Working in the emergency department mean you will fail (make some mistakes). You need to learn from these experiences and not let previous failures prevent you from trying. It's not the falling down that is the most important, but rather the picking ourselves up. 2) Never Leave Your Wingman: Maverick comes into Top Gun a bit of a loner. Only real friend is Lieutenant Nick Bradshaw Goose. He needs to learn to work together in a team. Have your team’s back (RNs, techs, docs, admin, etc). Early in the movie he helps a fellow pilot land his plane. Commander Tom Jardian (Stinger): "Maverick, you just did an incredibly brave thing. (Pause) What you should have done was land your plane! Maverick also leaves his wingman at one point at Top Gun while in a training session and loses. Later in the movie he stays with his wingman in combat and is successful. This leads to the exchange between Iceman and Maverick Lieutenant Tom Kazansky (Iceman): "You can be my wingman any time." Maverick: "Bull----! You can be mine." Working in an emergency department takes teamwork and you need to be there for each other. This will be discussed further. 3) Asking for Permission: Sometimes it is better to ask forgiveness than permission. Maverick asks for permission to buzz the tower. He is told no but does it anyway. Maverick: "Requesting permission for flyby". Air Boss Johnson: "That’s a negative Ghostrider, the pattern is full." Maverick and Goose get in trouble for this and learns another valuable lesson. Don’t disobey orders. Remember to put patient care at the centre of your decision making. This means at times you might be treating first and asking for permission from administration later. 4) Lack of Knowledge or Attitude: What gets us into trouble is often not our lack of medical knowledge (or our capacity to absorb new knowledge into our clinical armamentarium), but rather our attitude. Iceman: "Maverick, it's not your flying, it's your attitude. The enemy's dangerous, but right now you're worse. Dangerous and foolish. You may not like who's flying with you, but whose side are you on?" As clinicians, scientists and healthcare leaders, we need to have an attitude that we are a team working together for patients. 5) Time to Think: Often in EM we do not have time to think. We need to make life and death decisions at times quickly on limited information. This is why training and high-fidelity

Date: September 15, 2022 Reference: Ramnarayan P et al. Effect of high-flow nasal cannula therapy vs continuous positive airway pressure therapy on liberation from respiratory support in acutely ill children admitted to pediatric critical care units: a randomized clinical trial. JAMA July 2022 Dr. Spyridon Karageorgos Guest Skeptic: Dr. Spyridon Karageorgos is a Pediatric Resident at Aghia Sophia Childrens’ Hospital, Athens, Greece and a MSc student in Pediatric Emergency Medicine at Queen Mary University London. Case: A 10-month-old male infant presents to the emergency department (ED) with a low-grade fever, rhinorrhea and reduced feeding during the last two days. On exam, you notice increased work of breathing, nasal flaring, grunting with subcostal and intercostal retractions. He’s breathing at a rate of 75 per minute with oxygen saturations of 86% on room air. You make a clinical diagnosis of severe bronchiolitis. You start with low-flow O2 therapy but there is no clinical improvement. You discuss with the family the possibility that the child may need to be admitted in the pediatric intensive care unit (PICU) and require escalation of respiratory support with another modality of non-invasive ventilation. Parents look worried and ask you what kind of non-invasive support are you planning to start? Background: The use of High-Flow Nasal Cannula (HFNC) has increased in both PICU and in the Pediatric ED, especially for infants presenting acutely ill with respiratory distress requiring non-invasive ventilation (NIV). Despite the rise in popularity, there is a lack of high-quality evidence surrounding the use of high flow nasal cannula. Most studies are observational studies rather than randomized control trials (RCTs) [1-3]. Randomized control trials performed demonstrated that the early initiation of high flow nasal cannula led to lower rates of treatment failure/escalation…to high flow nasal cannula[4]. Even results from meta-analyses are mixed [5-6]. The SGEM covered the use of high flow nasal oxygen for bronchiolitis with Dr. Ben Lawton on SGEM #228. The bottom line for that episode was: "High flow oxygen therapy is not required for every child in hospital with bronchiolitis. It will continue to have a role in supporting those with more severe disease, but the potential benefits and harms will need to be considered within the context of where it is being used." There are a few proposed mechanisms for HFNC: Positive pressure Reduced upper airway resistance Washout of dead space in the nasopharynx More comfort from humidified air However, data regarding the clinical effectiveness of HFNC compared to continuous positive airway pressure (CPAP) is limited. In 2018, Ramnarayan et al. performed a multicentre pilot randomised controlled trial of HFNC vs CPAP in paediatric critical care that confirmed the feasibility of performing a large multicenter trial on HFNC vs CPAP in PICU [7]. The FIRST-ABC master protocol included two RCTs, one in acutely ill children requiring respiratory support (Step-Up RCT) and one in children requiring respiratory support after extubation from invasive ventilation (Step-Down RCT), with the aim of assessing the clinical and cost-effectiveness of HFNC as the first-line mode of non-invasive respiratory support in critically ill children. We’re focusing on the Step-Up RCT for today’s episode. Clinical Question: In acutely ill pediatric patients requiring non-invasive ventilation in the PICU, is High Flow Nasal Cannula (HFNC) noninferior to Continuous Positive Airway Pressure (CPAP) in terms of time to liberation from all forms of respiratory support? Reference: Ramnarayan P et al. Effect of high-flow nasal cannula therapy vs continuous positive airway pressure therapy on liberation from respiratory support in acutely ill children admitted to pediatric critical care units: a randomized clinical trial. JAMA July 2022 Population: Children between 36 weeks (corrected gestational age) and less than 16 years requiring non-invasive respiratory support for acute illness from 24 PICUs and HDUs in the UK between August 2019 and November 2021 Exclusion: Clinical decision to initiate other mode of ventilation (intubation, invasive ventilation), tracheostomy in place, receipt of CPAP or HFNC for >2 hours in the prior to randomization, supplemented O2 at home, presence of air-leak, midfacial/craniofacial anomalies, previously recruited to the FIRST-ABC trial Intervention: HFNC based on body weight Comparison: CPAP of 7 to 8 cm H2 Outcome: Primary Outcome: Time from randomization to liberation from respiratory support which was defined as the start of the 48-hour period during which the child was free from any respiratory support, excluding supplemental oxygen. Secondary Outcomes: Mortality at critical care discharge Rate of intubation at 48 hours Duration of critical care and acute hospital stay Patient comfort Sedation during noninvasive respiratory support Parental stress Adverse eve

Date: September 28th, 2022 Reference: Hartford et al. Disparities in the emergency department management of pediatric migraine by race, ethnicity, and language preference. AEM September 2022. 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 is a pulmonary embolism and implementation science researcher. Case: A 15-year-old patient presents to the Emergency Department with a unilateral pounding headache. The headache is similar to prior migraine headaches. They have photophobia but no vision changes, weakness, numbness, tingling, or neurologic deficits. They took 400 mg ibuprofen at home without relief. The patient and their mother ask what the next steps will be and what type of medication will be administered. Background: We have looked at migraine treatment a few times on the SGEM. That includes an episode on steroids to prevent bounce back visits to the ED (SGEM#28), ketorolac for acute treatment (SGEM#66), acupuncture for prophylaxis (SGEM#211) and a calcitonin gene-related peptide antagonist (SGEM#279). Patients with migraines often present to the ED looking for pain relief. There are many therapeutic options available to clinicians to address their pain. Unfortunately, poor pain control persists despite the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) making pain “the fifth vital sign” in 2001 to raise the awareness of oligoanalgesia in the ED. Despite the limitation of having a subjective measure as a vital sign, the problem of oligoanalgesia (poor pain management) persists (Motov and Khan). Some groups of patients who are at greater risk than others (elderly, women, mentally ill, certain ethnic groups, and insurance status). Children represent one group that is less likely to receive adequate analgesia. (Brown et al, Selbst and Clark). It is not well documented, whether gaps in pain assessment and treatment exist in conditions in which opioids are not indicated, such as migraine headaches. It is hypothesized that race, ethnicity and language (REaL) could also be independently associated with pain control. Clinical Question: Is there an association between patient demographics (race, ethnicity, and language) and pain management among pediatric ED patients presenting with migraine headaches? Reference: Hartford et al. Disparities in the emergency department management of pediatric migraine by race, ethnicity, and language preference. AEM September 2022. Population: All patients treated in a single pediatric ED with at least one migraine-relevant medication using an ED migraine pathway from pathway inception (October 14, 2016) through February 28, 2020. Excluded: Repeat encounters Intervention: Intravenous (IV) medications +/- oral (PO)/intranasal (IN) Comparison: Oral or intranasal medications only Outcome: Primary Outcome: Treatment group assignment according to race, ethnicity and language (REaL) categories. Secondary Outcomes: Pain intensity scores using the age-appropriate scale (FACES or 0-10 pain scale), ED length of stay, ED charges (billing data) Dr. Emily Hartford This is an SGEMHOP episode which means we have the lead author on the show. Dr. Emily Hartford is as assistant professor in Pediatric Emergency Medicine at the University of Washington and Seattle Children’s Hospital. She works to improve equity for patients of diverse backgrounds in the ED as well as in global partnerships to improve pediatric emergency education. This study was part of a quality improvement project that involved a migraine protocol (see below). Authors’ Conclusions: “In this retrospective analysis of pediatric migraine patients in the ED, we found that race/ethnicity and language for care were significantly associated with odds of receiving intravenous therapies compared to oral or intranasal treatments.” 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? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Somewhat 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 Conflicts of Interest? None Results: They included 833 pediatric ED patients with migraine in the study. The median age was 14.8 years and two-thirds were female. There were 51% non-Hispanic White (nHW), 23% Hispanic, 8.3% Black or African American, 4.3% Asian. Of the 833 patients, 546 (65.5%) received intravenous (IV) medications. Key Result: There were differences in the treatment of pain associations with r

Date: September 20th, 2022 Reference: Menon et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. The Lancet 2022 Guest Skeptic: Professor Daniel Fatovich is an emergency physician and clinical researcher based at Royal Perth Hospital, Western Australia. He is Head of the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research; Professor of Emergency Medicine, University of Western Australia; and Director of Research for East Metropolitan Health Service. Case: A 74-year-old man arrives from home by private vehicle complaining of right-sided weakness and dysarthria beginning two hours prior to arrival. Advance neuroimaging demonstrates no bleed and no large vessel occlusion. His NIHSS score is calculated to be 10 and he has no absolute contra-indications for systemic thrombolysis. Background: A lot has happened since you were on the SGEM last time discussing stroke (SGEM#325). This includes the CADTH report on thrombolysis by Alteplase for acute ischemic stroke in less than 4.5 hours with a letter to the editor from some neurologists representing CSC expressing their serious concerns about the report. Neurologist Dr. Ravi Garg was on an SGEM Xtra discussing his publication analysing the 1995 NINDS study. He showed the study had a high risk of selection bias. Dr. Garg concluded that the baseline imbalances observed in the NINDS study were more likely due to randomization errors than random chance. His advice was treatment decisions and guideline recommendations based on the original treatment effect reported in the NINDS tPA study should be done cautiously. We also had stroke neurologist Dr. Jeff Saver on an SGEM Xtra discussing his SRMA using the fragility index. He holds a much different interpretation of the stroke literature than Dr. Garg. The conclusion to Dr. Saver’s publication was that intravenous alteplase given within three hours of symptom onset for acute ischemic stroke is one of the most robustly proven therapies in medicine. Besides the disagreement about the strength of the evidence for tPA, there are challenges with administering this medication. It involves giving an infusion of 0.9mg/kg IV to a maximum dose of 90mg. The infusion starts with 10% of the total dose given as a bolus administered in one minute. The remaining amount is infused over 60 minutes. Tenecteplase (TNK) is a genetically modified variant of alteplase with greater fibrin specificity (15-fold higher) and longer plasma half-life (22 min vs 3.5 min). Because of its ease of use as a single bolus and more favourable benefit-to-risk profile, it is preferred over alteplase as the fibrinolytic agent of choice for acute myocardial infarction. Clinical Question: Is tenecteplase non-inferior to alteplase in treating acute ischemic stroke? Reference: Menon et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. The Lancet 2022 Population: Adult patients aged 18 years and older with ischemic stroke who met eligibility criteria for alteplase (ischemic stroke causing disabling neurologic deficit, within 4.5 hours of onset). Patients eligible for endovascular thrombectomy in addition to intravenous thrombolysis were eligible for enrolment. Exclusions: Standard contraindications to IV thrombolysis Intervention: Tenecteplase (0.25 mg/kg) bolus Comparison: Alteplase (0.09 mg/kg bolus + 60 min infusion total 0.9 mg/kg to maximum of 90mg) Outcome: Primary Outcome: Proportion mRS 0-1 at 90 days, up to 120 days Secondary Outcomes: mRS 0-2 at 90-120 days; 90-120 day EQ-VAS & EQ-5D-5L, door to needle time, proportion given endovascular therapy, recanalization status at first angiographic acquisition, baseline CT to arterial puncture time, cognition assessment (online), hospital length of stay, discharge destination. SAFETY outcomes: sICH, oroligual angio-oedema, extracranial bleeding requiring blood transfusion, all < 24 hours of thrombolysis; 90-day all-cause mortality. Type of Trial: Investigator-initiated, multicentre (22 stroke centres), parallel-group, open label, registry linked, RCT with blinded outcome assessment. Authors’ Conclusions: “Intravenous tenecteplase (0.25 mg/kg) is a reasonable alternative to alteplase for all patients presenting with acute ischaemic stroke who meet standard criteria for thrombolysis.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). No The patients in both gr

Date: September 16th, 2022 Reference: Gerlier C, et al. Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING and ABCD2 tests: A diagnostic cohort study. AEM 2021 Guest Skeptic: Dr. Peter Johns has been practicing emergency medicine since 1985 and has been passionate about vertigo education for the last two decades. He co-authored the Vertigo chapter in the current edition of Tintinalli’s emergency medicine textbook and has a YouTube channel about vertigo with over 16,000 subscribers and five million views. Case: This is a real case seen by Peter and you can see the actual exam findings in a video on his YouTube channel. A 70-year-old woman wakes up with dizziness and presents to the emergency department (ED) later that day. She’s vomited twice, and describes her dizziness as a constant spinning sensation, which gets worse when she moves her head. She has some unsteadiness but can walk unaided. She has no other neurologic symptoms. In particular, she denies any new significant headache or neck pain, or focal weakness or paresthesia, dysarthria, diplopia, dysmetria, dysphagia or dysphonia, (the so-called Dangerous D’s). When you examine her, and she is looking straight ahead, you observe that she has horizontal and slight torsional nystagmus beating towards her left ear. That means that the fast component of the nystagmus is horizontal, to the left, and there is a slight rotation with the upper pole of the eyes beating towards the left as well. Background: We have looked at acute vestibular syndrome (AVS) on the SGEM with Dr. Mary McLean who was the guest skeptic on SGEM #310. The bottom line from that episode was that: Dr. Mary McLean "the available evidence does not support the use of the HINTS examination alone by emergency physicians in patients with isolated vertigo or AVS to rule out a posterior stroke." In that episode, the case patient was told they would be admitted to the hospital to have a neurologist do the HINTS exam and decide if an MRI was necessary. But the question remains: can emergency physicians be taught how to use the HINTS exam to make clinical decisions? This is a difficult task, in part because vertigo education for emergency physicians has historically contained lots of misinformation. If there’s one thing we learned from the current pandemic, it is that misinformation is easier to spread than to correct. The tsunami of misinformation around COVID-19 has been coined the “infodemic”. We talked about this with Simon Carley on an SGEM Xtra and he emphasized “principles EBM are even more important now than in any time in our career”. There is a great quote by Thomas Francklin in 1787 about misinformation that rings true over two-hundred years later in the age of social media. He said: “Falsehoods will fly, as it were, on the wings of the wind, and carry its tale to every corner of the earth; whilst truth lags behind; her steps, though sure, are slow and solemn.” There is quote from another famous Franklin, Ben, which is apropos to the HINTS exam. "You will observe with concern how long a useful truth may be known, and exist, before it is generally received and practiced on." Myths & Misinformation about Dizziness: Myth: Asking what they mean by dizzy is the most important question to ask a dizzy patient. In fact, the patient's description of the sensation of their dizziness cannot be used to generate a reliable differential diagnosis. Myth: Tables of central vs peripheral characteristics of vertigo are helpful. Let us just say they are not. You can watch my YouTube video about this for more info. Myth: If it gets worse when you move your head, that means it’s a peripheral cause. All vertigo gets worse when you move your head. If it does not, it probably is not vertigo. Myth: A CT or CTA will prevent you from sending home a stroke presenting with dizziness. Nope. CT has very poor sensitivity for stroke. Myth: Hearing loss only happens in peripheral causes. In fact, an AICA stroke, (anterior, inferior cerebellar artery) can cause hearing loss. Myth: If you see any vertical nystagmus, it must be a central cause. In fact, the most common cause of nystagmus is BPPV, and vertical upward nystagmus is an expected finding. Spontaneous vertical nystagmus, (nystagmus you see when the patient is just sitting or lying there) is central. There are a lot of dogmas and myths in medicine. We have discussed some of them on the SGEM including SGEM#9, SGEM#63, and SGEM Xtra: Dogmalysis 2021. It is no wonder emergency physicians struggle with dizzy patients when what we were taught for decades is often not very helpful. Added to these myths is the fact that some cerebellar strokes appear very similar to vestibular neuritis. Poor understanding of vertigo leads to fear and avoidance of seeing these kinds of patients, which leads to continued poor knowledge, more avoidance and so on. I call this the Vertigo Vicious Cycle of

Date: August 25th, 2022 Reference: Martin et al. Single-dose dexamethasone is not inferior to 2 doses in mild to moderate pediatric asthma exacerbations in the emergency department. Pediatr Emerg Care. 2022 Dr. Harrison Hayward Guest Skeptic: Dr. Harrison Hayward is a Pediatric Emergency Medicine fellow at Children’s National Hospital. He finished his General Pediatrics residency at Yale-New Haven Hospital. As an editor and writer of continuing medical education material for the clinical case-sharing app, Figure 1, he enjoys interprofessional learning and is passionate about improving health care delivery to children with complex medical needs. Case: A 7-year-old female with asthma presents to the emergency department (ED) with difficulty breathing in the setting of 1-2 days of cough and runny nose. She reports that her albuterol helped her feel better yesterday, but it is providing no relief today. On exam, she has diffuse expiratory wheezing but good aeration to bilateral lung bases with a respiratory rate of 22. She has some intercostal retractions. SpO2 97% on room air. She can speak in full sentences. You diagnose her with a mild asthma exacerbation and begin treating her with albuterol/ipratropium and a dose of dexamethasone. After you explain the plan to the family, her mother says to you, “last time she was here, we got another dose of that steroid medication to take the next day. Do you think she needs it? She doesn’t like taking it, and it makes it hard for her to get to sleep.” Background: Asthma affects around 9% of children in the United States and asthma exacerbations are a common cause for ED visits. Corticosteroids are commonly use for treatment of acute asthma exacerbations. Previous research has compared the efficacy of a multi-day course of prednisone/prednisolone to single dose or two doses of dexamethasone [1-4]. We covered one of these studies on the SGEM: Highway to the Dexamethasone (SGEM #194) “A single dose of dexamethasone is non-inferior to a three-day course of oral prednisolone in the treatment of children with acute asthma exacerbation presenting to the emergency department.” So why are we back here talking about corticosteroids and asthma again? Studies had compared prednisone/prednisolone with one or two-dose dexamethasone. However, no prospective clinical trial has directly compared single dose dexamethasone to two doses. Clinical Question: Is a single dose of dexamethasone non-inferior to two doses of dexamethasone in the treatment of mild to moderate pediatric asthma exacerbations? Reference: Martin et al. Single-dose dexamethasone is not inferior to 2 doses in mild to moderate pediatric asthma exacerbations in the emergency department. Pediatr Emerg Care. 2022 Population: Children aged 2 to 20 years with known history of asthma who presented to the ED between April 2015 and March 2018 with an acute mild (PAS 5-7) or moderate (PAS 8-11) asthma exacerbation. “History of asthma” defined as at least one prior episode of wheezing responsive to beta agonists. Pediatric Asthma Score (PAS) Exclusion: Severe exacerbation (PAS >=12), systemic steroid use in the last two weeks, chronic lung disease (ie cystic fibrosis), or vomiting of two doses oral steroids in the ED Intervention: Two-dose dexamethasone Comparison: Single-dose dexamethasone Outcome: Primary Outcome: Return visits to either the primary care physician/ED/urgent care for persistent asthma symptoms Secondary Outcomes: Length of time symptoms persisted, missed school days, vomiting, adverse events (appetite changes, insomnia, mood swings) Trial: Prospective, randomized, single-center, unblinded, parallel-group randomized clinical trial Authors’ Conclusions: “In this single-center, unblinded randomized trial of children and adolescents with mild to moderate acute exacerbations of asthma, there was no difference in the rate of return visits for continued or worsened symptoms between patients randomized to 1 or 2 doses of dexamethasone.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were treated. 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. Unsure All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Unsure Financial conflicts of interest. No Results: 308 children were randomized into two groups of 154. Ultimately, 141 were enrolled in group 1 (single dose), 143 were enrolled

Date: September 3rd, 2022 Reference: Milne WK, Carpenter CR and Young T. A Hero Is Rising – Season#8 Book Dr. Tayler Young Guest Skeptic: Dr. Tayler Young is a first year Family Medicine resident at Queen’s University. Her interests are quality improvement and Free Open Access to Medical Education (FOAMed). This is an SGEM Xtra to announce Season#8 has now been summarized into a free PDF book. The SGEM provided the content, and Tayler designed the book. She has experience designing infographics for the Emergency Medicine Ottawa Blog and Emergency Medicine Cases. Tayler also one of the authors of the fourth version of the Emergency Medicine Ottawa Handbook which is now live. Seven seasons of the SGEM have been summarized into books, each with a different theme. Season#7 was designed by my daughter Sage and was inspired by the classic 1982 movie Tron. You can click on the cover page below and get access to all seven previous SGEM books. Tayler chose a Marvel theme for Season#8. This is because she is a huge fan of the Marvel Cinematic Universe (MCU). Her favourite Marvel movie is Avengers: Endgame and her favourite Marvel character is Steve Rogers or Captain America. I’m more of a DC fan myself and my favourite character is obviously Batman. I like him because he did not possess any superpower. He did not get bitten by a radioactive spider, exposed to gamma radiation like the Hulk or get his strength from our yellow sun like Superman. Bruce Wayne had to train very hard physically and study very hard to become Batman. Reminds me of the physical and mental training of residency. SGEM Season#8 Each chapter starts with the title of the SGEM episode, the clinical question and the bottom line on the first page. It also tells you who the guest skeptic is for the episode with a superhero cartoon picture of that individual. Then the format continues with the following sections: Case presentation using Spiderman and some background information on the topic. PICO question is represented by Thanos’ gauntlet with each infinity stone representing the population, intervention, comparison/control and outcome. Authors’ conclusions from the abstract Appropriate quality check list to probe the study for its validity Ironman shows up to give the key results. Talk nerdy to me section has Dr. Strange’s medallion, the eye of Agamotto. Clinical application, what do I tell the patients and a case resolution End notes with other FOAMed resources, twitter poll results and the Paper in a Picture infographic by Dr. Kirsty Challen summarizing the episode Part of the SGEM knowledge translation project is the theme music. Most of the music comes from the best musical era the 1980’s and that is a hill I'm willing to die upon. At the end of the book there are a few pages dedicated to listing all the songs that correspond to each chapter of the book. There is also a QR code that takes you directly to the SGEM Spotify Season#8 play list. 2021-2022 has been a long hard year as COVID continues. People are exhausted, burned out and suffering from moral injury. Remember, it is ok not to be ok. Asking for help is a sign of strength not weakness. As my friend Simon McCormack says, you cannot keep others warm by lighting yourself on fire. To provide great patient care you need to take care of yourself. The SGEM will be back next episode to start Season#11. It will be a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. So, patients get the best care, based on the best evidence. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Date: August 23rd, 2022 Reference: Schoenfeld et al. “Just give them a choice”: Patients’ perspectives regarding starting medications for opioid use disorder in the ED. AEM August 2022 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 24-year-old male presents to the emergency department (ED) after a fentanyl overdose. He is successfully resuscitated using naloxone and is stable after an observation period. You are interested in seizing this opportunity to offer some type of help to this patient to prevent another opioid overdose in his future. Background: We have done a few shows on opioids over the past decade: Incidence of opioid use disorder (SGEM#264) Observing patients after giving naloxone (SGEM#241) Department guideline to prevent opioid use disorder (SGEM#55) Drug overdose deaths continue to rise in the United States with opioids being the number one cause (1). There are several medications available to treat Opioid Use Disorder, including methadone and buprenorphine, which are the most effective means to decrease future illicit opioid use and death (2-5). The ED has been identified as a low barrier environment where medications for OUD (MOUD) can be initiated, even in resource-constrained settings (3,6,7). Despite the relatively easy availability of buprenorphine, less than 5% of patients discharged from the ED after a non-fatal opioid overdose fill a prescription for buprenorphine in the next 90 days (8-11). Past studies have focused on clinician-reported barriers to administering or prescribing buprenorphine in the ED (11-19). However, the perspectives and preferences of patients have not been so thoroughly explored. Shared decision making (SDM) puts patients at the center of clinical decisions and has been shown to increase knowledge, trust, and adherence in other clinical decisions (20-23). An SDM framework that fosters conversations and addresses common misconceptions around MOUD initiation may improve the patient-provider interaction and ultimately increased ED-based MOUD administration. Clinical Question: What are patient’s perspectives regarding the initiation of medications for opioid use disorder in the ED? Reference: Schoenfeld et al. “Just give them a choice”: Patients’ perspectives regarding starting medications for opioid use disorder in the ED. AEM August 2022 As this is a qualitative study, we will use a modified PICO question Population: Patients with opioid use disorder Interest: Exploring patient perspectives and experiences with OUD and using medications for OUD Context: Improving the initiation and adherence to treatment with medications for OUD from the ED Dr. Elizabeth Schoenfeld This is an SGEMHOP episode and it is my pleasure to introduce Dr. Elizabeth Schoenfeld. She is an Emergency Physician and researcher, and the Vice Chair for research in the Department of Emergency Medicine at UMass - Baystate. Her research focuses on Shared Decision-Making (SDM) in the setting of Emergency Department care. Dr. Schoenfeld and her co-authors used the Ottawa Decision Support Framework for their study. Listen to the podcast to hear her describe this tool in more detail. Authors’ Conclusions: “Although participants were supportive of offering buprenorphine in the ED, many felt methadone should also be offered. They felt that treatment should be tailored to an individual’s needs and circumstances, and clarified what factors might be important considerations for people with OUD.” CASP Checklist for Qualitative Research 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? Yes Have ethical issues been taken into consideration? Yes Was the data analysis sufficiently rigorous? Yes Is there a clear statement of findings? Yes How valuable is the research? Valuable Results: There were 26 participants interviewed, seven of whom were recruited and interviewed in the ED and 19 who were recruited and interviewed via video conferencing. The mean age of study participants was 36 and the majority had used an unprescribed opioid within the past two years. The majority had also tried both buprenorphine and methadone. Nearly all participants had ED visits related to opioid use and the goals for participant heterogeneity outlined in the methods were met. There are three themes we pulled out of the results section. Elizabeth added her own comments on the podcast after each theme was discussed. 1. Decisional Needs and Factors Relevant for Decision-Making Factors for decision making genera

Date: August 18th, 2022 Reference: Munn et al. Fragility Index Meta-Analysis of Randomized Controlled Trials Shows Highly Robust Evidential Strength for Benefit of <3 Hour Intravenous Alteplase. Stroke 2022 Dr. Jeff Saver Guest: Dr. Jeff Saver is a Professor and SA Vice Chair for Clinical Research, Carol and James Collins Chair, Department of Neurology, Director of the UCLA Comprehensive Stroke and Vascular Neurology Program at the David Geffen School of Medicine at UCLA. This is an SGEM Xtra. Jeff and I have an interesting back story to how we met. I knew about Jeff from his multiple publications in the stroke literature. I did not know he knew about me until an EM physician sent me a video of a presentation that was given at an international stroke meeting. On one of the slides, Professor Daniel Fantovich and I were referred to as "Non-Expert EM Contrarians". I reached out to Jeff and we had a very good conversation. He clarified what he meant by “non-experts”: that we were not stroke neurologists or emergency physicians with subspecialty neuro expertise, such as having completed fellowship training in neurologic critical care. He did acknowledge that both Dr. Fatovich and I had expertise on critical appraisal of the medical literature. The conversation ended well with Jeff requesting one of the t-shirts I planned to make with the title of non-expert ER contrarian on the chest. Jeff recently reached out to me with his new publication called Fragility Index Meta-Analysis of Randomized Controlled Trials Shows Highly Robust Evidential Strength for Benefit of <3 Hour Intravenous Alteplase asking about my thoughts. I thought this would be a great opportunity to dig deeper into the fragility index and have another expert in stroke neurology on the SGEM. Dr. Eddy Lang We have had a couple of individuals previously on the SGEM who strongly support the use of tPA in acute ischemic stroke (AIS). One was Dr. Eddy Lang who is a well-known Canadian researcher and emergency physician in Calgary, Alberta. Eddy appeared on the SGEM Xtra episode called the Walk of Life discussing AIS. We had a debate on the issue of tPA for stroke published in CJEM 2020 as part of their debate series. Eddy is also the senior author on the CJEM article summarizing the Canadian Stroke Best Practice (CSBP) 2018 Guidelines. This Canadian guideline gives a level “A” recommendation for the use of tPA in AIS in patients last seen normal within 4.5 hours. “All eligible patients with disabling ischemic stroke should be offered intravenous alteplase (tPA). Eligible patients are those who can receive intravenous alteplase (tPA) within 4.5 hours” of symptom onset time or last seen normal (Evidence Level A; Section 5.3.i). We also had a neurology resident on to critically appraise a systematic review and meta-analysis of endovascular therapy plus/minus tPA as a bridging therapy (SGEM#349). A few more publications have come out since that podcast and the European Stroke Organization (ESO) recommends intravenous thrombolysis before mechanical thrombectomy in patients with acute ischemic stroke and anterior circulation large vessel occlusion. There have been several tPA skeptics on the SGEM including Dr. Hoffman, Dr. Fatovich, and Dr. Morgenstern. However, not until now have we had a stroke neurologist who is very much in support of using tPA in AIS. I think it is very important to try and mitigate against echo chambers, our own biases and listen carefully to other points views. Fragility Index Meta-Analysis of Randomized Controlled Trials Shows Highly Robust Evidential Strength for Benefit of <3 Hour Intravenous Alteplase. Jeff was asked a number of questions about his new publication. Some of the answers are listed as bullet points, but most of his responses can be heard in full by listening to the SGEM podcast: Who were your co-authors on this publication? Why did you decide to write this article? What is the fragility index (FI)? The FI is the minimum number of nonevents that when changed to events in one arm of an interventional trial or meta-analysis of trials converts the result to statistical nonsignificance. Lower FIs indicate greater fragility, higher FIs more robust results. This definition of the FI is slightly different than the one provided by Walsh et al JClinEpi 2014 because it did not mention SRMA and was only looking at RCTs. There are critics of the FI who say, among other things, it could be viewed as just restating the p-value in a different way (Dr. Ed Palmer). Medicine has this very low bar of p-value of 0.05 (95%) or two sigmas to get over to consider something “statistically significant”. In contrast, particle physics uses five sigma or 99.9999%, this is a p-value of 3×10-7, or about 1 in 3.5 million chance the data is at least as extreme as what they observed. A lot of ink has been spilled about the problems with p-values. Over 800 scientists call for the abandonment of “statistical significance”. What are you

Date: August 7th, 2022 Dr. Dennis Ren Host Skeptic: Dr. Dennis Ren is a pediatric emergency medicine attending at Children’s National Hospital in Washington, DC. You might remember him from the SGEM episodes on febrile infants, aseptic meningitis, and community acquired pneumonia. This is an SGEM Xtra episode. Season 10 is coming to an end. We want to thank all our listeners and skeptics who have tuned in for ten years. We have ~67,000 subscribers and the SGEM has been translated into four other languages. We have tried different initiatives over the years to improve the quality of the SGEM. Sometimes this has worked (Keener contest, Meme Monday, Twitter Poll Tuesday and Paper in a Pic Thursday) and sometimes it has not worked (Hot or Not and Continuing Medical Education Credits). For Season 11, we knew we had to do something special and turn it up to eleven. To accomplish this we have invited Dennis to join the SGEM faculty and provide his pediatric expertise on a regular basis. Each month he will be leading an SGEM episode. Don't Panic! Dennis will use the same critical appraisal tools to probe the literature for its validity. The theme music may be more contemporary, but the content will still be fantastic FOAMed. We recognize that Dennis' clinical experience working in a tertiary centre may be different than the clinicians who provide care to the vast majority of pediatric patients that are seen in community EDs. The evidence-based medicine principles will still apply. The evidence discussed on the SGEM should inform your care but it should not dictate your care. You will still need to use your good clinical judgment and ask your patients about their values and preferences. The ultimate goal of the SGEM remains the same, to provide patients with the best care, based upon the best evidence. And we want to hear from you. Are you a passionate researcher who just published an amazing article? Or do you have an article or topic you want us to cover? Please send Dennis an email [email protected] to suggest an article or topic to cover. The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. So patients get the best care, based on the best evidence. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE

Date: July 28th, 2022 Reference: Brower et al. Point-of-Care Ultrasound-First for the Evaluation of Small Bowel Obstruction: National Cost Savings, Length of Stay Reduction, and Preventable Radiation Exposure. AEM July 2022 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. She is also the creator of all those wonderful Paper in a Pictures. Case: A 63-year-old woman presents to your emergency department (ED) with two-day history of nausea, vomiting and constipation. She tells you that she had appendicitis complicated by perforation and peritonitis ten years ago and you suspect she has adhesional small bowel obstruction. You call your surgical colleague who, predictably, asks you to order a CT. The patient asks if there is an alternative as she had several CTs on her last admission and is worried about her radiation exposure and her co-pay. Background: Somewhere between two and four percent of patients presenting to US EDs with abdominal pain have a small bowel obstruction (SBO) – those who are managed operatively (who are only 20-30%) account for 60,000 hospitalizations and 565,000 inpatient care days per year. We know that clinical examination has poor sensitivity and specificity for diagnosing SBO and that imaging is therefore necessary. CT is generally the first choice of imaging, the “abdominal series” of plain X-rays have been demonstrated to have poor predictive value, but a 2018 meta-analysis found 92.4% sensitivity and 96.6% specificity with ultrasound [1]. A 2020 national UK report into patients treated for bowel obstruction found delays in imaging and diagnosis and recommended CT with IV contrast as the first-line investigation [2]. Somewhat surprisingly, we’ve never covered SBO on the SGEM, although Ped EM Superhero, Dr Anthony Crocco shared his views on the (lack of) utility of abdominal X-rays in paediatric constipation back in 2016 (SGEM Xtra: RANThony#4). CLINICAL QUESTION: DOES USING POINT OF CARE ULTRASOUND FIRST LINE IN SUSPECTED SMALL BOWEL OBSTRUCTION REDUCE COST, LENGTH OF STAY AND RADIATION EXPOSURE? Reference: Brower et al. Point-of-Care Ultrasound-First for the Evaluation of Small Bowel Obstruction: National Cost Savings, Length of Stay Reduction, and Preventable Radiation Exposure. AEM July 2022 Population: Patients with ICD-10 coding “intestinal obstruction” from 2018 National Hospital Ambulatory Medical Care Survey. Intervention: POCUS-first approach Comparison: CT imaging as baseline Outcomes: Primary Outcome: Cost savings Secondary Outcomes: Reduction in ED length of stay, reduction in radiation exposure and preventable cancer Type: Monte Carlo Modelling This is an SGEM HOP episode, so we are pleased to have two of the authors on the show. Dr. Charles Brower is a second-year resident training in Emergency Medicine at the University of Cincinnati. His primary research interest is the intersection between clinical operations and ultrasound to improve patient outcomes in an efficient and cost-effective way. Also joining us is Dr. Andrew Goldsmith. He is the director of Emergency Ultrasound in the Department of Emergency Medicine at Brigham and Women’s Hospital at Harvard Medical School Authors’ Conclusions: “If adopted widely and used consistently, a POCUS-first algorithm for SBO could yield substantial national cost savings by averting advanced imaging, decreasing ED LOS, and reducing unnecessary radiation exposure in patients. Clinical decision tools are needed to better identify which patients would most benefit from CT imaging for SBO in the ED.” Quality Checklist for Cost Analysis Studies: Part 1: Are the recommendations valid? Did the investigators adopt a sufficiently broad viewpoint? Yes Are the results reported separately for patients whose baseline risk differs? No Were costs measured accurately? Yes Did investigators consider the timing of costs & outcomes? No Part 2: How can I apply the results to patient care? Are the treatment benefits worth the harms and costs? Yes Could my patients expect similar health outcomes? Unsure Can I expect similar costs at my setting? Unsure Are the criteria relevant to my practice setting? Yes Have the criteria been field-tested for feasibility of use in diverse settings, including settings similar to mine? No Results: In the US, a POCUS-first approach for imaging of SBO would avert a mean of 143,000 (+/- 31,000) CT scans annually, saving $30.1million (+/- $8.9million). 507,000 bed hours (+/- 268,000) could be saved, and 98 (+/-28) excess cancer deaths prevented. KEY RESULT: USING POCUS AS FIRST-LINE IMAGING IN SUSPECTED SBO COULD AVOID 143,000 CT SCANS ANNUALLY IN THE US POTENTIALLY SAVING MILLIONS OF DOLLARS Listen to the SGEM podcast to hear Charles and Andrew answer our five nerdy questions. Dr. Chalres Brower 1. Monte Carlo Simulation: Can you describe this for us in clinician-friendly language? And why is it the right method for your question? 2. Modelling Assumptions: Model

Date: July 22nd, 2022 Reference: Perry et al. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. The Lancet 2022 Guest Skeptic: Dr. Tessa Davis is a Paediatric Emergency Consultant at the Royal London Hospital, Senior Lecturer at Queen Mary University of London, Co-founder of Don’t Forget The Bubbles (DFTB). Tessa also has a weekly newsletter with tips to help you level up your use of everyday technology and to optimise your writing and to reach the audience you want. Case: Jack is nine years old, and he presents to emergency department (ED) with an arm injury. Today he was running at school, and he fell over onto his outstretched arm. His right arm is neurovascularly intact, with no swelling or deformity. He has bony tenderness at the distal radius. The X-ray shows a buckle fracture of his right distal radius. Background: We covered buckle fractures way back in Season#1 of the SGEM on SGEM#19. In that episode from ten years ago we made the distinction between a buckle fracture and greenstick fractures. Buckle fractures (also called torus fractures) are defined as a compression of the bony cortex on one side with the opposite cortex remains intact. In contrast, a greenstick fractures the opposite cortex is not intact. Buckles of the distal radius are the most common fracture seen in children and very commonly present to the ED [1-2]. Despite being a common injury they are often managed differently. Some clinicians apply casts, some a splint, some have orthopedic follow up, some have no follow up [3]. This practice variation is not new. A survey done almost 20 years ago in Canada demonstrated the variability of managing buckle fractures by Pediatric orthopedic surgeons and pediatric emergency physicians [4]. An RCT published 12 years ago reported that a soft bandage wrapping treatment for four weeks was not statistically different for discomfort, function or fracture displacement compared a below elbow back slab cast for one week followed by circumferential cast for three weeks despite some more pain in the first week with the soft bandage [5]. Yet here we are ten years later doing an SGEM episode on whether it is ok to put a soft bandage on these pediatric patients with a distal radius buckle fracture. It is a great example of how knowledge translation can take years or even decades for clinically relevant information to reach the patients’ bedside due to leaks in the EM knowledge translation pipeline [6-7]. Clinical Question: What is the appropriate management of torus fractures in children? Reference: Perry et al. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. The Lancet 2022 Population: Children between 4 and 15 years of age with a distal radius torus fracture that had been confirmed by x-ray. Exclusions: Other fractures, although a concomitant ulnar fracture did not lead to exclusion. Injury over 36 hours old, any cortical disruption seen on x-ray, and any reasons that meant follow-up would not be possible, such as a language barrier, lack of internet access or developmental delay. Intervention: Rigid immobiisation Comparison: Tensor (crepe) bandage Outcome: Primary Outcome: Pain on day three measured using the Wong-Baker FACES Pain Rating Scale [8]. Participants also recorded their pain score on day one, seven and weeks three and six. Secondary Outcomes: Measured a variety of other outcomes at the same time points, unless otherwise specified: Functional recovery using the PROMIS (Patient Report Outcomes Measurement System)Upper Extremity Score – a patient or parent-reported measure of physical function of the upper limbs. Health-related quality of life outcomes, using a EuroQol EQ-5DYa standardised questionnaire, suitable for children, which asks about quality of life, including activities of daily living and pain. Analgesia use and type taken (measured on days 1, 3 and 7) Days of school absence Health care resource use i.e. a new splint (measured at weeks 3 and 6), return to hospital Treatment satisfaction measured using a 7-item Likert scale determined on day 1 and week 6 Complications Trial: The FORCE study was a multi-centered, randomized, non-blinded, equivalence trial conducted at 23 Emergency Departments across the UK. Authors’ Conclusions: “This trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius assigned to the offer of a bandage group or the rigid immobilisation group, with no between-group differences in pain or function during the 6 weeks of follow-up.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no se

Date: July 16th, 2022 Reference: Lamontagne F et al. Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit. NEJM 2022. Guest Skeptic: Dr. Salim R. Rezaie completed his medical school training at Texas A&M Health Science Center and continued his medical education with a combined Emergency Medicine/Internal Medicine residency at East Carolina University. Currently, Salim works as a community emergency physician at Greater San Antonio Emergency Physicians (GSEP), where he is the director of clinical education. Salim is also the creator and founder of REBEL EM and REBEL Cast, a free, critical appraisal blog and podcast that try to cut down knowledge translation gaps of research to bedside clinical practice. Case: A 59-year-old woman presents to the emergency department (ED) with fever, tachycardia, and hypotension. She is found to have a urinary tract infection. She requires vasopressor therapy, intravenous fluids, and intravenous antibiotics. She is admitted to the intensive care unit (ICU) for septic shock. The ICU team is considering using Vitamin C therapy for this patient. Dr. Paul Marik Background: Dr. Paul Marik got the critical care world all excited when he claimed a Vitamin C cocktail (Vitamin C, hydrocortisone and thiamine) as a possible cure for sepsis. His position was in part based upon a retrospective before and after study he conducted at his hospital. The SGEM did a structured critical appraisal of Dr. Marik’s observational study on SGEM#174. A dozen top EM skeptics commented about the validity of the study. The SGEM bottom line was that Vitamin C, hydrocortisone and thiamine was associated with lower mortality in severe septic and septic shock patients in this one small, single centred retrospective before-after study but causation has yet to be demonstrated. We also did an episode looking at a SRMA of using Vitamin C in an adult critically ill ICU patient or cardiac surgery patients (SGEM#268). While there were several limitations to this study the bottom line was there was not enough evidence to support the routine use of Vitamin C in critically ill patients. There is a pathophysiologic basis for why Vitamin C may be beneficial in critically ill patients like those with sepsis. Vitamin C can potentially mitigate tissue injury induced by oxidative stress, but it cannot be synthesized by humans. Vitamin C levels are low in many critically ill patients. The reasonable hypothesis would be that by correcting these levels you could have a patient-oriented outcome (POO) of benefit. However, before accepting the claim of net benefit it would need to be demonstrated with high-quality evidence. Multiple studies have now been conducted and published looking at Vitamin C as a potential treatment. Only one randomized control trial (CITRIS-ALI), using a higher dose of vitamin C (50mg/kg every six hours) reported a lower 28 day risk of death compared to those randomly allocated to placebo. This outcome however was one of 46 secondary outcomes, making it hypothesis generating. No other study reported a statistical difference in the objective outcome of mortality. Clinical Question: In adult patients with sepsis, in the ICU, on vasopressor therapy, does Vitamin C reduce the risk of death or persistent organ dysfunction at 28 days compared to placebo? Reference: Lamontagne F et al. Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit. NEJM 2022. Population: Adult patients 18 years of age and older admitted to the ICU in less than 24 hours with proven or suspected infection as main diagnosis, and receiving vasopressor therapy Exclusions: Contra-indications to Vitamin C therapy, receipt of open-label Vitamin C, or expected death or withdrawal of life-sustaining therapy within 48 hours. Intervention: 50mg/kg infusion of Vitamin C mixed in 50cc of 5% dextrose solution every six hours for up to 96 hours Comparison: 5% dextrose in water or normal saline infusion every six hours for up to 96 hours Outcome: Primary Outcome: Composite of death or persistent organ dysfunction (defined as use of vasopressors, invasive mechanical ventilation, or new renal replacement therapy) on day 28 Key Secondary Outcomes: Number of days without organ dysfunction in the ICU up to day 28 and 6 months Trial: Phase 3, Multicenter, Randomized, placebo-controlled trial Authors’ Conclusions: “In adults with sepsis receiving vasopressor therapy in the ICU, those who received intravenous vitamin C had a higher risk of death or persistent organ dysfunction at 28 days than those who received 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

Date: July 1st, 2022 Guest Skeptic: Dr. Ravi Garg is a Neurologist in the Department of Neurology, Division of Neurocritical Care at Loyola University Chicago. Reference: Garg R, Mickenautsch S. Risk of selection bias assessment in the NINDS rt-PA stroke study. BMC Med Res Methodol. 2022 Jun 15;22(1):172. This is an SGEM Xtra episode. Dr. Garg saw some tweets about the NINDS trial and sent me his recent publication. I asked him to come on the SGEM and discuss the original NINDS trial, some of the reanalyses and share his analysis of the NINDS data. One of the criticisms of Emergency Medicine physicians who have done FOAMed post publication reviews of the stroke literature like Dr. Justin Morgenstern, Dr. Ryan Radecki, Dr. Anand Swaminathan and Dr. Salim Razaie, is that we are not neurologists and specifically not stroke neurologists. While this is true, we are part of the team that diagnose and treat acute stroke patients. The SGEM tries to include a wide variety of clinicians in this knowledge translation project. Great emergency care takes a team from the prehospital setting, emergency department, inpatient and outpatient all working together. That is why we have had paramedics, nurses, physiotherapists, pharmacists and a wide spectrum of physician specialists on the SGEM. However, until now have we not had a neurologist on the SGEM who has a specialized interest in stroke neurology and published on thrombolysis as a guest skeptic. Dr. Garg sent me his analysis of the NINDS trial that he wrote with his co-author Dr. Steffen Mickenautsch. This new peer reviewed publication is the basis of this SGEM Xtra episode. The NINDS trial was published back in 1995 and we did a structured critical appraisal of the classic paper with Dr. Anand Swaminathan on SGEM#70. I was a resident at the time of publication and Dr. Garg was only eight years old. Dr. Garg was asked a series of questions. You can listen to his responses on the SGEM podcast. Thoughts on the NINDS Trial and Some of the Reanalyses Dr. Ravi Garg Any general thoughts about NINDS trial? One concern about the NINDS trial was the baseline differences in NIHSS score. This resulted in multiple reanalyzes attempting to control for these factors. NINDS commissioned an independent committee to investigate if any of these imbalances invalidated the entire trial. This committee’s findings supported the use of tPA in less than three hours (Ingall et al 2004). What are your thoughts on this commissioned report? Another reanalysis was done by Kwiatkowski et al 2005 that also confirmed that the baseline imbalance in the NINDS trial did not account for the better outcome of tPA-treated patients. Any brief comments on this reanalysis? Hoffman and Schrieger stirred things up a bit with their graphic reanalysis of the NINDS trial using the NIHSS score. They published their findings in Annals of EM 2009. The results questioned the effect of tPA for acute ischemic stroke in patients treated within three hours. The graphs created in the publication also failed to support the "time-is-brain" hypothesis. There are some criticisms of this graphic reanalysis. What are your thoughts on this contrarian view? Saver et al responded to Hoffman and Schrieger’s graphic reanalysis in Academic Emergency Medicine 2010. They pointed out number concerns with the publications. Did Saver and colleagues make some sound arguments? Ravi Garg and Steffen Mickenautsch BMC June 2022 The title of your paper is Risk of selection bias assessment in the NINDS rt-PA stroke study. It was published in BMC Medical Research Methodology, June 2022. With all the other reanalyses, what motivated you to do this another reanalysis of the NINDS trial? You were able to get patient level data for this review. Why is that important? What tool did you use to assess the NINDS trial for risk of selection bias? Can you walk us through the Cochrane Risk of Bias-2 (RoB-2) tool that address systematic error arising from the randomization process? You did four sensitivity analyses based on the randomization process using participant level data. Briefly what were the four analyses? What did you do to assess the potential effect of baseline imbalances on reported alteplase treatment effects? What were the results of your study on the NINDS trial? What did you discover with the four sensitivity analyses? You adjusted for the differences found in the sensitivity analyses. How did that impact the results? Why is unbiased randomization so important in RCTs? What points do you want to highlight from your discussion What do you think the limitations are to your study? Conclusions to this New Analysis of the NINDS Trial Data What conclusions did you draw from your assessment of the NINDS trial? What does this high risk of selection bias due to your certainty about this data? You conclude the imbalances seen in the NINDS trial were not noise (random error) in the data but rather an error in randomization. This can bias the r

Date: June 30th, 2022 Reference: McGinnis et al. Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? AEM June 2022. 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 working a shift in your local community emergency department (ED) when a 47-year-old male presents with chest pain. His symptoms are moderately suspicious, he has a normal EKG, and a history of hypertension. His father had a minor heart attack at the age of 63. With a negative initial troponin, this gives him a HEART score of 4. He has no history of coronary artery disease. You have been reading about the overuse of objective cardiac testing (OCT) and wonder if this patient really needs admission to the hospital. Background: Chest pain is one of the most common presentations to the ED. Much ink has been spilled over the years on trying to find a way to safely rule-out acute coronary syndrome in these patients. Multiple clinical decision instruments have been created to risk stratify patients and guide clinicians (TIMI, GRACE, MAC, T-MAC, HE-MAC, ADAPT, VCPR, EDACS, etc). The HEART score was originally developed in 122 patients in the Netherlands and published in 2008. Backus and colleagues published their multi-centre validation of the HEART score in 2010. Since then, there have been several studies looking at this clinical decision instrument. We looked at a HEART Score Pathway that included a HEART Score and 0 and 3 hour cardiac troponin testing on SGEM#151 with our friend Salim Rezaie. The bottom line from that episode was that the HEART Pathway appears to have the potential to safely decrease objective cardiac testing, increase early discharge rates and cut median length of stay in low-risk chest pain patients presenting to the ED with suspicion of ACS. In prior decades nearly all patients presenting to EDs with chest pain were admitted to hospital. If we thought about ACS, we brought them in. This would be for objective cardiac testing including stress test, CT-angiography, and/or invasive angiography. However, all this recent research into clinical decision tools and pathways to risk-stratify these patients is reducing admissions and therefore ED and hospital overcrowding [1-5]. Many patients risk stratified as “non-low” risk are admitted, but the benefit of objective cardiac testing in this cohort is unclear in the absence of elevated troponins or abnormal EKGs [6-9]. The study we will be reviewing today seeks asks if the presence of known coronary artery disease is predictive of major adverse cardiac events (MACE) in a previously identified non-low risk group of patients. Clinical Question: What is the 30-day incidence of MACE in patients who are non-low risk but have known coronary artery disease? Reference: McGinnis et al. Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? AEM June 2022. Population: Adult patients (age >21 years) with chest pain or suspected ACS, HEAR >4, elevated troponin, ischemic EKG or prior CAD Exclusions: Patients with evidence of an ST-segment elevated myocardial infarction and patients who were identified as low risk (HEAR < 4) by the HEART Pathway Intervention: Assessment of moderate-risk patients as described in the inclusion/exclusion criteria Comparison: None Outcome: Primary Outcome: 30-day MACE defined as the composite of all-cause death, MI, or coronary revascularization. Secondary Outcomes: Individual components of the MACE composite at the index visit Study Design: A preplanned subgroup analysis of non–low-risk patients in the HEART Pathway Implementation Study was conducted. The original study was a prospective interrupted time-series of accrued adults with possible ACS from three US sites (November 2013–January 2016). Dr. Henderson McGinnis This is an SGEMHOP episode, which means we have the lead author on the show. Dr. Henderson McGinnis is a Professor in the Dept of Emergency Medicine at Atrium Health Wake Forest Baptist. Henderson is the Medical Director for AirCare, the system’s critical care air and ground transport service. He is also the fellowship director of the Wilderness Medicine Fellowship at the Wake Forest EM Program. Authors’ Conclusions: “MACE rates at 30 days were low among moderate-risk patients but were significantly higher among those with prior CAD.” Quality Checklist for Clinical Decision Tools: The study population included or focused on those in the ED. Yes The patients were representative of those with the problem. Yes All important predictor variables and outcomes were explicitly specified. Unsure This is a prospective, multicenter study including a broad spectrum of patients and clinicians (level II). No Clinicians interpret individual predictor variables and score the clinical decision rule reliably and accurately. Yes This is an impact analysis of a previously validated CD

Date: June 18th, 2022 Reference: Crombie et al. Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. The Lancet Haematology 2022 Guest Skeptic: Dr. Casey Parker is a Rural Generalist that includes in his practice emergency medicine, anaesthesia 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. Case: You are working in the emergency department (ED) and receive a call from the Advanced Care Paramedics who are at the scene of a stabbing. Apparently, two rival gangs (Jets and Sharks) had a rumble. The young man has been stabbed in the abdomen and lost a lot of blood. The patient is tachycardic (120 beats/minute), hypotensive (80/60 mmHg) and looks very pale. They have two large bore intravenous (IV) access and are planning to bring them to your ED as soon as possible. The paramedic asks you, “we have saline, and we also have red-cells and this fancy new lyophilised plasma. Should we give our shocked patient saline or plasma / red cells en route to the ED?” What do you advise him? Background: The use of fluids in trauma resuscitation has been studied in a number of trials in recent years. A lot of observational data has been collected from the battlefields of Iraq and Afghanistan. The Control of Major Bleeding After Trauma (COMBAT) Trial was published in the Lancet in 2018. It was a pragmatic, randomised, single-centre trial done at the Denver looking at the use of plasma in the prehospital setting. This trial did not show a statistical mortality benefit within 28 days of injury. First10EM and REBEL EM both did a review of the COMBAT trial. The Prehospital Air Medical Plasma (PAMPer) trial was published in NEJM, also in 2018. The goal of this trial was to determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock. This trial did report that prehospital administration of plasma was safe and resulted in lower 30-day mortality. PAMPer was reviewed by First10EM and The Bottom Line. The traditional teaching in trauma is to replace blood with blood products, so we would expect that we should see a benefit if we used blood and plasma instead of saline alone for the initial resuscitation. Clinical Question: In the resuscitation of pre-hospital trauma patients with hemorrhagic shock is there a patient-oriented benefit to using blood and plasma over 0.9% saline? Reference: Crombie et al. Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. The Lancet Haematology 2022 Population: Adult patients 16 years of age or older suffering traumatic injury resulting in shock believed to be due to a traumatic haemorrhage. Shock was defined as a systolic BP less than 90 mmHg or an absent radial pulse. Exclusions: Patients known to refuse blood produces, those who received transfusion of prehospital blood products before assessment for eligibility, pregnancy (known or apparent), isolated head injury without evidence of major haemorrhage, and prisoners. Intervention: Up to four units of blood products boluses one unit at a time. Units were alternating between units of O-negative packed red cells (PRBC) or or reconstituted lyophilised plasma to a maximum of two units of either. Comparison: Up to four boluses of 0.9% saline (250ml/bolus) Outcome: Primary Outcome: Composite outcome of mortality from time of injury to hospital discharge or the failure to clear lactate by 20% within the first two hours after randomisation. Secondary Outcomes: Individual components of the composite primary outcome, fluid volumes, measures of coagulopathy, 30 day mortality and common side effects of transfusion such as reaction and adult respiratory distress syndrome (ARDS) Trial: This was a multi-centre, open-label, concealed, single-blinded, randomised controlled trail Authors’ Conclusions: “The trial did not show that prehospital PRBC–LyoPlas resuscitation was superior to 0.9% sodium chloride for adult patients with trauma related haemorrhagic shock. Further research is required to identify the characteristics of patients who might benefit from prehospital transfusion and to identify the optimal outcomes for transfusion trials in major trauma. The decision to commit to routine prehospital transfusion will require careful consideration by all stakeholders.” 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

Date: June 12th, 2022 Reference: Finfer et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. NEJM 2022. Guest Skeptic: Dr. Aaron Skolnik is an Assistant Professor of Emergency Medicine at the Mayo Clinic Alix School of Medicine and Consultant in the Department of Critical Care Medicine at Mayo Clinic Arizona. He is board certified in Emergency Medicine, Medical Toxicology, Addiction Medicine, Internal Medicine-Critical Care, and Neurocritical Care. Aaron is a full-time multidisciplinary intensivist. He is the Medical Director of Respiratory Care for Mayo Clinic Arizona and is most proud of his position as medical student clerkship director for critical care. Case: A 62-year-old man is brought in by EMS from home with lethargy and hypotension. Chest x-ray is clear, labs are remarkable for a leukocytosis of 16,000 with left shift; exam is notable for left flank pain and costovertebral tenderness. Straight catheter urinalysis is grossly cloudy, and pyuria is present on microscopy. Blood pressure is 85/50 mmHg. You wonder which IV fluid should you order? Background: There has been a longstanding debate about which intravenous fluid is the best for volume resuscitating critically ill patients. We’ve known for some time that albumin is bad for injured brains, and that hydroxyethyl starch solutions have been associated with kidney injury and mortality. Since then that debate has broadly centered on the choice between what we will call “abnormal saline” (0.9% sodium chloride), and balanced crystalloid solutions, meaning those with a chloride composition closer to plasma such as lactated ringer’s or Plasma Lyte 148. Early work suggested potential harm from 0.9% saline, that may be partly driven by kidney injury associated with the administration of high-chloride content IV fluids. In the last few years, the pendulum has swung back and forth. Two large, cluster-randomized trials (SMARTand SALT-ED) showed a small benefit to the use of balanced crystalloids in preventing a composite outcome of Major Adverse Kidney Events within 30 days (aka MAKE-30). Then, the BaSICS trial (a multicentred RCT done in 75 Brazilian ICUs) came along and compared saline to Plasma-Lyte at what the authors deemed slow and fast infusion rates. We reviewed that last time on SGEM#347. There was no interaction between fluid type or rate of infusion with the primary outcome of 90-day survival. Among 19 secondary outcomes, which should only be considered hypothesis generating, SOFA scores and neuro SOFA scores at day seven were worse in the balanced crystalloid group. Now we have the PLUS trial, from Australia and New Zealand to add to the medical literature on this issue. Clinical Question: Is the 90-day mortality in critically ill adult patients lower with the use of Plasma-Lyte 148, a balanced crystalloid solution, for fluid resuscitation and therapy, than with the use of normal saline? Reference: Finfer et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. NEJM 2022. Population: Patients 18 years or older, admitted to 53 ANZ ICUs over 38 months, whom the treating clinician deemed to need fluid resuscitation and were expected to be in the ICU on three consecutive days. Exclusions: Patients with specific ICU fluid requirements, those who received disqualifying fluid prior to enrollment (> 500 mL in the ICU), those at imminent risk for death or with life expectancy < 90 days, and those at risk for cerebral edema. Intervention: Plasma-Lyte 148 for all resuscitation episodes while in ICU for up to 90 days after the first episode of fluid resuscitation Comparison: 0.9% saline for all resuscitation episodes while in ICU for up to 90 days after the first episode of fluid resuscitation Outcome: Primary Outcome: All-cause mortality within 90 days after randomization Secondary Outcomes: Peak serum creatinine level during the first seven days after randomization, the maximum increase in creatinine level during ICU stay, receipt of new renal-replacement therapy, receipt and duration of treatment with vasoactive drugs, duration of mechanical ventilation in the ICU, length of ICU and hospital stays, and death from any cause during ICU stay, during hospital stay, and within 28 days after randomization. Trial: Double-blind, parallel-group, randomized, controlled trial. Authors’ Conclusions: “We found no evidence that the risk of death or acute kidney injury among critically ill adults in the ICU was lower with the use of [Plasmalyte 148] than with saline.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Yes The patients in both groups were similar with respect to prognostic facto

Date: May 24th, 2022 Reference: Broder et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department. AEM May 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com Case: A 33-year-old male presents to the emergency department (ED) complaining of abdominal pain. He states he has had the same pain for more than 10 years, and no one has ever been able to figure out what is going on. He doesn’t have any specific symptoms today, including no fever, vomiting, diarrhea, or urinary symptoms. His vital signs are normal. His abdomen is diffusely tender, but without any surgical findings. You review his chart and note that he has had five CTs performed in the last year at your hospital alone, all of which were negative. You are worried about the cumulative radiation dose he has received but find it hard to exclude significant pathology on history and physical. After all, even patients with chronic abdominal pain can develop a new acute issue like appendicitis. Background: The Society of Academic Emergency Medicine (SAEM) has launched an initiative called GRACE which stands for Guidelines for Reasonable and Appropriate Care in the Emergency Department. GRACE-1 The first GRACE publication looked at low risk chest pain, and in my opinion, they filled a very valuable role. Most guidelines focus on a single emergency visit in isolation, but a patient who presents to the emergency department recurrently with the same symptoms may require a different approach. In the context of recurrent chest pain, they made eight key recommendations. The SGEM bottom line was there is moderate level of evidence that ACS can be excluded in adult patients with recurrent, low-risk chest pain using a single hs-troponin below a validated threshold without further diagnostic testing in patients who have a CCTA within the past two years showing no coronary stenosis. The writing group of GRACE-2 wanted to look at clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the ED. Through consensus, four questions were developed and then a systematic review of the literature was performed. This literature was then synthesized to come up with recommendations, following GRADE methodology. GRADE stands for Grading of Recommendations, Assessment, Development, and Evaluation, it was pioneered at McMaster University, in creating rigorous, transparent, and trustworthy guidelines on common clinical problems for EM physicians that are not always directly studied in EM research activities. There can be many presentations for low-risk abdominal pain. We have covered cannabis hyperemesis on SGEM#318 and SGEM#46 and pediatric gastroenteritis on SGEM#254. Clinical Question: What are the recommendations for managing patients with low-risk, recurrent, previously undifferentiated abdominal pain in the ED? Dr. Joshua Broder Reference: Broder et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department. AEM May 2022 This is an SGEMHOP episode which means we have the lead author on the show. Dr. Joshua Broder is the Residency Program Director and Vice Chief for Education In the Division of Emergency Medicine Duke University School of Medicine. Authors’ Conclusions: “No direct evidence exists to direct the care of patients with low-risk recurrent undifferentiated abdominal pain in the ED. Improved definitions are required to better define this population, and clinically relevant outcomes of interest should be described and studied with rigorous research methodology to inform future clinical guidelines.” Quality Checklist for a Guideline: The study population included or focused on those in the emergency department? Yes An explicit and sensible process was used to identify, select and combine evidence? Yes The quality of the evidence was explicitly assessed using a validated instrument? Yes An explicit and sensible process was used to the relative value of different outcomes? Yes The guideline thoughtfully balances desirable and undesirable effects? Yes The guideline accounts for important recent developments? Yes The guidelines has been peer-reviewed and tested? Yes/No Practical, actionable and clinically important recommendations are made? Yes The guideline authors’ conflicts of interest are fully reported, transparent and unlikely to sway the recommendations of the guidelines? Yes Key Recommendations: We don't have a key result section but what we do have is the key recommendations. It is important to understand the definitions created by the guideline committee for terms "low-risk, undifferentiated and recurrent". Listen to the SGEM podcast to hear Josh comment on each of these four recommendations. Recommendation

Date: May 13th, 2022 Reference: Abril et al. The Relative Efficacy of Seven Skeletal Muscle Relaxants. An Analysis of Data From Randomized Studies. J Emerg Med 2022 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 and specifically the use of ketamine. His twitter handle is @PainFreeED. Case: A 45-year-old man without a significant past medical history presents to your emergency department (ED) with two days of severe lower back pain after shoveling some dirt. The pain is 10/10 in intensity, gets worse with bending, turning, and prolonged walking. He denies numbness or paresthesia in both lower extremities, as well as bowel or bladder dysfunctions. A heating pad and acetaminophen has not helped with the pain. On examination, he is in moderate distress and has prominent tenderness to palpation at the bilateral paralumbar region and intact neurovascular examination. You diagnose him with a lumbar muscle strain and plan to prescribe him a non-steroidal anti-inflammatory (NSAID) while setting expectations. However, the patient wonders if you can give him something that can relax his back muscles and take his pain away. Background: Low back pain (LBP) is one of the most encountered ailments in clinical practice and is responsible for 2.6 million visits to U.S. EDs annually (1). Many patients with acute LBP experience substantial improvement in the first month, but up to one third report persistent back pain, and 1 in 5 report some limitations in activity. These persistent symptoms are associated with high costs, including those related to health care, and indirect costs from missed work or reduced productivity (2). Many pharmaceutical treatments besides opioids have been tried to address acute LBP pain with limited success (SGEM#87 and SGEM#173). These include: acetaminophen (Williams et al Lancet 2014), steroids (Balakrishnamoorthy et al Emerg Med J 2014) and benzodiazepines (Friedman et al Ann Emerg Med 2017). Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line medication therapy for patients with LBP despite a lack of evidence of efficacy (Machado et al Ann Rheum Dis 2017), There are several non-pharmaceutical treatments that have also been tried to treat LBP. They include: CBT and mindfulness (Cherkin et al JAMA 2016), chiropractic (Paige et al JAMA 2017), physical therapy (Paolucci et al J Pain Research 2018) and acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013). Unfortunately, none of these other treatment modalities has high-quality evidence supporting their use. Skeletal muscle relaxants (SMRs) are a frequently used in the ED and at discharge for acute back pain management and include methocarbamol, cyclobenzaprine, orphenadrine, carisoprodol, tizanidine, metaxalone, and baclofen. Estimates suggest up to 35% of patients with nonspecific low back pain are prescribed SMRs, with orphenadrine, and methocarbamol being used in more than 250,000 U.S. ED visits for low back pain annually (3-5). Despite their branding as muscle relaxants, the anti-spasmodic and analgesic effects of SMRs are predominantly due to unknown mechanism of action. Clinical Question: What is the efficacy of skeletal muscle relaxant administration in addition to an NSAID in treating acute low back pain? Reference: Abril et al. The Relative Efficacy of Seven Skeletal Muscle Relaxants. An Analysis of Data From Randomized Studies. J Emerg Med 2022 Population: Patients were considered for inclusion if they were 18– 69 years of age and presented to the ED primarily for management of acute LBP. This was defined as pain of two weeks’ duration or less originating between the lower border of the scapulae and the upper gluteal folds, and received a diagnosis consistent with nontraumatic, non-radicular, musculoskeletal LBP, as determined by the attending emergency physician. All patients had already received a dose of an NSAID. Exclusions: Radicular pain, pain duration for greater than two weeks, direct trauma to the back within the previous month, or a history of experiencing LBP on average more than several times per year, pregnancy, breastfeeding, allergy to study medications. Intervention: One of seven skeletal muscle relaxants (metaxalone, tizanidine, baclofen, diazepam, orphenadrine, methocarbamol, or cyclobenzaprine) Comparison: Placebo Outcome: Primary Outcome: Improvement in the Roland-Morris Disability Questionnaire (RMDQ) between ED discharge and the 1-week follow-up. The RMDQ goes from 0 to 24 with a 5-point improvement on this scale generally considered clinically significant. Secondary Outcomes: Moderate or severe LBP 1 week after the ED visit and medication adverse effects, assessed by asking patients to report any symptoms from the medications and dichotomizing their responses (yes/no). Authors’ Conclusions:

Date: April 19th, 2022 Guest Skeptic: Sarah Mojarad is a Lecturer in Advanced Writing, #SciComm, & Mis/disinfo topics • Kavli Fellow • Reed Awardee. Sarah Mojarad This is an SGEM Xtra episode. When planning a brief trip to Los Angeles for the EMRAP One Conference, I remembered that Sarah is from LA. I thought to myself, perhaps she would come on the SGEM as a special guest. I'm happy to say Sarah graciously accepted the invitation. We recorded the episode sitting outside on the patio at the Luskin Conference Centre. It is an example of how twitter can be a great way for making new friends. When I reached out to Sarah for a topic for the podcast she suggested five tips for science communication (SciComm) using social media. She shared with me a short YouTube video she had made for students interested in SciComm. We based our discussion on that video. It is clearly not an exhaustive list of tips but it did serve as the basis of our discussion. You can hear our conversation on the SGEM Xtra Podcast. Five Tips for Science Communication Tip #1: Be Yourself I think this is such an important piece of advice. Authenticity really resonates with people. One of the best compliments I received recently was from a wonderful dental student named Ellie from Schulich School of Medicine and Dentistry. We met at an Interprofessional Educational event, and she said it was so great to meet someone IRL who is so much like their twitter feed. Follow me and you will find out I am a huge advocate for evidence-based medicine (EBM), love Star Trek TOS, have a dog named Loki the Dog of Mischief, upset other physicians like neurologists when discussing the evidence for tPA in acute ischemic stroke, I think the 80’s is the best era for music/movies, and have been known to play BatDoc at times. Tip #2: Don't’ Be Afraid of Failing Another great tip. One of the best presentations I gave was about my many failures. The joke was that first grade was the longest two years of my life because I needed to repeat grade one. I failed to get into medical school the first time. I felt guilty and inadequate when I could not complete my orthopaedic residency. These and so many other “failures” that cause a lot of pain over the years. However, as Maya Angelou said: “Without defeats, how do you really know who the hell you are? If you never had to stand up to something - to get up, to be knocked down, and to get up again - life can walk over you wearing football cleats. But each time you do get up, you're bigger, taller, finer, more beautiful, more kind, more understanding, more loving. Each time you get up, you're more inclusive. More people can stand under your umbrella.” Tip #3: Find A Mentor I have had many mentors over the years. These include amazing people like: Dr. Kirsty Challen, Dr. Andrew Worster, Dr. Dara Kass, Dr. Michelle Johnson, Dr. Rick Bukata, Dr. Chris Carpenter and many, many more people who have helped me get where I am today. Sir Isaac Newton Tip #4: What Do You Want to Say? What is your message? Do you have a story, a narrative or goal in mind? My goal for the SGEM is to provide structured critical appraisals of the recent literature and probe it for its validity. We are trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. Ultimately, the goal is for patients to get the best care, based on the best evidence. Tip #5 How Do You Want to Say It? I want to make critical appraisal, clinical epidemiology, and biostatistics fun, engaging and exciting. I try to do this with 80’s music, memes, twitter polls, the keener contest, and other things. I learned a lot from Ross Fisher and his P Cubed Presentation initiative on how to create better presentations. I really like the way Melanie Trecek-King from Thinking is Power does her SciComm. She has a great educational approach and posts some useful tools for critical thinking like the FLOATER acronym. I’ve also learned from Dr. Brian Goldman to be more kind online. It follows the Spinoza philosophy of not ridiculing or bewailing or scorning people on twitter but rather trying to understand them. Some Dangers of SciComm Mansplaining I’ve seen a lot of women mansplained on twitter. For those who do not know mansplaining is a pejorative term meaning "to comment on or explain something to a woman in a condescending, overconfident, and often inaccurate or oversimplified manner". It is often done by a male layperson to a woman who is an expert in the field he is mansplaining to her. Examples include experts like Dr. Jennifer Gunter on gynecology, Dr. Megan Ranney on the science of gun safety, and Dr. Michelle Cohen on gender equity in the house of medicine. Harassment There was a recent disturbing article published in Science about scientists who have spoken out during this current global pandemic and have been threatened. The title of the article was In the Line of Fire. It talks about how CO

Date: April 16th, 2022 Reference: Blom et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021 Guest Skeptic: Dr. Matt Schmitz, Pediatric Orthopedics, Adolescent Sports Medicine and Young Adult Hip Preservation Surgeon at San Antonio Military Medical Center in Texas. Disclaimer: The views and opinions of this blog and podcast do not represent the United States Government or the US Military. Case: A 55-year-old man comes into the emergency department (ED) for increasing knee pain and decrease in function. He’s had an anterior cruciate ligament (ACL) repair and used to run marathons. However, he is finding it more difficult to even put his socks on. Physical exam shows varus deformity at the knee, decreased range of motion, crepitus, no locking and neurovascularly intact distal. X-rays show severe, tri-compartment arthritis. Background: Musculoskeletal complaints are one of the most common presentations to emergency departments. Often emergency physicians are assessing, treating, and answering patients question about orthopedic surgical procedures. How good is the evidence for the most common elective procedures? Before we answer that question, let’s remind everyone that only a small number (2.8%) of interventions published in SRMA and relevant to emergency medicine have unbiased and strong evidence for improved outcomes (SGEM#361). This is a broader problem in medicine. Tricoci et al. JAMA Feb 2009 looked at the ACC/AHA guidelines from 1984 to 2008. They found 53 guidelines with 7,196 recommendations. Only 11% of recommendations were considered Level A, 39% were Level B and 50% were Level C. An update was published by Fanaroff et al in JAMA 2019. The level of high-quality evidence had not changed much when looking at the ACC/AHA guidelines from 2008-2018. There were 26 guidelines with 2,930 recommendations. Now Level A recommendations were down to 9%, Level B 50% and Level C 41%. Time to turn our skeptical eye to the evidence for elective orthopaedic procedures. Clinical Question: What is the effectiveness of common elective orthopaedic procedures compared with no treatment, placebo, or non-operative care? Reference: Blom et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021 Population: Meta-analyses of randomised controlled trials Exclusions: Network meta-analyses (when pairwise meta-analyses were available), narrative reviews, systematic reviews that did not pool data or do a meta-analysis, and meeting abstracts Intervention: Surgery Comparison: No treatment, placebo, or non-operative care Outcome: Quality and quantity of evidence behind the ten most common elective orthopaedic surgeries and comparisons with the strength of recommendations in relevant national clinical guidelines. Authors’ Conclusions: “Although they may be effective overall or in certain subgroups, no strong, high quality evidence base shows that many commonly performed elective orthopaedic procedures are more effective than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes/Unsure The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. Yes The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Yes There was low statistical heterogeneity for the primary outcomes. Unsure The treatment effect was large enough and precise enough to be clinically significant. Yes, No and Unsure Results: The ten most common elective orthopaedic procedures were identified using a literature search, an assessment of Hospital Episode Statistics procedure frequency counts, and discussions with expert orthopaedic surgeons. Ten Most Common Elective Orthopaedic Procedures arthroscopic anterior cruciate ligament reconstruction arthroscopic meniscal repair of the knee arthroscopic partial meniscectomy of the knee arthroscopic rotator cuff repair arthroscopic subacromial decompression carpal tunnel decompression lumbar spine decompression lumbar spine fusion total hip replacement total knee replacement Key Result: Only two out of ten common procedures, carpal tunnel decompression and total knee replacement, showed superiority over non-operative care. They identified no RCTs that specifically compared total hip replacement or meniscal repair with non-operative care. The six other common orthopaedic procedures showed no benefit over non-operative care. 1. Jadad Decision Algorithm: This is probably an unfamiliar process to most SGEM listeners. It is a process proposed in the late 1990’s to help decision-makers select from among discordant reviews [1]. Since its publication, the Jadad decisions algorithm is now commonly used to interp

Date: April 7th, 2022 Reference: Wong et al. Sensitivity of diffusion-weighted magnetic resonance imaging in transient global amnesia as a function of time from symptom onset. AEM April 2022 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. Case: A 65-year-old man presents to your emergency department with his wife. She tells you that he woke up normally this morning, but after breakfast he began asking the same questions repetitively and was amnestic to the answer, seemingly unable to form new memories. He remained completely awake and alert and otherwise appeared well. There was no history of recent trauma, infectious symptoms, or any other illness. Background: Transient global amnesia (TGA) is an idiopathic acute neurological disorder that presents with sudden onset anterograde memory loss. It was first described as a syndrome in 1956 by Courjon and Guyotat and also by Bender [1,2]. Fisher and Adams formally described as TGA in 1964 [3]. The usual presentation is a patient between 50 and 70 years of age who are cognitively and neurologically intact but asking repetitive questions, unable to form new memory. Symptoms do not last very long and resolve within 24 hours. The incidence has been reported as 23.5 per 100,000 people per year [4] and is more common in people who get migraine headaches [5]. TGA is often precipitated by physical or emotional stressors, pain, the Valsalva maneuver, hot or cold-water immersion or sexual intercourse [6] Diagnosing TGA combines items put forward by Hodges and Warlow and Caplan [7-9]. This results in seven diagnostic criteria for TGA. Diagnostic Criteria for Transient Global Amnesia Attack is witnessed Clear-cut anterograde amnesia during the attack No neurologic symptoms or signs during the attack other than amnesia (no clouding of consciousness or loss of personal identity) No neurologic physical examination findings others than anterograde amnesia Memory loss is transient (resolution within 24 h) No epileptic features and no active epilepsy (defined as no seizure within 2 years or on antiepileptic medication) No recent head injury A diagnostic algorithm has been published for patients with sudden onset of anterograde amnesia [6]. Included in this differential is transient epileptic amnesia, transient ischemic attack, stroke, metabolic disorders, psychogenic disorders, and post traumatic amnesia. The workup can include laboratory testing, EEGs, ECGs, echocardiogram and advanced neuroimaging. Clinical Question: What is the sensitivity of diffusion-weighted magnetic resonance imaging (DW-MRI) as a function of time from symptom onset compared to clinical diagnosis of TGA? Reference: Wong et al. Sensitivity of diffusion-weighted magnetic resonance imaging in transient global amnesia as a function of time from symptom onset. AEM April 2022 Population: Adult patients 16 years of age and older with a diagnosis of TGA based on the existing clinical criteria Intervention: Evaluation with DW-MRI at varying time intervals post symptom onset Comparison: No comparison as no studies of patients without DW-MRI were included Outcome: Sensitivity of DW-MRI in diagnosis of TGA Dr. Matt Wong This is a back-to-back SGEMHOP episode. We did the March episode at the end of last month and the April episode is the first week of this month. We are pleased to have the lead author on the show. Dr. Matthew Wong is an emergency physician and educator at Beth Israel Deaconess Medical Center, and an Assistant Professor at Harvard Medical School. Authors’ Conclusions: “DW-MRI lesions are uncommon in patients with TGA early after symptom onset, but the sensitivity (i.e., positivity rate) of DW-MRI increases with time. Despite the limited quality of existing evidence, obtaining an early DW-MRI in patients with clinical diagnosis of TGA in the acute setting is likely a low-yield test.” Quality Checklist for Systematic Review Diagnostic Studies: The diagnostic question is clinically relevant with an established criterion standard. Yes The search for studies was detailed and exhaustive. Yes The methodological quality of primary studies were assessed for common forms of diagnostic research bias. Yes The assessment of studies were reproducible. Yes There was low heterogeneity for estimates of sensitivity or specificity. No The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. No Results: They identified 23 studies in their search with a total of 1,688 patients who met inclusion criteria. All studies were case series of adult patients clinically diagnosed with TGA who underwent DW-MRI. Key Result: The sensitivity of DW-MRI in diagnosing TGA increases with time. In the first 12 hours from symptom onset, sensitivity of DW-MRI is 15.6%. It improves thereafter to sensitivities between 66 and 83%, with very wide confidence intervals for all point estimates. There is also significant hete

Date: March 31st, 2022 Reference: Butt et al. Take-Pause: Efficacy of mindfulness-based virtual reality as an intervention in the pediatric emergency department. AEM March 2022 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 is a pulmonary embolism and implementation science researcher. Lauren won the 2021 SAEM FOAMed Excellence in Education Award. Case: A 15-year-old male presents to the pediatric emergency department (ED) with right ankle pain sustained while twisting his ankle during dance practice. The right ankle is swollen and tender. He rates his pain a 5 on the FACES scale and is awaiting examination by the treating clinician. Background: Pediatric emergency department (ED) visits and related procedures can invoke pain and anxiety among children. Patients who experience adequate pain relief during their ED stay have significant reductions in distress, improved rapport with their physician, improved intent to comply with discharge instructions and higher levels of personal and caregiver satisfaction. Children represent one group of patients that are less likely to receive adequate analgesia (Brown et al, Selbst and Clark). This phenomenon is known as oligoanalgesia or poor pain management through the underuse of analgesia. Dr. Anthony Crocco We have covered pediatric pain with PEM super hero Dr. Anthony Crocco on SGEM#78 who did a RANThony on this issue. Dr. Samina Ali is a PEM super (s)hero who was on SGEM#242 looking at intranasal (IN) ketamine vs fentanyl on pain reduction for extremity injuries in children. The bottom line from that trial was IN ketamine appears to be non-inferior to IN fentanyl for efficacy, but with more adverse events. Many clinicians utilize distraction techniques to reduce pain and anxiety in children during their ED visits [4]. However, there are no prospective randomized trials using virtual reality (VR) as a distraction technique while awaiting physician evaluation. Clinical Question: Does a 5-minute virtual reality program reduce situational anxiety in the pediatric ED? Reference: Butt et al. Take-Pause: Efficacy of mindfulness-based virtual reality as an intervention in the pediatric emergency department. AEM March 2022 Population: Patients ages 13-17 years who presented to the pediatric ED with mild to moderate acute pain (pain score 2-6 on FACES pain scale) Exclusions: Patients with developmental delays, inability to speak English, prone to motion sickness, significant visual/hearing impairment, pregnancy, parental refusal, received analgesic ≤4 hours prior to ED arrival, or inability to use the pain scale. Intervention: Virtual reality “Take Pause” program for 5 minutes Comparison: Passive distraction technique with hospital-owned iPad with pre-downloaded age-appropriate games for 5 minutes Outcome: Primary Outcome: Difference in the change in situational anxiety level between groups 15 minutes after intervention using the Spielberger State – Trait Anxiety Inventory (STAI: Y-6 item) Secondary Outcomes: Mean difference in pain score on the FACES scale, heart rate, respiration rate from baseline to 15 minutes after intervention Trial: Prospective, randomized, single-blind trial Mahlaqa Butt This is an SGEMHOP episode which means we have the lead author on the show. Mahlaqa Butt, MPH is a third-year medical student at New York Institute of Technology-College of Osteopathic Medicine and a clinical research associate at the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn NY. She has co-authored 11 peer-reviewed emergency medicine research publications primarily focused on opioid-free pain management in the ED. She will be pursuing a residency in emergency medicine this fall. Authors’ Conclusions: “Take-Pause, offering an active and immersive distraction technique, is more effective than a passive distraction approach to lower anxiety levels in adolescent ED patients.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). No The patients in both groups were similar with respect to prognostic factors. Unsure All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. No The treatment effect was large enough and precise enough to be clinically significant. Unsure Financial conflicts of interest. The authors stated they had no potential conflicts to disclose. Results: They enrolled

Date: March 26th, 2022 Guest Skeptic: Professor Melanie Trecek-King Associate professor of biology at Massasoit Community College in Massachusetts. Founder and creator of Thinking Is Power. Reference: Trecek-King M.A Life Preserver for Staying Afloat in a Sea of Misinformation. Skeptical Inquirer March/April 2022 Prof Trecek-King This is an SGEM Xtra episode. I met Melanie through our online interactions on Twitter. She posts excellent tweets about critical thinking. I then discovered her amazing website called Thinking is Power. We also discovered through our social media interactions that were were both Feynman fans. I asked Melanie to come on the show and discuss her recent article in Skeptical Inquirer and explain the acronym she created called FLOATER. Melanie explains that FLOATER grew out of James Lett’s “A Field Guide to Critical Thinking” (Lett J. Skeptical Inquirer 1990), in which he summarized the scientific method with the acronym FiLCHeRS (Falsifiability, Logic, Comprehensiveness of evidence, Honesty, Replicability, and Sufficiency of evidence). The FLOATER acronym stands for Falsifiability, Logic, Objectivity Alternative explanation, Tentative conclusion, Evidence, and Replicability. This was the basis for her article in Skeptical Inquirer. Melanie published her first article in the January/February edition called "Teach Skills, Not Facts". Listen to the SGEM Xtra podcast to hear Melanie explains each of the seven tools/rules that make up the FLOATER acronym. Tool 1: Falsifiability It must be possible to think of evidence that would prove the claim false. It seems counterintuitive, but the first step in determining if a claim is true is to determine if you can prove it wrong. Tool 2: Logic Arguments for the claim must be logical. They can be deductive or inductive arguments. We should try and not commit logical fallacies when arguing positions. Tool 3: Objectivity The evidence for a claim must be evaluated honestly. Tool 4: Alternative Explanations Other ways of explaining the observation must be considered. Tool 5: Tentative Conclusions In science, any conclusion can change based on new evidence. Tool 6: Evidence The evidence for a claim must be reliable, comprehensive, and sufficient. Tool 7: Replicability Evidence for a claim should be able to be repeated. We have a reproducibility crisis in science. We ended this SGEM Xtra show with a quote from Marie Curie. I think Melanie is an amazing skeptic and educator. It was an absolute pleasure to have her on the show as the guest skeptic. 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 Additional Readings: Kahan et al. Science Curiosity and Political Information Processing. Political Psychology. January 2017 Kahan DM. Why Smart People Are Vulnerable to Putting Tribe Before Truth. Scientific America. December 2018 Trecek-King M. Teach Skills, Not Facts. Skeptical Inquirer. January/February 2022

Date: March 3rd, 2022 Reference: Macnow et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatrics 2021 Guest Skeptic: Dr. Catherine Varner is an Assistant Professor and Clinician Investigator in the Department of Family and Community Medicine at the University of Toronto. She is an emergency physician at Mount Sinai Hospital and a Clinician Scientist and the Deputy Director of the Schwartz-Reisman Emergency Medicine Institute. Dr. Varner's research interests are in concussion and pregnancy care in the ED. Case: An 18-year-old female presents to the emergency department (ED) after falling off a moving snowmobile and hitting her head on the ground. It was a witnessed fall; she was wearing a helmet at the time and there was no loss of consciousness. There were no other injuries reported and she is found to have a GCS score of 15 after the injury. The Acute Concussion Evaluation–Emergency Department (ACE-ED) Tool is used, and she scores a 2 for headache and feeling foggy. She knows about taking it easy physically for the next couple of days but wonders if she must stay off her computer as well? Background: Concussions or mild traumatic brain injury (mTBI) are commonly diagnosed in the Emergency Department (ED). Most patients recover within the first week; however, 15-30% of patients develop persistent post-concussive symptoms. An issue that often comes up with minor head injuries is do we need to get advanced imaging. A paper by Dr. Ian Stiell and his group gave us a tool to help us decide who to scan with the now infamous clinical decision instrument called the Canadian CT Head Rule [1]. This classic paper was published in Lancet 2001 and reviewed on SGEM#106. Another issue that comes up is whether children need strict rest after a concussion. SGEM#112 reviewed a small study by Thomas et al published in Pediatrics 2015 asking if there was a benefit to recommending strict rest after a child has a concussion [2]. The bottom line from that episode was that in children with concussion, two days of rest followed by a gradual return to activity is preferred over five days of rest followed by a gradual return to activity. The longer strict rest period appears to cause more post-concussive symptoms. Our episode together looked at the impact of light exercise in adults with mild concussions on the likelihood of developing persistent symptoms up to 30 days following their injury (SGEM#331). We found there was not a statistical difference between light activities like walking and 48 hours of rest with gradual return to activity as tolerated. Our conclusions were that early light exercise may be encouraged as tolerated at ED discharge following mTBI, but this guidance is not sufficient to prevent persistent concussion symptoms [3]. The Acute Concussion Evaluation–Emergency Department (ACE-ED) tool is an instrument used by ED clinicians to diagnose a concussion and identify risk factors for prolonged recovery. It is both helpful for diagnosis and future management of symptoms. When a patient is recovering from a concussion, whether you are using ACE or another symptom scoring tool like the Postconcussion Symptom Scale or the Rivermead Post-concussion Symptom Questionnaire, future health care providers caring for the concussion patient may refer to the quantitative assessment of the patient’s symptoms in the acute phase of the injury. Clinical Question: Does screen time in the first 48 hours after concussion have an impact on the duration of concussive symptoms? Reference: Macnow et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatrics 2021 Population: Patients aged 12 to 25 years presenting to the emergency department within 24 hours of sustaining a concussion according to the Acute Concussion Evaluation–Emergency Department (ACE-ED) tool (Giola et al 2008) Exclusions: Attending physician declined participation; their guardian was not present; the patient was younger than 18 years, or they (or their parent or guardian) were not fluent in English; intoxication; had a GCS score < 15; had intracranial abnormalities identified on imaging; had pre-existing intellectual disability, severe psychiatric illness, severe neurological conditions, or substantial previous neurological surgery; or required neurosurgical intervention, intubation, or hospital admission. Intervention: Patients were asked to abstain from screen time for 48 hours after injury. This was the screen time abstinent group. Comparison: Patients were permitted to engage in screen time in the first 48 hours after injury. This was the screen time permitted group. Outcome: Primary Outcome: Number of days until functional resolution of concussive symptoms, which was defined as the first day with a total score of three points or lower on the Post-Concussive Symptom Scale (PCSS) Secondary Outcomes: Amount of screen and sleep time during the intervention period, the day of re

Date: February 24th, 2022 Reference: Parish et al. An umbrella review of effect size, bias, and power across meta-analyses in emergency medicine. AEM 2021 Guest Skeptic: Professor Daniel Fatovich is an emergency physician and clinical researcher based at Royal Perth Hospital, Western Australia. He is Head of the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research; Professor of Emergency Medicine, University of Western Australia; and Director of Research for East Metropolitan Health Service. Case: A resident has been following the literature over their four years of training. They have already seen several things come into fashion and go out of fashion during this short time. This includes therapeutic hypothermia for out-of-hospital cardiac arrest (OHCA), tranexamic acid (TXA) for epistaxis and electrolyte solutions for mild pediatric gastroenteritis. They wonder how strong the evidence is for much of what we do in emergency medicine. Background: There are many things in medicine that could be considered myth or dogma. We have covered some of these over the 10 years. Topical anesthetic uses of 24-48 hours for mild cornea abrasions will cause blindness- No (SGEM# 315) Epinephrine for adult out-of-hospital cardiac arrests (OHCAs) results in better neurologic outcomes – No (SGEM#238) TXA for intracranial hemorrhage, isolated traumatic brain injury, post-partum hemorrhage or gastrointestinal bleed results in better primary outcomes - No (SGEM#236, SGEM#270, SGEM#214, and SGEM#301) Therapeutic hypothermia in adult OHCA saves lives – No (SGEM#336) Electrolyte solutions are needed in mild pediatric gastroenteritis - No (SGEM#158) A lot of medical practice is based on low quality research. Tricoci et al. JAMA Feb 2009 looked at the ACC/AHA guidelines from 1984 to 2008. They found 53 guidelines with 7,196 recommendations. The results were only 11% of recommendations were considered Level A, 39% were Level B and 50% were Level C. The definitions used for each level of evidence are as follows: An update was published by Fanaroff et al in JAMA 2019. The level of high-quality evidence had not changed much when looking at the ACC/AHA guidelines from 2008-2018. There were 26 guidelines with 2,930 recommendations. Now Level A recommendations were down to 9%, Level B 50% and Level C 41%. This lack of evidence is not isolated to cardiology. A recent study looked at the top ten elective orthopaedic procedures. It was an umbrella review of meta-analyses of randomized control trials (RTCs) or other study designs if no RCTs existed (Blom et al BMJ 2021). The comparison was the clinical efficacy of the most common orthopaedic procedures with no treatment, placebo, or non-operative care. The primary outcome was the quality of the evidence for each procedure. Only two out of ten common procedures, carpal tunnel decompression and total knee replacement, showed superiority over non-operative care. Clinical Question: What is the effect of faults such as underpowered studies, flawed studies (i.e. methodologic and statistical errors, poorly designed studies) and biases in the field of therapeutic interventions in the emergency medicine literature? Reference: Parish et al. An umbrella review of effect size, bias, and power across meta-analyses in emergency medicine. AEM 2021 Population: SRMAs 1990-2020 in the top 20 journals under the google scholar subcategory: emergency medicine; emergency medicine meta-analyses from JAMA, NEJM, BMJ, The Lancet, and the Cochrane Database of Systematic Reviews; emergency medicine topics across all PubMed journals; and an extraction of all studies from the Annals of Emergency Medicine Systematic Review Snapshots (SRS) series. Exclusions: Articles were excluded if they did not include a quantitative synthesis (meta-analysis); did not contain at least two summarized studies; did not make a comparison between two groups to assess an effect size; did not report an effect size as at least one of mean difference or standardized mean difference (SMD; Cohen's d), odds ratio (OR), risk ratio (RR), hazard ratio (HR), or transformations of these effect sizes; were meta-analyses of diagnostic accuracy studies; or were not related to the practice of emergency medicine. Intervention: Data supplement 1 lists all 431 MAs derived from 332 published SRMAs. Comparison: Includes placebo, usual care, nothing. Outcomes: Identify broad patterns in study parameters (effect size, power, mortality benefit and potential bias). Dr. Austin Parish We are fortunate to have the lead author on this episode even though it is not an SGEMHOP. Dr. Austin Parish is the Chief Resident in Emergency Medicine at the Lincoln Medical Center, Bronx NY. He is also a researcher for the Meta Research Innovation Center at Stanford (METRICS) Authors’ Conclusions: “Few interventions studied within SRMAs relevant to emergency medicine seem to have strong and unbiased evidence for improving outcomes. The fiel

Date: February 21st 2022 Reference: Kim et al. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. AEM February 2022. Guest Skeptic: Dr. Kirsty Challen (@KirstyChallen) is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). 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 is also the creator of the wonderful infographics called #PaperinaPic. Case: You are in discussion with your emergency department (ED) manager about the number of patients boarding for hours to days and you are both aware that many of these patients are attending with mental health crises. You wonder whether a model of care involving a specifically designed unit would improve their patient experience and ED boarding times. Background: We have covered mental health issues only a few times on the SGEM. The latest SGEM Xtra was a very powerful episode with Dr. Tim Graham sharing his story of burnout, anxiety, and depression. This was based upon his article published in the Canadian Medical Association Journal (CMAJ). We also had Dr. Tyler Black on that episode to provide his expertise as a suicidologist. ED visits in the US for mental health conditions has increased by 44% from 2006 to 2014. Inadequately resourced provision for emergency mental health care is familiar to health care professionals in multiple jurisdictions and patients can spend days in the ED waiting for inpatient admission. We've talked about mental health issues in SGEM #252 in 2019. In that episode we concluded that clinician gestalt was likely to be as accurate and efficient in screening for suicidality as a specific tool (Convergent Functional Information for Suicidality screening tool). Also, in SGEM #313 we recognised that three or more ED attendances for alcohol-related issues was associated with a 1-year mortality risk of over 6%. Clinical Question: Does the implementation of a dedicated interdisciplinary unit for mental health patients presenting to an ED with suicidal ideation or a suicide attempt reduce inpatient admissions and ED boarding time? Reference: Kim et al. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. AEM February 2022. Population: Adults presenting to a single academic tertiary referral ED in Iowa with suicidal ideation or after a suicide attempt – determined using administrative data.. Excluded: Patients that were medically unstable, needed co-management of a medical condition, were incarcerated, actively violent or judged by the provider to be intoxicated. Also, patients with mental health conditions other than suicidal ideation or attempt. Intervention: Post-establishment of EmPATH unit Nov 2018 – May 2019. Comparison: Pre-establishment of EmPATH unit Nov 2017 – May 2018. Outcome: Primary Outcome: Proportion of patients admitted to inpatient psychiatric unit (direct from ED, via EmPATH Unit or by transfer). Secondary Outcomes: Any admission including psychiatry, intensive care, or medicine; complete vs incomplete psychiatric admission; hospital length of stay in those with a bed requested; ED length of stay; use of restraints in ED, scheduled follow-up, 30-day ED return; restraint use; code green Dr. Allie Kim This is an SGEMHOP episode which means we have the lead author on the show (Dr. Kim). And as a special treat we also have the senior author (Dr. Lee). Dr. Allie Kim graduated from emergency medicine residency at the University of Iowa last July and now works as an attending physician at Unity Point Health hospitals in Des Moines, Iowa. We also have senior author Dr. Sangil Lee who is a Clinical Associate Professor of Emergency Medicine at the University of Iowa. The state of Iowa has only a handful of inpatient psychiatric units. The University of Iowa, where the EmPATH unit was implemented, is one of them. We see patients from all over the state, plus even out of state, and with the increase in numbers of mental health presenting to our emergency department, the sheer percentage of our patients needing inpatient psychiatric care was high. And, as many of us have seen, patients may wait in their ER bed for days until an inpatient bed became available. This “boarding” of patients delayed their psychiatric care and left less room for us to see other patients. Dr. Sangil Lee The EmPATH program we created, in conjunction with the Department of Psychiatry, is an open concept unit with the capacity to treat 12 adults. Patients must be medically cleared first in the ED, and also be behaviorally appropriate, to enter the EmPATH unit. Once in the unit, there are psychiatrists, nurses, and social workers to help patients. Average

Date: February 15th, 2022 Guest Skeptic: Dr. Tim Graham is a Clinical Professor of emergency medicine at the University of Alberta, and Associate Chief Medical Information Officer, Edmonton Zone, of Alberta Health Services from Edmonton, Alberta. Reference: Graham T. Physician heal thyself. CMAJ 2021 TRIGGER WARNING: As a warning to those listening to the podcast or reading this blog post, there may be some things discussed that could be upsetting. The SGEM is a free open access project trying to cut the knowledge translation down to less than one year. It is intended for clinicians providing care to emergency patients, so they get the best care, based on the best evidence. Some of the material we are going to be talking about on this episode could trigger some strong emotions. If you are feeling upset by the content, then please stop listening to the podcast or reading the blog. There will be resources listed at the end of the blog for those looking for assistance. Dr. Tim Graham This is an SGEM Xtra episode. Tim approached me about an article he wrote and published in the Canadian Medical Association Journal (CMAJ). The title of the article was "Physician, heal thyself" and was in the humanities section of the October 2021 issue. This article resonated with many people and was the 6th most read CMAJ article of 2021. Tim thanked his wife, Dr. Samina Ali, in the CMAJ article and on the podcast. Samina has been a guest skeptic on the SGEM. She is the one who suggested Tim share his story to reach an even wider audience. In this SGEM Xtra episode, Tim tells his experience with burnout. This is a topic we have discussed many times on the SGEM and I have shared my personal experience with burnout. SGEM Xtra: The Water is Wide SGEM#289: I Want a Dog to Relieve My Stress in the Emergency Department SGEM Xtra: CAEP Wellness Week 2019 SGEM Xtra: On the Edge of Burnout SGEM Xtra: Don’t Give Up – The Power of Kindness SGEM#178: Mindfulness – It’s not Better to Burnout than it is to Rust SGEM Xtra: Five Tips to Avoid Emergency Medicine Burnout A 2015 study by Shanafelt et al of US physicians showed that more 50% had at least one symptom of burnout. The highest prevalence of burnout was reported by emergency physicians. COVID19 has been hard on the health care system. Medscape just published a 2021 survey of 13,000 physician from 29 specialties and emergency physicians were still #1 reporting the highest level of burnout. People have made a distinction between burnout and moral injury. Journalist Diane Silver describes moral Injury as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.” It is something that tears us apart at the fabric of what it is to be a physician. Tim discusses how he started getting suicidal ideations and what he did to try and address these thoughts. This included seeking professional help, medication, and lifestyle changes. Some interventions helped more than others. Tim reports he is now in the best place mentally and physically than he has been in many years. Tim also gives some advice to prevent others from going through a similar experience. This includes a wellness tool kit that starts with a healthy diet, regular exercise and good sleep. Two things he found really helpful were meditation and yoga. Suicidologist: Dr. Tyler Black When preparing this SGEM Xtra episode, I suggested to Tim we get an expert in mental health to give us some more information on the topic. I'm not an expert in this area and reached out to Dr. Tyler Black. Tyler is a suicidologist, emergency psychiatrist and pharmacologist from Vancouver. Dr. Tyler Black Tyler provided a definition for suicidologist. He discussed burnout and the association with suicidal ideation in physicians (Menon et al JAMA 2020. Tyler gave some potential reasons why physicians do not seek mental health care (stigma, colleges/regulatory bodies, access to care, etc). He also described how we can help each other and ourselves stay mentally healthy. Tyler was also asked what he would do if given a blank cheque to address this problem of physician burnout. He would spend the money on research and getting scribes to interact with the EMR and not buy muffins for the break room. Tim was asked at the end of the podcast what he would tell his younger self. I challenge the SGEM audience to think about what you would say to your younger self. Here is what Tim would say: "I would tell young me that no matter how important I think work is, I am really just another cog in the never-ending gears of the health care system. Once internalized, this knowledge was liberating, and it gave me permission to prioritize myself and my well-being. In the end, if you die tomorrow, your employer will replace you, but your loved ones cannot." 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 te