The Skeptics Guide to Emergency Medicine

Date: January 20th, 2021 Guest Skeptic: Dr. Lauren Westafer an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and research methodology editor for Annals of Emergency Medicine and as an Associate Editor for the NEJM Journal Watch Emergency Medicine. Reference: Pines et al. Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain. AEM January 2021 Case: A 50-year-old male presents to the Emergency Department (ED) with left lower quadrant abdominal pain. The patient is seen by an advanced practice provider (APP). He wants to know if being seen by an APP alters his chance of diagnostic testing or hospital admission. Background: We covered the use of advanced practice providers (APPs) on the SGEM#308. That SGEMHOP episode asked how the productivity of APPs compare to emergency physicians and what is its impact on ED operations? The key result from that study of 13 million ED visits across 94 states was that physicians were more productive than PAs and NPs. The SGEM bottom line was that increasing APP coverage has minimal effect on ED flow and safety outcomes based on the data. Over the past two decades, the use of APPs has increased. APPs have a significantly truncated medical training (about 2 years of training) and practice experience compared with the traditional 4 years of medical school and 3-4 years of residency for emergency physicians. There has been a concern about post-graduate training of NPs and PAs in the ED. A joint statement on the issue was published in 2020 by AAEM/RSA, ACEP, ACOEP/RSO, CORD, EMRA, and SAEM/RAMS. The American Academy of Emergency Medicine (AAEM) has a position statement on what they refer to as non-physician practitioners that was recently updated. The American College of Emergency Physicians (ACEP) also has a number of documents discussing APPs in the ED. The difference in training between and emergency medicine physician and APPs is well recognized. A concern is that some APPs may compensate for this training gap by increased testing. Clinical Question: Is ED evaluation by an APP associated with higher test utilization and hospitalization compared with evaluation by a physician? Reference: Pines et al. Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain. AEM January 2021 Population: All ED patients with a chief complaint of chest pain or abdominal pain triaged as an Emergency Severity Index (ESI) 2,3, or 4 who were seen independently by either an APP or emergency physician Excluded: Patients who left without treatment or against medical advice, those who were dead on arrival or died in the ED. They also excluded those with a triage level ESI 1 or 5, as these are less common, as well as those with a final diagnosis of injury or poisoning – as in those cases the diagnosis would generally be apparent. Intervention: Evaluated by an APP Comparison: Evaluated a physicial Outcome: Primary Outcomes: Laboratory tests, ECGs, imaging studies as well as hospital admissions (including transfer to other hospitals and observation admissions) Secondary Outcomes: Testing based on evidence-based practice Dr. Jesse Pines This is an SGEMHOP episode which means we have the lead author on the show. Jesse Pines MD is the National Director for Clinical Innovation at US Acute Care Solutions and a Professor of Emergency Medicine at Drexel University. In this role, he focuses on developing and implementing new care models including telemedicine, alternative payment models, and also leads the USACS opioid programs. Authors’ Conclusions: “We demonstrate that the care delivered in the ED by advanced practice providers and emergency physicians for patients matched on complexity and acuity presenting with chest pain or abdominal pain chief complaints is largely similar with respect to diagnostic test utilization and admission decisions. Future research should continue to explore the optimal use of advanced practice providers in the ED and the best ways to deploy this expanding part of the U.S. ED workforce". Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Unsure Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? No Was the follow up of subjects complete enough? Yes How precise are the results? Fairly precise Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evid

Date: January 5th, 2021 Reference: Shipman et al. Short-Term Topical Tetracaine Is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions: A Double-Blind, Randomized Clinical Trial. Annals of EM 2020 Dr. Glaucomflecken Guest Skeptic: Dr. Will Flanary is an ophthalmologist, writer, and comedian who moonlights in his free time as “Dr. Glaucomflecken” on Twitter and TikTok. Effortlessly blending humor with education, Dr. Glaucomflecken has spent the last five years informing audiences on a wide range of topics, like navigating the confusing world of over-the-counter eyedrops, the horrifying consequences of sleeping in contact lenses, and his recent experiences as a patient in the medical system. Case: A 32-year-old healthy man presents with left eye pain. He was giving his 9-month-old a hug and got poked in the eye with a sharp little fingernail. His visual acuity is 20/20 bilaterally and he doesn’t wear corrective lenses or contact lenses. He tried some over-the-counter red eye drops that did not seem to work. In the emergency department (ED), tetracaine drops are applied prior to slit lamp examination and the pain is completely resolved. On examination, you see a vertical corneal abrasion with no evidence of ulceration and no foreign body. You prescribe antibiotic drop and prepare to discharge him home when he asks, “can I get some of those numbing drops to use at home”? Background: Even small corneal abrasions can cause significant pain because the cornea is highly innervated. The first documented use of topical ophthalmologic anesthetics was in 1818. A cocaine derivative was employed to effectively block nerve conduction in the superficial cornea and conjunctiva (Rosenwasser). A number of proposed dangers have limited the use of topical anesthetic agents for the treatment of corneal abrasion associated pain. These dangers include delayed healing secondary to mitosis inhibition and decreased corneal sensation. The latter issue is of concern because of the potential for the abrasion to progress to an ulcer without the patient noticing. Additionally, these agents may have direct toxicity to corneal epithelium with prolonged use, leading to increased corneal thickness, opacification, stromal infiltration, and epithelial defects. The fear of these complications has led to the pervasive teaching that topical anesthetics should never be used for outpatient management of corneal abrasions. This is reflected in the condemnation of their use in major Emergency Medicine textbooks, including Rosen’s and Tintinalli’s. Some of the evidence used to support the claim of local anesthetics causing corneal harm comes from case reports, animal models or local anesthetic injected directly into the anterior chamber of the eye for cataract surgery. More information on the where the no topical anesthetic use on corneal abrasions come from can be found on a REBEL EM blog post. We covered and randomized control trial by Waldman et al on topical tetracaine for simple corneal abrasions on SGEM#83. The bottom line from that episode was that tetracaine appears safe for uncomplicated corneal abrasions and provides more effective pain relief than saline eye drops. We also did a critical appraisal of a systematic review by Swaminathan et al looking at topical anesthetics for these types eye injuries on SGEM#145. The SGEM bottom line from that review was that the best evidence we currently have demonstrates that dilute topical anesthetic drops of either proparacaine or tetracaine are safe for use in ED patients with simple corneal abrasions to provide analgesia. The studies are small, but the data contained in them is far superior to the case series published 50 years ago which led to the dogma that using them is dangerous. Clinical Question: What is the efficacy of topical tetracaine in the treatment of simple corneal abrasions? Reference: Shipman et al. Short-Term Topical Tetracaine Is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions: A Double-Blind, Randomized Clinical Trial. Annals of EM 2020 Population: Adults 18 years to 80 years of age with suspected acute cornea abrasion Exclusions: Contact lens wearer, previous corneal surgery or transplant in the affected eye, injury greater than 36 hours old, had a grossly contaminated foreign body, or had coexisting ocular infection. Intervention: Tetracaine 0.5% one drop every 30 minutes as needed for pain for a maximum of 24 hours plus topical antibiotics (polymyxin B sulfate/ trimethoprim sulfate, two drops every four hours into the affected eye) and oral analgesic (hydrocodone/acetaminophen 7.5/325 mg, one or two tablets as needed every six hours) Comparison: Placebo (balanced artificial tear solution) one drop every 30 minutes as needed for pain for a maximum of 24 hours plus topical antibiotics (polymyxin B sulfate/ trimethoprim sulfate, two drops every four hours into the affected eye) and oral analgesic (hydrocodone/acetaminophen 7.5/325 mg, one

Date: January 5th, 2021 Reference: Grunau et al. Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA 2020 Guest Skeptic: Mike Carter is a former paramedic and current PA practicing in pulmonary and critical care as well as an adjunct professor of emergency medical services at Tacoma Community College. Case: During a busy emergency department (ED) shift the paramedic phone rings. On the other end of the line is one of your local crews who have responded to a 54-year-old male with a witnessed cardiac arrest. CPR is currently in progress with a single shock having been delivered. The crew is asking if they should transport the patient with resuscitation ongoing? 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), and epinephrine (SGEM#238). One aspect we have not looked at is the “load and go” vs. “stay and play” approach for OHCA. Different countries have different approaches to this problem. There is the European model that is physician led and provides more care in the field while the North American model tends to scoop and run. However, there is a fair bit of heterogeneity between EMS systems even in the US. In patients with OHCA, some EMS agencies transport almost all patients regardless of ROSC, while others rarely transport if ROSC is not achieved. It is unclear from the existing literature which practice is superior to the other in providing patient-oriented benefit to among adult patients in refractory arrest who have suffered an OHCA. Clinical Question: What is the association of intra-arrest transport compare to continued on-scene resuscitation in regards to survival to hospital discharge in adult patients with an OHCA? Reference: Grunau et al. Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA 2020 Population: Adults 18 years and older with non-traumatic OHCA between 2011 and 2015treated by 192 EMS agencies in the USA. EMS. OHCA was defined as persons found apneic and without a pulse who underwent either external defibrillation (bystanders or EMS) or chest compressions. Exclusions: Age less than 18 years, do-not-resuscitate (DNR) order being discovered, transport prior to cardiac arrest, missing data to classify as intra-arrest or to classify the primary outcome, missing variables required for propensity score analysis Intervention: Intra-arrest transport prior to any episode of return of spontaneous circulation (ROSC) defined as palpable pulse for any duration Comparison: Continued on-scene resuscitation Outcome: Primary Outcome: Survival to hospital discharge Secondary Outcomes: Survival with favorable neurologic outcome defined as a modified Rankin scale (mRS) score of less than 3 mRS is categorized to 7 different levels, with 0 being no disability and 6 being death. A 3 is defined as moderate disability requiring some help, but able to walk without assistance Authors’ Conclusions: “Among patients experiencing out-of-hospital cardiac arrest, intra-arrest transport to hospital compared with continued on-scene resuscitation was associated with lower probability of survival to hospital discharge. Study findings are limited by potential confounding due to observational design.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Fairly precise Do you believe the results? Yes [1,2] Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes [3,4] Key Results: The entire cohort consisted of 43,969 patients with a median age of 67 years, 1/3 were female and ½ were bystander or EMS witnessed. Of these OHCAs, 22% had an initial shockable rhythm and ¼ underwent intra-arrest transport. The probability of survival was greater with continuous on-scene resuscitation compared to intra-arrest transport in adults with OHCAs. 1) Association: The biggest limitation of study design is its observational nature. This means we can only conclude an association, not causation. Propensity score matching can help but is not able to eliminate unmeasured confounders that could bias the results. There were some details that should be explained about propensity matching.

Date: January 7th, 2021 Happy New Years to all the SGEMers. I know 2020 has been a bit of a dumpster fire. We have all faced challenges During the COVID19 global pandemic. I tried not to contribute to the large volume of information coming out on Sars-Cov2. There were only four episodes that directly addressed COVID19: SGEM Xtra: Mask4All Debate SGEM#229: Learning to Test for COVID19 SGEM Xtra: CAEP National Grand Rounds - COVID19 Treatments SGEM#309: That’s All Joe Asks of You – Wear a Mask There have been many other FOAMed resources (REBEL EM, First10EM, EM Cases, St. Emlyn's, and others) that have done a great job covering the pandemic. This is an SGEM Xtra episode to announce a few exciting new things for 2021. SGEM Continuing Medical Education Credits The BIG news is that the SGEM will now be offering Continuing Medical Education (CME) credits for all SGEM episodes. Click on this LINK to find out more. The Skeptics' Guide to Emergency Medicine (SGEM) is part of the Free Open Access to Meducation movement (FOAMed). The SGEM tries to cut the knowledge translation window down from over ten years to less than one year with the power of social media. The ultimate goal is for patients to get the best care, based on the best evidence. The FOAMed philosophy is that the information should be available to anyone, anytime, anywhere at no cost. This is similar to the philosophy of emergency medicine. It is the light in the house of medicine that is always on for anyone, at anytime, for anything. The SGEM has been free since it started in 2012 and will always be free open access. Many of you have asked about getting CME credits for listening to the SGEM podcast and reading the SGEM blog. We know physicians (MD and DO), Nurse Practitioners (NP) and Physician Assistants (PA) have to collect so many CME credit hours for their respective professional organizations. This can be more challenging with the cancelation of in-person conferences and meetings. The SGEM Hot Off the Press (SGEMHOP) episodes which are published once a month do offer CME credits. However, you can only claim these credits if you are a member of the Society of Academic Emergency Medicine (SAEM). This new initiative will allow anyone to claim CME credits for all of the SGEM episodes. Getting CME credits for the weekly SGEM episodes is something I have been wanting to do for years. The barriers to getting CME credits for the SGEM before now was that it takes a lot of time and costs a lot of money to get accreditation. The cancellation of in-person conferences due to COVID19 has been the push I needed to finally get this service added to the SGEM. This project has been made possible through a partnership with a Legend of Emergency Medicine, Dr. Richard Bukata, and his Center for Medical Education (CCME) company. CCME has been providing providing medical education in the form of audio programs and conferences since 1977. They have the infrastructure to provide this type of service. They also have an arrangement to get the CME credits at a very reasonable price. Sign up by January 31st, 2021: There can be only one... The SGEM CME program offers up to 26 credits (1 credit hour per SGEM episode) over 6 months for only $195. If you sign up before January 31st, 2021 we will also give you 26 credits for free. This will be the previous six months of SGEM content that has already been approved for CME credits. Basically it is a 50% off promotion to kick start the SGEM CME program. Signing up for your education credits is easy. This is because "there can be only one" subscription option. You can earn up to 26 credit hours in six months. The price is $195 ($7.50/credit hour) for the six months. Again, those that sign up by January 31st, 2021 will receive a bonus 26 CME credits for free. That makes it only $3.75 for every credit hour of SGEM content!. It is as easy as 1-2-3 to start earning your CME credit today. Just click on the picture of the Highlander for all the details. SGEM Season#7 Book The SGEM continues to grow and has approximately 51,000 subscribers. It would not be so successful without the wonderful people like you who listen to the podcast and read the blog every week. I would also like to thank the SGEMHOP Team (Drs. Bond, Heitz and Morgenstern), PaperinaPic creator (Dr. Challen), all the guest skeptics and my best friend Chris Carpenter. The SGEM Season#7 book was put together with the help of my daughter Sage Milne. She came up with the steam punk theme and drew all the artwork for the book. The cover art was inspired by the 1982 movie TRON. She knows very well how much I like 1980's movies and music. Sage is currently doing doing a degree in Global Health Studies at Huron University College. Here are links to all six season of the SGEM as PDF books. You can download each season by clicking on the link: Season#1, Season#2, Season#3, Season #4, Season#5 and Season#6 If you are looking for the amazing theme music that help

Date: January 4th, 2021 This is an SGEM Xtra episode. I had the honour of presenting at the McGill University Emergency Medicine Academic Grand rounds. They titled the talk "Evidence-Based Medicine Master Class". The presentation is available to watch on YouTube, listen to on iTunes and all the slides can be downloaded (McGill 2020 Part 1 and McGill 2020 Part 2). Five Objectives: Look at the burden of proof and talk about what is science Discuss EBM and give a five step process of critical appraisal Talk about biases and logical fallacies Do a check list for randomized control trials Record a live episode of the SGEM 1) Who has the Burden of Proof and What is Science? Those making the claim have the burden of proof. It is called a burden because it hard - not because it is easy. We start with the null hypothesis (no superiority). Evidence is presented to convince us to reject the null and accept there is superiority to their claim. If the evidence is convincing we should reject the null. If the evidence is not convincing we need to accept the null hypothesis. It is a logical fallacy to shift the burden of proof onto those who say they do not accept the claim. They do not have to prove something wrong but rather not be convinced that the claim is valid/“true” and this is an important distinction in epistemology. What is science? It is the most reliable method for exploring the natural world. There are a number of qualities of science: Iterative, falsifiable, self-correcting and proportional. What science isn’t is “certain”. We can have confidence around a point estimate of an observed effect size and our confidence should be in part proportional to the strength of the evidence. Science also does not make “truth” claims. Scientists do make mistakes, are flawed and susceptible to cognitive biases. Physicians took on the image of a scientist by co-opting the white coat. Traditionally, scientists wore beige and physicians wore black to signify the somber nature of their work (like the clergy). Then came along the germ theory of disease and other scientific knowledge. It was the Flexner Report in 1910 that fundamentally changed medical education and improved standards. You could get a medical degree in only one year before the Flexner Report. The white coat was now a symbol of scientific rigour separating physicians from “snake oil salesman”. Many medical schools still have white coat ceremonies. However, only 1 in 8 physicians still report wearing a white lab coat today (Globe and Mail). Science is usually iterative. Sometimes science takes giants leaps forward, but usually it takes baby steps. You probably have heard the phrase "standing on the shoulders of giants"? In Greek mythology, the blind giant Orion carried his servant Cedalion on his shoulders to act as the giant's eyes. The more familiar expression is attributed to Sir Isaac Newton, "If I have seen further it is by standing on the shoulders of Giants.” It has been suggested that Newton may have been throwing shade at Robert Hooke. Hooke was the first head of the Royal Society in England. Hooke was described as being a small man and not very attractive. The rivalry between Newton and Hooke is well documented. The comments about seeing farther because of being on the shoulders of giants was thought to be a dig at Hooke's short stature. However, this seems to be gossip and has not been proven. Science is also falsifiable. If it is not falsifiable it is outside the realm/dominion of science. This philosophy of science was put forth by Karl Popper in 1934. A great example of falsifiability was the claim that all swans are white. All it takes is one black swan to falsify the claim. There are some philosophers that refute Popper's claim about falsifiability. Science is self-correcting. Because science is iterative and falsifiable it is also self correcting. Science gets updated. We hopefully learn and get closer to the “truth” over time. Medical reversal is a thing and there is a great book and by Drs. Prasad and Cifu on this issue called Ending Medical Reversal: Improving Outcomes, Saving Lives. The evidence required to accept a claim should be in part proportional to the claim itself. The classic example was given by the famous scientist Carl Sagan (astronomer, astrophysicist and science communicator). Did the TV series Cosmos and wrote a number of popular science books (The Dragons of Eden). Sagan made the claim that there was a “fire-breathing dragon that lives in his garage”. The quality of evidence to convince you of something should be in part proportional to the claim being asserted. The summary is the famous quote by Carl Sagan that "extraordinary claims require extraordinary evidence". Science does not make claims about the truth. It gives an approximation of the the best point estimate of the observed effect. It’s the best known method for exploring the natural world. Science has no agency but rath

Date: December 18th, 2020 Reference: Hulme et al. Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study. CMAJ 2020 Guest Skeptic: Dr. Hasan Sheikh is an emergency and addictions physician in Toronto and a lecturer at the University of Toronto. He holds a Masters in Public Administration from the Harvard Kennedy School of Government. Hasan was on an SGEM Xtra last year discussing the Canadian Association of Emergency Physician's (CAEP) position statement on Dental care in Canada. "The Canadian Association of Emergency Physicians believes that every Canadian should have affordable, timely, and equitable access to dental care." CAEP has put out other position statements. The most recent is on sick notes for minor illness. For a list of other positions statements from CAEP click on this LINK. Case: A 45-year-old male with no fixed address is found by a bystander with decreased level of consciousness (LOC) on the street. Emergency Medical Services (EMS) is called, and the patient is brought to the emergency department (ED). An empty bottle of vodka is found on the patient, and the decreased LOC is suspected to be due to alcohol intoxication. It is the patient’s fifth visit to the ED in the last two weeks with a similar presentation. The patient is observed over many hours, their LOC improves, and they are discharged after demonstrating that they can ambulate safely. Background: A leading driver of morbidity and mortality worldwide is alcohol (1). Alcohol consumption is attributed to approximately 5% of all global deaths. This works out to an estimated 3 million deaths due to alcohol (2). Alcohol was the single greatest risk factor for ill health worldwide among people aged 15–49 years according to the 2016 Global Burden of Disease Study (3). There are more hospital admissions in Canada for alcohol-attributable conditions than for myocardial infarction (4). There is a cost associated with alcohol related harms. In Canada, that number is around $14.6 billion a year with $3.3 billion in health care costs (5). Alcohol related ED visits has also increased more than four times greater than the overall rate of ED visits (6). This trend of increasing alcohol related ED visits is not unique to Canada. It has also been reported in England, Australia and the US (7-9). Clinical Question: What is the one-year overall mortality rate for adults with frequent visits to the ED for alcohol related reasons? Reference: Hulme et al. Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study. CMAJ 2020 Population: Adults aged 16-105 years of age who made frequent ED visits for alcohol related reasons (two or more ED visits in a year). Excluded: Data inconsistencies, not Ontario residents, Age < 16 or > 105 or death at discharge Exposure: Patients with ED visits for alcohol-related mental and behavioural disorders, using the ICD-10-CA code of F10. This includes simple intoxication and withdrawal Comparison: Comparisons were made between groups of frequent ED users for alcohol-related reasons, including those that visited the ED twice in a year, 3-4 times in a year, and greater than four times in a year Outcome: Primary Outcome: One-year mortality, adjusted for age, sex, income, rural residence, and presence of co-morbidities Secondary Outcomes: Mental and behavioural disorders, diseases of the circulatory system, diseases of the digestive system, and external causes of morbidity and mortality (e.g., accidents, including accidental poisoning, accidental injuries, injuries, intentional self-harm, assault) with frequency >5%. Cause of death using alcohol-attributable ICD-10-CA codes as well as ICD-10-CA codes for death by suicide. Authors’ Conclusions: “We observed a high mortality rate among relatively young, mostly urban, lower-income people with frequent emergency department visits for alcohol-related reasons. These visits are opportunities for intervention in a high-risk population to reduce a substantial mortality burden.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? 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 Key Results: They identified 160,170 alcohol-related ED visits that had at least one more alcohol-related visit in the 1-year time frame. This represented a cohort of 25,813 patients. T

Date: December 21st, 2020 Professor Tim Caulfield This is a SGEM Xtra book review. I had the pleasure of interviewing Professor Timothy Caulfield. Tim is a Canadian professor of law at the University of Alberta, the Research Director of its Health Law Institute, and current Canada Research Chair in Health Law and Policy. His area of expertise is in legal, policy and ethical issues in medical research and its commercialization. Tim came on the SGEM and discussed his new book called Relax, Dammit! A User's Guide to the Age of Anxiety. Listen to the podcast to hear us discuss his new book, skepticism, and science communication in general. The SGEM has a global audience with close to 45,000 subscribers. Many of the SGEMers live in the US and Tim's book has a different title in America. It is called Your Day Your Way: The Facts and Fictions Behind Your Daily Decisions. Tim gives some insight on the podcast why there is a different title in Canada and the US. Tim and I met in 2015 at the Canadian Associate of Emergency Physicians (CAEP) Annual Conference in Edmonton. He was a keynote speaker and discussed his previous book Is Gwyneth Paltrow Wrong about Everything? How the Famous Sell Us Elixirs of Health, Beauty & Happiness. Tim gave a fantastic presentation. I was in Edmonton talking nerdy as part of the CAEP TV initiative. We have been in contact via social media ever since trying to improve science communication. Besides writing books, Tim has stared in his own Netflix series called: A User guide to Cheating Death. He has also collaborated Dr. Jennifer Gunter who wrote the book The Vagina Bible. Dr. Gunter visited BatDoc a few years ago for an SGEM Xtra extra episode. A Few of Professor Caulfield's academic publications: Commentary: the law, unproven CAM and the two‐hats fallacy. Focus on Alternative and Complementary Therapies, 17: 4-8. Stem cell hype: Media portrayal of therapy translation. Science Translational Medicine.11 Mar 2015: Vol. 7, Issue 278, pp. 278ps4 Injecting doubt: responding to the naturopathic anti-vaccination rhetoric. Journal of Law and the Biosciences, Volume 4, Issue 2, August 2017, Pages 229–249 COVID-19 and ‘immune boosting’ on the internet: a content analysis of Google search. BMJ Open 2020;10:e040989. Previous books reviewed on the SGEM: Jeanne Lenzer The Danger Within Us: America's Untested, Unregulated Medical Device Industry and One Man's Battle to Survive It. Dr. Steven Novella Skeptics Guide to the Universe: How to Know What's Really Real in a World Increasingly Full of Fake. Dr. Brian Goldman The Power of Kindness: Why Empathy is Essential in Everyday Life Tim's new book Relax Dammit! is organized into the day in the life of Tim Caulfield. It discusses the science behind our daily activities. On the podcast Tim provides five examples that he thinks might be interesting to the SGEM audience. This includes: Breakfast, coffee, commuting to work, napping and raw milk. I hope you like this type of SGEM Xtra. Let me know what you think and I will consider doing more book reviews with authors if the feedback is positive. The SGEM will be back episode with a structured critical review of a recent publication trying to cut the knowledge translation window down from over ten years to less than one year. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Date: December 16th, 2020 Reference: Butler et al. Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial. The Lancet 2020 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com. He has a great new blog post about how we are failing to protect our healthcare workers during COVID-19. Case: A 45-year-old female presents to her primary care clinician complaining of fever, sore throat and muscle aches. She did not get a flu shot this year. You diagnose her with an influenza-like illness (ILI). She wants to know if taking an anti-viral like oseltamivir (Tamiflu) will help? Background: We covered oseltamivir six years ago in SGEM#98. This is still the longest Cochrane review (300+ pages) I have ever read (Jefferson et al 2014a). The overall bottom line was when balancing potential risks and potential benefits, the evidence does not support routine use of neuraminidase inhibitors like oseltamivir for the treatment or prevention of influenza in any individual. There has been some controversy around oseltamivir. It was approved by licensing agencies and promoted by the WHO based on unpublished trials. None of those agencies had actually looked at the unpublished data. In fact, the primary authors of key oseltamivir trials had never been given access to the data – Roche just told them what the data supposedly said. Other papers were ghost-written (Cohen 2009). The BMJ was involved in a legal battle with Roche for half a decade trying to get access to that information. When they finally got their hands on the data, the conclusions of the reviews suddenly changed. After countries had spent billions stockpiling the drug, it turned out that oseltamivir had no effect on influenza complications, was not effective in prophylaxis, and had significantly more harms than originally reported (Jefferson 2014a; Jefferson 2014b). You can read more details about this controversy in the BMJ. The oseltamivir issue is a great example of the problems with conflicts of interest (COI) in medical research. This is something I have spoken about often. It is not an ad hominem attack on any of the authors. Our current system of medical research involves industry funding. COIs are just another data point that needs to be considered. This is because the evidence shows COIs can introduce bias into RCTs, SRMA and Clinical Practice Guidelines. When I use the term bias I am referring to something that systematically moves us away from the “truth”. There is specific evidence of bias in the oseltamivir literature. Dunn and colleagues looked at 37 assessments done in 26 systematic reviews and then compared their conclusions to the financial conflicts of interest of the authors. Among eight assessments where the authors had conflicts, seven (88%) had favourable conclusions about neuraminidase inhibitors. However, among the 29 assessments that were made by authors without conflicts, only five (17%) were positive (Dunn et al 2014). The current best evidence shows that oseltamivir (Jefferson et al 2014a): Decreased time to first alleviation of symptoms by less than one day Does not statistically change hospital admission rate (1.7% vs 1.8%) Does increase nausea (NNH 28) and vomiting (NNH 22) Does increase neuropsychiatric events (NNH 94) Does increase headaches (NNH 32) Clinical Question: Does oseltamivir improve time to recovery in patients presenting to their primary care clinician with an influenza-like illnesses? Reference: Butler et al. Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial. The Lancet 2020. Population: Patients from 15 European countries over three influenza seasons who were one year of age and older and who presented to their primary care clinician with symptoms of influenza-like illness (ILI). ILI was defined as a “sudden onset of self-reported fever, with at least one respiratory symptom (cough, sore throat, or running or congested nose) and one systemic symptom (headache, muscle ache, sweats or chills, or tiredness), with symptom duration of 72 h or less during a seasonal influenza epidemic.” Exclusions: Chronic renal failure, substantial impaired immunity, patients in whom the treating clinician thought Tamiflu or admission to hospital was required, allergy, planned general anesthesia in the next two weeks, life expectancy less than six months, severe hepatic impairment, requirement for any live viral vaccine in the next seven days, and in some jurisdictions pregnant or lactating women. Intervention: Oseltamivir (Tamiflu) 75 mg by mouth twice daily for five days in adults and children more than 40 kg. For children (13 years or younger), oral suspension was given according to weight (children weighing 10–15 kg received 30 mg, >15–23 kg received 45 mg, >23–40 kg received 60 mg, and

Date: December 10th, 2020 Reference: Ladde et al. A Randomized Controlled Trial of Novel Loop Drainage Technique Versus Drainage and Packing in the Treatment of Skin Abscesses. AEM December 2020 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: A 52-year-old previously healthy woman presents to your emergency department (ED) with an abscess on her left forearm. She is systemically well and there is no sign of tracking, so you decide to perform incision and drainage in the ED. When you ask your nursing colleague to set up the equipment, he wants to know if you will be using standard packing or a vessel loop drainage technique. Background: We have covered the issue of abscesses multiple times on the SGEM. Way back in 2012 we looked at packing after incision and drainage (I&D) on SGEM#13 and concluded routine packing might not be necessary. Another topic covered was whether irrigating after I&D was superior to not irrigating (SGEM#156). The bottom line from that critical appraisal was that irrigation is probably not necessary. Chip Lange (PA) The use of antibiotics after I&D is another treatment modality that has been debated over the years. Chip Lange and I interviewed Dr. David Talan about his very good NEJM randomized control trial on SGEM#164. The bottom line was that the addition of TMP/SMX to the treatment of uncomplicated cutaneous abscesses represents an opportunity for shared decision-making. One issue that has not been covered yet is the loop technique. This is when one or multiple vessel loops are put through the abscess cavity. This is done by making a couple of small incisions. An advantage to this technique over packing (which is not necessary) is that the Vessel loops do not need to be changed or replaced. Clinical Question: In uncomplicated abscesses drained in the ED, does the LOOP technique reduce treatment failure? Reference: Ladde et al. A Randomized Controlled Trial of Novel Loop Drainage Technique Versus Drainage and Packing in the Treatment of Skin Abscesses. AEM December 2020 Population: Patients of any age undergoing ED drainage of skin abscesses Exclusions: Patient with abscess located on hand, foot, or face or if they required admission and/or operative intervention. Intervention: LOOP technique where a vessel tie is left in situ Comparison: Standard packing with sterile ribbon gauze Outcome: Primary Outcome: Treatment failure (need for a further procedure, IV antibiotics or operative intervention), assessed at 36 hours. Secondary Outcomes: Ease of procedure, pain at the time of treatment, ease of care at 36 hours, pain at 36 hours. Dr. Ladde This is an SGEMHOP episode which means we have the lead author on the show. Dr. Ladde is in an active academic emergency physician working at Orlando Regional Medical Center serving as core faculty and Senior Associate Program Director. Jay also has the rank Professor of Emergency Medicine for University of Central Florida College of Medicine. Authors’ Conclusions: “The LOOP and packing techniques had similar failure rates for treatment of subcutaneous abscesses in adults, but the LOOP technique had significantly fewer failures in children. Overall, pain and patient satisfaction were significantly better in patients treated using the LOOP technique.” 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. Unsure The study patients were recruited consecutively (i.e. no selection bias). No The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. No Key Results: They recruited 256 participants into the trial with 90% (196) having outcome data. The mean age was 22 years, 71% were thought to also have cellulitis and 83% (213/256) received antibiotics at discharge. More than 80% of those prescribed antibiotics were given the combination of cephalexin and TMX-SMP. No statistical difference in treatment failure between loop technique and packing. Primary Outcome: Treatment failure 20% (95% CI 12-28%) in packing group vs. 13% (6-20%) LOOP group; p=0.25. Secondar

Date: November 30th, 2020 Reference: Ohle R et al. Can Emergency Physicians Accurately Rule Out a Central Cause of Vertigo Using the HINTS Examination? A Systematic Review and Meta-analysis. AEM 2020 Guest Skeptic: Dr. Mary McLean is an Assistant Program Director at St. John’s Riverside Hospital Emergency Medicine Residency in Yonkers, New York. She is the New York ACEP liaison for the Research and Education Committee and is a past ALL NYC EM Resident Education Fellow. Case: A 50-year-old female presents to your community emergency department in the middle of the night with new-onset constant but mild vertigo and nausea. She has nystagmus but no other physical exam findings. You try meclizine, ondansetron, valium, and fluids, and nothing helps. Her head CT is negative (taken 3 hours after symptom onset). You’re about to call in your MRI tech from home, but then you remember reading that the HINTS exam is more sensitive than early MRI for diagnosis of posterior stroke. You wonder, “Why can’t I just rule out stroke with the HINTS exam? How hard can it be?” You perform the HINTS exam and the results are reassuring, but the patient’s symptoms persist… Background: Up to 25% of patients presenting to the ED with acute vestibular syndrome (AVS) have a central cause of their vertigo - commonly posterior stroke. Posterior circulation strokes account for approximately up to 25% of all ischemic strokes [1]. MRI diffuse-weighted imagine (DWI) is only 77% sensitive for detecting posterior stroke when performed within 24h of symptom onset [2,3]. As an alternative diagnostic method, the HINTS exam was first established in 2009 to better differentiate central from peripheral causes of AVS [4]. But what is the HINTS exam? It’s a combination of three structured bedside assessments: the head impulse test of vestibulo-ocular reflex function, nystagmus characterization in various gaze positions, and the test of skew for ocular alignment. When used by neurologists and neuro-ophthalmologists with extensive training in these exam components, it has been found to be nearly 100% sensitive and over 90% specific for central causes of AVS [5-8]. Over the past decade, some emergency physicians have adopted this examination into their own bedside clinical assessment and documentation. We’ve used it to make decisions for our patients, particularly when MRI is not readily available. We’ve even used it to help decide whether or not to get a head CT. But we’ve done this without the extensive training undergone by neurologists and neuro-ophthalmologists, and without any evidence that the HINTS exam is diagnostically accurate in the hands of emergency physicians. Clinical Question: Can emergency physicians accurately rule out a central cause of vertigo using the HINTS examination? Reference: Ohle R et al. Can Emergency Physicians Accurately Rule Out a Central Cause of Vertigo Using the HINTS Examination? A Systematic Review and Meta-analysis. AEM 2020 Population: Adult patients presenting to an ED with AVS Exclusions: Non-peer-reviewed studies, unpublished data, retrospective studies, vertigo which stopped before or during workup, incomplete HINTS exam, or studies with data overlapping with another study used Intervention: HINTS examination by emergency physician, neurologist, or neuro-ophthalmologist Comparison: CT and/or MRI Outcome: Diagnosis of HINTS examination for central cause for AVS (i.e., posterior stroke) Authors’ Conclusions: “The HINTS examination, when used in isolation by emergency physicians, has not been shown to be sufficiently accurate to rule out a stroke in those presenting with AVS.” Quality Checklist for Systematic Review Diagnostic Studies: The diagnostic question is clinically relevant with an established criterion standard. Unsure 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. Unsure Key Results: They searched multiple electronic databases with no language or age restrictions and the gray literature. The authors identified 2,695 citations with five articles meeting inclusion criteria and a total of 617 patients. There were no studies that included only emergency physicians performing the HINTS examination. Essentially, the authors separated the studies into two cohorts according to the medical specialties of the HINTS examiners, and for each cohort they reported the sensitivity and specificity of the HINTS exam for diagnosis of posterior stroke. The first cohort included neurologists and neuro-ophthalmologists. The sensitivity and specificity of the HINTS examination were 96.7% (95% CI; 93.1 to 98.5) and 94.8% (95% CI; 91 to 97.1). In contrast, the second cohort (onl

Date: November 25th, 2020 Guest Skeptic: Dr. Joe Vipond has worked as an emergency physician for twenty years, currently at the Rockyview General Hospital. He is the President of the national charity Canadian Association of Physicians for the Environment (CAPE), as well as the co-founder and co-chair of the local non-profit the Calgary Climate Hub, and during COVID, the co-founder of Masks4Canada. Joe grew up in Calgary and continues to live there with his wife and two daughters. Reference: Bundgaard et al. Effectiveness of Adding a Mask Recommendation to Other Public Health Measures to Prevent SARS-CoV-2 Infection in Danish Mask Wearers: A Randomized Controlled Trial. Annals of Internal Medicine 2020 Case: : Alberta is the last province in Canada that has yet to enact a mandatory mask policy. Should they do it? Mask4All Debate Background: During a respiratory pandemic, there still remains substantial questions about the utility and risk of facial masks for prevention of viral transmission. We debated universal mandatory masking back in the spring on an SGEM Xtra episode. Some very well known evidence-based medicine experts like Dr. Trisha Greenhalgh were advocating in favour of stricter mask regulations based on the precautionary principle (Greenhalgh et al BMJ 2020). She was challenged on her position (Martin et al BMJ 2020) and responded with an article called: Laying straw men to rest (Greenhalgh JECP 2020). A limitation of science is the available evidence. SARS-CoV-2 is a novel virus and we did not have much information specifically about the efficacy of masks. We needed to extrapolate from previous research on masks and other respiratory illnesses. However, we do have a firm understanding of the germ theory of disease and masks have been used for over 100 years as an infectious disease strategy. It was surgeons in the late 1890’s that began wearing masks in the operating theaters. There was skepticism back then as to the efficacy of a “surgical costume” (bonnet and mouth covering) to prevent disease and illness during surgery (Strasser and Schlich Lancet 2020). There was one recent cluster randomized control trial looking at surgical masks, cloth masks or a control group in healthcare workers (MacIntyre et al BMJ 2015). The main outcomes were clinical respiratory illness, influenza-like illness and laboratory-confirmed respiratory virus infection. All infectious outcomes were highest in the cloth mask group, lower in the control group and lowest in the medical mask group. As with all studies this one had limitations. One of the main ones is this looked at healthcare workers wearing a mask as protection not in the general public as a source control. There has been a systematic review meta-analysis on physical distancing, face masks and eye protection to prevent SARS-Cov-2 (Chu et al Lancet 2020). With regards to masks, they found that face masks could result in a large reduction in risk of infection with a stronger association with N95 or similar respirators compared with disposable surgical masks or similar cloth masks. SRMA also have limitations and one of the main ones is they are dependent on the quality of the included studies. This review in the Lancet included ten studies (n=2,647) with seven from China, eight looking at healthcare workers (not general public) and only one looking at COVID19. All 10 studies were observational designs and the authors correctly only claim associations. They also say their level of certainty about masks being associated with a decrease in disease is considered “low certainty” based on the GRADE category of evidence. When considering an intervention, we cannot just consider the potential benefit, but we must also consider the potential harms. There is little or no evidence that wearing a face mask leads to potential harms. Yes, there are case reports of harm, children under 2 years of age should not wear face coverings (AAP News) and studies systematically under report adverse events (Hodkinson et al BMJ 2013) but the pre-test probability of individual harm is very low. What many studies on masks conclude is we need better evidence to inform our decisions. Now we have the first published randomized control trial on mask wearing in public to prevent transmission of COVID19. Clinical Question: Does recommending surgical mask use outside the home reduces wearers' risk for SARS-CoV-2 infection in a setting where masks were uncommon and not among recommended public health measures? Reference: Bundgaard et al. Effectiveness of Adding a Mask Recommendation to Other Public Health Measures to Prevent SARS-CoV-2 Infection in Danish Mask Wearers: A Randomized Controlled Trial. Annals of Internal Medicine 2020 Population: Danish adults > 18 years of age without symptoms associated with SARS-CoV-2 (or previously tested positive for SARS-CoV-2), working out-of-home with exposure to other people for more than three hours per day and who do not normally wear a face mask at

Date: November 19th, 2020 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Reference: Pines et al. The impact of advanced practice provider staffing on emergency department care: productivity, flow, safety, and experience. AEM November 2020. Case: You are the medical director of a medium sized urban emergency department (ED). Volumes have increased over the past few years and you’re considering adding an extra shift or two. Your hospital has asked you to consider adding some advanced practice providers (APPs) instead of physician hours. Background: Advanced practice providers (APPs) such as nurse practitioners (NPs) and Physician Assistants (PAs) are increasingly used to cover staffing needs in US emergency departments. This is in part driven by economics, as APPs are paid less per hour than physicians. The calculation works if APP productivities are similar enough to physicians to offset differentials in billing rates. However, little data exists comparing productivity, safety, flow, or patient experiences in emergency medicine. The American Academy of Emergency Medicine (AAEM) has a position statement on what they refer to as non-physician practitioners that was recently updated. The American College of Emergency Physicians (ACEP) has a number of documents discussing APPs in the ED. There has been a concern about post-graduate training of NPs and PAs in the ED. A joint statement on the issue was published in September this year by AAEM/RSA, ACEP, ACOEP/RSO, CORD, EMRA, and SAEM/RAMS. Clinical Question: How does the productivity of advanced practice providers compare to emergency physicians and what is its impact on emergency department operations? Reference: Pines et al. The impact of advanced practice provider staffing on emergency department care: productivity, flow, safety, and experience. AEM November 2020. Population: National emergency medicine group in the USA that included 94 EDs in 19 states Exposure: Proportion of total clinician hours staffed by APPs in a 24-hour period at a given ED Comparison: Emergency physician staffing Outcome: Primary Outcome: Productivity measures (patients per hour, RVUs/hour, RVUs/visit, RVUs per relative salary for an hour) Safety Outcomes: Proportion of 72-hour returns and proportion of 72-hour returns resulting in admission Other Outcomes: ED flow by length of stay (LOS), left without completion of treatment (LWOT) Dr. Jesse Pines This is an SGEMHOP episode which means we have the lead author on the show. Dr. Jesse Pines is the National Director for Clinical Innovation at US Acute Care Solutions and a Professor of Emergency Medicine at Drexel University. In this role, he focuses on developing and implementing new care models including telemedicine, alternative payment models, and also leads the USACS opioid programs. Authors’ Conclusions: “In this group, APPs treated less complex visits and half as many patients/hour compared to physicians. Higher APP coverage allowed physicians to treat higher-acuity cases. We found no economies of scale for APP coverage, suggesting that increasing APP staffing may not lower staffing costs. However, there were also no adverse observed effects of APP coverage on ED flow, clinical safety, or patient experience, suggesting little risk of increased APP coverage on clinical care delivery. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Unsure Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? 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? Unsure Key Results: Over five years there were more than 13 million ED visits at these 94 sites. The majority (75%) of visits were treated by physicians independently. PAs treated 18.6%, NPs 5.4% and 1.4% were treated by both a physician and an APP. Physicians were more productive than physician assistants and nurse practitioners. Effect of 10% increase in APP coverage: Patients/hour: -0.12 (95% CI; -0.15 to -0.10) RVUs/hour: -0.4 (95% CI; -0.5 to -0.3) Safety and Outcome: No significant effect on length of stay, left without treatment, and 72-hour returns Listen to the podcast on iTunes to hear Jesse’s responses to our five nerdy questions. 1) Surprise: These results surprise me somewhat due to personal experience where APPs see lower acuity patients, often in a “fast-track” area. I don’t know our facility data, but would be surprised if the APPs had significantly lower overall patients/hour than the doctors. 2) Physici

Date: October 29th, 2020 Guest Skeptic: Martha Roberts is a critical and emergency care, triple-certified nurse practitioner currently living and working in Sacramento, California. She is the host of EM Bootcamp in Las Vegas, as well as a usual speaker and faculty member for The Center for Continuing Medical Education (CCME). She writes a blog called The Procedural Pause for Emergency Medicine News and is the lead content editor and director for the video series soon to be included in Roberts & Hedges' Clinical Procedures in Emergency Medicine. Reference: Vent et al. Buffered lidocaine 1%, epinephrine 1:100,000 with sodium bicarbonate (hydrogencarbonate) in a 3:1 ratio is less painful than a 9:1 ratio: A double-blind, randomized, placebo-controlled, crossover trial. JAAD (2020) Case: A 35-year-old female arrives to the emergency department with a 3 cm laceration to the palmar surface of her left forearm sustained by a clean kitchen knife while emptying the dishwasher. The patient reports a fear of needles and has concerns about locally anaesthetizing the area because, “I got stitches on my arm once before and that shot burned like crazy”! The patient asks the practitioner if there is any chance, she can get a shot that “burns less” than her last one. Background: We have covered wound care a number of times on the SGEM. This has included some myth busing way back in SGEM#9 called Who Let the Dogs Out. That episode busted five myths about simple wound care in the Emergency Department: Patients Priorities: Infection is not usually the #1 priority for patients. For non-facial wounds it is function and for facial wounds it is cosmetic. This is in contrast to the clinicians’ #1 priority that is usually infection. Dilution Solution: You do not need some fancy solution (sterile water, normal saline, etc) to clean a wound. Tap water is usually fine. Sterile Gloves: You do not need sterile gloves for simple wound treatment. Non-sterile gloves are fine. Save the sterile gloves for sterile procedures (ex. lumbar punctures). Epinephrine in Local Anesthetics: This will not make the tip of things fall off (nose, fingers, toes, etc). Epinephrine containing local anesthetics can be used without the fear of an appendage falling off. All Simple Lacerations Need Sutures: Simple hand lacerations less than 2cm don’t need sutures. Glue can be used in many other areas including criss-crossing hair for scalp lacerations. Other SGEM episodes on wound care include: SGEM#63: Goldfinger (More Dogma of Wound Care) This episode looked at how long do you have to close a wound. The bottom line was that there is no good evidence to show that there is an association between infection and time from injury to repair. SGEM#156: Working at the Abscess Wash The question from that episode was: does irrigation of a cutaneous abscess after incision and drainage reduce the need for further intervention? Answer: Irrigation of a cutaneous abscess after an initial incision and drainage is probably not necessary. SGEM#164: Cuts Like a Knife – But you Might Also Need Antibiotics for Uncomplicated Skin Abscesses. SGEM Bottom Line: The addition of TMP/SMX to the treatment of uncomplicated cutaneous abscesses represents an opportunity for shared decision-making. The issue of buffering lidocaine was covered on SGEM #13. This episode briefly reviewed a Cochrane SRMA that looked at buffering 9ml of 1% or 2% lidocaine with 1ml of 8.4% sodium bicarbonate (Cepeda et al 2010). The SRMA of buffering lidocaine contained 23 studies with 8 of the 23 studies having moderate to high risk of bias. The SGEM bottom line was that patients might appreciate the extra effort of buffering the lidocaine. Interestingly, this Cochrane Review was withdrawn from publication in 2015. The reason provided was that the review was no longer compliant with the Cochrane Commercial Sponsorship Policy. The non-conflicted authors have decided not to update the review. Clinical Question: Does buffering lidocaine with sodium bicarbonate make local anesthetic less painful? Reference: Vent et al. Buffered lidocaine 1%, epinephrine 1:100’000 with sodium bicarbonate (hydrogencarbonate) in a 3:1 ratio is less painful than a 9:1 ratio: A double-blind, randomized, placebo-controlled, crossover trial. JAAD (2020) Population: Healthy volunteers age 18-75 years of age Exclusions: Hypersensitivity or allergies to local anesthetics of the amide type or to auxiliary substances such as sulfites, pregnant, damaged skin on the arms, or inability to give informed consent. Intervention: IMP (investigational medicinal products) were injected 5cm distal from the cubital fossa IMP1: 1% lidocaine with epinephrine plus sodium bicarbonate in a 3:1 mixing ratio IMP2: 1% lidocaine with epinephrine plus sodium bicarbonate in a 9:1 mixing ratio IMP3: 1% lidocaine with epinephrine Comparison: Placebo of 0.9% sodium chloride (IMP4) Outcomes: Primary Outcome: Pain during infiltration on a numerical rating scale (0-10

Date: October 21st, 2020 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician, creator of the excellent #FOAMed project called First10EM.com and a member of the #SGEMHOP team. Reference: Derkenne et al. Mobile Smartphone Technology Is Associated With Out-of-hospital Cardiac Arrest Survival Improvement: The First Year "Greater Paris Fire Brigade" Experience. AEM Oct 2020. Case: You are waiting in line for coffee, discussing the latest SGEM Hot Off the Press episode on twitter, when an alert pops up on your phone. It says that someone in the grocery store next door has suffered a cardiac arrest and needs your help. You remember installing this app at a conference last year, but this is the first time you have seen an alert. You abandon your coffee order and quickly head next-door, where you are able to start cardiopulmonary resuscitation (CPR) and direct a bystander to find the store’s automated external defibrillator (AED) while waiting for emergency medical services (EMS) to arrive. After the paramedics take over, you wonder about the evidence for this seemingly miraculous intervention. Background: Out of hospital cardiac arrest (OHCA) is something that we have covered many times on the SGEM. SGEM#64: Classic EM Papers (OPALS Study) 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#231: You’re So Vein – IO vs. IV Access for 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 The American Heart Association promotes the “Chain-of-Survival”. There are five steps in the Chain-of-Survival for OHCA: Step One – Recognition and activation of the emergency response system Step Two – Immediate high-quality cardiopulmonary resuscitation Step Three – Rapid defibrillation Step Four – Basic and advanced emergency medical services Step Five – Advanced life support and post arrest care Bystander CPR and early defibrillation are key components of the out of hospital cardiac arrest chain of survival. Unfortunately, most patients don’t receive these crucial interventions. Many people are trained in CPR but never use their skills, because it is unlikely that they will happen to be in exactly the right place at the right time. They may be willing and able to help, but if the patient in need is one block over, they may never know about it. The advent of the smart phone with GPS capability means that we should be better able to direct individuals trained in basic life support (BLS) to those in need around them. We should also be able to use smart phones to more easily identify the closest AEDs. Over the last decade, numerous apps have been developed to do exactly that, but the impact of those apps on clinical outcomes is still unclear. Clinical Question: Is the use of a smart phone app that can match trained responders to cardiac arrest victims and indicate the closest available AEDs associated with better clinical outcomes? Reference: Derkenne et al. Mobile Smartphone Technology Is Associated With Out-of-hospital Cardiac Arrest Survival Improvement: The First Year "Greater Paris Fire Brigade" Experience. AEM Oct 2020. Population: Cardiac arrests from a single emergency medical service (EMS) agency in Paris, France that were called through the central dispatch center and occurred while the chief dispatcher was available to participate, occurred in a public area, and in which there was not obvious environmental danger. Intervention: Alerts were sent through the Staying Alive app to volunteers trained in BLS who were within 500 meters of the reported cardiac arrest. The intervention group is the group of patients for whom someone responded to the alert and provided BLS treatment. Comparison: The control group consisted of patients in whom no volunteer was within 500 meters at the time of the arrest, for whom no volunteer responded to the alert, or for whom the volunteer responded to the alert but did not perform BLS. Outcomes: Return of spontaneous circulation (ROSC) upon hospital admission, survival outcomes upon hospital discharge and impact of first responders (commonly referred to as“Bons Samaritains”[BS]) on survival outcomes. Dr. Clementt Derkenne This is an SGEMHOP episode which means we usually have the lead author on the show. Dr. Clement Derkenne is an emergency physician in the Emergency Medical Department, Paris Fire Brigade, Clamart, France. He did not feel comfortable doing a podcast in English which we completely understand. Authors’ Conclusions: “We report for the that mobile smartphone technology was associated with OHCA survival through accelerated initiation of efficient cardiopulmonary resuscitation by first responders in a large urban area

Date: October 21st, 2020 This is an SGEM Xtra episode. I had the honour of presenting at the Department of Family Medicine's Grand Rounds at the Schulich School of Medicine and Dentistry. The title of the talk was: How to think, not what to think. The presentation is available to watch on YouTube, listen to on iTunes and all the slides can be downloaded from this LINK. Five Objectives: Discuss what is science Talk about who has the burden of proof Discuss Evidence-based medicine (EBM), limitations and alternatives Provide a five step approach to critical appraisal Briefly talk about COVID19 and the importance of EBM What is Science? It is the most reliable method for exploring the natural world. There are a number of qualities of science: Iterative, falsifiable, self-correcting and proportional. What science isn’t is “certain”. We can have confidence around a point estimate of an observed effect size and our confidence should be in part proportional to the strength of the evidence. Science also does not make “truth” claims. Scientists do make mistakes, are flawed and susceptible to cognitive biases. Physicians took on the image of a scientist by co-opting the white coat. Traditionally, scientists wore beige and physicians wore black to signify the somber nature of their work (like the clergy). Then came along the germ theory of disease and other scientific knowledge. It was the Flexner Report in 1910 that fundamentally changed medical education and improved standards. You could get a medical degree in only one year before the Flexner Report. The white coat was now a symbol of scientific rigour separating physicians from “snake oil salesman”. Many medical schools still have white coat ceremonies. However, only 1 in 8 physicians still report wearing a white lab coat today (Globe and Mail). Science is Usually Iterative: Sometimes science takes giants leaps forward, but usually it takes baby steps. You probably have heard the phrase "standing on the shoulders of giants"? In Greek mythology, the blind giant Orion carried his servant Cedalion on his shoulders to act as the giant's eyes. The more familiar expression is attributed to Sir Isaac Newton, "If I have seen further it is by standing on the shoulders of Giants.” It has been suggested that Newton may have been throwing shade at Robert Hooke. Hooke was the first head of the Royal Society in England. Hooke was described as being a small man and not very attractive. The rivalry between Newton and Hooke is well documented. The comments about seeing farther because of being on the shoulders of giants was thought to be a dig at Hooke's short stature. However, this seems to be gossip and has not been proven. Science is Falsifiable: If it is not falsifiable it is outside the realm/dominion of science. This philosophy of science was put forth by Karl Popper in 1934. A great example of falsifiability was the claim that all swans are white. All it takes is one black swan to falsify the claim. Science and Proportionality: The evidence required to accept a claim should be in part proportional to the claim itself. The classic example was given by the famous scientist Carl Sagan (astronomer, astrophysicist and science communicator). Did the TV series Cosmos and wrote a number of popular science books (The Dragons of Eden). Sagan made the claim that there was a “fire-breathing dragon that lives in his garage”. How much evidence would it take for you to accept the claim about the dragon? His word, pictures, videos, bones, other biological evidence, how about knowing any other dragons or dragons that breathe fire? Compare that to if I said we just got a new puppy and it’s in the garage. You would probably take my word for it. There is nothing extraordinary about the claim. Most of you should be familiar and have had experience with a puppy at some point in your life. So the quality of evidence to convince you of something should be in part proportional to the claim being asserted. The summary is the famous quote by Carl Sagan that "extraordinary claims require extraordinary evidence". Science is Self-Correcting: Because science is iterative and falsifiable it is also self correcting. Science gets updated. We hopefully learn and get closer to the “truth” over time. Medical reversal is a thing and there is a great book and by Drs. Prasad and Cifu on this issue called Ending Medical Reversal: Improving Outcomes, Saving Lives. Burden of Proof: Those making the claim have the burden of proof. It is called a burden because it hard - not because it is easy. We start with the null hypothesis (no superiority). Evidence is presented to convince us to reject the null and accept there is superiority to their claim. If the evidence is convincing we should reject the null. If the evidence is not convincing we need to accept the null hypothesis. It is a logical fallacy to shift the burden of proof onto those who say they do not accept the claim. They

Date: October 14th, 2020 Guest Skeptic: Dr.Salim Rezaie is a community emergency physician at Greater San Antonio Emergency Physicians (GSEP), where he is the director of clinical education. Salim is probably better known as the creator and founder of the wonderful knowledge translation project called REBEL EM. It is a free, critical appraisal blog and podcast that try to cut down knowledge translation gaps of research to bedside clinical practice. Reference: Rowell et al. Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury. JAMA 2020. Case: A 42-year-old helmeted bicycle rider is involved in an accident where he hits his head on the ground. At the time of emergency medical services (EMS) arrival, the patient is alert but seems a bit confused. The accident was within one hour of injury and his Glasgow Coma Scale (GSC) score was 12. Vital signs show a slight tachycardia but otherwise normal. Pupils were both equal and reactive and he doesn’t appear to have any other traumatic injuries, or focal neurologic deficits. Other injuries appear minimal with some abrasions from the fall. Background: The CRASH-2 trial, published in 2010, showed a 1.5% mortality benefit (NNT 67) for patients with traumatic hemorrhage who received tranexamic acid (TXA) compared to placebo. Dr. Anand Swaminathan and I covered that classic paper on SGEM#80. TXA has become standard practice in many settings as a result of this data. However, patients with significant head injury were excluded in this study and it was unclear of the effect of TXA in this group. CRASH-3 Fast forward to October 2019, when CRASH-3 was published. This large, very well-done randomized placebo-controlled trial examined the use of TXA in patients with traumatic brain injuries (TBIs) with GCS score of 12 or lower or any intracranial bleed on CT scan and no extracranial bleeding treated within 3 hours of injury. The authors reported no statistical superiority of TXA compared to placebo for the primary outcome of head injury-related deaths within 28 days. We reviewed that article published in the Lancet in SGEM#270. Subgroup analysis did demonstrate that certain patients (GCS 9 to 15 and ICH on baseline CT) showed a mortality benefit with TXA. While very interesting and potentially clinically significant, we need to be careful not to over-interpret this subgroup analysis. We did express concern over the possibility that this subgroup would be highlighted and “spun”. Unfortunately, that did happen with a subsequent media blitz and a misleading infographic. Further data is clearly needed to elucidate the role of TXA in patients with TBI. Clinical Question: Does pre-hospital administration of TXA to patients with moderate or severe traumatic brain injury improve neurologic outcomes at 6 months? Reference: Rowell et al. Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury. JAMA 2020. Population: Patients 15 years of age or older with moderate or severe blunt or penetrating TBI. Moderate to severe TBI was defined as a GCS 3 to 12, at least one reactive pupil, systolic blood pressure ≥90mmHg prior to randomization, able to receive intervention or placebo within two hours from injury, and destination to a participating trauma center. Exclusions: Prehospital GCS=3 with no reactive pupil, start of study drug bolus dose greater than two hours from injury, unknown time of injury, clinical suspicion by EMS of seizure activity, acute MI or stroke, or known history, of seizures, thromboembolic disorders or renal dialysis, CPR by EMS prior to randomization, burns > 20% total body surface area, suspected or known prisoners, suspected or known pregnancy), prehospital TXA or other pro-coagulant drug given prior to randomization or subjects who have activated the “opt-out” process. Interventions: They had two intervention groups. The Bolus Maintenance Group received an out-of-hospital TXA 1g intravenous (IV) bolus and in-hospital TXA 1g IV 8-hour infusion. The Bolus Only Group received an out-of-hospital TXA 2g IV and in-hospital placebo 8-hour IV infusion. Comparison: The Placebo Group received Out-of-hospital saline IV bolus and in-hospital saline 8-hour infusion. Outcome: Primary Outcome: Favorable neurologic function at 6 months (defined as Glasgow Outcome Scale-Extended Score >4 which is considered moderate disability or good recovery) Secondary Outcomes: There were 18 secondary endpoints, of which 5 reported statistical analysis in this trial 28 day mortality 6-Month Disability Rating Scale Score (0 equals no disability and 30 equals death) Progression of intracranial hemorrhage (Defined as >33% increase in the combined volume of hemorrhage) Incidence of seizures Incidence of thromboembolic events Authors’ Conclusions: “Among patients with moderate to severe TBI, out-of-h

Date: October 9th, 2020 Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department, specifically the use of ketamine. His twitter handle is @PainFreeED. Reference: Friedman et al. Ibuprofen Plus Acetaminophen Versus Ibuprofen Alone for Acute Low Back Pain: An Emergency Department-based Randomized Study. AEM 2020. Case: A 41-year-old man without a significant past medical history presents to the emergency department (ED) with a chief complaint of lower back pain that started 48 hours prior to the ED visits after attempting to move a couch in his house. He describes the pain as sharp, constant, non-radiating, and 6/10 in intensity. Pain gets worse with movement and minimal bending. The pain is limiting his usual activities included his ability to go to work. He denies weakness or numbness of the legs as well as bowel or bladder dysfunctions. You perform a physical exam and note prominent tender area to palpation at the right lumbar region. You explain to the patient the most likely diagnosis is a muscle strain. Your usual approach is to treat this type of case scenario with Ibuprofen. The patient asked you if Ibuprofen alone will be strong enough to control his pain. Background: Pain is one of the most frequent reasons to attend an ED. Low back pain (LBP) is responsible for 2.3% of all ED visits resulting in 2.6 million visits each year in the USA (Friedman et al Spine 2010). We have covered back pain a number of times on the SGEM. SGEM#87: Let Your Back Bone Slide (Paracetamol for Low-Back Pain) SGEM#173: Diazepam Won’t Get Back Pain Down SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain The SGEM bottom line from SGEM#240 was: There appears to be no long-term analgesics benefits from prescribing opioids for chronic non-cancer pain (nociceptive and neuropathic). However, their use is associated with increased adverse events. The American College of Emergency Physicians (ACEP) has updated their clinical policy on prescribing opioids for adult ED patients. There are no Level A recommendations, one Level B recommendation and multiple Level C recommendations (ACEP June 2020) In adult patients experiencing opioid withdrawal, is emergency department-administered buprenorphine as effective for the management of opioid withdrawal compared with alternative management strategies? Level B Recommendations: When possible, treat opioid withdrawal in the emergency department with buprenorphine or methadone as a more effective option compared with nonopioid-based management strategies such as the combination of α2-adrenergic agonists and antiemetics Many other pharmaceutical treatments besides opioids have been tried to address acute LBP pain with limited success. These include: acetaminophen (Williams et al Lancet 2014), muscle relaxants (Friedman et al JAMA 2015), NSAIDs (Machado et al Ann Rheum Dis 2017), steroids (Balakrishnamoorthy et al Emerg Med J 2014) and benzodiazepines (Friedman et al Ann Emerg Med 2017). Pain outcomes for patients with LBP are generally poor; One week after an ED visit in an unselected LBP population, 70% of patients report persistent back pain–related functional impairment and 69% report continued analgesic use (Friedman et al AEM 2012). There are a number of non-pharmaceutical treatment modalities that have also been tried to treat low back pain. 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). None of these other treatments has high-quality evidence supporting their use. Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line medication therapy for patients with acute LBP. Acetaminophen is often used for acute LBP, although it is unlikely to be effective when used as monotherapy. Whether or not combining an NSAID with acetaminophen can improve patient outcomes is unknown. Clinical Question: Is the addition of acetaminophen to ibuprofen better than ibuprofen alone in treating ED patients with acute, non-traumatic, non-radicular low back pain? Reference: Friedman et al. Ibuprofen Plus Acetaminophen Versus Ibuprofen Alone for Acute Low Back Pain: An Emergency Department-based Randomized Study. AEM 2020. Population: Adults aged 21 to 69 years who presented to the ED primarily for management of acute non-traumatic, non-radicular, musculoskeletal LBP with Roland Morris Disability Questionnaire (RMDQ)score of >5. The RMDQ is a 24-item questionnaire commonly used to measure LBP and related functional impairment. The scale goes from 0 (no impairment) to 24 (maximum impairment). Exclusions: “non- musculoskeletal etiology of low back, such as urinary tract infection or influenza-like illness; radicular pain, defi

Date: September 28th, 2020 Guest Skeptic: Dr.Michelle Cohen (@DocMCohen). She is a rural Family Physician, writer (CBC News, Toronto Star and McLean’s Magazine), Assistant Professor Queens University and the Co-Chair of the Advocacy Committee of Canadian Women in Medicine. Dr. Michell Cohen This is an SGEM Xtra episode based on an article by Dr. Cohen and Dr. Kiran published in the Canadian Medical Association Journal (CMAJ). The article was called Closing the gender pay gap in Canadian medicine. Please listen to the SGEM podcast to hear Dr. Cohen answer five questions and discuss the issue of gender pay inequity. Five Questions about the Gender Pay Gap Is the gender pay gap real? Do women just work less (or less efficiently) than men? What are some of the root causes of the gender pay gap? What can we learn from other jurisdictions? What can be done to close the gender pay gap in Canadian medicine? The CMAJ article fits with the evidence presented at FIX19. It also is consistent with the study published a year ago that showed Ontario female surgeons made 24% less per hour than male surgeons. This pay gap persisted even after adjusting for various factors (Dossa et al JAMA 2019). The Ontario Medical Association (OMA) has published a report called Understanding Gender Pay Gaps Among Ontario Physicians from their Human Resources Committee. It found that male physicians on average bill 15.6% more than female physicians even after controlling for a number of variables. There was a recent study that looked at the 194 countries and the gender of the national leader (Garikipati and Kambhampati 2020). They found that countries led by women were associated with better COVID-outcomes. This is low quality evidence because it is an observational study that is pre-print (not peer reviewed) and we should not over-interpret the results. This association between women leaders and good COVID responses was discussed in a debate about masks back in the spring of this year (SGEM Xtra Masks4All). There was a stronger association between women leaders and good COVID responses than to mandatory universal masking policies. Conclusions to the CMAJ Article “Women continue to be paid less than men in medicine. The gender pay gap exists within every specialty and also between specialties, with physicians in male­dominated specialties receiving higher payments. The gap is not explained by women working less but, rather, relates more to systemic bias in medical school, hiring, pro­motion, clinical care arrangements, mechanisms used to pay physicians and societal structures more broadly. Progress in Canada will require a commitment from medical associations and governments to close the pay gap, starting with transparent reporting of physician payments stratified by gender. We need to go further as a professionto understand how gender, race, disability and other identi­ties intersect to affect gaps in pay and then take action to address these gaps to realize the vision of pay equity for all in medicine.” We need to ensure that everyone gets the emergency care they need, regardless of whether they identify as a man or woman. The emergency department is like a lighthouse. It is the one place in the house of medicine where the light is always on and will treat anyone at any time for anything. The gender inequity discussion does dichotomize things into men and women. This is a false dichotomy. There are people who do not identify as a man or women. Gender is complex and on a spectrum. There is how a person identifies, expresses themselves, the sex assigned at birth, who they are physically attracted to and who they are emotionally attracted to. I would suggest that FBM is just the starting point and we need to take it one step further to Gender-Based Medicine (GBM). The Gender Unicorn is a graphic representation demonstrating the complexity of gender and sexuality. We need to make sure that the house of medicine is not just inclusive and tolerant but accepting and welcoming to everyone regardless of how they identify. The progression, in my opinion, should be from Evidence-Based Medicine (male dominated) to Feminist-Based Medicine (recognizing gender inequity) to Gender-Based Medicine (more inclusive) and ultimately to Humanist-Based Medicine (HBM). There are other inequities in medicine besides just gender. There are problems with race, religion, socioeconomic status, mental health, physical ability, etc. In order to provide patients with the best care, based on the best evidence we need high-quality, clinically relevant research that is inclusive and representative of everyone; remove inequities for those who generate research and provide care at the bedside; and finally, recognize everyone has value and should expect and deserve great care. 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

Date: October 2nd, 2020 Guest Skeptic: Dr.Barbra Backus is an emergency physician at the Emergency Department of the Erasmus University Medical Center in Rotterdam, the Netherlands. She is the creator of the HEART Score and an enthusiastic researcher. Reference: Claiborne Johnston S et al. Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA. NEJM July 2020 Case: A 65-year-old man with a history of well controlled hypertension presents to the emergency department and is diagnosed with a mild stroke (NIHSS score 3). He is a non-smoker, not diabetic and has never had a stroke before. The only medicine he takes is an angiotensin converting enzyme inhibitor. You are wondering if he should be discharged on just aspirin or aspirin plus another antiplatelet agent like ticagrelor. Background: Acute ischemic strokes are the leading cause of disability in our society and the third most common cause of death. Aspirin has been used to prevent a subsequent stroke in patients who suffered an acute ischemic stroke (AIS) or transient ischemic attack (TIA), which occur in approximately 5-10% of patients in the first few months after their primary event. Trials have shown mixed results with the combination of aspirin with clopidogrel in this population. SGEM#24 reviewed a randomized controlled trial (RCT) of aspirin vs. aspirin + clopidogrel in patients with recent symptomatic lacunar infarcts identified by MRI (Benavente et al NEJM 2012). Adding clopidogrel to aspirin did not reduce recurrent strokes but did increase risk of bleed and death. The study was stopped early due to harm and lack of efficacy. An RCT done in China on patients with minor strokes or TIAs who were treated within 24 hours after the onset of symptoms showed that aspirin plus clopidogrel is superior to aspirin alone for reducing the risk of stroke in the first 90 days and does not increase the risk of hemorrhage (Wang et al NEJM 2013). A third RCT assigned patients with minor ischemic stroke or high-risk TIA to ASA alone or the combination of both aspirin and clopidogrel. This trial was also stopped early because of lower risk of major ischemic events but higher risk of major hemorrhage with the combination therapy compared to aspirin alone (Johnston et al NEJM 2018). As an antiplatelet agent that blocks the P2Y12 receptor, clopidogrel requires hepatic conversion to its active form through a pathway that is ineffective in 25% of white and 60% of Asian patients; efficacy is therefore uncertain in these patients (Pan et al Circulation 2017). Ticagrelor is a direct-acting antiplatelet agent that does not depend on metabolic activation. A trial of ticagrelor alone did not show a benefit over aspirin in preventing subsequent cardiovascular events (Johnston et al NEJM 2016). The effect of the combination of ticagrelor and aspirin on prevention of stroke has not been well studied. Clinical Question: Is the combination of ticagrelor and aspirin superior to aspirin alone in reducing the risk of subsequent stroke or death among patients with acute non-cardioembolic cerebral ischemia? Reference:Claiborne Johnston S et al. Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA. NEJM July 2020 Population: Patients 40 years and older who experience a mild-to-moderate acute noncardioembolic ischemic stroke (NIHSS score of 5 or less), or high-risk TIA (ABCD2>5) or symptomatic intracranial or extracranial arterial stenosis (>50% lumen narrowing accounting for the TIA) Excluded: Thrombolysis or EVT was planned <24 hours before randomization or if there was planned use of anticoagulation or specific anti-platelet therapy other than ASA. Patients were also not eligible if they had “hypersensitivity to ticagrelor or ASA, a history of atrial fibrillation or ventricular aneurysm or a suspicion of a cardioembolic cause of the TIA or stroke, planned carotid endarterectomy that required discontinuation of the trial medication within 3 days after randomization, a known bleeding diathesis or coagulation disorder, a history of intracerebral hemorrhage, gastrointestinal bleeding within the past 6 months, or major surgery within 30 days before randomization.” Intervention: 30-day regimen of ticagrelor (180-mg loading dose followed by 90 mg twice daily) plus aspirin (300 to 325 mg on the first day followed by 75 to 100 mg daily). Comparison: 30-day regimen of matching placebo plus aspirin. Outcomes: Primary Outcome: Composite of stroke or death within 30 days. Secondary Outcomes: First subsequent ischemic stroke, incidence of disability within 30 days and adverse events. Authors’ Conclusions: “Among patients with a mild-to-moderate acute noncardioembolic ischemic stroke (NIHSS score ≤5) or TIA who were not undergoing intravenous or endovascular thrombolysis, the risk of the composite of stroke or death within 30 days was lower with ticagrelor–aspirin than with aspirin alone, but the incidence of disability did not differ significantly betwee

Date: September 22nd, 2020 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician in Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Reference: Warren et al. Antacid monotherapy is more effective in relieving epigastric pain than in combination with lidocaine. A randomized double-blind clinical trial. AEM Sept 2020. Case: A 34-year-old male presents to the emergency department with burning epigastric pain after eating two hours ago. He says he gets this from time to time but this is the worst it has ever been. He denies chest pain, shortness of breath, fever and vomiting. His vital signs are within normal limits and his abdominal exam reveals mild epigastric and left upper quadrant tenderness with no peritonitis. Pink Lady Cocktail Background: Patients presenting to emergency departments (EDs) with epigastric pain are typically treated with an antacid, either alone or combined with other medications. Such medications include viscous lidocaine, an antihistamine, a proton pump inhibitor, or an anticholinergic (1,2). In Canada we often use an antacid plus viscous lidocaine referred to as a “Pink Lady”. This is different than the alcoholic cocktail called a Pink Lady. In the US, combination treatment is often called a “GI Cocktail”. There are mixed results from studies with varying methodological quality looking at acute dyspepsia management in the ED. One single-blind study comparing 30 mL of antacid with or without 15 mL of viscous lidocaine found the addition of lidocaine significantly increased pain relief, decreasing patient pain score by 40 mm compared to 9 mm with antacid monotherapy (3). Another single-blind RCT comparing antacid plus either benzocaine solution or viscous lidocaine found no statistical difference between the two interventions, however, there was no antacid monotherapy group (4). A larger, double-blind RCT of 113 patients compared 30 mL of antacid monotherapy, antacid with 10 mL of an anticholinergic, and antacid with anticholinergic and 10 mL of 2% viscous lidocaine. This study found all treatments had clinical efficacy and there was no statistical difference in pain relief between the three treatment groups. The conclusion from Berman et al was to recommend antacid monotherapy (5). Clinical Question: Is antacid monotherapy more effective in relieving epigastric pain than in combination with lidocaine? Reference: Warren et al. Antacid monotherapy is more effective in relieving epigastric pain than in combination with lidocaine. A randomized double-blind clinical trial. AEM Sept 2020. Population: Adult patients with epigastric pain or dyspepsia presenting to the emergency department. Excluded: Patients unable to consent or under 18 years of age. Intervention: Arm 1 (Viscous): Received 10 mL oral lidocaine 2% viscous gel plus 10 mL antacid (traditional antacid/lidocaine mixture) Comparison: Arm 2 (Solution): Received 10 mL lidocaine 2% solution plus 10 mL antacid Arm 3 (Antacid): Received 20 mL antacid alone Outcome: Primary Outcome: Change in pain scores on 100mm visual analog scale (VAS) at 30 minutes after treatment. Secondary Outcomes: Medication palatability (taste, bitterness, texture, and overall acceptability) using a VAS, change in pain score 60 minutes post administration and adverse events. Dr. Jamie Warren This is an SGEMHOP episode which means we have the lead author on the show, Dr. Jaimee Warren. She is a first-year doctor at the Royal Melbourne Hospital and an aspiring emergency and retrieval physician. She hopes to one day work in rural and extreme environments. Authors’ Conclusions: “A 20 mL dose of antacid alone is no different in analgesic efficacy than a 20 mL mixture of antacid and lidocaine (viscous or solution). Antacid monotherapy was more palatable and acceptable to patients. A change in practice is therefore recommended to cease adding lidocaine to antacid for management of dyspepsia and epigastric pain in the ED.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The study participants were adequately randomized. Yes The randomization process was concealed. Yes The participants were analyzed in the groups to which they were randomized. Yes The study participants were recruited consecutively (i.e. no selection bias). No The participants in both groups were similar with respect to prognostic factors. Unsure All participants 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 Key Results: The trial enrolled 94 patients and 89 could be analyzed (30 viscous, 31 solution and 28 antacid group). The mean age was in the early 40’s, with around 2/3 female and 80% of patients

Date: September 16th, 2020 Guest Skeptics: Dr. Robert Goulden and Dr. Audrey Marcotte are Chief Residents from the Royal College of Emergency Medicine Program at McGill University. Robert’s academic interests include research and evidence-based medicine. Alongside his EM residency, he is doing a PhD in epidemiology. Audrey’s academic interests include trauma and resuscitation. Outside of medicine, Audrey likes to play rugby and run. Reference: Roberts et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet 2020 This was an SGEM Journal Club episode recorded live at McGill University Grand Rounds. This was the third time coming to McGill University Department of Emergency Medicine to give Grand Rounds. The first visit was back in 2013 for SGEM#50: Under Pressure - Vasopressin, Steroids and Epinephrine in Cardiac Arrest. The bottom line was this was interesting, but VSE protocol was not ready for routine use. The second visit was SGEM#176: Somebody’s Watching Me – Cardiac Monitoring for Chest Pain. We were trying to answer the question: Do all patients presenting to the emergency department with chest pain need to be placed on cardiac monitoring or could some be safely removed? The SGEM Bottom Line was that for some patients presenting with chest pain who are chest pain free and have normal/non-specific ECG findings could potentially be safely removed from cardiac monitoring using the Ottawa CPCM Rule. Five Rules of SGEM-JC Case:A 58-year-old man presents with hypotension, tachycardia, and pallor. He vomits a large amount of bloody emesis and has epigastric discomfort. He is not taking any anti-coagulants. He remains hemodynamically unstable despite initial resuscitation and has another episode of hematemesis in front of you. While waiting for your consultant to answer the phone, you consider treating him with tranexamic acid (TXA), but wonder if it will prevent death from gastrointestinal (GI) bleeding. Background: We have covered the use of TXA a number of times on the SGEM. TXA is an anti-fibrinolytic agent that inhibits clot breakdown and has demonstrated mixed results in different clinical settings. The CRASH-2 trial showed a 1.5% absolute mortality benefit with TXA in adult trauma patients compared to placebo (SGEM#80). TXA also seems to improve patient-oriented outcomes in epistaxis (SGEM#53 and SGEM#210). However, TXA did not show a statistically significant difference for the primary outcome in post-partum hemorrhage (SGEM#214) WOMAN Trial, hemorrhagic stroke (SGEM#236) or traumatic intracranial hemorrhage (SGEM#270) CRASH-3. A Cochrane systematic review and meta-analysis of eight smaller trials (n=1,701) using TXA in gastrointestinal bleeding suggested a large (40%) risk reduction in all-cause mortality (Bennett et al 2014). However, even a meta-analysis is prone to bias and is only as good as the quality of the included trials. When all participants in the intervention group with missing outcome data were included as treatment failures, or when the analysis was limited to trials with low risk of attrition bias the mortality benefit of TXA disappeared. Clinical Question: Does treatment with TXA reduce the mortality of patients with upper or lower GI bleeds? Reference: Roberts et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet 2020 Population: Adult patients (16 years of age or 18 years of age and older depending on country) with significant upper or lower GI bleed. Significant bleed was defined clinically (judged at risk of bleeding to death, hypotension <90 mmHg systolic, tachycardia, signs of shock, needing transfusion, urgent endoscopy or surgery). Exclusion: Any patient whom the clinician felt had a clear indication or clear contraindication for TXA Intervention: Intravenous TXA, 1g loading dose over 10 minutes followed by 3g maintenance over 24 hours Comparison: Matching placebo (Sodium chloride 0.9% IV) Outcome: Primary Outcome: Death due to gastrointestinal (GI) bleeding within five days Secondary Outcomes: Death due to gastrointestinal bleeding within 24h and within 28 days All-cause and cause specific mortality at 28 days Rebleeding within 24h, 5 days, 28 days Surgical or radiological intervention Blood product transfusion Thromboembolic events (deep vein thrombosis, pulmonary embolism, stroke, myocardial infarction) Seizures and other complications (sepsis, pneumonia, renal and liver failure, cardiac event) Days in intensive care unit Functional status (Katz index of Independence in activities of daily living) Authors’ Conclusions: “We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the bas

Date: September 11th, 2020 This is an SGEM Xtra episode. I was invited by the College of Physicians and Surgeons of Ontario (CPSO) to give a talk at their council meeting on burnout. It was an opportunity to share my journey and give an important message about kindness. I have discussed burnout and wellness a number of times on the SGEM: 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 Burnout vs. Moral Injury The word burnout was coined by Herbert Freudenberger in 1974. He defined it as “a state of fatigue or frustration that resulted from professional relationships that failed to produce the expected rewards”. A distinction between burnout and moral injury was made during the presentation. Moral injury has been defined as: “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations". This was originally described in soldiers’ responses to their actions during war. Journalist Diane Silver described moral injury in her State News article as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.” The moral injury of physicians is being unable to provide high-quality care they want to provide to their patients. My struggle with Burnout My struggle with burnout included the death of my father (Dr. Ken Milne Sr.) in November of 2018, the sudden death of my "little" brother Scottie (The Moose) in February 2020 and the unexpected death our family dog Moxy (best dog every) this summer. Much of this taking place in the context of the COVID19 global pandemic. All the slides from this CPSO presentation can be downloaded and shared from this link. The CPSO video recorded the presentation and it should be available soon. There are also a number of references for further information on burnout. Shanafelt et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc 2015 Shanafelt et al. Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clin Proc 2016 West et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016 Dr. Goldman & BatDoc One of the big lessons I have learned over the last two years is to be kinder. This was taught to me by my kindness mentor Dr. Brian Goldman from CBC show White Coat Black Art. He has published a book called The Power of Kindness: Why Empathy Is Essential in Everyday Life. I had the honour of interviewing Dr. Goldman on an SGEM Xtra. We need to try to be kinder to ourselves, kinder to each other and kinder to each other. In a world where you can be anything, be kind. College of Physicians and Surgeons of Ontario The CPSO has recognized that our health care system is facing pressures and the COVID19 pandemic has made things even worse. The June 2020 eDialogue highlighted five things the college is doing to mitigate this increase in stress. Introduced Alternative Dispute Resolution mech as an option for the handling of low-risk matters Decreased the time to complete a complaint by 47% in 2019, compared to 2018 Promoted connectedness through the quality improvement’s (QI) emphasis on peer interactions Encouraged professionalism to flourish by developing a QI framework that allows physicians to self-direct their learning Redesigned policies that allow physicians to immediately understand and access College expectations Pills that can be hard to swallow - but can help a lot Admitting that you're not okay Asking for help Allowing yourself to feel your emotions Removing toxic people, habits and belief systems Learning to accept change You can listen to the SGEM Podcast on iTunes or GooglePlay to hear more about my journey. Telling my personal burnout story is not to get sympathy or pity. Rather it is to remind you that everyone has a story. Everyone can be fighting a battle you know nothing about. My story is only unique because it is my story, everyone will have their own story, and we all can struggle facing our personal difficulties. While it can feel like we have the weight of the world on our shoulders right now please remember it is OK not to be OK. you do not need to be a super hero. Asking for help is a sign of strength and not a weakness. And don’t panic, this too shall pass.There are a number of resources available if you are struggling with burnout: Physician Health Program ACEM Member Wellbeing ACEP Wellness Section CAEP Resident Wellness EMRA Wellness Committee The SGEM will be back next episode with a critical appraisal of a recent publi

Date: August 27th, 2020 Guest Skeptic: Dr. Malthaner is the Chair/Chief of the Division of Thoracic Surgery, Director of Thoracic Surgery Research and Simulation, and Professor in the Departments of Surgery, Oncology, and Epidemiology and Biostatistics at the Schulich School of Medicine and Dentistry and Western University. Rick is also the founder of Western University’s Department of Surgery Journal Club and runs The Skeptik Thoracik Journal Club. Reference: Brown et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. NEJM 2020 Case: A 49-year-old healthy male electrician presents to the emergency room with right chest pain and dyspnea. The work-up reveals a diagnosis of a right pneumothorax confirmed by chest x-ray (CXR). What do you do? Background: A patient with a pneumothorax is a common presentation to the emergency department. Pneumothoraxes can be broken down into either primary or secondary. Primary pneumothorax occurs in healthy people. Secondary pneumothoraxes are associated with underlying lung disease. There is considerable heterogeneity in the management of primary spontaneous pneumothoraxes, but the most common treatment is interventional drainage, sometimes progressing to surgical intervention. However, the insertion of a chest tube is often painful and can cause organ injury, bleeding, and infection. An alternative approach is conservative management, with intervention reserved for patients for whom the pneumothorax becomes physiologically significant. I covered in the Skeptik Thoracik Journal Club which can be viewed on YouTube. Clinical Question: Does everyone with a large first-time spontaneous pneumothorax need a chest tube? Reference: Brown et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. NEJM 2020 Population: Patients 14 to 50 years of age with a unilateral primary spontaneous pneumothorax of 32% or more on chest radiography according to the Collins method. Exclusion: Previous primary spontaneous pneumothorax on the same side Secondary pneumothorax (defined as occurring in the setting of acute trauma or underlying lung disease including asthma with preventive medications or symptoms in the preceding two years) Coexistent hemothorax Bilateral pneumothorax “Tension’ pneumothorax” (systolic BP <90 mmHg, mean arterial pressure <65 mmHg, or shock index HR/SBP ≥1) Pregnancy at time of enrolment Social circumstances (inadequate support after discharge to re-attend hospital if required or unlikely to present for study follow up) Planned air travel within the following 12 weeks Intervention: A small chest tube (≤12 French) was inserted and attached to an underwater seal, without suction and a CXR was obtained one hour later. If the lung had re-expanded and the underwater drain no longer bubbled, the drain was closed with the use of a three-way stopcock. Four hours later, if the patient’s condition was stable and a repeat CXR showed that the pneumothorax had not recurred, the drain was removed, and the patient was discharged. If the initial drain insertion did not result in resolution on CXR or if the pneumothorax recurred under observation, the stopcock was opened, the underwater seal drainage was recommenced, and the patient was admitted. Subsequent interventions were at the discretion of the attending clinician. Comparison: Patients were observed for a minimum of four hours before a repeat CXR was obtained.After observation, if patients did not receive supplementary oxygen and were walking comfortably, they were discharged with analgesia and written instructions. Interventions were allowed in the conservative-management protocol under five conditions: Clinically significant symptoms persisted despite adequate analgesia; Chest pain or dyspnea prevented mobilization; Patient was unwilling to continue with conservative treatment; Patient’s condition became physiologically unstable (systolic blood pressure of <90 mm Hg, heart rate in beats per minute greater than or equal to systolic blood pressure in millimeters of mercury, respiratory rate of >30 breaths per minute, Spo2 of <90% while the patient was breathing ambient air or a repeat chest radiograph showed an enlarging pneumothorax along with physiological instability. In these situations, subsequent interventions were at the discretion of the attending clinician. Outcome: Primary Outcome: Complete radiographic resolution of primary spontaneous pneumothorax (full lung re-expansion), as determined by the treating physician, within eight weeks after randomization. Secondary Outcomes: Per-protocol analysis of the primary outcome. Time to radiographic resolution. Time to symptom resolution of symptoms. Pneumothorax recurrence 24 hours or later after chest tube removal. Adverse events. Length of stay (LOS) in the hospital in the first eight weeks. Number of invasive procedures. Number of radiologic investigations. Number of days off from work. Chest-tube drainage for equal

Date: September 3rd, 2020 It has been a tough year for all of us with the global pandemic of COVID19. I hope everyone is safe and taking care of themselves both physically and mentally. It is more important than ever during these difficult times to stay socially connected to those we love and care about. You are all leaders in your own way and can set the tone for your community. Lead by example: wash your hands well, practice physical distancing (not social distancing) and be smart about wearing a mask. More than anything else, try to be kinder to each other as we get through this challenging time. We have just finished Season#8 of the SGEM with an episode on the diagnostic accuracy of clinical findings, lab tests and imaging studies for COVID19 (SGEM#299). This was an SGEM Hot off the Press episode in partnership with Academic Emergency Medicine (AEM). We track these special shows and this one got close 2.6 million twitter impressions in one week. It is also now in the top 50 papers every published by AEM according to Altmetrics. This represents some excellent knowledge translation (KT) by addressing awareness. The SGEM continues to grow and has approximately 43,000 subscribers. It has been successful because of people like you who listen every week. I would also like to thank the SGEMHOP Team (Drs. Bond, Heitz and Morgenstern), PaperinaPic producer (Dr. Challen), all the guest skeptics and my best friend Chris Carpenter. The SGEM continues to try and cut KT window down from over ten years to less than one year. It does this by doing a structured critical review of a recent publication and then shares the information using social media. Our ultimate goal is for patients to get the best care based on the best evidence. Scottie (The Moose) Milne As many of you know, 2020 has been additionally difficult for the Milne family with the unexpected death of my little brother Scottie in February. I'm still processing the grief and appreciate all the love and support everyone has provided. We all deal with death in our own way and on our own time schedule. Part of my grieving process was to plant an oak tree for Scott this spring. I know it will grow as big and strong as he did. If you have a sibling, friend, or anyone you care deeply about, I would encourage you to reach out to them today. Let them know how much you love them and appreciate them being part of your life. It may be your last opportunity. It is also ok not to be ok. You do not need to be a super hero. Asking for help is a sign of strength not weakness. I asked for and received help from many of you and it got me through this very painful time. You know who you are and thank you so much. I would like to take this opportunity to thank you SGEMers for everything you do in providing excellent patient care. As a gift, please accept this PDF book of SGEM Season#6. You will find links to all your favourite episodes, PaperinaPic infographics, and Twitter polls. Don't Panic! Dr. Chris Carpenter's chapter on evidence based medicine, Dr. Justin Morgenstern's (First10EM) simplified guide to approaching the literature and Dr. Anthony Crocco's SketchyEBM chapter are all still part of the book. Please feel free to share SGEM Season#6 book via your social media networks (email, Facebook, Twitter, Instagram, etc). If you are looking for the amazing theme music that helps with the KT for each SGEM episode, you can find them on Spotify. Most of the music comes from the 1980's because it is clearly the best musical era. This KT project continues to be part of the free open access to medical education movement (FOAMed). I continue to strongly believe we should share our intellectual capital and efforts with everyone around the world with no paywalls. This information should be for anyone, anywhere and at anytime. The SGEM Season#6 was put together with the help of my niece Rhiannon Milne who just finished her degree in Global Business and Digital Arts from the University of Waterloo. My daughter Sage Milne also helped put the book together and did the cover art that was inspired by the movie the Last Star Fighter. She knows I am just as obsessed with 80's movies as I am with 80's music. Sage is entering third year at Huron University College and is doing a degree in Global Health Studies. Here are links to all six season of the SGEM as PDF books. You can download each season by clicking on the link: Season#1, Season#2, Season#3, Season #4, Season#5 and Season#6 The SGEM Season#9 will be starting soon. We have some exciting things to introduce to try and make the SGEM even better. I might even start making a TikTok video for each episode. Watch your social media feeds for the announcements coming this fall. One last thing. Could you please write a review on iTunes, like the SGEM on Facebook and follow the SGEM on Twitter? Remember to be skeptical of anything you learn, even if you heard it on the Skeptics' Guide to Emergency Me

Date: August 18th, 2020 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Reference: Carpenter et al. Diagnosing COVID-19 in the Emergency Department: A Scoping Review of Clinical Exam, Labs, Imaging Accuracy and Biases. AEM August 2020 Case: You are working in the emergency department during the COVID-19 outbreak, and you see a patient with oxygen saturations of 75% on room air, a fever, and a cough. Upon review of systems, you learn that she lost her sense of taste about two days ago. Your hospital performs COVID reverse transcriptase polymerase chain reaction (rt-PCR) nasal swabs on suspected patients, so you order this test and await the results. Background: In early 2020, a pandemic broke out with origins thought to be in the Wuhan region of China. A novel coronavirus, SARS-Co-V-2, commonly called COVID-19, rapidly spread around the world, overwhelming hospitals and medical systems, causing significant morbidity and mortality. The speed with which the outbreak occurred made identification of cases difficult, as the disease exhibited a variety of symptoms, and testing lagged spread. The US Federal Drug Administration (FDA) allowed for emergency development and use of rt-PCR assays, and dozens of companies released assay kits. Mask4All Debate I consciously have tried to avoid contributing to the COVID-19 information overload. However, I did do a CAEP Town Hall on therapeutics (SGEM Xtra: Be Skeptical) with Dr. Sean Moore and a friendly debate on mandatory universal masking in public with Dr. Joe Vipond (SGEM Xtra: Masks4All). This review discusses the diagnostic accuracy of rt-PCR for COVID-19, as well as signs, symptoms, imaging, and other laboratory tests. Clinical Question: What is the diagnostic accuracy of history, clinical examination, routine labs, rt-PCR, immunology tests and imaging tests for the emergency department diagnosis for COVID19? Reference: Carpenter et al. Diagnosing COVID-19 in the Emergency Department: A Scoping Review of Clinical Exam, Labs, Imaging Accuracy and Biases. AEM August 2020 Population: Original research studies describing the frequency of history, physical findings, or diagnostic accuracy of history/physical findings, lab test, or imaging tests for COVID-19 Intervention: None Comparison: None Outcome: Diagnostic accuracy (sensitivity, specificity, and likelihood ratios) Dr. Chris Carpenter This is an SGEMHOP episode which means we have the lead author on the show. Dr. Chris Carpenter is Professor of Emergency Medicine at Washington University in St. Louis and a member of their Emergency Medicine Research Core. He is a member of the SAEM Board of Directors and the former Chair of the SAEM EBM Interest Group and ACEP Geriatric Section. He is Deputy Editor-in-Chief of Academic Emergency Medicine where he is leading the development of the "Guidelines for Reasonable and Appropriate Emergency Care" (GRACE) project. He is also Associate Editor of Annals of Internal Medicine’s ACP Journal Club and the Journal of the American Geriatrics Society, and he serves on the American College of Emergency Physician's (ACEP) Clinical Policy Committee. Dr. Carpenter also wrote the book on diagnostic testing and clinical decision rules. Authors’ Conclusions: “With the exception of fever and disorders of smell/taste, history and physical exam findings are unhelpful to distinguish COVID-19 from other infectious conditions that mimic SARS-CoV-2 like influenza. Routine labs are also non-diagnostic, although lymphopenia is a common finding and other abnormalities may predict severe disease. Although rRT-PCR is the current criterion standard, more inclusive consensus-based criteria will likely emerge because of the high false-negative rate of polymerase chain reaction tests. The role of serology and CT in ED assessments remains undefined.” Quality Checklist for Systematic Review Diagnostic Studies: The diagnostic question is clinically relevant with an established criterion standard. Yes/No The search for studies was detailed and exhaustive. No 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 6. The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. No Key Results: The authors screen 1,907 citations and 87 were included in the review. None adhere to the Standards for Reporting of Diagnostic Accuracy (STARD) or the updated reporting framework for history and physical examination. Rt-PCR was used as the criterion standard for many of the studies, but none explored the possibility of false negatives. 1) PRISMA-ScR (Scoping Review): What are the differences between PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and the PRISMA-ScR g

Date: July 20th, 2020 Guest Skeptic: Professor Simon Carley is Creator, Webmaster, owner and Editor in Chief of the St. Emlyn’s blog and podcast. He is Professor of Emergency Medicine at Manchester Metropolitan University and a Consultant in adult and paediatric Emergency Medicine at Manchester Foundation Trust. Dr. Carley is even verified on twitter as @EMManchester. Reference: Carley et al. Evidence-based medicine and COVID-19: what to believe and when to change. BMJ_EMJ July 2020 This is an SGEM Xtra episode. It was great to have one of the giants of the FOAMed world back on the SGEM. The last time Dr. Carely was on was on SGEM#148. The bottom line from that episode on skin glue for peripheral intravenous lines was: "Skin glue does appear to decrease the failure rate of IVs in patients admitted to hospital from the ED at 48 hours. We do not know if this is a good idea for all ED patients and we do not know the true effect size, but for high stakes cannulas that we really want to stay in this intervention should be considered.” This SGEM Xtra is based on a wonderful article by Simon Carley, Daniel Horner, Rick Body, and Kevin Mackway-Jones published in the BMJ-Emergency Medicine Journal. The article was titled: Evidence-based medicine and COVID-19: what to believe and when to change. Simon and I discussed the what inspired him to write this article. It was great that it started with a definition of evidence-based medicine (EBM). They used the one proposed by Dr. David Sackett in 1996: “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients" We gave a shout out to our friends Dr. Justin Morgenstern (First10EM) and Dr. Casey Parker (Broome Doc) on their recent podcast called EBM 2.0 with guest Dr. Senthi. It is important to remember the literature is just one of three pillars of EBM. There are many problems and limitations with medical research. This includes the dreaded p-value (dichotomization), biases (something that systematically moves us away from the "truth"), and the replication crisis. However, the other two pillars of EBM are equally as important. That includes the clinician’s judgment and the patient’s values and preferences. The first section of the article was about knowledge translation (KT) during the COVID19 pandemic. Listeners know the the SGEM is trying to cut the KT window down from over 10 years to less than one year using the power of social media. There is a study that quantify the KT gap being 17 years for 14% of high-quality, clinically relevant information to reach the patient (Morris, Wooding and Grant JRSM 2011). We then went on to talk about the precipitous decisions that are being made during COVID19 and give some examples. This is not a unique situation to a pandemic. There is something called intervention bias. This is the desire by the "medical community to intervene, whether it is with drugs, diagnostic tests, non-invasive procedures, or surgeries, when not intervening would be a reasonable alternative." Dr. Jerome Hoffman The concept of intervention bias reminds me of one of my favourite ideas I learned from the Legend of EM, Dr. Jerry Hoffman, "don’t just do something, stand there". There is a great fantastic article on this idea by Keijzers et al 2018. Many of us have been asked many questions during the pandemic. Some probably have been asked "what would you want if you got COVID19" or "what's the harm in trying" something to treat this terrible new infectious deadly disease? We talked about some of these questions and Simon listed some of the potential harms of just trying without good evidence including: distraction, false hope, suboptimal use of resources, misunderstanding of patient trajectory and loss of equipoise. It is also known that harms are systematically underreported in research studies (Saini et al BMJ 2014). Four Strategies As A Way Forward Ensure that every patient with COVID-19 has the opportunity to enter a clinical trial. Ensure that research delivered during a pandemic is of the highest possible quality. Encourage the use of routinely collected, anonymised data to support epidemiological studies. Design studies for deployment in future pandemics and place them in a ‘hibernated state’ such that the research infrastructure is in place prior to requirement. I suggested one more strategy to arrive at my favourite number five. The fifth strategy would be (not just during global pandemic) to be skeptical and teach critical thinking skills to other clinicians and the public so they are less likely to be fooled by all the poor arguments and information on social media. There is a great quote from the website the Logic of Science about this global pandemic and science. Simon's final thoughts were from the manuscript. The SGEM will be back next episode with a critical appraisal of a recent publication. Trying to cut the

Date: July 13th, 2020 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com. He has a great new blog post about increasing diversity in medicine using something called the BSAP approach and an interesting Broome Doc podcast with Dr. Casey Parker called EBM 2.0. Reference: Ebell et al. Accuracy of Signs and Symptoms for the Diagnosis of Community‐acquired Pneumonia: A Meta‐analysis. AEM July 2020 Case: A 67-year-old woman with no previous health problems presents with fever, cough, and myalgias. You are working with a medical student on their very first rotation, and you want to spend some time teaching them about the history and physical exam. However, being an evidence-based medicine enthusiast, you wonder what aspects of the patient’s presentation are going to be truly helpful in making a diagnosis. Background: Depending on the time of year, fever and cough can be one of the most common presentations seen in the emergency department. It is important not to miss pneumonia in the sea of viral illnesses. We have covered various aspects of this issue a number of times on the SGEM: SGEM#287: Difficult to Breathe – It Could Be Pneumonia SGEM#286: Behind the Mask – Does it need to be an N95 mask? SGEM#263: Please Stop, Prescribing – Antibiotics for Viral Acute Respiratory Infections SGEM#216: Pump It Up – Corticosteroids for Patients with Pneumonia Admitted to Hospital SGEM#120: One Thing or Two for Community Acquired Pneumonia? Antibiotic overuse is a significant problem, and ordering chest x-rays (CXR) on everyone is inefficient, expensive, and adds potentially unnecessary risk from radiation. Thus, it is important to know how accurate the history and physical exam is for identifying patients with pneumonia. A prior meta-analysis demonstrated that the combination of normal vital signs and normal lung exam effectively rules out pneumonia (Marchellow eat al JABFM 2019), and that a physician’s overall clinical impression is moderately accurate (Dale et al BrJGP 2019). However, there has not been a meta-analysis looking at the evidence for individual signs and symptoms for pneumonia in the last decade. Clinical Question: What is the accuracy of individual signs and symptoms for diagnosing community acquired pneumonia? Reference: Ebell et al. Accuracy of Signs and Symptoms for the Diagnosis of Community‐acquired Pneumonia: A Meta‐analysis. AEM July 2020 Population: Adolescents and adults presenting with symptoms of respiratory infection or clinically suspected pneumonia in the outpatient setting Intervention: Any clinical sign or symptom (including vital signs) for pneumonia Comparison: Outcome: Radiologically confirmed pneumonia (using CXR as the gold standard) Dr. Mark Ebell This is an SGEMHOP episode which means we have the lead author on the show. Dr. Mark Ebell is a Family Physician and Professor at the University of Georgia in Athens. He is a co-founder of POEMs, editor-in-chief of Essential Evidence, deputy editor of American Family Physician, and co-host of the podcast Primary Care Update and POEM of the Week. Authors’ Conclusions: “While most individual signs and symptoms were unhelpful, selected individual signs and symptoms are of value for diagnosing CAP. Teaching and performing these high value elements of the physical examination should be prioritized, with the goal of better targeting chest radiographs and ultimately antibiotics. Quality Checklist for Systematic Review Diagnostic Studies: The diagnostic question is clinically relevant with an established criterion standard. Unsure. The search for studies was detailed and exhaustive. Yes The methodological quality of primary studies were assessed for common forms of diagnostic research bias. Yes The assessment of studies were reproducible. Yes There was low heterogeneity for estimates of sensitivity or specificity. Yes/No The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. No Key Results: They identified 16 studies that met their inclusion and exclusion criteria. Seven studies were based in the emergency department and nine in a primary care setting. The number of participants ranged from 52 to 2850. The mean age ranged from 32 to 62 years, and between 48% and 60% of the participants were female. A CXR was used as the gold standard in all studies. The risk of bias was assessed as low in 12 studies and moderate in five. The prevalence of pneumonia was 10% in the primary care studies and 20% in emergency department studies. No individual sign or symptom was good enough to independently rule in or rule out pneumonia. The most helpful indicator was “overall clinical impression”, with a positive likelihood ratio of 6.32 (the highest of any finding) (95% CI 3.58-10.5) and a negative likelihood ratio of 0.54 (95% CI 0.46-0.64). Although a number of symptoms and signs were associated with pneumonia, the low positive lik

Date: June 30th, 2020 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 Royal Perth Hospital. Reference: Alper et al. Thrombolysis with alteplase 3–4.5 hours after acute ischaemic stroke: trial reanalysis adjusted for baseline imbalances. BMJ Evidence Based Medicine 2020 Case: A 65-year-old man arrives from home to the emergency department by EMS with right-sided weakness beginning three hours prior. Advance neuroimaging demonstrates he does not qualify for endovascular clot retrieval. He has an NIHSS score of 11 and no contra-indications for systemic thrombolysis. Background: Thrombolysis for acute ischemic stroke has to be one of, if not the most, controversial subjects of my career. The debate dates back to the classic NINDS paper published in the NEJM in 1995. We reviewed that publication with Dr. Anand Swaminathan on SGEM#70. Some people might argue that it’s less relevant now because of endovascular clot retrieval, but it’s a living example of issues with research methodology, critical appraisal, bias, conflicts of interest, etc. These elements are continuously present in medicine – look at all the COVID-19 literature – made worse by the preprint archives of non-peer reviewed papers. Thrombolysis in acute ischaemic stroke. The Lancet 2012 Truth, thinking and thrombolysis. EMA 2016 Response from Prof. Fatovich to Stroke thrombolysis: Leaving the past, understanding the present and moving forward. EMA 2013 The “Fragility” of Stroke Thrombolysis. TMJ 2020 Believing is seeing: Stroke thrombolysis remains unproven after the third international stroke trial (IST-3). EMA 2012 Don't Just Do Something, Stand There! The Value and Art of Deliberate Clinical Inertia. EMA 2018 Dr. Jerome Hoffman It was Dr. Jerome Hoffman that introduced me to this issue and was a basis of my skepticism. I used to think if the study was published in a high-impact journal it must be true. His mentorship and teaching are why I consider Dr. Hoffman a legend of emergency medicine. We have covered the issue of thrombolysis for acute ischemic stroke a number of times on the SGEM. I have also published a review on the topic of thrombolytics for stroke beyond three hours (Carpenter et al JEM 2011). More recently, I published a pro/con debate on the subject with Dr. Eddy Lange looking at the evidence (Milne et al CJEM 2020). SGEM#29: Stroke Me, Stroke Me SGEM Xtra: Walk of Life SGEM Xtra: No Retreat, No Surrender SGEM#269: Pre-Hospital Nitroglycerin for Acute Stroke Patients? SGEM#290: Neurologist Led Stroke Teams – Working 9 to 5 There has been a lot of skepticism around thrombolysis in acute ischemic stroke since the beginning. A reanalysis of the NINDS data by Dr. Hoffman and Dr. Schriger was published in Annals of Emergency Medicine in 2009. At least one other reanalysis has questioned the 2009 reanalysis (Saver et al Ann Emerg Med 2010). Thus, there is a degree of uncertainty in the NINDS-II results. The major takeaway from this reanalysis was that the baseline imbalance in stroke severity led to the difference in outcomes. If tPA really works, we should see a bigger change in the NIHSS score in the tPA group vs. the placebo group. Yet the difference was 0.0. People can forget that a clinical trial has internal validity if and only if the imbalance between groups, bias in the assessment of outcome, and chance, have been excluded as possible explanations for the difference in outcomes. Baseline imbalance is a recurring theme. So, replication studies are hugely important. It was the NINDS trial that changed guidelines and practices to provide thrombolysis in patients with stroke symptoms less than three hours after onset. This despite the multiple other trials that did not show efficacy and reported an increase in harm (bleeding). The increase in adverse events prompting some to be stopped early (SGEM Xtra:Thrombolysis for Acute Stroke). The only other randomized control trial claiming benefit for the primary outcome was ECASS III (Hacke et al NEJM 2008). ECASS I and II did not show a benefit with thrombolysis. ECASS III reported a 7% absolute benefit of improved mRS at 90 days compared to placebo, 9% increase in intracranial hemorrhage, 2% increase in symptomatic intracranial hemorrhage and no significant difference in mortality. The American College of Emergency Physicians (ACEP) is the largest organization of EM physicians in the world. ACEP has a clinical policy statement on the issue (Brown et al AEM 2015). They looked at the <3 hour time frame and the 3-4.5 hour time frame. ACEP made no level “A” recommendations but did make level B and C recommendations. Is IV tPA safe and effective for patients with acute ischemic stroke if gi

Date: June 27th, 2020 I had the pleasure of presenting at the Northern Constellation Faculty Development Conference 2020 on May 8th. This was the 9th annual conference put on by the Northern School of Medicine (NOSM). Dr. Sarah McIsaac was kind enough to invite me to present at the Northern Constellation Conference. She is an anesthesiologist/intensivist at Health Sciences North, Assistant Professor and Medical Director of Faculty Development for NOSM. This presentation is available to watch on the SGEM YouTube Channel or listened to on the SGEM podcast. All of the slides can also be downloaded from this link. I was asked to give a presentation about evidence-based medicine (EBM), critical appraisal and relate it back to COVID. Certainly there has been a lot of information coming out on the topic and it can seem like you are drinking from a fire hose at times. The presentation was broken down into three parts: Evidence-Based Medicine (EBM), critical appraisal and the Peltzman Effect (risk compensation): Part I: Evidence-Based Medicine (EBM) It is always good to define terms at the beginning of any discussion. I used the original definition of EBM given by Dr. David Sackett: “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” (Sackett et al BMJ 1996) There are three pillars to EBM than can be represented in a Venn diagram. People often make the mistake of thinking that EBM is just about the scientific literature. This is not true. The evidence informs and guides our care but it does not dictate our care. EBM also needs your clinical judgement based on your experience. We also need to engage with patients and ask them about their preferences and values. These three components make up EBM: The literature, our judgement and the patients values. There is a hierarchy to the evidence and we want to use the best evidence so patients get the best care. The hierarch is usually described as a pyramid with the lowest form of evidence being expert opinion and the highest level being a systematic review. This is an over simplification of the levels of evidence. A good randomized control trial (RCT) can be more informative than a systematic review (SR) that only includes low quality study (GIGO - garbage in, garbage out). There are arguments against EBM and it does have limitations. One that is often pointed out is that it would be unethical to do an RCT on harm. The 2003 Smith and Pell parachute trial is usually pointed to as an example (BMJ 2003). This could be considered a straw man argument because most medical practices are not parachutes (Hayes et al CMAJ 2018). In addition, a randomized control trial has been done assessing the efficacy of parachutes to prevent gravitationally related morbidity and mortality and was reviewed on SGEM#284. Five alternatives to EBM were discussed (Adapted from Isaacs and Fitzgerald BMJ 1999) : Eminence-Based Medicine (EmBM): The more senior the colleague, the less importance he or she placed on the need for anything as mundane as evidence. Experience, it seems, is worth any amount of evidence. These colleagues have a touching faith in clinical experience, which has been defined as ‘‘making the same mistakes with increasing confidence over an impressive number of years.” The eminent physician’s white hair and balding pate are called the “halo” effect. Vehemence-Based Medicine (VBM): The substitution of volume for evidence is an effective technique for brow beating your more timorous colleagues and for convincing relatives of your ability. Eloquence-Based Medicine (ElBM): The year round suntan, silk tie, Armani suit, and tongue should all be equally smooth. Sartorial elegance and verbal eloquence are powerful substitutes for evidence. Nervousness-Based Medicine (NBM): Fear of litigation is a powerful stimulus to over investigation and over treatment. This may be a greater factor in the US while in Canada it might be more of being shamed or reported to the College. In an atmosphere of litigation/shame phobia, the only bad test is the test you didn’t think of ordering. Confidence-Based Medicine (CBM): This is restricted to surgeons. EBM is like democracy, it is the worst form of medicine except all the others that have been tried. Part II: Five Steps of Critical Appraisal Step 1: Use a PICO (population, intervention, comparison/control and outcome) to formulate the clinical question you are trying to answer Step 2: Search for the best evidence (try the TRIP Database) Step 3: Find the least bias evidence (bias is something that systematically moves us away from the “truth” not just noise in the data) Step 4: Critically appraise the literature using a quality check list (SGEM Make it So) Step 5: Decide if it is practice changing (consider the number needed to treat for benefit [NNTB] and the number needed to treat for harm [NNTH]) Then once you have done all that you can discuss it with the patient in front of y

Date: June 14th, 2020 Guest Skeptic: Dr. Dennis Ren is a Pediatric Emergency Medicine fellow at Children’s National Hospital in Washington, DC. Reference: Kuppermann et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. 2019. Case: A 5-week-old full term female presents to the Emergency Department (ED) for fever with rectal temp of 100.6F (38.1C). Her mother states that she has been fussier today. She also seems “congested” and is not feeding as well. She continues to have the usual number of wet diapers. The mother is worried about her sick baby. She wants to know if they will need a spinal tap, be placed on antibiotics or will need to be admitted to the hospital? Background: Fever without source in infants less than three months old represents a significant diagnostic dilemma for clinicians. Several criteria have been developed previously, including the Rochester (Jaskiewicz et al 1994), Boston (Baskin et al 1992) and Philadelphia (Baker et al 1993) criteria to help clinicians stratify the risk of serious bacterial infections (SBI). Febrile infants commonly present to the emergency department. It is estimated 8-13% may have SBI that may include urinary tract infections, bacteremia, and bacterial meningitis. It is difficult to identify which infants have SBI by clinical examination alone. There are serious consequences from missed SBI. Workup for SBI may include lumbar puncture, antibiotics, and hospitalization. These criteria (Rochester, Boston and Philadelphia) could be considered out of date in our current era of vaccinations. We covered a new protocol called the Step-by-Step approach on SGEM#171. The “Step-by-Step”rule combined both clinical factors and laboratory factors in febrile infants aged 22 to 90 days. It had a sensitivity of 98.9% to detect all SBIs. The SGEM Bottom Line #171: “If you have availability of serum procalcitonin measurement in a clinically-relevant time frame, the Step-by-Step approach to fever without source in infants 90 days old or younger is better than using the Rochester criteria or Lab-score methods. With the caveat that you should be careful with infants between 22-28 days old or those who present within two hours of fever onset.” It is important to balance the consequences of missing an SBI with performing unnecessary procedures (lumbar punctures), exposing infants to antibiotics, and prolonging hospital stay. The new study proposes a novel way of identifying low risk febrile infants 29-60 days based on three objective lab criteria. Clinical Question: Can a clinical prediction rule (tool) using laboratory data identify febrile infants under 60 days of age who are at low risk for serious bacterial infection (urinary tract infection, bacteremia, and bacterial meningitis) and reduce unnecessary lumbar punctures, antibiotic exposure, and hospitalization? Reference: Kuppermann et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. 2019. Population: Febrile infants <60 days of age who look good and whose blood cultures were obtained to rule out SBI (fever was a rectal temperature of at least 38C) Excluded: Infants who looked critically ill, had antibiotics in the previous 48 hours, history of prematurity (≤36 weeks’ gestation), pre-existing medical conditions, indwelling devices or soft tissue infections. Intervention: Derivation and validation of accurate clinical prediction rule (tool) for infants at low risk of SBI using a negative urinalysis, ANC <4,090/uL, and procalcitonin 1.71 ng/ml or less Comparison: Pre-existing algorithms combining subjective clinical findings and lab markers Outcome: Accuracy of the prediction rule to identify infants at low risk for SBI (sensitivity, specificity, negative prediction value and negative likelihood ratio). SBI was defined as bacterial meningitis, bacteremia or UTI. UTI was defined as growth of a single urine pathogen with at least 1,000 cfu/ml on culture obtained by suprapubic aspiration, at least 50,000 cfu/ml from catheterized specimens or 10,000-50,000 cfu/ml from catheterized specimens in association with an abnormal urinalysis (presences of leukocytes esterase, nitrite or pyuria). Authors’ Conclusions:“We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.” 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. Yes This is a prospective, multicenter study

Date: June 9th, 2020 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. Reference: Westafer et al. Provider Perspectives on the Use of Evidence-based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study. AEM June 2020. Case: A 63-year-old female presents to the emergency department (ED) with chest pain for the past eight hours. It is pleuritic, worse with certain movements and associated with some shortness of breath. Her vital signs are within normal limits and oxygen saturation is 95% on room air. An ECG, chest x-ray and troponin are all within normal limits and she has no calf swelling or tenderness. She does have a previous history of DVT/PE 12 years ago after returning from a transatlantic flight. She has also been doing more work around the house and lifting the past few weeks because of COVID and has some mild chest wall tenderness on palpation. The remainder of her Wells’ criteria are unremarkable. How do you proceed in evaluating this patient for pulmonary embolism (PE)? Background: Pulmonary embolism is a common ED diagnosis with an estimated 1-2% of all patients presenting to United States EDs undergoing CT for suspected PE (1). However, less than 10% of these scans show PE (2-4). We have covered the topic of PE frequently on the SGEM. SGEM#51: Home (Discharging Patients with Acute Pulmonary Emboli Home from the Emergency Department) SGEM#118: I Hope you Had a Negative D-dimer (ADJUST PE Study) SGEM#126: Take me to the Rivaroxaban – Outpatient treatment of VTE SGEM#163: Shuffle off to Buffalo to Talk Thrombolysis for Acute Pulmonary Embolism SGEM#219: Shout, Shout, PERC Rule Them Out SGEM#277: In the Pregnant YEARS – Diagnosing Pulmonary Embolism SGEM#282: It’s All ‘bout that Bayes, ‘Bout that Bayes- No Trouble – In Diagnosing Pulmonary Embolism There are multiple validated risk stratification tools to evaluate for PE and reduce inappropriate testing, including the Pulmonary Embolism Rule Out Criteria (PERC), Wells’score, YEARS algorithm and D-Dimer testing (5-7). There have also been more recent adjustments to D-Dimer threshold based on clinical probability as calculated by a trichotomized Wells score (8). Unfortunately, clinician uptake of these validated tools has been incomplete, with some ED studies finding 25% of patients who warranted no laboratory or imaging studies still received testing (4, 9-12.) Low-value testing increases costs, ED length of stay and subjects patients to unnecessary ionizing radiation and risk of anaphylaxis from intravenous contrast dye (13-14). Moreover, false positives CT scans are common and estimated to be between 10-26%, resulting in unnecessary anti-coagulation and risk to patients (15-17). This can ultimately lead to over-testing, over-diagnosing and over-treating. The American Board of Internal Medicine (ABIM) started the project called Choosing Wisely to try and mitigate this problem. The SGEM looked at this imitative on an SGEM Xtra. The American College of Emergency Physicians (ACEP) is part of the Choosing Wisely program and has a number of recommendations. One of the recommendations is on CT scans for ruling out PE. They have encouraged physicians to” “Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer.” ACEP 2014 The Right Care Alliance (RCA) was established in 2015. Certainly, patients at times need less care but they also at times need more care. This group’s goal is to advocate for the goldilocks zone of care, not too much but also not too little (SGEM Xtra). Clinical Question: What are the barriers and facilitators to the uptake of evidence-based practice in the ED evaluation for pulmonary embolism? Reference: Westafer et al. Provider Perspectives on the Use of Evidence-based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study. AEM June 2020. Dr. Lauren Westafer As this is a qualitative study, we will use a modified PICO question Population: Emergency physicians Interest: The use of evidence-based risk stratification tools Context: The evaluation of acute pulmonary embolism This is an SGEMHOP episode and we have the lead author of this quantitative study, Dr. Lauren Westafer. Lauren is an emergency medicine physician practicing in Massachusetts, and avid FOAM producer. Authors’ Conclusions: “Our findings suggest that common barriers exist to the use of risk stratification tools in the evaluation of pulmonary embolism in the ED and provide insight into where to focus efforts for future implementation endeavors. Overall, provider-level factors such as risk avoidance and lack of knowledge of the tools dominated as barriers, while inner-setting factors were identified as faci

Date: June 2nd, 2020 Reference: Permpikul et al. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER): A Randomized Trial. Respir Crit Care Med 2019. Guest Skeptic: Dr. Max Hockstein trained as an Emergency Medicine physician at University of Texas Southwestern and is finishing his Intensive Care fellowship at Emory. Max is then going to Georgetown to be an attending in both EM and ICU. Case: It’s another day in your emergency department (ED). Six hours into your shift, you finish dispo’ing the “really quick sign-out” from the night before. The triage nurse places a 61 year-old-man with fever, hypotension, cough into the smallest room in the ED. You scan through the EMR and see the blood pressure is 60/40. Being an astute emergency physician, you surmise that this value is one number column short of normal. It’s uncomfortably low – is it time to start a norepinephrine infusion? Background: I think we have covered sepsis more often than any other topic on the SGEM. It was the landmark paper published 19 years ago by Dr. Emanuel Rivers on early goal directed therapy in the treatment of severe sepsis and septic shock that sensitized the medical community (Rivers et al NEJM 2001). SGEM#44: Pause (Etomidate and Rapid Sequence Intubation in Sepsis) SGEM#69: Cry Me A River (Early Goal Directed Therapy) ProCESS Trial SGEM#90: Hunting High and Low (Best MAP for Sepsis Patients) SGEM#92: ARISE Up, ARISE Up (EGDT vs. Usual Care for Sepsis) SGEM#113: EGDT – ProMISe(s) ProMISe(s) SGEM#174: Don’t Believe the Hype – Vitamin C Cocktail for Sepsis SGEM#207: Ahh (Don’t) Push It – Pre-Hospital IV Antibiotics for Sepsis. One of the goals of the early treatment of septic shock is to restore end-organ perfusion. Significant effort has been placed on the administration of IV crystalloids to address concerns for hypovolemia in septic shock. However, it has become evident that patients are often over-resuscitated with IV fluids which adversely impacts outcome. As such, the idea of the early norepinephrine administration to restore end-organ perfusion in septic shock has been suggested. Monitor-Oriented Outcomes (MOOs) Trials that examine outcomes in shock, historically, have examined two types of outcomes: patient-oriented outcomes (POOs) and monitor-oriented outcomes (MOOs). POOs focus on occurrences that matter to patients while MOOs do not. Many trials examining vasoactive infusions use MOOs as an endpoint(s) targeted to the medication’s intended use (i.e. increase in MAP). Much like titrating a therapy to an outcome, MOOs are frequently easier to monitor (ex: blood pressure, heart rate, mean arterial pressure, oxygen saturation, etc). An old adage in resuscitating the hypotensive patient “first, fill the tank” has gone largely unchallenged over the past several years. Oddly enough, however, shortening the duration of shock time-to-shock-resolution hasn’t translated to any measurably better outcomes. Clinical Question: Does starting norepinephrine earlier in septic shock lead to earlier shock control? Reference: Permpikul et al.Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER): A Randomized Trial. Respir Crit Care Med 2019. Population: Adult patients (18 year of age and older) presenting to the ED with a mean arterial pressure (MAP) < 65 mmHg. Infection needed to be the suspected cause of the hypotension. Patients also had to meet 2012 surviving sepsis diagnostic criteria. Exclusions: Acute cardiac and cerebral conditions, pulmonary edema, status asthmaticus, gastrointestinal bleeding, pregnancy, burn, drug overdose, trauma, need immediate surgery and cancer. Intervention: Early norepinephrine adjusted to 0.05ug/kg/min for 24hrs plus usual care Comparison: Placebo plus usual care (intravenous fluids, appropriate antibiotics, source control and organ support as directed by the attending physician) Outcome: Primary Outcome: Shock control (sustained MAP > 65mmHg) by six hours after diagnosis of sepsis with hypotension together with adequate tissue perfusion (urine flow >0.5ml/kg/h for two consecutive hours or a decrease in serum lactate by > 10% from the initial lactate level). Secondary Outcomes: 28-day mortality and hospital mortality, time from initial treatment to achieving target MAP and tissue perfusion goal (and within six hours), urine output within six hours, rate of respiratory failure requiring mechanical ventilator support, rate of renal failure requiring renal replacement therapy, lactate clearance, and number of organ support-free days to day 28 were also recorded. Authors’ Conclusions: “Early norepinephrine was significantly associated with increased shock control by 6 hours. Further studies are needed before this approach is introduced in clinical resuscitation practice.” 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 w

Date: May 29th, 2020 Reference: Erramouspe et al. Mortality and Complication Rates in Adult Trauma Patients Receiving Tranexamic Acid: A Single-center Experience in the Post–CRASH-2 Era. AEM May 2020 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: A 44-year-old male presents to your level 1 trauma center by EMS after a motor vehicle collision. He is hypotensive and tachycardic. You suspect abdomen and pelvic trauma and calculate his injury severity score (ISS) to be 22. Your hospital protocol is to give tranexamic acid (TXA) 1g IV over 10 minutes followed by a 1g infusion over eight hours. You wonder what his over-all chance of dying or developing a thromboembolic event when treated with TXA. Background: TXA is synthetic derivative of lysine that controls bleeding by inhibiting fibrinolysis and thus stabilizing clots that are formed. We have covered TXA as a treatment modality a number of times on the SGEM. The evidence for TXA providing a patient-oriented outcome (POO) has been mixed. It seems to work for epistaxis (SGEM#53 and SGEM#210), failed to demonstrate a decrease in all-cause mortality in post-partum hemorrhage (SGEM#214), and did not result in an improved neurologic outcome in hemorrhagic strokes (SGEM#236). REBEL EM has looked at using TXA for those conditions plus a few others (we will include a table in the show notes). It is unclear if it provides a benefit for gastrointestinal bleeds (GIB). Nebulized TXA shows promise for both post-tonsillectomy bleeding and hemoptysis. However, better studies are needed to confirm these observations. Dr. Anand Swaminathan and I covered the classic CRASH-2 Trial (SGEM#80). This study published in 2010 showed an absolute mortality reduction of 1.5% in adult trauma patients giving a number needed to treat to prevent one death of 67 (Shakur et al. Lancet 2010) CRASH-3 was a well-designed, large, multi-centred randomized placebo controlled trial published in October 2019 (The Lancet). It asked if TXA had a mortality benefit in patients with isolated head trauma (SGEM#270)? While there was a suggestion of benefit in a secondary subgroup analysis, the primary outcome demonstrated no statistical difference in head-injury related mortality with TXA compared to placebo (18.5% TXA vs. 19.8% placebo, RR 0.94 [95% CI 0.86 to 1.02]). One of the limitations to both CRASH-2 and CRASH-3 was the external validity. The majority of sites involved were in middle to low income countries. CRASH-3 had one Canadian site and the USA had no participating centres. Transfusion practices and identification of adverse events may differ in developing countries compared to the USA. Clinical Question: What is the mortality and thromboembolic events in adult trauma patients receiving TXA an American Level 1 Trauma Center? Reference: Erramouspe et al. Mortality and Complication Rates in Adult Trauma Patients Receiving Tranexamic Acid: A Single-center Experience in the Post–CRASH-2 Era. AEM May 2020 Population: Adults (18 years or older) who received TXA after an acute traumatic injury Excluded: Patients who received oral TXA, received it for elective surgery or nontrauma indications, received TXA 8 hours or longer after the injury, and patients with cardiac arrest at time of ED arrival. Intervention: TXA 1g IV over 10 minutes and maintenance infusion of 1g IV over 8 hours Comparison: None Outcome: Primary Outcome: In-hospital mortality Safety Outcome: Thromboembolic event within 28 day Dr. Erramousepe This is an SGEMHOP episode and we are pleased to have both the lead author and senior author on the episode. Dr. Joaquin Erramouspe is a medical doctor, who finished medical school in Uruguay, moved to the USA for further training and research, and now, is working as a researcher at Queensland University of Technology while obtaining his masters in science. Dr. Daniel Nishijima Dr. Daniel Nishijima is an emergency medicine physician at University of California Davis. His research focus is on trauma and neurological emergencies, particularly those with coagulation disorders. Authors’ Conclusions: “Adult trauma patients receiving TXA had similar incidences of death but higher incidences of thromboembolic events compared to the CRASH-2 trial. Variation in patient characteristics, injury severity, TXA dosing, and surgery and transfusion rates could explain these observed differences. Further research is necessary to provide additional insight into the incidence and risk factors of thromboembolic events in TXA use.” Quality Checklist for Observational Study: 1. Did the study address a clearly focused issue? Yes 2. Did the authors use an appropriate method to answer their question? Yes 3. Was the cohort recruited in an acceptable way? Yes 4. Was the exposure accurately measured to minimize bias? Yes 5. Was the outcome accurately measured to minimize bias? Yes 6. Have the authors identified all-important conf

Date: May 19th, 2020 Reference: Yang P et al. Endovascular thrombectomy with or without intravenous alteplase in acute stroke. NJEM 2020. Guest Skeptic: Dr. Anand Swaminathan is an Assistant Professor of Emergency Medicine at St. Joseph’s Regional Medical Center in Paterson, NJ. Managing editor of EM:RAP and Associate Editor at REBEL EM. Case: A 53-year-old previously healthy man presents with 1.5 hours of right sided weakness as well as slurred speech. A rapid bedside assessment gives you a National Institute of Health Stroke Score/Scale (NIHSS) of 9 and you are concerned about a large vessel occlusion (LVO) based on the high NIHSS as well as the presence of both an upper extremity drift and the speech abnormality. A non-contrast CT shows no evidence of intracranial hemorrhage. A CT angiogram plus CT perfusion demonstrate a clot in the left proximal middle cerebral artery (MCA) with a small infarcted area and a large penumbra. Based on your institution’s current guidelines, the patient is a candidate for endovascular therapy, but they are also within the current window for the administration of alteplase. You wonder if you should give the alteplase while waiting for your neurointerventional team? Background: The issue of thrombolytics for stroke has been debated since at least 1995. This is the year that the famous NINDS trial was published. We cover this as an SGEM classic that all EM physicians should know about on SGEM#70. Our bottom line was that we were skeptical thrombolysis has a net patient-oriented benefit for acute ischemic strokes. We have covered this issue of thrombolysis for acute ischemic stroke a number of times on the SGEM SGEM#29: Stroke Me, Stroke Me SGEM Xtra:Thrombolysis for Acute Stroke SGEM#290: Neurologist Led Stroke Teams – Working 9 to 5 You also had the Legend of Emergency Medicine, Dr. Jerome Hoffman on to reflect upon the last 25 years and the thrombolysis for acute ischemic stroke debate (No Retreat, No Surrender) I also invited my EBM friend, Dr. Eddy Lang onto the SGEM to discuss his perspective on the issue (SGEM Xtra). This led to a pro/con publication in the Canadian Journal of Emergency Medicine (CJEM) tPA should be the initial treatment in eligible patients presenting with an acute ischemic stroke (Milne et al CJEM April 2020). The publication of the MR CLEAN trial in January 2015 changed the face of ischemic stroke care. This was the first study demonstrating a benefit to endovascular treatment of a specific subset of ischemic stroke patients: those with LVOpresenting within sixhours of symptom onset. MR CLEAN was followed by a flurry of publications seeking to replicate and refine treatment as well as expand the window for treatment. The REBEL EM team reviewed this literature back in 2018 and, with the help of Dr. Evie Marcolini, created the below workflow: One major component of LVO management is the use of systemic thrombolytics in patients presenting within the current thrombolytic treatment window prior to endovascular intervention. However, it’s unclear if systemic thrombolytic administration results in better outcomes or if it simply exposes the patient to increased risks at a higher cost. Limited evidence questions the utility of the current approach with thrombolytics plus endovascular therapy (Phan 2017, Rai 2018). There is a clear need for further research into systemic thrombolytics dosing and use. Clinical Question: Is endovascular therapy alone non-inferior to endovascular therapy plus systemic thrombolytics in the treatment of patients with large vessel occlusion strokes presenting within 4.5 hours of onset? Reference: Yang P et al. Endovascular thrombectomy with or without intravenous alteplase in acute stroke. NJEM 2020. Population: Adult patients (18 years of age or older) presenting within 4.5 hours of ischemic stroke symptom onset and with cerebral vascular occlusion on CT angiography of the intracranial internal carotid artery or middle cerebral artery (first and/or second segments) and an NIHSS > 1 and if endovascular thrombectomy was intended to be performed. Exclusions: Disability from a previous stroke or contraindication to IV alteplase and any contra-indication for thrombolysis according to American Heart Association (AHA) guidelines. Intervention: Endovascular thrombectomy alone Comparison: Endovascular thrombectomy + systemic alteplase 0.9 mg/kg Outcomes: Primary Outcome: Modified Rankin Scale (mRS) score assessed at 90 days after randomization looking for non-inferiority (defined as a lower end of the odds ratio > 0.80) Secondary Outcomes: Death from any cause at 90 days, successful reperfusion before thrombectomy, recanalization at 24-72 hours (assessed by CTA), NIHSS score at 24 hours, and 5-7 days, final lesion volume on CT and mRS comparisons Safety Outcomes: All hemorrhages and symptomatic intracranial hemorrhages according to the Heidelberg criteria, occurrence of pseudoaneurysm and groin hematoma at the site of arterial punctu

Date: May 18th, 2020 I was asked to participate in a debate regarding the issue of Masks4All in Canada by the people involved in the COVID Information for Canadian Physicians Facebook group. This is a private group ~22,000 physicians, residents, students and nurse practitioners from around the world. Dr. Joe Vipond I was reluctant to participate but was convinced after having a good conversation with the organizers and Dr. Vipond. They assured me it would be respectful, focus on the evidence and be an educational experience for the audience. These are stressful times and we all want the best recommendation for patients, based on the best evidence to ensure community well-being. Arguing for the affirmative position was Dr. Joe Vipond. He is an emergency physician at the Rockyview General Hospital and a clinical assistant professor at the University of Calgary. He has generously made available his notes from the debate that include links to more information. I argued against the resolution. This does not mean I am against wearing a cloth mask in public. Those who know my not so secret identity (BatDoc) know that I am often seen in public wearing a mask. This is not the type of mask Dr. Vipond and I were debating. We were not talking about wearing medical masks, surgical masks, N95 masks or respirators by healthcare providers on the front lines of COVID19. The debate also did not include symptomatic people or those caring for high-risk people. We were only debating the issue of universal cloth Masks4All in public. To be very clear, I am not anti-mask wearing in public. My position is "it all depends" as taught by my evidence-based medicine (EBM) mentor Dr. Andrew Worster from BEEM. I am just not in favour of a mandatory universal Masks4All in public in Canada. You can watch the Mask4All debate on YouTube. Resolution: Be it resolved that a mandatory universal mask for all to prevent transmission of COVID19 be recommended for Canadians. Dr. Kashif Pirzada We were each given four minutes for an opening statement, three minutes for a rebuttal, four more minutes for a second affirmative statement and finished with three minutes for another rebuttal and closing statement. We had two moderators for this debate. Dr. Kashif Pirzada is an emergency physician in Toronto with an interest in startups and innovation. He is also a co-founder of Conquer-Covid19, a charity that sources personal protection equipment for frontline health workers. Dr. Jennifer Kwan Dr. Jennifer Kwan is a family physician in Burlington, Ontario. She is known for COVID19 data visualizations on Twitter (@jkwan_md) along with the HowsMyFlattening team, and is an advocate for #Masks4Canada and personal protection equipment donations with Halton Regional Chinese Canadian Association. I am not against wearing a cloth mask in public. My position is that I am not convinced that a mandatory Masks4All in public by people that are practicing physical distancing will prevent transmission of clinical disease (COVID19). This is an important distinction. Dr. Samir Grover Questions on the Facebook feed were moderated by Dr. Samir Grover. He is an associate professor and program director for gastroenterology at the University of Toronto. Kashif and Samir have a podcast about COVID-19 called "The Medicine Club" which can be accessed on Twitter @TheMedClubTO It is important in any discussion to be clear on the terms being used. Mandatory: Required by a law or rule : OBLIGATORY. Universal: Including or covering all or a whole collectively or distributivity without limit or exception. Public: All public places (not to private places) Clinical Disease: There is a difference between a DOO (Disease Oriented Outcome- detection of COVID19 RNA) and a POO (Patient-Oriented Outcome - clinical disease). As a clinician, I am more interested in POOs and less interested in DOOs. Epistemology: The study or a theory of the nature and grounds of knowledge especially with reference to its limits and validity I want to accept positions for good reasons not because it is someone’s opinion. Just because someone is a gifted clinician and an excellent advocate for the environment does not mean they are an expert in clinical epidemiology, biostatistics and critical appraisal. This brings up the possibility of a Dunning-Kruger Effect. Here is a link to a great video made by Dr. Rohin Francis (@MedLifeCrisis). It is a satirical ad for Dunning-Kruger Alcohol and uses humour as a COVID19 coping strategy. “The Dunning-Kruger effect is a cognitive bias in which people wrongly overestimate their knowledge or ability in a specific area. This tends to occur because a lack of self-awareness prevents them from accurately assessing their skills.” My credentials included 37 years of medical research, Senior Editor of Academic Emergency Medicine (AEM), advance training in clinical epidemiology, biostatistics and critical appraisal. I teach these skills and cognitive bias and logical

Date: May 9th, 2020 Guest Skeptic: Dr. Sean Moore is an Assistant Professor at the Northern Ontario School of Medicine (NOSM), Chief of Emergency Services at Lake of the Woods Hospital in Kenora, Medical director with Ornge, and Associate Medical Director with CritiCall Ontario. CAEP Town Hall We had the pleasure of presenting for the Canadian Association of Emergency Physicians (CAEP) COVID-19 Town Hall this week. CAEP is the national voice of emergency medicine (EM) in Canada and provides continuing medical education, advocates on behalf of emergency physicians and their patients, supports research and strengthens the EM community. In co-operation with other specialties and committees, CAEP also plays a vital role in the development of national standards and clinical guidelines. Our CAEP COVID-19 Town Hall presentation is available to watch on the CAEP website. It has also been uploaded to CAEP's YouTube channel. All of the the CAEP COVID-19 Town Halls talks are available free open access. Copies of our slides can be downloaded at this link. Dr. Sean Moore Dr. Moore and I were asked to speak about the treatments being used for COVID-19. In this global pandemic, clinicians and researchers have been throwing multiple different treatments at this new corona virus hoping something will work. This includes things like: Azithromycin, Steroids, Famotidine, IL-6 inhibitors, Chloroquine, Hydroxychloroquine, Remdesivir, Vitamin C, and Zinc. We narrowed our presentation down to five treatments and the evidence behind those treatments. These are listed below with links to the references mentioned in the presentation. Chloroquine / Hydroxychloroquine Dr. Didier Raoult Gautret et al. Clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 COVID-19 patients with at least a six-day follow up: A pilot observational study. Travel Med Infect Dis. April 11th, 2020 Tang et al. Hydroxychloroquine in patients with COVID-19: an open-label, randomized, controlled trial. MedRxIV April 14th, 2020 Chowdhury et al. A Rapid Systematic Review of Clinical Trials Utilizing Chloroquine and Hydroxychloroquine as a Treatment for COVID‐19. AEM May 2020. We cannot recommend hydroxychloroquine or chloroquine based on the available evidence. Steroids Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020 Mar 28. Steroids Wilson et al. COVID‐19: Interim Guidance on Management Pending Empirical Evidence. From an American Thoracic Society‐led International Task Force. Thoracic April 3rd, 2020 Villar et al. Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial. Lancet Resp Med Feb 7th, 2020 Wu et al. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Int Med March 13th, 2020 We cannot recommend the use of steroids outside of an RCT. However, steroids should be considered when patients have other indications like COPD or asthma. Remdesivir Grein et al. Compassionate Use of Remdesivir for Patients with Severe Covid-19. NEJM April 10th, 2020 Wang et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. The Lancet April 29th, 2020 Fauchi A. Adaptive COVID-19 Treatment Trial (ACTT). Press Conference April 29th, 2020 We cannot recommend the routine use of remdesivir based on the available evidence. Convalescent Plasma Convalescent plasma is being investigated but there is very little information on this treatment modality. Currently the CONCOR Trial is underway in Canada using 200-500 ml of plasma. Researchers from across the country are involved including Drs. Donald Arnold, Philippe Begin and Jeannie Callum. Plasma collection was started in April. We cannot recommend the use of convalescent plasma outside of a research study. Vaccines Much work is being done on developing a COVID19 vaccine but that is a least months if not years away. My position on vaccines is that the evidence for potential benefit is much greater than the evidence for potential harm. Vaccines are safe and effective for the vast majority of people. SGEM#20 with guest skeptic Dr. Lauren Westafer (@LWestafer) from FOAMCast discussed the issue of flu shots for healthcare workers. We do not know how effective a vaccine will be, it's safety or how long the immunity would last at this time. George Santayana Dr. Moore and I continued the presentation with a reminder that we should remember our history. We have made mistakes in the past by adopting new technology or treatments too soon in medicine. There are examples of when the treatment was properly studied it was found not to work or even worse, increase mobility or mortality. It was George Santayana who said "those who cannot remember the past are condemned to repeat it". A

Date: April 24th, 2020 Reference: Watanabe et al. Is Use of Warning Lights and Sirens Associated With Increased Risk of Ambulance Crashes? A Contemporary Analysis Using National EMS Information System (NEMSIS) Data. Annals of Emergency Medicine. July 2019 Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the US Air Force in Virginia. This is Bob’s eleventh visit to the SGEM. Disclaimer: The views and opinions of this podcast do not represent the United States Government or the US Air Force. Case:You are visiting with your father, a 64-year-old overweight man with hypertension. He describes significant pain in his chest upon awakening and tells you to call an ambulance. The EMS crew arrives and performs a 3 lead EKG that does not show an ST elevated myocardial infarction. They prepare to load your father into the ambulance, and since you’re his only child and he’s a talker, he mentions you’re an emergency physician. The crew then asks if you want them to transport your father Code 3 with full lights and sirens. Background: The use of warning lights and sirens in ambulances is fairly widespread. Their use is associated with marginally faster response and transport times (7). Several studies have found ambulance crashes occurring while lights and sirens are used to have a higher injury rate, and a majority of fatal ambulance crashes involve their use (12-15). EMS agencies have varying guidelines on when to use lights and sirens, and the amount of time saved with lights and sirens is approximately 1-3 minutes (REF). This means the intervention is likely unhelpful for the patient in many transports. Clinical Question: What is the association between warning lights and sirens use by EMS and crash-related delays? Reference: Watanabe et al. Is Use of Warning Lights and Sirens Associated With Increased Risk of Ambulance Crashes? A Contemporary Analysis Using National EMS Information System (NEMSIS) Data. Annals of Emergency Medicine. July 2019 Population: All dispatches of a transport-capable ground EMS vehicle to a 911 emergency scene from the 2016 National EMS Information System, both the response to the scene and the transport from the scene. Excluded: Interfacility transfers, intercepts, medical transports, and standbys; responses by nontransport or rescue vehicles, mutual aid activations, and supervisor responses; and events documented as responses or transports by rotor-wing or fixed-wing air-medical services. Intervention: Use of lights and sirens Comparison: No lights and sirens Outcome: Crash-related delay (proxy for EMS vehicle crash) Authors’ Conclusions: “Ambulance use of lights and sirens is associated with increased risk of ambulance crashes. The association is greatest during the transport phase. EMS providers should weigh these risks against any potential time savings associated with lights and sirens use.” 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/No Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes How precise are the results/estimate of risk? Adequate 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 Results: The 2016 NEMSIS database contained 20.4 million 911 dispatches of ground EMS. There was a total of 2,539 crash-related delays. Key Result: There was a greater odds ratio of crashing with the use of lights and sirens. 1) Reporting Bias: The authors mention how the study is entirely dependent on crash related delays. It is unknown how widespread reporting of crash-related delays is and since this is dependent on individual agencies self-reporting, there may be bias from the agencies to report this more commonly when lights and sirens are used, as this was already believed at the time of the study to induce additional risk. Alternatively, as the authors point out, some upgrades to lights and sirens may occur after an ambulance crash has occurred, which would bias the results. 2) Association not Causation: It would not be correct to conclude that lights and sirens cause crashes from this publication. This was a retrospective database study not a randomized controlled trial. There could have been unmeasured confounders responsible for the observed results. 3) Partial Lights and Sirens:The authors teased apart three scenarios-complete absence of lights and sirens, full use of lights and sirens, and partial use of lights and sirens. These partial use cases include both cases where there was initially no lights and sirens and then they upgraded to lights and sirens, as well as cases where the crew started with lights and sirens, a

Date: April 21st, 2020 Reference: Juergens et al. Effectiveness of emergency physician determinations of the need for thrombolytic therapy in acute stroke. Proc Baylor Univ Med Center Oct 2019 Guest Skeptic: Dr. Chuck Sheppard is an attending Emergency Department Physician at Mercy Hospital in Springfield, Missouri and the medical director for Mercy Life Line air medical service. He has been practicing in Emergency Medicine for over 40 years and involved in EMS services for over 30 years. Case: 56-year-old female with sudden onset of left arm and leg weakness with slurred speech presents to the emergency department (ED). She was last seen well two hours prior. Her past medical history includes hypertension and type II diabetes. She is not on any anticoagulation except ASA. There is no previous history of stroke. The neurology led stroke team is not available and you wonder if that will affect her outcome. Background: Treatment for acute ischemic stroke has been debated between neurologists and emergency physicians for years now. A recent PRO/CON debate on the subject was published in CJEM April 2020 with Dr. Eddy Lang and myself. It was the legend of emergency medicine, Dr. Jerome Hoffman that really raised the concern about the lack of evidence for using thrombolytics in acute ischemic stroke. He was interviewed on an SGEM Xtra segment called No Retreat, No Surrender. We have covered acute ischemic stroke many times on the SGEM. SGEM#29: Stroke Me, Stroke Me SGEM#70: The Secret of NINDS SGEM Xtra:Thrombolysis for Acute Stroke SGEM Xtra: Walk of Life SGEM#269: Pre-Hospital Nitroglycerin for Acute Stroke Patients? Clinical Question: Does the presence of a neurologist led stroke team affect the likelihood of receiving tPA and does that improve a patient-oriented outcome? Reference: Juergens et al. Effectiveness of emergency physician determinations of the need for thrombolytic therapy in acute stroke. Proc Baylor Univ Med Center Oct 2019 Population: All patients presenting to the ED meeting stroke activation criteria Intervention: Neurologist led stroke team Comparison: No neurologist led stroke team Outcomes: Primary Outcome: Rate of tPA administration Secondary Outcomes: Door-to-needle times, modified Rankin Scale (mRS) at discharge, change in National Institutes of Health Stroke Scale (NIHSS), and discharge disposition Authors’ Conclusions: “Emergency physicians administered significantly less thrombolytics than did neurologists. No significant difference was observed in outcomes, including mRS and admission-to-discharge change in NIHSS. 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? 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 Results: There were 415 stroke activations during the study period (Jan 1, 2015 to June 30, 2016). Of those activations, 153 (37%) were managed by the neurologist led team and 262 (63%) were treated by emergency physicians. The median age was early 60’s with slightly more female patients in the cohort. Three-quarters arrived by EMS and the median NIHSS score was 7 for the EM physicians and 6 for the neurologists. The diagnosis was hemorrhagic stroke (~10%), ischemic stroke (~70%), neurological/psychiatric (~15%) and other (~5%). Key Result: Neurologists gave tPA 13% more often than EM physicians Primary Outcome: Rate of tPA administration 26.3% EM physicians and 39.2% neurologists (p=0.006) Secondary Outcomes: No statistical difference in mRS score at discharge 1. Single Center: This was a single center study that may have a unique practice pattern limiting its external validity to other practice environments. As someone who practices in a rural environment, we transport our stroke patients “code stroke” to a higher level of care or use telemedicine with a neurologist who decides on tPA administration. 2. Retrospective Study: This was a retrospective single-center study and results demonstrate association not causation. There could be unmeasured confounders responsible for the observed differences in the results. 3. When Thrombolysed: The neurologists led the team Monday to Friday during business hours. There could be differences that were not measured on nights, weekends and holidays. The baseline NIHSS score was one-point different at baseline between the two cohorts. We know that the severity of the stroke at presentation has a strong influence on the final outcome. We also don’t know if the radiology coverage after hours and on we

Date: April 9th, 2020 Reference: Kline et al. Randomized trial of therapy dogs versus deliberative coloring (art therapy) to reduce stress in emergency medicine providers. AEM April 2020 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com Case: It has been a hard shift. You wish you could say “uncharacteristically”, but recently all your shifts in the emergency department have felt a little hard. The increased workload due to COVID-19 hasn’t been helping. You sit down to chart after a difficult resuscitation, and the charge nurse, seeing that you look a little stressed, asks if you would like to take a break to play with a dog. Background: Medicine is an incredibly rewarding profession. However, it is undeniably marked by significant levels of stress. Reports of burnout are high across medicine, and even higher in emergency medicine (1,2). A study of USA physicians showed that they had more than 50% with at least one symptom of burnout. Emergency physicians reported the highest prevalence of burnout at around 70% (3). Burnout is associated with a loss of empathy and compassion towards patients, decreased job satisfaction, and shorter careers in medicine (4,5). It has also been associated with negative impacts on patient care including self-perceived medical error (6), risk of medical errors (7), and quality of care (8,9). We have covered burnout a few times on the SGEM including my own personal experience of being on the edge of burnout: Five Tips: To Avoid Emergency Medicine Burnout SGEM#178:Mindfulness – It’s not Better to Burnout than it is to Rust SGEM Xtra: On the Edge of Burnout ACEM18 SGEM Xtra: CAEP Wellness Week 2019 YouTube: Being on the Edge of Burnout One Year Later There is some prior literature that exposure to animals decreases stress (10,11). Theoretically, time spent deliberately coloring as a mindfulness practice could also decrease stress (12). Therefore, these authors designed a prospective, randomized trial comparing the effects of dog therapy, deliberate coloring, and control on stress levels for emergency department providers (13). Clinical Question: Does dog therapy result in lower perceived stress than deliberate coloring or control when applied as a break during an emergency medicine shift? Reference: Kline et al. Randomized trial of therapy dogs versus deliberative coloring (art therapy) to reduce stress in emergency medicine providers. AEM April 2020 Population: Emergency care providers, including nurses, residents, and physicians, from a single center emergency department. Exclusions: Dislike, allergy, fear, or other reason not to interact with a therapy dog. Intervention: There were two interventions, which occurred approximately midway through the provider’s shift. Dog therapy consisted of an interaction with a therapy dog, which providers could pet or touch if they wished. The coloring group was provided with three mandalas to choose to color and a complete set of coloring pencils. Both of these activities occurred in a quiet room, physically separated from the clinical care area, with no electronic devices, telephone, window, or overhead speaker. Comparison: A convenience sample of providers that were not offered any break. Outcomes: Primary Outcomes: There were two primary outcomes. The first was a self-assessment of stress using a visual analogue scale. The second was a 10-item validated perceived stress scores, altered to focus providers on the past several hours rather than months, as it was originally designed. These were both measured at the beginning of the shift, about 30 minutes after the intervention, and near the end of the shift. Secondary Outcomes: They looked also looked at a FACES scales as a measure of stress, and provider cortisol levels. Dr. Jeff Kline This is an SGEMHOP episode which means we have the lead author on the show. Dr. Jeff Kline (@klinelab) is the Vice Chair of Research in Emergency Medicine and a professor of physiology, Indiana University School of Medicine. He is the editor in chief of AEM, creator of Pulmonary Embolism Rule-out Criteria (PERC) Rule and has published extensively in the area of pulmonary emboli. Authors’ Conclusions: "This randomized, controlled clinical trial demonstrates preliminary evidence that a five minute therapy dog interaction while on shift can reduce provider stress in Emergency Department physicians and nurses.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. No The randomization process was concealed. Unsure The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). No The patients in both groups were similar with respect to prognostic factors. Unsure All participants (patients, clinicians, outcome assessors) were

Date: April 4th, 2020 It has been just over a year since Dr. Salim Razaie (REBEL EM) and I stepped into the ring for a boxing matched theme debate in Sydney, Australia. It was the EBM rumble down under for SMACC 2019. How the world has changed with COVID19. You can see the original SGEM Xtra post from March 2019. It has more details about each issue we discussed and our slides. This is being posted now because a high-definition video is available on YOUTUBE for those who could not attend or for those who want to watch this epic match again. It is an example of mixing education and entertainment for some great knowledge translation. You can also listen to an edited version on the SGEM iTunes feed. We went four rounds punching and counter punching arguments about critical care controversies. The REBEL took the fight to the Skeptic. He supported his position with a flurry of publications.. The skeptic responded with his own citations. As with boxing, the champion must be beat, the challenger cannot win with a draw and there were no knockouts in the match. The skeptic fell back on the burden of proof and asserted he had not been convinced to accept any of the REBELs claims. The ultimate winner was the patient. We both agree that the patient deserves the best care, based on the best evidence. Four Critical Care Controversies: Round#1: Mechanical CPR - SGEM#136 Round#2: Epinephrine in Out-of-Hospital Cardiac Arrest (OHCA) - SGEM#238 Round#3: Stroke Ambulances with CT Scanners Round#4: Bougie for First Pass Intubation - SGEM#271 Conclusion/Winner - Use EBM and the winner is the patient We appreciate Dr. Justin Morgenstern (First10EM) being the impartial referee for this contest. He ensured it was a good clean fight about the evidence and did not allow us to punch each other below the belt (in the p-value). We encourage you to read the primary literature yourself. There are multiple links provided to the relevant studies in the original post. The literature should guide your care but it should not dictate your care. You will still need to apply your good clinical judgment and ask the patient what they value and prefer. Thank you to all the students who supported me in the skeptical corner of the ring. I hope it encouraged their critical thinking skills. Not just to accept anything because their supervisor/attending told them. They also made sure I had plenty of maple syrup between the rounds. 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. The ultimate goal is for patients get the best care, based on the best evidence. REMEMBER TO BE SKEPTICAL ABOUT ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

Date: March 27th, 2020 Reference: Secko et al. Musculoskeletal Ultrasonography to Diagnose Dislocated Shoulders: A ProspectiveCohort. Ann Emerg Med Feb 2020 Guest Skeptic: Dr. Tony Zitek is an Emergency Medicine physician in Miami, Florida. He is an Assistant Professor of Emergency Medicine for Florida International University and Nova Southeastern University, and Tony is the Research Director for the Emergency Medicine residency program at Kendall Regional Medical Center. DISCLAIMER: THIS IS NOT AN EPISODE ON COVID19 Here are five websites to get up-to-date information about COVID19: Centre for Disease Control and Prevention Health Canada Public Health Ontario World Health Organization Food and Drug Administration Case: An 18-year-old, previously healthy male presents to the emergency department after sustaining an injury to his right shoulder after colliding with another player during a football game. On examination, there is a loss of the normal rounded appearance of the shoulder. You suspect the patient may have a shoulder dislocation. He has no history of shoulder dislocations in the past. Will you order an x-ray or perform a point-of-care ultrasound to confirm the diagnosis? Background: Despite shoulder dislocations being a very common injury presenting to the ED, it has only been covered once on SGEM#121. This episode tried to answer whether it was better for the shoulder to be immobilized in an external or internal rotation post-reduction. We still don’t know if one position is superior to another. Emergency physicians frequently perform pre- and post-reduction x-rays for patients with shoulder dislocations. However, some prior studies suggest that the routine performance of these x-rays may not be necessary, especially in patients with recurrent dislocations who have not sustained any direct trauma [1-2]. Point-of-care ultrasound (POCUS) has previously been studied for the use of the diagnosis of shoulder dislocations with most prior data suggesting that POCUS is highly sensitive and specific for the diagnosis of shoulder dislocations [3-4]. As with other applications of POCUS, the use of ultrasound for shoulder dislocations has the potential to reduce the time to diagnosis, reduce radiation exposure, and lower cost. However, prior studies about the use of POCUS for shoulder dislocations have used a variety of scanning techniques and some have utilized as few as 2 sonographers [4]. One study found only a 54% sensitivity for identifying persistent dislocation after a reduction attempt [5]. Clinical Question: What is the diagnostic accuracy of point-of-care ultrasound for the diagnosis of shoulder dislocations as compared with x-ray? Reference: Secko et al. Musculoskeletal Ultrasonography to Diagnose Dislocated Shoulders: A Prospective Cohort. Ann Emerg Med Feb 2020 Population: Adult patients with suspected shoulder dislocations who presented to one of two EDs when a study investigator was present. Exclusion: Patients with multiple traumatic injuries, decreased level of consciousness, or hemodynamic instability. Intervention: Pre- and post-reduction POCUS utilizing a posterior approach in which they traced the scapular spine towards the glenohumeral joint. The POCUS technique they used is basically as follows --- the sonographer palpates the spine of the scapula, and then places the ultrasound probe directly over the scapular spine. The study protocol allowed the sonographer to choose either a linear or curvilinear probe. The sonographer then follows the scapular spine laterally until the glenoid and humerus are identified. Using this technique, the glenoid and humeral head both look like hyperechoic semicircles. They should be very close to each other, and if not, that indicates a shoulder dislocation. After assessing for dislocation, the sonographer can assess for fracture by fanning the probe from a cephalic to caudal direction. A fracture appears as a disruption in the normal contour of the hyperechoic humerus. (shown below in Figure 1 from the manuscript). Figure 1. A, Proper probe placement on the patient and the 3-step sequence to examine the shoulder from the posterior approach. The blue dot above the probe corresponds to the probe indicator. B, The corresponding ultrasonographic images to the probe placement in A at the level of the scapular spine (1), the glenohumeral joint (2), and the humerus (3). Comparison: Pre- and post-reduction x-rays. Outcomes: Primary Outcome: The diagnostic accuracy of POCUS for shoulder dislocations. Secondary Outcomes: Presence or absence of fracture, time from triage to POCUS exam as compared to x-ray, time from POCUS exam initiation to diagnosis, determination of glenohumeral distance of non-dislocated and dislocated shoulders, and sonographer confidence in diagnosis (from 0-10). Authors’ Conclusions: “A posterior approach point-of-care ultrasonographic study is a quick and accurate tool to diagnose dislocated shoulders. Ultrasonography was also able to accura

Date: March 18th, 2020 Reference: Ebell et al. Accuracy of Biomarkers for the Diagnosis of Adult Community-Acquired Pneumonia: A Meta-analysis. AEM March 2020 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. Disclaimer: This is Not an Episode on COVID19 Things are changing quickly with the COVID19 pandemic. Here are five basic things you can do to help flatten the curve as of this blogpost: Wash your hands well and often (at least 20 seconds with soap and water) Try not to touch your face Physically isolate yourself from large gatherings but stay socially connected electronically Cough into your elbow or use a tissue, throw the tissue out and go to #1 Disinfect objects or surfaces with a regular household cleaning wipe or spray If you are unsure of what to do or for more information, here are five websites to get up-to-date information about COVID19: COVID19 Centre for Disease Control and Prevention Health Canada Public Health Ontario World Health Organization Food and Drug Administration Case: A 47-year-old healthy, non-smoker, presents to the emergency department (ED) with a productive cough, fever and says it has been difficult to breathe for the past four days. He appears well, with a temperature of 38.7 Celsius, heart rate of 90 beats per minute, respiratory rate of 20 breaths per minute and room air oxygen saturation of 91%. On auscultation you hear some fine crackles at the bases. You wonder if there is value in ordering any bloodwork, particularly a biomarker such as C-reactive protein (CRP), procalcitonin (PCT) or a complete blood count for white blood cell count (WBC) in addition to doing a chest x-ray (CXR). Background: Community-acquired pneumonia (CAP) is a significant source of morbidity and mortality in adults (1,2). We have covered this issue a couple of times on the SGEM. One episode looked at β-Lactam monotherapy vs. β-Lactam plus macrolide combination therapy in adult patients admitted to hospital with moderately severe CAP (SGEM#120). This study supported the combination therapy in these patients. More recently, we looked at the question of whether steroids improve morbidity and mortality in patients admitted to hospital with CAP (SGEM#216). The bottom line was that corticosteroids appear to improve mortality and/or morbidity in patients admitted to hospital with CAP. There is evidence that an accurate diagnosis of CAP may lead to earlier treatment while avoiding unnecessary antibiotics for patients who do not have CAP. Pervious research has demonstrated that individual signs and symptoms have limited accuracy in the diagnosis of CAP. The diagnosis of CAP is usually based on an abnormal chest x-ray in a patient with signs and symptoms of a lower respiratory tract infection (3,4). White blood cell count (WBC), C-reactive protein (CRP), and procalcitonin are biomarkers associated with an increased likelihood of CAP. There are also clinical prediction rules that include CRP for the diagnosis of CAP (5,6). Procalcitonin is another potential biomarker that may help in the diagnosis of bacterial pneumonia (7). Guidelines such as the National Institute for Health and Care Excellence (NICE) recommend the use of CRP at the point of care to reduce inappropriate antibiotic when diagnosing CAP (8) These various biomarkers are readily available in the ED setting in the US, as well as in the primary care setting in other countries in Europe. The study we are reviewing on this SGEM episode performs an updated systematic review and meta-analysis (SRMA) of the diagnostic accuracy of biomarkers for CAP. Clinical Question: What is the accuracy of biomarkers for the diagnosis of community acquired pneumonia? Reference: Ebell et al. Accuracy of Biomarkers for the Diagnosis of Adult Community-Acquired Pneumonia: A Meta-analysis. AEM March 2020 Population: Adult patients presenting with symptoms of acute respiratory infection and patients with clinically suspected pneumonia based on physician order of a chest radiograph, reporting sufficient information to calculate sensitivity and specificity for the diagnosis of CAP for at least one biomarker. Exclusions: Studies of dyspnea or sepsis rather than suspected CAP. Studies limited to patients with chronic lung disease, patients in skilled nursing facilities, or immunosuppressed/HIV patients. Ventilator or hospital acquired pneumonia. Studies of the diagnosis of a specific pathogen (i.e. mycoplasma or legionella). Studies that did not use a cohort design (i.e. recruited patients with known CAP and healthy controls). Intervention: C-reactive protein (CRP), procalcitonin or white blood cell (WBC) count Comparison: Chest imaging with CXR or CT scan Outcome: Diagnosis accuracy of biomarkers for pneumonia This is an SGEMHOP episode which means we have the lead author on the show. Dr. Mark Ebell is a Family Ph

Date: March 12th, 2020 Dr. Jonathan Stea Guest Skeptic: Dr. Jonathan Stea (@Jonathanstea) is a PhD Clinical Psychologist working at the Foothills Medical Centre in Calgary, Alberta. He is also an Adjunct Assistant Professor, Department of Psychology, University of Calgary. This SGEM Xtra is based on a tweet from about a month ago on The 10 Commandments of helping distinguish between science from pseudoscience for psychology students. It was written by Scott O. Lilienfeld (Association for Psychological Science 2005). This seemed like a good time to discuss pseudoscience because of the legitimate concerns about COVID19. These high anxiety situations regarding health seem to bring out those looking to sell fraudulent products. The FDA has even had to issue warning letters to firms with claims to “prevent, treat, mitigate, diagnose or cure coronavirus disease 2019 (COVID-19).” Dr. Nina Shapiro has written a couple of articles in Forbes about this issue of “miracle cures” and FDA warnings. There was also an article by Timothy Caulfield (@CaulfieldTIm). In that piece he specifically mentioned a Calgary naturopathy who made some unsupported claims about COVID19. Fears Of The COVID-19 Coronavirus Provide More Opportunity For Misinformation About Miracle Cures (March 1, 2020) FDA Issues Warnings To Companies Selling Fraudulent COVID-19 Coronavirus Therapies (March 9, 2020) Misinformation, alternative medicine and the coronavirus (March 12, 2020) We also need to be careful not to paint with too broad of a brush. There are bad people out there making false claims. It does not mean all practitioners are bad and all practices are fraudulent. Massage therapy and Reiki may relieve some peoples’ anxiety over COVID19. In contrast, there is no high-quality evidence that homeopathy and chiropractic care can cure COVID19. We should try to focus on the claims that people are making and hold those who are making incorrect claims accountable. Even the Canadian Association of Naturopathic Doctors (CAND) said that the Calgary naturopath had made: “false and misleading statements” and there “are no proven methods for the prevention or treatment of COVID-19 — claims otherwise made by any health professionals are invalid and should be reported immediately to applicable regulators.” We should apply the same level of skepticism and science to all claims. These include claims made by all health care providers including psychologists, physicians, nurses, chiropractors, naturopaths, acupuncturists, etc. It is not just about COVID19 claims but about any therapeutic claims. Patients deserve the best care, based on the best evidence. COVID19 The COVID19 story is evolving quickly and could be out of date when this episode is published. Here are some basic things that you could do to try and stay healthy: Wash your hands well (at least 20 seconds with soap and water) and try not to touch your face Avoid people who are sick and limit your social gatherings Stay home if you are feeling ill Cough into a tissue and throw it out immediately or cough into your elbow and disinfect objects or surfaces with a regular household cleaning wipe or spray People who are feeling ill should wear a facemask but other people who are feeling fine and not caring for a sick person do not need to wear a mask If you are unsure of what to do, please contact your local health authority. There are some official websites to get the latest update on the COVID19 situation: Centre for Disease Control and Prevention Health Canada Public Health Ontario World Health Organization Food and Drug Administration A Rough Guide To Spotting Bad Science Science is very exciting and does not need to be made more sensational. As a science communicator, it is disappointing when research is hyped up in the media. A recent example of this would be the CRASH#3 trial. This was a well-designed randomized control trial asking an important question. The research group successfully completed and published their trial in a high impact journal. The primary outcome was “negative” but that in no way negates the science or its importance. It was unfortunate to see the spin that came out on CRASH#3 (SGEM#270). The 10 Commandments of EBM The 10 Commandments of Helping Students Distinguish Science from Pseudoscience in Psychology. There are a number of definitions of science and here is one: “Science is the study of the nature and behaviour of natural things and the knowledge that we obtain about them.” Collins Dictionary. American Psychological Association Dictionary of Psychology has a definition for Pseudoscience: "a system of theories and methods that has some resemblance to a genuine science but that cannot be considered such. Examples include astrology, numerology, and esoteric magic. Various criteria for distinguishing pseudosciences from true sciences have been proposed, one of the most influential being that of falsifiability." Using these definitions, here is the list of the 10 Command

Date: March 4th, 2020 Reference: Radonovich et al. N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel. A Randomized Clinical Trial. JAMA 2019 The Respiratory Protection Effectiveness Clinical Trial (ResPECT) Guest Skeptics: Dr. Christopher Patey is an Assistant Professor with Memorial University Medical School in St. John’s, Newfoundland Canada. Over the past seventeen years he has practiced as a rural emergency and family physician and Clinical Chief of Emergency at Carbonear Hospital. Paul Norman is a registered nurse working as a frontline emergency nurse in Eastern Health, Newfoundland, Canada. Paul has greater than ten years of experience working in Emergency Nursing and Critical Care. His focus is implementation of LEAN strategies, quality and process improvement. Paul's work has been extended to reach emergency services throughout Canada and he has contributed on many platforms including local, regional, provincial and national speaking engagements. Disclaimers: This episode is about influenza not coronavirus (Covid-19) Dr. Patey's Disclaimer: I am not an expert on PPE (Personal Protective Equipment), Influenza/HINI/Coronavirus, Journal Reviews or Emergency Department management of pandemics. Paul Norman's Disclaimer: We (Dr. Patey and I) are experts on asking questions on the frontline of a Rural Emergency Department to ensure quality, and most importantly, effective patient care. Dr. Ken Milne's Disclaimer: I am an expert on critical appraisal but do not know what mask (if any) is best for preventing the Covid-19 virus. I think we can all agree on a few general recommendation: Get a flu shot if possible, wash your hands well (at least 20 seconds with soap and water), try not to touch your face, avoid people who are sick, stay home if you are feeling ill, cough into a tissue and throw it out immediately or cough into your elbow, disinfect objects or surfaces with a regular household cleaning wipe or spray, people who are well do not need to wear a facemask, people who are feeling ill should wear a facemask, and reach out to your local health authority if you think you might have the COVID-19. Covid-19 Information: This story is evolving quickly, and people should go to official websites to get the latest update on the Cover-19 situation: Centre for Disease Control and Prevention Health Canada Public Health Ontario World Health Organization Food and Drug Administration Case: With the potential global impact of the coronavirus (COVID-19) and our rural emergency departments (ED) having an extremely low compliance rate for N95 mask fit testing, our ED administration sends an urgent request for everyone to have N95 mask testing as soon as possible (ASAP). The urgent email also request shaving facial hair. You wonder about the evidence supporting the initiative and if there is any recent evidence surrounding N95 masks usage for preventing health care workers getting acute respiratory illnesses. Background: Many hospitals had their health care workers fitted with N95 masks in response to the 2009 H1N1 pandemic. The N95 masks were known to prevent small particles and therefore thought to be more effective. What was not known is whether or not this better effectiveness would translate into less viral respiratory infections acquired in hospital compared to regular disposable surgical medical masks. In other words, would N95 masks have a healthcare provider-oriented outcome. When it appeared that the transmission of the pandemic H1N1 was not different from seasonal influenza the recommendation for medical masks in most settings was reinstated. With the potential for an epidemic/pandemic outbreak of coronovirus, there is the demand for increased vigilance in preventive measures to prevent and contain the outbreak of this communicable disease. There have been a number of other studies discussing masks in preventing influenza spread: Loeb et al 2009 did a non-inferiority trial of surgical masks vs. N95 respirator masks for preventing flu in Ontario nurses working at tertiary care hospitals. They concluded surgical masks were non-inferior. MacIntyre et al 2009 did a cluster RCT on the use of face masks to control for respiratory virus transmission in households. They found face masks were unlikely to be an effective policy for seasonal respiratory diseases. This was in part because <50% of participants had mask adherence. Those who wore the mask did have a statistically significant reduction in clinical infection. MacIntyre et al 2011 published another study in the same year comparing efficacy non-face masks to fit tested and non-fit tested N95 respiratory mask in preventing respiratory infections in hospital workers in China. The results showed a significant decrease in respiratory illnesses including influenza. The authors did cautioned readers that the trial may have been underpowered. Smith et al CMAJ 2016 did a systematic review and meta-analysis on th

Date: February 28th, 2020 Reference: Rajendran et al. Randomised control trial of adult therapeutic colouring for the management of significant anxiety in the Emergency Department. AEM February 2020 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: One night during an overnight shift, you are taking care of a patient who presented to the emergency department (ED) due to anxiety and vague suicidal ideation. The process for medical clearance and psychiatric evaluation can take quite a while, and you notice that this patient seems stressed and anxious. You wonder if there’s a way to assist them during the prolonged wait without resorting to sedative medication. Background: Psychological disorders are a common reason for presenting to the ED. Anxiety disorders are the most common (Marchesi et al EMJ 2004). However, we have only covered mental health issues a few times on the SGEM: SGEM#45: Vitamin H (Haloperidol for Psychosis) SGEM#178: Mindfulness – It’s not Better to Burnout than it is to Rust SGEM#218: Excited Delirium Syndrome SGEM#237: Screening Tool for Child Sex Trafficking SGEM#252: Blue Monday- Screening Adult ED Patients for Risk of Future Suicidality Patients with psychological disorders are often kept in the ED for a prolonged period of time. The ED itself can be a stressful environment and exacerbate anxiety. Emergency physicians have pharmaceutical options to treat anxiety. One of the most common medications to use is a benzodiazepine like lorazepam or diazepam. There is a need for non-pharmacological therapies to treat anxiety, and in some settings, art therapy has been studied. Specifically, adult coloring books have been used in the community and seem to function through cognitive easing (Rigby et al BMJ 2016 and Curry et al Art There 2005). Clinical Question: Can colouring decrease anxiety in adult patients presenting to the emergency department? Reference: Rajendran et al. Randomised control trial of adult therapeutic colouring for the management of significant anxiety in the Emergency Department. AEM February 2020 Population: Patients >15 years old with a score of >6 on the Hospital Anxiety and Depression Scale Anxiety (HADS-A). A score of >6 is considered moderate to severe anxiety. Intervention: Colouring pack (10 adult colouring pages and 36 pencil colours) Comparison: Placebo pack (10 plain sheets of paper, a Bic pen and instructions to draw or write freely) Outcome: Primary Outcome: Within-patient change in HADS-A score from baseline after two hours of therapy. Secondary Outcomes: Survey questions regarding value of therapy and level of engagement with treatment packs (length of time) Dr. Naveen Rajendran This is an SGEMHOP episode which means we have the lead author on the show. Dr. Naveen Rajendran is an intern at the Westmead Hospital in Sydney with a keen interest in emergency medicine and the investigation of novel therapies that could aid in alleviating the growing stress on modern emergency departments. This study was conducted when he was a medical student at the University of Sydney with Dr. Coggins (@coggi33) who was his research supervisor. Authors’ Conclusions: “Among ED patients, exposure to adult colouring books resulted in lower self-reported levels of anxiety at 2-hours compared to placebo.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Unsure The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. 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 Key Results: They screened 179 patients that were flagged as being anxious. The cohort included 53 participants with a mean age of 33 years and 73% were female. HADS-A decreased significantly more in the adult colouring group Primary Outcome: Intervention Group: Mean HADS-A decrease at two hours was 3.7 (95%CI 2.4 to 5.1, p<0.001) Control Group: Mean HADS-A decrease at two hours: 0.3 (95%CI -0.6 to 1.2, p=0.51) Secondary Outcomes: For the question "would you recommend colouring" on a Likert Scale (1-5) the average satisfaction score was 4.2. We asked Naveen ten questions to get a greater understand of his publication. Listen to the SGEMHOP podcast to hear all of his answers. Single Centre: This was a relatively small sample size of 53 patients. However,

Date: January 27th, 2020 Guest Skeptics: Dr. Richelle Cooper is a Professor of Emergency Medicine at the UCLA Department of Emergency Medicine. Dr. Maia Dorsett is an Emergency and EMS Physician at the University of Rochester Medical Center. Reference: Dorsett et al. Bringing value, balance and humanity to the emergency department: The Right Care Top 10 for emergency medicine. Emerg Med J 2019 This is an SGEM Xtra based on a recent publication by Dr. Dorsett and her team. It is an article of ten recommendations on how we might provide a more balanced approach to healthcare tailored to the needs of the patients we see in the emergency department. One of the authors of the article was the Legend of Emergency Medicine, Dr. J. Hoffman. SGEMers have heard about over-testing, over-diagnosing and over-treating. These authors have some concerns about what they call the unmentioned "elephant in the room". "While specialty societies do undertake advocacy work to address the health needs of the public, they also have a fundamental duty to advocate for and protect the interests of their specialty. Furthermore, healthcare dollars that are ‘wasted’ are of course not actually thrown away but rather end up in someone’s pocket; thus, there is clearly a conflict of interest when specialty societies address the overuse of extremely lucrative medical procedures that provide substantial income to their members." Choosing Wisely is an initiative trying to address the issue of over-testing, over-diagnosing and over-treating. To be clear, these authors are not against Choosing Wisely. "Important to note that we are not against choosing wisely, however the issue is larger and more nuanced. It is not just about “low value” care and costs but about harms, harms from overuse of diagnostic tests and treatment and also from underuse in other cases. The right care alliance is concerned about the right care for the right patients at the right time, thus not just overused tests." The organization this group of authors are associated with is called the Right Care Alliance (RCA). How is it different from the Choosing Wisely Campaign? "The Right Care Alliance was formed in 2015 by the Lown Institute, a healthcare think tank. Many of us, such as myself, became involved with the work of the Lown because of our interest in reducing the harms of overtesting and overdiagnosis. But we quickly realized that talking about Right Care was actually a conversation about the Right amount of care and that this was more than just about too much care, it was also about underuse, health care access and a focus on treating the whole patient. It was this realization – that we cannot address overuse without talking about underuse - that lead to the formation of the RCA. The powerful part of the RCA is that it is a grassroots coalition of not just healthcare practitioners, but also patients and community members." Where does emergency medicine fit into the RCA initiative? "Nowhere in healthcare is the unfortunate dichotomy between overuse and underuse as apparent as in our emergency departments, which function simultaneously as centers of high acuity healthcare and healthcare safety nets. Organizationally, the RCA has a number of subcommittees or “councils”. The Emergency Medicine (EM) Council is one of these subgroups and is composed primarily of emergency physicians and nurses." "In May 2016, the RCA asked its specialty councils to create their own ‘top 10’ lists, The goal was to identify not merely interventions that are overused but also others that need to be used more widely, if we are to achieve both better and more equitable health outcomes and financial savings." What were the guiding principles put forward by the RCA to generate the top 10 list? Guiding Principles for Top 10 List: Patient-centred Holistic in approach Understandable to both healthcare professionals and non-health care professionals Meaningful to everyone who participates in the healthcare system Criteria Used to Select the Top 10 Items: Matter to patients Have high potential to harm or to benefit Be common (overuse) or rare (underuse) enough that avoiding or doing the item routinely would move the needle towards the right care Examine or illustrate how it ties to system failures. The committee was predominantly made up of emergency physicians, including residents, faculty and community physicians, and emergency medicine nurses. Patients were invited to participate on all the committees, and it was required that members of the Patient council review and provide input to all lists. The Emergency Medicine (EM) members of the RCA were all invited to participate, ultimately 125 gave input on potential items. They participated in each part of the scoring and ranking and in a smaller group for the discussion of the items. Similarly, Maia presented and received input from patients/patient advocates at a Lown conference. Two Overriding P

Date: February 11th, 2020 Reference: Yeh et al. Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial. BMJ 2018. Guest Skeptic: Marcus Prescott is a nurse in Norway. He is also now a third-year medical student. Case: A 32-year-old woman with no previous medical history calls you while a passenger on a crashing plane. She has been offered a parachute by the flight attendant but is unsure whether jumping from the plane is wise. You quickly scour the literature for evidence to inform her decision. Background: The parachute– an umbrella term for devices to slow the motion of an object through an atmosphere by creating drag – was first deployed in China roughly 4,000 years age. The modern versions reached widespread use with the invention of heavier than air flight early last century. Different variants of parachutes have been used both for recreational and safety purposes; in either case aiming to avoid death in people falling from heights presumed to be lethal. Despite the near universal application, a systematic review from 2003 (Smith and Pell, BMJ) found no RCTs of parachute intervention. That systematic review published in the BMJ is a classic paper and part of their annual holiday edition. It stated that there was observational data showing parachutes failed at times to prevent morbidity and mortality. There are also case reports of free falls that did not result in 100% mortality. The authors suggested taking evidence-based medicine advocates up in a plane for a double blinded randomized control trial. The intervention would be a parachute and the control arm would be a sham parachute (backpack). To make it more rigorous, anyone who survived the first jump would cross over into the other arm of the study and jump again. Only then would we have definitive evidence that a parachute was effective in preventing death and major trauma related to gravitational challenges. After years of trying to organize a trial, researchers were finally able to recruit some volunteers to jump out of a plane with a parachute or backpack. Clinical Question: Do parachutes reduce death or major injury when jumping from aircraft? Reference: Yeh et al. Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial. BMJ 2018. Population: Adults 18 years of age and older, seated on aircraft and deemed rational decision makers. Intervention: Jumping from aircraft with parachute Comparison: Jumping from aircraft with backpack Outcome: Primary Outcome: Composite of death and major traumatic injury (ISS>15) within five minutes of impact or at 30 days. Secondary Outcomes: Health status and subgroup analysis based on type of aircraft or previous parachute use. Authors’ Conclusions: “Parachute use did not significantly reduce death or major injury when jumping from aircraft in the first randomized evaluation of this intervention. However, the trial was only able to enroll participants on small stationary aircraft on the ground, suggestion cautious extrapolation to high altitude jumps. When beliefs regarding the effectiveness of an intervention exists in the community, randomized trials might selectively enroll individuals with a lower perceived likelihood of benefit, thus diminishing the applicability of the results to clinical practice.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). No The patients in both groups were similar with respect to prognostic factors. 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. No Key Results: They screened 92 adults with only 23 agreeing to be in the trial. The median age was 38 years and 43% were female. Parachutes did not reduce death or major injury Primary Outcome: Composite of death and major traumatic injury (ISS>15) within five minutes of impact was 0% vs. 0% with p>0.9 Composite of death and major traumatic injury (ISS>15) within 30 days was 0% vs. 0% with p>0.9 Secondary Outcomes: No statistical difference in health status No statistical differences when stratified by type of aircraft or previous parachute use. Talk Nerdy: There were many limitations to this study including a composite outcome for the primary outcome. However, we will only discuss five things that threaten the validity and interpretation of this trial. Convenience Sample: These were not cons

Date: January 29th, 2020 Reference: Perry et al. Prospective Implementation of the Ottawa Subarachnoid Hemorrhage Rule and 6-Hour Computed Tomography Rule. Stroke 2019 Guest Skeptic: Dr. Rory Spiegel is an EM/CC doctor who splits his time in the Emergency Department and Critical Care department. He also has this amazing #FOAMed blog called EM Nerd. Case: A 48-year-old male presents to your emergency department with a sudden onset headache, which started about one-hour prior to arrival. The headache is severe is quality and the patient does not have a history of similar headaches in the past. It is associated with nausea, vomiting and photophobia. Background: Headaches are a common complaint presenting to the emergency department. Subarachnoid hemorrhage represents one of the most serious underlying causes of headaches and we have covered it a number of times on the SGEM: SGEM#48: Thunderstruck – Subarachnoid Hemorrhage SGEM#134: Listen, to what the British Doctors Say about LPs post CT for SAH SGEM#140: CT Scans to Rule Out Subarachnoid Hemorrhages in A Non-Academic Setting SGEM#201: It’s in the Way That You Use It – Ottawa SAH Tool In patients who present neurologically intact making the diagnosis early is key to preventing subsequent more life-threatening bleeding. A number of controversies surround the diagnosis of SAH in the emergency department. Two of the more provocative are the use of the Ottawa SAH Rule and whether a lumbar puncture (LP) is required following a negative CT if the scan is performed within 6-hours of symptom onset. The Ottawa SAH Rule (tool) was covered on SGEM#201. The bottom line from that study was that the clinical decision instrument needed external validation, a meaningful impact analysis performed and patient acceptability of incorporating this rule into a shared decision-making instrument before being widely adopted. We were surprised that in their background/introduction material they did not include the excellent SRMA on this topic by Carpenter et al. AEM 2016. Clinical Question: What is the clinical impact of the Ottawa SAH Rule and the 6-hour CT Rule compared to standard care when implemented in six emergency departments across Canada? Reference: Perry et al. Prospective Implementation of the Ottawa Subarachnoid Hemorrhage Rule and 6-Hour Computed Tomography Rule. Stroke 2019 The senior author on this publication was the legend of emergency medicine, Dr. Ian Stiell from Ottawa. Population: Neurologically intact adult presenting to the ED with a chief complaint of a nontraumatic, acute headache, or syncope associated with a headache. Exclusions: Patients with any of the following: 3 or more previous similar headaches (ie, same intensity/character as their current headache) over a period of >6 months (eg, established migraines) confirmed SAH before arrival at study ED previously investigated with CT and LP for the same headache papilledema new focal neurological deficit previous diagnosis of intracranial aneurysm or SAH known brain neoplasm cerebroventricular shunt headache within 72 hours following a LP headache described as gradual or peak intensity beyond 1 hour. Intervention: Physicians were actively encouraged to use the Ottawa SAH Rule and the 6-hour-CT Ruleto determine when to undergoing diagnostic workups for SAH and when a CT alone with an appropriate workup. Clinicians had the option to override the proposed rules. Comparison: The control phase was standard care. Clinicians were encouraged to not use any clinical decision instrument and make the decision to pursue diagnostic studies based on their own clinical discretion. Outcome: The primary outcome was the clinical impact of the Ottawa SAH Rule and 6-hr CT Rule for making the diagnosis of a SAH compared to usual care. SAH was defined as: Subarachnoid blood on CT Xanthochromia in the cerebrospinal fluid Red blood cells in the final tube of cerebrospinal fluid with an aneurysm demonstrated on cerebral angiography, CTA, or magnetic resonance imaging angiography. Dr. Jeff Perry Authors’ Conclusions: “This implementation study validates the accuracy of the Ottawa SAH rule and 6-hour-CT rule for SAH. Both the Ottawa SAH rule and the 6-hour-CT rule are now fully validated and ready to use clinically. Using the Ottawa SAH rule did not increase or decrease the number of investigations performed. The 6-hour-CT rule resulted in a modest decrease in testing following a normal early CT. Utilizing the Ottawa SAH rule and the 6-hour-CT rule allows clinicians in ED to safely standardize care for alert, patients with acute headache.” Quality Checklist for A Diagnostic Study: The clinical problem is well defined. Yes The study population represents the target population that would normally be tested for the condition (ie no spectrum bias). Yes The study population included or focused on those in the emergency department. Yes The study patients were recruited consecutively (ie no selection bias). Yes The diagnostic evaluation w

Date: January 25th, 2020 SGEM#281: EM Docs Got an AmbuBag Statistically Significant: Dan Lane We want to make the SGEM even better and address some of the criticisms from the ClinEpi world about clinicians trying to do critical appraisal. In order to do that we now have a Dr. Dan Lane who has a PhD in Clinical Epidemiology. He will be commenting on each the SGEM episodes. Dr. Dan Lane On this episode of Statistically Significant we are going to discuss the importance of balance of prognostic factors in randomized controlled trials, using the PreVent trial as an example. Characteristics that indicate when a patient more likely to have an outcome, what we call prognostic factors, need to be accounted for when assessing the effectiveness of a treatment. Without accounting for prognostic factors, the measures of treatment effect can be biased due to observed or unobserved factors amongst patients in each group. Consider if this same study had been conducted as a non-randomized design –clinicians may have decided to ventilate select patients between induction and intubation because they perceived them as more unstable prior to induction. These patients may also be at higher risk for hypoxia during this period for the same reasons the clinicians chose to ventilate them and therefore they would look worse when compared to patients not receiving ventilation if you did not account for these reasons – this is what epidemiologists call an indication bias. The goal of randomization in clinical trials is to balance patient characteristics between the different groups being investigated in the study. By randomly assigning patients to groups, the sole indication for receiving the treatment is the randomization process. As long as there are enough patients randomized, all known and unknown prognostic factors will be mathematically balanced between the groups. Therefore when talking about the balance of prognostic factors as part of critical appraisal, the key point to realize is there are both known and unknown factors. Although in this study they found some statistical differences between measured prognostic factors at baseline, these are just the prognostic factors that happen to be reported by the investigators. If we trust their randomization process then we can assume that the overall risk of the primary outcome, which includes measured and unmeasured prognostic factors, is mathematically balanced between the groups. One final point - the use of statistical hypothesis testing to compare prognostic factors is actually inappropriate here because by definition the null hypothesis that the two groups are the same is assumed to be true when the two groups are selected based on randomization. Therefore, any differences between the groups would be due to chance alone and considering them different would be a type 1 error. Additional Reading: Altman and Bland. Treatment allocation in controlled trials: why randomise? BMJ May 1999 Sander Greeland. Randomization, statistics, and causal inference. Epidemiology Nov 1990 Stephen Sean. Baseline Balance and Valid Statistical Analyses: Common Misunderstandings. Applied Clinical Trials. May 2005. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

Date: January 9th, 2020 Reference: Casey et al. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. NEJM February 2019 Guest Skeptic: Andrew Merelman is a critical care paramedic and second year medical student at Rocky Vista University in Colorado. His primary interests are resuscitation, critical care, airway management, and point-of-care ultrasound. Case: A 60-year-old male is in your emergency department with sepsis from pneumonia. He has worsening work of breathing and a decreasing level of consciousness. You decide based on his clinical presentation that he needs to be intubated. Due to his already poor oxygenation, you are concerned about him desaturating during intubation and wonder if there is anything you can do to help prevent it. Background: Emergency medicine is often referred to as the ABC (Airway, Breathing and Circulation) specialty. We have covered airway a few times on the SGEM: SGEM#75: Video Killed Direct Laryngoscopy? SGEM#96: Machine Head – NIPPV for Out of Hospital Respiratory Distress SGEM#247:Supraglottic Airways Gonna Save You for an OHCA? SGEM#249: Ace in the Hole – Confirming Endotracheal Tube Placement with POCUS SGEM#271: Bougie Wonderland for First Pass Success Rapid Sequence Intubation (RSI) has been a mainstay of emergency airway management for years. However, there are aspects of the procedure that have been debated, one of which is how best to oxygenate the patient during the apneic period while not increasing rates of aspiration. Clinical Question: Is bag-mask ventilation (BMV) performed during the apneic period of RSI (defined as the time between administration of RSI medications and intubation) in critically ill adults safe and effective? Reference: Casey et al. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. NEJM February 2019 Population: Adults patients (older than 17 years of age) undergoing induction and tracheal intubation in the intensive care unit. Exclusions: Patients who were pregnant, incarcerated, had immediate need for intubation or if the treating clinicians felt that ventilation was indicated or contraindicated between induction and laryngoscopy. Intervention: Bag-mask ventilation (BMV) during the time between administration of sedation/paralysis and insertion of the laryngoscope into the mouth for intubation. Comparison: Apnea with or without nasal cannula oxygen during the time between administration of sedation/paralysis and insertion of the laryngoscope into the mouth for intubation. Outcome: Primary Outcome: The lowest oxygen saturation observed during the interval between induction and two minutes after tracheal intubation. Secondary Outcome: The incidence of severe hypoxemia (oxygen saturation of less than 80%). Authors’ Conclusions: “Among critically ill adults undergoing tracheal intubation, patients receiving bag-mask ventilation had higher oxygen saturations and a lower incidence of severe hypoxemia than those receiving no ventilation.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. No All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. No 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 Key Results: They screened 667 patients and enrolled 401. The median age was 60 years, 56% were male and half the patients had sepsis or septic shock. Bag-mask ventilation group had higher oxygen saturations and less severe hypoxemia compared to the control group. Primary Outcome: Lowest oxygen saturation 96% (interquartile range, 87% to 99%) in the BMV group vs. 93% (interquartile range, 81% to 99%) in the no-ventilation group (P = 0.01). Secondary Outcome: 21 patients (11%) in the BMV group had severe hypoxemia vs. 45 patients (23%) in the no-ventilation group (relative risk, 0.48; 95% CI: 0.30 to 0.77). 1. Patients: Patients in this study were recruited from seven academic intensive care units (ICUs) in the United States. Eighty percent of the patients were intubated for respiratory failure. While many adult patients in the emergency department are intubated for the same reason many others are intubated of cardiac arrest and trauma depending on your place of practice. It is unclear if this study population has external validity outside the ICU and to the emergency department. Another thing about the patients who were excluded. The study did not enroll