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

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

Dive into the latest findings in emergency medicine as key research papers are dissected. Discover innovative pre-oxygenation techniques and the reliability of trials that can reshape clinical practices. Explore pivotal insights into pediatric injuries and the nuances of decision-making in critical situations. The discussion highlights biases in research and safe sedation methods for agitated patients, while also questioning the safety of anticoagulant reversal trials. A must-listen for anyone in the medical field!

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

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

In this discussion, Dr. Lauren Westafer, an Assistant Professor and pulmonary embolism expert from the University of Massachusetts Medical School, delves into the nuances of D-dimer testing. She highlights the challenges of ruling out pulmonary embolism (PE) in high-risk patients, spotlighting striking findings from recent research. The conversation critically assesses the reliability of D-dimer levels and biases in existing studies, urging a need for reevaluation of testing strategies for better outcomes in emergency medicine.

Dr. Aaron Skolnik, an Assistant Professor at Mayo Clinic and critical care expert, dives into the complexities of diagnosing sepsis. He highlights a critical case of a 62-year-old man with severe symptoms and discusses the limitations of current biomarkers. The conversation centers on monocyte distribution width (MDW) as a promising but not yet routine diagnostic tool for sepsis in emergency settings. Skolnik also examines biases in sepsis studies, underscoring the importance of clinician judgment in making accurate diagnoses.

Dr. Ross Prager, an Intensivist and adjunct professor, dives into the transformative role of AI in clinical research. He discusses how AI can enhance everything from study design to data analysis, but emphasizes the importance of collaboration for success. Ethical challenges, such as privacy risks and biases in AI models, are explored, along with the necessity of maintaining research integrity. Ultimately, the conversation reveals a future where AI revolutionizes patient-centered care while demanding vigilance from researchers.

In this engaging discussion, Dr. Tabitha Cheng, a board-certified emergency medicine physician with a focus on pediatric injuries, is joined by Dr. Caleb Ward and Dr. Julie Leonard, experts from the PECARN Network. They delve into the challenges of diagnosing cervical spine injuries in children post-accident and present a new three-tiered risk stratification system for imaging. The conversation emphasizes the importance of minimizing unnecessary radiation exposure and rethinking traditional emergency protocols, promoting a collaborative approach in pediatric care.

Dr. Jestin Carlson, a prominent figure in emergency medicine education, discusses the importance of engaging learning experiences, showcasing a dynamic course that reviews over 200 medical articles in exciting locales. The conversation shifts to the intricacies of ROC curves, emphasizing their role in evaluating medical tests while uncovering issues like p-hacking. Carlson advocates for transparency in research and stresses the need to consider various factors in clinical models, urging a skeptical approach to medical literature to improve patient care.