The Skeptics Guide to Emergency Medicine

Reference: Solnick et al. Sex Disparities in Chlamydia and Gonorrhea Treatment in US Adult Emergency Departments: A Systematic Review and Meta-analysis. AEM June 2025 Date: June 24, 2025 Guest Skeptic: Dr. Suchismita Datta. She is an Assistant Professor and Director of Research in the Department of Emergency Medicine at the NYU Grossman Long Island Hospital Campus. Case: A 24-year-old woman presents to the emergency department (ED) with a two-day history of dysuria, lower abdominal discomfort, and abnormal vaginal discharge. She is sexually active with multiple male partners and does not consistently use condoms. A urine nucleic acid amplification test (NAAT) is sent, and the patient is clinically diagnosed with a possible sexually transmitted infection (STI). She is not in acute distress, has no fever, and requests discharge after symptom control. Background: STIs such as chlamydia and gonorrhea remain significant public health concerns in the United States (US), particularly among young adults. EDs are increasingly serving as critical access points for STI screening and treatment. However, emerging evidence suggests that treatment practices may differ by patient sex, raising concerns about potential inequities in care delivery. Women are disproportionately affected by the long-term sequelae of untreated STIs, including pelvic inflammatory disease, ectopic pregnancy, and infertility. Despite this, treatment disparities may exist. Men presenting with STI symptoms often receive expedited care, while women, even when symptomatic or diagnosed, may not receive timely or adequate treatment. Potential explanations include differing clinical presentations, provider bias, and system-level barriers such as follow-up challenges or diagnostic uncertainty. Chlamydia and gonorrhea can present with a range of symptoms or be asymptomatic, which complicates timely diagnosis and treatment. While the Centers for Disease Control and Prevention (CDC) guidelines recommend empiric treatment in cases of high clinical suspicion, especially when patients may be lost to follow-up, the extent to which these guidelines are equitably applied across sexes remains uncertain. Clinical Question: Are there sex-based disparities in the treatment of chlamydia and gonorrhea among adults presenting to US emergency departments? Reference: Solnick et al. Sex Disparities in Chlamydia and Gonorrhea Treatment in US Adult Emergency Departments: A Systematic Review and Meta-analysis. AEM June 2025 Population: Adults (≥18 years) presenting to US EDs with testing for chlamydia or gonorrhea. Exclusions: Pediatric patients, individuals with incomplete demographic or treatment data, and those not diagnosed in the ED. Exposure: Receipt of appropriate antibiotic treatment during the ED visit. Comparison: Male versus female patients. Outcomes: GC/CT positivity, empiric treatment rates, and discordance between treatment and test results stratified by sex. Type of Study: Systematic review and meta-analysis Dr. Rachel Solnick This is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Rachel Solnick is an Assistant Professor of Emergency Medicine at the Icahn School of Medicine at Mount Sinai. Her research focuses on HIV prevention, STI care, and maternal health, with an emphasis on expanding access to high-quality reproductive and sexual healthcare for all emergency department patients. She is the PI of an NIH Career Development Award studying the implementation of HIV pre-exposure prophylaxis (PrEP) for ED patients diagnosed with STIs during telephone callbacks. Authors’ Conclusions: “Significant sex-based disparities exist in ED empiric antibiotic treatment for GC/CT. Females were 3.5 times more likely than males to be potentially under-treated. These findings underscore the need for targeted interventions to reduce disparities and improve treatment accuracy.

Dr. Aine Yore, an experienced Emergency Physician from Seattle and former ACEP president, dives into the critical topic of pre-oxygenation strategies for high-risk intubations. She highlights the superiority of high-flow nasal cannula in enhancing patient safety and reducing hypoxia. The discussion also critiques existing randomized controlled trials, emphasizing the importance of transparency in research. Yore engages listeners with intriguing insights from a network meta-analysis, wrapping it up with a fun musical trivia segment that blends entertainment with medical education.

Date: June 2, 2025 Dr. Andrew Tagg Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder and website lead of Don’t Forget the Bubbles. This is another SGEM Xtra that talks about what we can learn about being physicians from certain pop culture (TV and Movies). Past episodes include: Star Trek Made Me A Better Physician Lead Me On – What I Learned from Top Gun Holding Out for a Hero – Lessons from The Dark Knight Yeah, Might Be All that You Get – How Ted Lasso Made Us Better Doctor, Doctor – Paging Dr. Robby (The Pitt) Five EM Lessons from Mission Impossible Movies Precision Under Pressure: Ethan Hunt doesn’t get extra time or perfect conditions — and neither do we. Whether defusing a bomb or managing a crashing patient, calm execution under pressure saves lives. The Team is Everything: Hunt may be the face, but he’s nothing without Luther, Benji, and the crew. Medicine is no different: the best outcomes happen when we trust our team and play to each other’s strengths. Always Question the Intel: Just because it’s in the mission briefing doesn’t mean it’s true. Skeptical medicine is about challenging the “received wisdom” and verifying it before acting — just like a good IMF agent would Know Your Exit Strategy: Whether escaping a vault or de-escalating a high-stakes family discussion, always have a way out. Good clinicians plan for failure just as much as success — that’s what keeps patients (and careers) safe. Mission Fatigue is Real: Even Ethan looks wrecked sometimes. Adrenaline is not a sustainable fuel. We need to rest, recover, and recalibrate — especially if we want to perform at a high level over decades. The SGEM will return with a structured critical appraisal of a recent publication. We will continue to strive to reduce the Knowledge Translation (KT) window from over ten years to less than one year, leveraging the power of social media. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Dr. Ross Prager, an Intensivist at the London Health Sciences Centre, shares ten crucial life lessons that are often missing from medical education. He highlights the importance of emotional connections with patients, focusing on how genuine care trumps clinical knowledge. Prager emphasizes that true character shines in tough moments and shows that passion is not a weakness in medicine. He also critiques reliance on standard evidence while advocating for accuracy in diagnoses and nurturing personal joy in healthcare. Authenticity and kindness remain central themes.

Reference:  St Peter, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomized noni-inferiority trial. The Lancet. Jan 2025 Date: March 19, 2025 Dr. Camille Wu Guest Skeptic: Dr. Camille Wu is a paediatric surgeon based at Sydney Children’s Hospital where she is the Head of Department. She is also on the Training Committee of Paediatric Surgery for Australia and New Zealand. Case: A 10-year-old boy presents to the emergency department (ED) with his parents. He started having abdominal pain yesterday and did not want to eat. Today, his abdominal pain worsened, and he developed a fever. On examination, he looks uncomfortable and is tender to palpation in the right lower quadrant. You tell the parents that his examination is concerning for appendicitis. You order an ultrasound that demonstrates a dilated and non-compressible appendix. You consult the surgery team and both of you come to speak with the family. His parents tell you, “His sister was diagnosed with appendicitis during the Covid pandemic. At that time, she was admitted to the hospital but just treated with antibiotics. She was able to go home and has done well since that time. Do you think he needs surgery, or can he be treated with antibiotics as well?” Background: Acute appendicitis is one of the most common pediatric surgical complaints that we encounter in the ED. Traditionally, appendicectomy has been the gold standard for treatment, based on its effectiveness in preventing complications such as perforation, abscess formation, and peritonitis​. This is typically done laparoscopically through a few small incisions. The concept of non-operative treatment of appendicitis (NOTA) with antibiotics has gained interest over the past decade. This has been supported by growing evidence suggesting that some cases of uncomplicated appendicitis may resolve without surgery​. We have covered NOTA before on the SGEM that included some meta-analyses, randomized controlled trials, and observational studies. SGEM #115: Complicated-Non-operative Treatment of Appendicitis (NOTA) SGEM #180: The First Cut is the Deepest- N.O.T. for Paediatric Appendicitis SGEM #256: Doctor Doctor Give Me the News, I Gotta Bad Case of RLQ Pain- Should I have an Appendectomy? SGEM #345: Checking In, Checking Out for Non-Operative Treatment of Appendicitis (APPAC II RCT) SGEM #384: Take Me Out Tonight, I Don’t Want to Perforate My Appendix Alright The results have been mixed. Some of these studies have suggested that antibiotic therapy is non-inferior to surgical management while other studies have suggested antibiotic therapy did not meet criteria for non-inferiority compared to appendectomy. Most of these studies were conducted in the adult population with fewer studies conducted in children. The question remains: To cut or not to cut? Clinical Question: In children with acute uncomplicated appendicitis, is treatment with antibiotics non-inferior to appendicectomy? Reference:  St Peter, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomized noni-inferiority trial. The Lancet. Jan 2025 Population: Children aged 5-16 years with suspected non-perforated appendicitis based on clinical diagnosis +/- imaging Excluded: suspicion of perforated appendicitis, appendix mass/phlegmon, previous antibiotic treatment, positive pregnancy test, current treatment for malignancy, comorbid condition altering length of stay Intervention: Antibiotic therapy, initially with IV antibiotics followed by oral antibiotics after clinical improvement Comparison: Laparoscopic appendectomy Outcome: Primary Outcome: Treatment failure within 1 year. Secondary: Complications (adverse events that required interventions without general anesthesia), length of hospital stay,

Dr. Matt Schmitz, an orthopedic surgeon specializing in adolescent sports medicine at Rady Children’s Hospital, shares invaluable insights into scaphoid fracture management. He discusses the dilemmas of diagnosing these complex injuries, advocating for evidence-based approaches. Innovative research reveals that short-term bandaging may work as effectively as traditional casting. Schmitz also emphasizes the need to understand biases in clinical trials and offers alternative strategies for monitoring patients with suspected fractures, ultimately aiming for improved care outcomes.

Date: May 6, 2025 Guest Skeptic: Actor, producer and director Noah Wyle. Many of us know him as Dr. John Carter from ER, the show that arguably influenced an entire generation of EM physicians. Since that groundbreaking show, he has been busy with multiple movie roles (Pirates of Silicon Valley, Donnie Darko, White Oleander, Shot, and At the Gate) and TV series (The Librarian, Falling Skies, The Red Line and Leverage: Redemption). Noah is back in scrubs again, playing Dr. Robinavitch in The Pitt, a new medical drama that captures one chaotic, fifteen-hour emergency department shift. There will be no spoilers for the one or two SGEM listeners who haven’t streamed The Pitt. A  big shout-out to Dr. Mel Herbert, creator of EMRap, for setting up this interview. Mel has been on the SGEM talking about the extraordinary power of being average. Mel is also a medical consultant for The Pitt. Let’s set the scene of how The Pitt starts: Noah is shown walking to work for a day shift, hoodie on, earbuds in, scruffy beard, backpack, Yeti and cargo pants. He nailed the look of a seasoned EM doctor. The hoodie was from a brewery called Beers of the Burgh, and they are selling the hoodie Noah wears for the entire season. Noah's portrayal as Dr. Robby is so believable that I was instantly willing to suspend disbelief and accept him as a legit EM attending.  As an EM physician who has been practicing for nearly 30 years, I felt seen. We’ve done previous SGEM Xtra episodes on how pop culture helps us reflect on our practice of EM—Star Trek, Top Gun, Batman, and even Ted Lasso. But ER was perhaps the most formative show for this EM doctor. I started residency in 1995, and identify with the character, Dr. Robby, in The Pitt. This is especially true in today’s healthcare environment. FIVE NERDY QUESTIONS for Noah Wyle Listen to the SGEM Podcast to hear Noah answer the five nerdy questions. 1. Three Decades: It’s been 30 years since ER first aired in 1994. What’s changed in emergency medicine besides the disappearance of white lab coats and ties and the introduction of designer scrubs (Figs) or, in your case, a hoodie from a beer company? 2. Being A Doctor Again: What was the easiest and hardest part about returning to a role as an emergency physician? For me, it’s the incorporation of ultrasound and a drug names that keeps getting harder to pronounce. What was the easiest and hardest part for you stepping into the role of an EM attending decades later? Teamwork is essential in EM. We talk a lot about being on “Team Patient.” The cast, crew, set designers, writers, directors, and producers of The Pitt captured that flow state we strive for on shift. How did you and your team get into the flow? 3. Feedback: The show has resonated widely; dare I say cultural phenomenon. How has the response been from different groups from your perspective: healthcare workers (doctors, nurses, residents, etc), administrators, and patients? I’m watching it with my wife (Barb) while encouraging my friends and colleagues to do the same. It’s the most accurate window into my life as an attending EM physician that I’ve ever seen. 4. Evidence-Based Medicine: I teach EBM, which combines the best available evidence with clinical judgment while asking patient about their values and preferences. This means not following GUIDElines as if they were GODlines. The show reflects EBM beautifully. I hear you had an EM bootcamp to get the cast up to speed on terminology, procedures and other things. What was that like? I also hear you shadowed some real EM docs on shift. Any specific memories from that experience that informed your acting and the show? 5. Tough Topics: The show doesn’t shy away from tough topics like abortion, healthcare worker violence, vaccine hesitancy, miscarriage, organ donation, burnout, mass shootings, substance use among staff, moral injury, and so much more. Why was it important to tackle these head-on?

Reference: Umana E, et al. Performance of clinical decision aids for the care of young febrile infants: A multicenter prospective cohort study. eClinicalMedicine Lancet December 2024 Date: March 6, 2025 Dr. Demetris Athanasiou Guest Skeptic: Dr. Demetris Athanasiou is a paediatric registrar based in London and enrolled in the PEM MSc program through Queen Mary University in London. Case: A 6-week-old boy is brought by his parents to your emergency department (ED) for fever. His older sister has been sick with upper respiratory symptoms for the past week but seems to be recovering. Today, while his father was feeding him a bottle, he noticed that the baby was feeling warm and took his temperature, which was 38.2°C (100.7 °F). The boy has otherwise been feeding and acting normally. You examine the baby with an astute medical trainee. As you discuss the next steps in management, she asks you, “I know there’s a bunch of guidelines or decision tools to help risk stratify which babies are low risk for bacterial infections, but I can never keep them straight. Is there one you prefer?” Background: Back in the day, we were performing lumbar punctures (LP) on febrile infants up to 3 months of age because there was concern for bacterial infections. We used to lump urinary tract infections, bacteremia, and meningitis under one umbrella term, “serious bacterial infection” or SBI. Recently, we’ve been told to stop using that term and be more specific about what we are referring to. Bacteremia and meningitis have been termed invasive bacterial infections (IBI) and, fortunately, are rare, occurring in 1-4%. There have been several guidelines and clinical decision tools, such as those developed by the National Institute for Health and Care Excellence (NICE), the American Academy of Pediatrics (AAP), and others that offer strategies to identify low-risk infants who might avoid invasive procedures like a lumbar puncture. These clinical decision tools have been developed to stratify febrile infants into high- and low-risk categories to balance the risk of under-treatment and over-treatment. Several of these tools have been reviewed on the SGEM. SGEM #341: AAP Guidelines SGEM #296: PECARN SGEM #171: Step By Step The hot new test is procalcitonin. Unfortunately, it’s expensive, and not all EDs have access to it or can receive the results promptly to help with decision making. Some are still using other inflammatory markers like C-reactive protein (CRP). With ongoing research and evolving guidelines, the clinical utility of these decision tools continues to be refined. Understanding their strengths, limitations, and applicability in various healthcare systems remains a crucial aspect of evidence-based emergency medicine. Clinical Question: How well do various clinical decision aids perform in identifying febrile infants at low risk for invasive bacterial infection? Reference: Umana E, et al. Performance of clinical decision aids for the care of young febrile infants: A multicenter prospective cohort study. eClinicalMedicine Lancet December 2024 Population: Infants from birth to 90 days of age from across 35 paediatric EDs and paediatric assessment units across the UK and Ireland with fever ≥38°C Excluded: Guardians who declined or withdrew consent Intervention: Application of clinical decision aids (CDA) [American Academy of Pediatrics (AAP), British Society Antimicrobial Chemotherapy (BSAC), National Institute for Health and Care Excellence (NICE) NG143, Aronson] Comparison: Against each other and “treat all” approach Outcome: Primary Outcome: Diagnostic accuracy of CDAs Secondary Outcomes: Etiology of IBI, clinical predictors of IBI, and mean cost per patient Trial: Prospective multicenter cohort study Guest Author : Dr. Etimbuk Umana (Timbs) is a consultant in emergency medicine and lead author of the FIDO study.

Dr. Howie Mell, a board-certified emergency physician and EMS expert, dives into the heated debate over using Midazolam versus Ketamine for acute agitation in pre-hospital settings. He unpackages clinical decision-making, examining the urgency of sedation strategies and their safety implications. Listeners will gain insights into observational study challenges and the importance of local factors in applying research findings. With a focus on real-world scenarios, Mell highlights key considerations for managing agitated patients effectively among varied emergency environments.

In this discussion, emergency physician researcher Hashem Kareemi delves into the integration of AI in emergency medical care, exploring its potential to improve clinical decisions under pressure. Dr. Kirsty Challen, a seasoned emergency medicine consultant, shares insights on the evolution of clinical decision support systems and the pressing need for ethical AI implementation. They tackle challenges in the current AI landscape, reflect on healthcare inequities, and emphasize the necessity of clinician involvement to ensure technology enhances patient care rather than complicates it.