The Skeptics Guide to Emergency Medicine

Reference: Jessen et al. Pharmacological interventions for the acute treatment of hyperkalaemia: A systematic review and meta-analysis. Resuscitation 2025 Date: August 6, 2025 Guest Skeptic: William Toon is a paramedic who, this past May achieved over 50 years of continuous EMS certification. His professional path has taken him from front-line paramedic to national presenter, expert witness, flight medic, EMS program director, and senior training executive with a doctorate in Higher Education. Case: A 65-year-old patient presents to the emergency department (ED) with general weakness, mild abdominal cramping, and nausea over the past 12 hours. The patient has poorly controlled type 2 diabetes, heart failure with reduced ejection fraction, and chronic kidney disease stage 4 on hemodialysis. The patient missed their last dialysis appointment two days ago. The patient takes several medications for kidney disease and blood pressure, including a potassium-sparing diuretic. His ECG shows peaked T-waves. Stat chemistry reveals a serum potassium of 6.5 mmol/L. He is not yet oliguric and is hemodynamically stable. The team must initiate pharmacologic treatment immediately while preparing for possible escalation to dialysis. Background: Hyperkalemia is a potentially life-threatening electrolyte abnormality frequently encountered in the ED. It’s common in patients with chronic kidney disease, diabetes, or those on renin-angiotensin-aldosterone system (RAAS) inhibitors. While treatments like insulin, beta-agonists, and calcium gluconate are well-known, the comparative efficacy and safety of pharmacologic agents used to rapidly reduce serum potassium remain uncertain. Clinicians must balance rapid action with safety when choosing treatment for hyperkalemia. Understanding which pharmacologic interventions work best and how quickly they act is vital to optimizing care. Unfortunately, much of the existing data on hyperkalemia treatment is derived from small or methodologically limited trials. Clinical Question: What is the effectiveness of pharmacological interventions in the acute treatment of hyperkalemia compared to standard care, placebo, or other interventions in adults? Reference: Jessen et al. Pharmacological interventions for the acute treatment of hyperkalaemia: A systematic review and meta-analysis. Resuscitation 2025 Population: Adult patients with hyperkalemia (typically defined as serum potassium ≥5.0 mmol/L). Studies included varied populations such as those with CKD, dialysis patients, and acutely ill inpatients. Exclusions: Patients under 18 and those receiving non-pharmacologic interventions (dialysis) were excluded. Intervention: Any acute pharmacological intervention to mitigate the harmful effects of hyperkalemia or to lower potassium levels. Comparison: Placebo, standard care, or head-to-head comparisons of other pharmacologic interventions. Outcome: Primary Outcome: Change in serum potassium from baseline at specific time points (1, 2, 4, and 6 hours). Secondary Outcomes: Proportion of patients achieving normokalaemia, adverse events (hypoglycaemia), need for rescue therapy (dialysis), and all-cause mortality. Type of study: Systematic review and meta-analysis Authors’ Conclusions: “Evidence supports treatment with insulin in combination with glucose, inhaled or intravenous salbutamol, or the combination. No evidence supporting a clinical effect of calcium or bicarbonate for hyperkalaemia was identified.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. No The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Yes There was low statistical heterogeneity for the primary outcomes. No

Date: August 11, 2025 Dr. Gillian Schmitz Guest Skeptic: Dr. Gillian Schmitz is a board-certified Emergency Physician practicing at The Naval Medical Center in San Diego. She is also a former President of the American College of Emergency Physicians (ACEP). This SGEM Xtra is inspired by the 1992 film A League of Their Own. Unlike our previous pop culture references like Buffy the Vampire Slayer, Star Trek, Batman, Top Gun, Ted Lasso and Mission: Impossible, this story is based on real events. The All-American Girls Professional Baseball League (AAGPBL) was created in 1943 and lasted until 1954. This league gave over 600 women a chance to play pro baseball. For the SGEMers who may not have seen this movie, here is a summary. A League of Their Own (1992) is a sports drama directed by Penny Marshall that tells the fictionalized story of the real-life All-American Girls Professional Baseball League. It was formed during World War II when many male baseball players were serving overseas. The film follows sisters Dottie Hinson and Kit Keller as they join the Rockford Peaches and navigate the challenges of playing professional baseball in a male-dominated society. With a blend of humour, heart, and historical insight, the film highlights themes of gender roles, perseverance, and the lasting bonds formed through sport. Top 5 Themes from “A League of Their Own” As chosen and interpreted by Dr. Gillian Schmitz. Listen to the SEGM podcast to hear her full description of what the quotes mean to her. “I don’t have ball players. I have girls.” – Jimmy Dugan This quote reflects how society has historically minimized women’s capabilities in professional arenas. Emergency medicine, like baseball in the 1940s, has not always welcomed women without skepticism. Concerns about femininity, perception, and acceptance parallel the gender biases faced by women in emergency medicine leadership today. Even ‘proper’ women had concerns, expressing their worries about the ‘masculinization’ of these pioneer female athletes. Sound familiar? We have done several shows on the SGEM illustrating the gender inequity in the house of medicine. SGEM#352: Amendment – Addressing Gender Inequities in Academic Emergency Medicine SGEM Xtra: From EBM to FBM – Gender Equity in the House of Medicine SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease SGEM#248: She Works Hard for the Money – Time’s Up in Healthcare SGEM Xtra: Money, Money, Money It’s A Rich Man’s World – In the House of Medicine SGEM Xtra: I’m in a FIX State of Mind “Why should you go? To say for once you actually did something… something special.” – Kit to Dottie This line speaks to the deep calling many women in emergency medicine feel. It reminds us of the early emergency medicine pioneers who were often told they were wasting their time. Yet they pressed forward, driven by the belief they could make a real difference. That passion to do something special, despite the challenges, still drives many of us in emergency medicine today. If you want to do something special, despite the challenge, then head over to FemInEM.org led by Drs. Dara Kass, Esther Choo, Jenny Beck-Esmay and the legend of emergency medicine, Dr. Diane Birnmaumer.  We also recently did an SGEM Xtra: This is My Fight Song - FeminEM 2.0. They are doing some amazing things, advancing gender equity in emergency medicine, improving reproductive healthcare delivery in emergency departments, mentorship and being champions of change. “You know, if I had your job, I’d kill myself.” – John Lovitz This moment of dry sarcasm reflects the burnout and emotional toll our specialty can bring. But it also highlights that, despite the difficulty, emergency medicine remains the best job in the world for many. I couldn’t imagine doing anything else. Emergency medicine still lights me up. “You gotta go where things happen.” – Marla’s Dad

Reference: Otterness et al. The Use of TENS for the Treatment of Back Pain in the Emergency Department: A Randomized Controlled Trial. AEM Aug 2025 Date: August 22, 2025 Guest Skeptic: Dr. Lauren Westafer is an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School, Baystate. She is the co-founder of FOAMcast and a researcher in pulmonary embolism and implementation science.  Dr. Westafer serves as the research methodology editor for Annals of Emergency Medicine. Case: A 44-year-old man presents to the emergency department (ED) with low back pain after bending to pick up his child. He has pain in his left lower back that is worse when he moves. He has no fever, chills, weakness, or numbness. He has well-controlled hypertension and no history of recent antibiotic use or drug use. The patient has no midline tenderness, is without neurological deficit, and has no red flag features on history and physical exam. He took 500 mg of acetaminophen a few times without significant relief. Background: Back pain is one of the most common reasons patients seek ED care, with an estimated 2.5 million ED visits for back pain each year. After dangerous diagnoses such as spinal epidural abscess, cord compression, and ruptured abdominal aortic aneurysm have been excluded, the next challenge for emergency clinicians is analgesia to improve the patient’s pain and mobility. Unfortunately, there are numerous causes of musculoskeletal low back pain, rendering a single treatment course inconsistently effective for all-comers. Many pharmacological and non-pharmacological therapies have been tried with limited efficacy.  Acetaminophen (Williams et al Lancet 2014) Muscle relaxants (Friedman et al JAMA 2015) NSAIDs (Machado et al Ann Rheum Dis 2017) Steroids (Balakrishnamoorthy et al Emerg Med J 2014) Benzodiazepines (Friedman et al Ann Emerg Med 2017) Cognitive Behavioral Therapy and mindfulness (Cherkin et al JAMA 2016) Chiropractic (Paige et al JAMA 2017) Physical therapy (Paolucci et al J Pain Research 2018) Acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013) One treatment that can be very effective but comes with very real potential harms is opioids. The American College of Emergency Physicians (ACEP) has addressed the issue of opioid use in patients being discharged home after an acute episode of pain. They give a Level C Recommendation saying: Do not routinely prescribe, or knowingly cause to be co-prescribed, a simultaneous course of opioids and benzodiazepines (as well as other muscle relaxants/sedative-hypnotics) for treatment of an acute episode of pain in patients discharged from the emergency department (Consensus recommendation).  Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological modality that administers low-intensity electrical stimulation to inhibit nociceptive pain signals. The efficacy of TENS devices in acute low back pain is uncertain. Clinical Question: Is transcutaneous electrical nerve stimulation (TENS) more effective at relieving back pain than sham TENS? Reference: Otterness et al. The Use of TENS for the Treatment of Back Pain in the Emergency Department: A Randomized Controlled Trial. AEM Aug 2025 Population: Adult ED patients (≥18 yr) with thoracic or lumbar back pain of at least moderate severity when research assistants were present (Mon–Fri, 8a–8p). Exclusions: Patients with suspected spinal cord injury or infectious etiology, fractures, hemodynamic instability, allergy to standard analgesics, pacemakers, and those with skin conditions precluding TENS application were excluded. Intervention: Two cutaneous TENS adhesive pads above and below the point of maximal tenderness with TENS unit set at a point just below the pain threshold and gradually increased for up to 30 minutes. Comparison: Sham TENS pads applied but no electrical current.

Reference:  Othman AA, et al. Combined ketamine and midazolam vs. midazolam alone for initial treatment of pediatric generalized convulsive status epilepticus (Ket-Mid study): A randomized controlled trial. Pediatric Neurology. June 2025 Date: May 27, 2025 Dr. James Chamberlain Guest Skeptic: Dr. James Chamberlain is a pediatric emergency medicine attending physician at Children’s National Hospital in Washington, DC where he is the Director of Data Analytics and Informatics for the Division of Emergency Medicine. He is also a Professor of Emergency Medicine and Pediatrics at George Washington School of Medicine and Health Sciences. He has led or co-led two large national trials of status epilepticus and is starting a third, the Ketamine adjuvant for Established Status Epilepticus Treatment Trial (KESETT). Case: A two-year-old boy with a known seizure disorder is brought to the emergency department (ED) by his family for a seizure at home. The episode is described as generalized tonic-clonic activity which self-resolved after about a minute. He was post-ictal afterwards and has not fully returned to baseline. He has not had any recent fevers or illnesses. During your conversation with his parents, he starts seizing again. You administer two doses of a benzodiazepine, but the seizure continues. You give an additional levetiracetam load, which stops the seizure activity, and he is admitted to the hospital for observation. Afterwards, a medical trainee you are working with says to you, “I read that there’s been interest in other medications like ketamine in the treatment of seizures. Do you think there would have been any benefit in giving ketamine earlier?” Background: We often see children presenting with seizures in the ED. Currently, the standard of care recommends the use of benzodiazepines such as midazolam as first-line treatment. Midazolam, but not the other benzodiazepines, can be given intravenously, intramuscularly, intranasally, or as a buccal paste. Sometimes this works and stops the seizure activity. Sometimes it does not. Seizures that are refractory to treatment are dangerous and can lead to neuronal injury, long-term deficits, or even death. We want to stop seizure activity as quickly as we can. The typical management of seizures is to give a benzodiapene. If that does not work, give a second dose. If that still doesn't stop the seizure, then administer another anti-seizure medication like levetiracetam, fosphenytoin, or valproate. There’s been increasing interest in the use of ketamine for seizures. There are several factors that make ketamine potentially a very powerful drug for status epilepticus. Ketamine is an NMDA receptor antagonist and therefore theoretically should break the vicious cycle of status. There have been dozens of animal studies in at least 4 different species demonstrating efficacy as early treatment of status. In some of these studies, ketamine and other NMDA receptor antagonists are neuroprotective. In humans, ketamine is widely used for super refractory status, when all other medications have failed. Estimates are that it is about 70% effective for this indication. We have a long track record of using ketamine safely in the emergency department setting and growing experience in EMS. Ketamine is well tolerated, short-acting, and preserves protective airway reflexes and ventilation. Even very large accidental overdoses have been well tolerated. The one caveat is that we don’t know if all these safety parameters hold in the condition of status epilepticus, but limited case series have not shown safety problems. Currently, it is not part of conventional therapy for pediatric status epilepticus, but there is thought that it may work synergistically with benzodiazepines in stopping seizures. Clinical Question: Is ketamine combined with midazolam more effective than midazolam alone in the treatment of pediatric generalized convulsive status...

Date: July 10, 2025 Guest Skeptics: Professor Timothy Caulfield is a Canadian professor of law at the University of Alberta, the Research Director of its Health Law Institute. His area of expertise is in legal, policy and ethical issues in medical research and its commercialization. This is another SGEM Xtra book review. Tim was our guest skeptic a few years ago, discussing his book called Relax, Dammit! A User’s Guide to the Age of Anxiety. He is back on the SGEM to discuss his latest book called The Certainty Illusion: What You Don't Know and Why It Matters. I asked Tim several questions about his book. Please listen to the podcast to hear his responses.  Questions for Professor Caulfield The book is structured into three main parts. In Part I: The Science Illusion, you examine how scientific language and imagery are co-opted to confer credibility on dubious claims. You discuss how quantum physics has been misappropriated by the wellness and alternative medicine industries. Why do you think "quantum" has become such a powerful marketing tool? The phrase "It’s Science!" is often used to shut down debate. What are the dangers of weaponizing the language of science? You talk about Zombie Science (ideas that refuse to die despite mountains of evidence). I’ve given a lecture for the Gateway Centre of Excellence in Rural Health on zombie ideas about hospital crowding. What is a good example of zombie science in health and wellness? At the end of Part I, you introduce ‘The Humility Fix" as a potential solution. Can you explain why intellectual humility is a necessary antidote to misinformation? In Part II: The Goodness Illusion, you unpack how concepts of health, sustainability, and morality are manipulated to create a false sense of certainty. You explore things like "health halos," in which terms like "clean," "organic," and "natural" are used to mislead consumers. Can you expand on that concept? You list 12 words in total that you call the "Devious Dozen". These are a set of misleading or overhyped health and wellness claims that exploit public perception and create a false sense of certainty. These terms and concepts are often used in marketing, politics, and public discourse to manipulate consumers and reinforce misinformation. Do you have a couple of favourites? You also talk about how virtue signalling and ideological narratives shape public opinion, often overriding evidence-based reasoning. The idea that our desire to do what’s "right" can be exploited through misleading claims about health, wellness, and even sustainability. What’s an example of this in the medical field, and how can healthcare professionals push back against it? You also discuss the White Hat Bias in this section of the book. It is a phenomenon where research findings are distorted in the service of what is perceived as a noble or righteous cause. This bias leads to the overrepresentation of certain findings, particularly in fields like public health, nutrition, and medicine, where there is strong societal motivation to support outcomes. Who coined the term White Hat Bias? Can you give an example of the White Hat Bias from the COVID-19 pandemic? In Part III of the book, you discuss The Opinion Illusion. This delves into how the digital age has fueled an economy of opinion, where ratings, reviews, and social media influence create misleading perceptions of truth and expertise. How has the “opinion economy” shaped modern decision-making? How has this shift impacted our ability to discern truth from misinformation? You highlight the influence of online reviews and rankings. Why do people trust anonymous reviews more than expert opinions or personal recommendations? What role do algorithms play in distorting our perception of consensus and credibility?  The book isn’t all doom and gloom. You do offer some solutions for navigating this chaotic information environm...

Reference: Kemal et al. Emergency department utilization by youth before and after firearm injury. AEM July 2025 Date: July 28, 2025 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine in the UK and an evidence-based medicine advocate. She's a seasoned knowledge translator with her wonderful PaperinaPic infographics.   Case: Your non-US emergency department (ED) has recently been shaken by the attendance of a teenager with a gunshot injury. Subsequent investigation has found he attended a different hospital in the region six weeks ago with a stab wound. The team wonders if that attendance was an opportunity to intervene. Background: Firearm injuries are now the leading cause of death in youth in the United States, surpassing motor vehicle collisions.[1] While the immediate clinical management of gunshot wounds is well covered in emergency medicine training, there is less clarity around what happens before and after that ED visit. Could we identify these high-risk youth earlier? Do patterns of ED use provide clues for intervention? The ED often serves as the primary healthcare contact point for youth exposed to community violence. Some youth injured by firearms may have prior ED visits for mental health crises or minor injuries, presenting opportunities for preventative strategies. But are we missing these cues? Additionally, once youth survive a firearm injury, they face elevated risk for repeat injury, psychological trauma, and even death. Understanding post-injury healthcare utilization may reveal missed chances for intervention, particularly in general EDs that may lack pediatric-specific resources. Clinical Question: Do youth with firearm injuries have increased emergency department utilization before and after their injury compared to their peers? Reference: Kemal et al. Emergency department utilization by youth before and after firearm injury. AEM July 2025 Population: Youth aged 10 to 19 years who had an index ED visit for a firearm injury in 2019 across eight US states, identified from the Healthcare Cost and Utilization Project database. Exclusion: Youth who lacked the data to assess 90 days before or after the index injury, and those without longitudinal ED visit linkage, injuries from non-power firearms, and recurrent visits with firearm injury. Exposure: Having sustained a firearm injury as indexed by an ED visit. Comparison: ED utilization by the same patients in the 90 days before and after the firearm injury. Outcomes: Primary Outcome: Number and types of ED visits 90 days before and after the index firearm injury. Secondary Outcomes: Types of ED visits and recurrence of trauma. Type of Study: Retrospective cohort study using linked administrative claims data. Dr. Samaa Kemal This is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Samaa Kemal is an early-career pediatric emergency medicine clinician-investigator at Ann & Robert H. Lurie Children's Hospital of Chicago. Her work is primarily focused on the intersection of violence and health equity in children. Her research priorities are focused on developing and implementing novel and effective solutions to prevent violent injuries and subsequent adverse outcomes in children.  Authors’ Conclusions: “Youth have high rates of ED utilization before and after firearm injury. Half of firearm-injured youth receive their emergency care exclusively in general EDs. Implementing firearm injury prevention and intervention efforts in all ED settings is critical.” 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

Reference: Bourke EM, et al. PEAChY-O: Pharmacological Emergency Management of Agitation in Children and Young People: A Randomized Controlled Trial of Oral Medication. Annals of Emergency Medicine. Feb 2025 Date: April 29, 2025 Guest Skeptic: Dr. Brad Sobolewski, is a pediatric emergency medicine physician at Cincinnati Children’s Hospital and Professor of Pediatrics at the University of Cincinnati College of Dr. Brad Sobolewski Medicine. He is the creator of the PEMBlog and host of PEM Currents: The Pediatric Emergency Medicine Podcast. Brad is passionate about using digital media to translate complex clinical concepts into engaging, accessible educational content. His work centers on advancing knowledge sharing through innovative, tech-forward approaches to medical education. Case: A 14-year-old girl with no known medical or psychiatric history presents to the emergency department (ED) with her family for aggression. Her parents tell you that they have been getting into arguments a lot recently. Today, she became so angry that she started punching and kicking the walls at home. You interview the girl and perform your physical examination, and determine that there are likely no medical diagnoses contributing to her aggression, nor that she has sustained any injuries requiring immediate management. After you leave the room and her parents enter, you hear them get into another argument, and she gets more agitated. The staff try a combination of de-escalation techniques, but she continues to be aggressive and starts threatening the staff. A nurse working with you asks, “I don’t think our de-escalation techniques are working. Do you want to give her something to help calm her down? We have olanzapine or diazepam here. Which one do you want to give?”  Background: Pediatric agitation can be defined as a clinical state characterized by heightened motor activity, emotional arousal, and often aggressive or disruptive behavior outside of expected developmental norms. It can be triggered by many things like underlying psychiatric disorders, medical conditions (like delirium, hypoxia, or metabolic disturbances), substance intoxication or withdrawal, and situational stressors, such as hospitalization or separation from caregivers​. In the ED setting, pediatric agitation presents unique challenges. Not only can it compromise the safety of the child, caregivers, and medical staff, but it can also delay care and exacerbate underlying conditions​. When a child presents with extreme agitation or aggression, the first step is to take a broad, thoughtful approach. We can’t just assume it’s a psychiatric issue. Medical causes like hypoglycemia, intoxication, or even something like new-onset diabetic ketoacidosis can present this way. Missing these diagnoses could be dangerous. Once we’ve ruled out organic causes, the focus shifts to early recognition and de-escalation. We try to identify the signs that a child is becoming more agitated before they escalate further. The goal is to intervene early and often with non-pharmacologic strategies. This can mean adjusting the environment: dimming the lights, reducing noise, giving the child space, or removing extra staff from the room. Sometimes something as simple as offering a snack, a drink, or a comfort item can make a big difference. Re-direction, distraction, and using calm, supportive language can also go a long way. Of course, there are times when those strategies aren’t enough, and we may need to use physical restraints or medications. But that should never be our starting point. The overarching goal is to approach these situations with empathy and respect. Support the child and their family while protecting everyone’s safety, including our own. There’s no perfect medication for agitation so it really depends on the situation. If the child is cooperative, start with an oral option. It gives the child a bit of control and helps avoid the trauma of restraint or an ...

Date: July 9, 2025 Guest Skeptics: Dr. Cindy Bitter is an Associate Professor in the Division of Emergency Medicine at Saint Louis University. She has a Master’s in Bioethics, and she is passionate about EM capacity building and physician resilience, especially improving wellness through time in nature.    Dr. Amy Bi is a graduate from the SSM Health Saint Louis University Emergency Medicine residency and the University of Missouri School of Medicine. She is interested in continuing medical education, orange theory, and travelling. This is an SGEM Xtra episode, which takes us back to the late '90s to explore the intersection of pop culture and professional practice through the lens of Buffy the Vampire Slayer. It's similar to the episodes we did about Star Trek, Top Gun, Dark Knight, Ted Lasso, and The Pitt. Cindy reached out to me about a presentation she made at the HumanisEM conference. It's an interdisciplinary conference that explores the intersections of the Health Humanities and Emergency Medicine, started in 2023. The presentation at the conference was inspired by a conversation with female residents about why Buffy remains a must-watch show for young professionals, especially in medicine. In the lecture, we explore lessons from the show that resonate with emergency physicians and healthcare professionals. Click on the LINK for a copy of the slides. There may be some people like me who are not familiar with the show. Buffy the Vampire Slayer premiered in 1997 and ran for seven seasons. Its central premise was that the seemingly dumb blonde chick who is the first to get killed in horror movies is trained to fight back. Ultimately, the monsters were symbols of the challenges we face on the way to growing up and creating a meaningful life. The show hid a healthy dose of existential philosophy under the quips, music, and 90s fashion, and continues to gain fans more than 20 years after it ended. Career Advice from Buffy the Vampire Slayer Honour Your Calling Quote: “You talk about slaying like it’s a job, it’s not. It’s who you are”. What’s My Line? Part 2; S2, ep 10. Writer: Marti Noxon Our path in medicine is somewhat different than the “one girl in all the world” who is destined to fight the forces of darkness, but there are analogies. Buffy sometimes struggles with her calling but ultimately accepts her path (Prophecy Girl). And she shows that this is not a single event, but something she chooses every day (What’s My Line, Anne, Amends). We come to medicine with our own set of strengths and skills, choose our path, and actively reaffirm it as we complete years of education and residency training. There are certainly challenges in our healthcare system, but there is also connection and sometimes even joy. Meeting Challenges Quote: “Bottom line is, even if you see 'em coming, you're not ready for the big moments. No one asks for their life to change, not really. But it does. So, what are we, helpless? Puppets? No. The big moments are gonna come. You can't help that. It's what you do afterwards that counts. That's when you find out who you are.” Becoming, part 1; S2, ep 22. Writer: Joss Whedon Quote: “From now on, we won’t just face our worst fears, we will seek them out. There’s only one thing in this world more powerful than evil, and that’s us.” Bring on the Night; S7, ep 10. Writer: Marti Noxon with Douglas Petrie Medical school, residency, and even attending life are filled with learning from students, residents, coworkers, nurses, colleagues, and administrators. We must incorporate new evidence into our practice, learn from mistakes, and improve for future encounters. New situations come at us all the time; it’s how we strategize and confront them that counts. That might mean reading up on disease presentations we do not see often or practicing high-acuity, low-occurrence procedures. Knowing we are prepared for the challenges we s...

Reference: Arnold CG, et al. Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule. Acad Emerg Med. Jan 2025 Date: May 7, 2025 Dr. Sandi Angus Guest Skeptic : Dr. Sandi Angus is a Paediatric and Adult Emergency Medicine Registrar in the Shrewsbury and Telford Hospital NHS Trust. She is passionate about paediatric EM, wellbeing and medical education. Case: A ten-year-old boy presents to your emergency department (ED) after being involved in a motor vehicle collision at high speed. Emergency Medical Service (EMS) tells you that he was properly restrained. His parents were also in the vehicle and are currently being brought to the ED as well. He appeared a bit dazed initially, but he has had a Glasgow Coma Scale (GCS) score of 15 throughout transport. Your primary survey is unremarkable. He complains of some abdominal pain, although you note a soft abdomen on exam and no seatbelt sign. As you complete your secondary survey, he vomits once, which is non-bloody. A medical trainee working with says to you, “He says his stomach hurts and threw up. Do you think we need to CT scan his abdomen?” Background: Intra-abdominal injury (IAI) in children is a significant concern for emergency physicians. This is particularly true in cases of blunt trauma. Although relatively uncommon compared to adults, IAIs in children can be life-threatening. We have to identify them early and manage them appropriately. The organs most frequently injured include the spleen, liver, and kidneys, but any abdominal organ can be affected​. Diagnosing IAIs in pediatric patients poses a unique challenge. Children often present with subtle clinical findings, and the physical examination can be unreliable due to factors such as altered mental status, distracting injuries, or the child’s inability to articulate their symptoms​. Imaging modalities like computed tomography (CT) are the gold standard for diagnosis, but CT use must be balanced against the risks of ionizing radiation. Traditionally, clinicians relied heavily on their clinical gestalt, but this approach can miss injuries or lead to unnecessary imaging. The risks of CT imaging are not inconsequential. Children are more radiosensitive than adults, and for each  abdominal or pelvic scan, the lifetime risks of cancer are 1 per 500 scans, irrespective of the age at exposure. However, this is actually very small compared with the background risk of developing cancer in a lifetime, which is 1 in 3, so if your scan is clinically justified, the benefit is likely to outweigh the potential harm [1]. To improve diagnostic accuracy and minimize unnecessary CT scans, clinical decision rules (CDRs) or “tools” have been developed. One such tool, the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rule for intra-abdominal injuries, identifies children at very low risk of clinically important IAIs, aiming to safely reduce CT utilization​ [2-3]. This rule was composed of seven variables, all of which could be collected on history and physical exam. There was no need for labs or imaging in this decision rule. These seven variables were: Evidence of abdominal wall trauma or seat belt sign GCS <14 and blunt abdominal trauma Abdominal tenderness Thoracic wall trauma Complaint of abdominal pain Decreased breath sounds Vomiting If all seven variables were negative, the child was at very low risk of having intra-abdominal injury requiring intervention and the decision rule recommended against a CT scan. Despite the benefits of existing decision rules, the question remains how best to apply these tools when only one or two PECARN criteria are positive—a clinical gray zone not well characterized in earlier validation studies. Understanding the individual performance of PECARN rule components in predicting IAI is crucial for refining decision-making in pediatric t...

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.