The Skeptics Guide to Emergency Medicine

Date: December 23, 2025 Reference: Todd et al. Antihypertensive prescription is associated with improved 30-day outcomes for discharged hypertensive emergency department patients. J Am Coll Emerg Physicians Open. 2024 Guest Skeptic: Dr. Mike Pallaci is a Professor of Emergency Medicine at Northeast Ohio Medical University and a Clinical Professor of Emergency Medicine at Ohio University Heritage College of Osteopathic Medicine. He currently serves as Core Faculty for the USACS EM Residency at Summa Health System in Akron, OH where he is also Medical Director for the Virtual Care Simulation Lab, Director for the Simulation Medicine Fellowship and Vice Chair for Faculty and Resident Development. Over the course of his 24-year career in EM (15 in academics), he has worked in EDs with volumes ranging from 6,000 to 85,000 per year in urban and rural areas, in community and academic institutions, and has served as Program Director for two EM residencies. He has given lectures and published podcasts and articles in all areas of Emergency Medicine, including at the ACOEP Scientific Assembly, on the EM:RAP platform and right here on the SGEM. Prior research has resulted in book chapters, journal publications and presentations at multiple regional, national and international conferences on numerous topics including medical education, chest pain, pain management, gender bias, documentation, wellness, medicolegal issues, emergency ultrasound, hypertension and others. Case: A 47-year-old male presents to the emergency department (ED) with an ankle sprain. Admitting vital signs include a blood pressure of 210/130, which is similar on repeat measurements. He has no complaints except for ankle pain. He is in good health, has no known medical history, and has a primary care doctor whom he hasn't seen in about 6 or 7 years. Background: Hypertension is one of the most common “incidental” findings in the ED. In the US, there are over 900,000 annual ED visits with elevated blood pressure, and that number is climbing each year. Up to a third of these patients have no prior diagnosis of hypertension. Chronic uncontrolled blood pressure is strongly associated with myocardial infarction, stroke, heart failure, renal failure, and death, so these “incidental” readings are not benign. Standard outpatient care focuses on confirming the diagnosis with repeated measurements and then starting long-term therapy (lifestyle plus medications) to reduce cardiovascular events and mortality over the years, with randomized trial and meta-analytic evidence that treating hypertension reduces composite cardiovascular events and death. The ED, however, sits at an awkward intersection between chronic disease and acute care. Many patients we see with elevated blood pressure are asymptomatic or have nonspecific complaints, with no clear end-organ damage. Guidelines generally allow ED physicians considerable discretion about whether to initiate oral antihypertensives at discharge versus simply arranging follow-up. In 2025, the American College of Emergency Physicians (ACEP) published an updated policy regarding patients with asymptomatic markedly elevated blood pressure. They asked whether ED medical intervention reduces rates of adverse outcomes. They provided a Level C Recommendation that said: In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required. In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control. [Consensus recommendation] Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up. [Consensus recommendation] Previous work suggests that starting antihypertensives from the ED is safe and improves short-term blood pressure control in high-risk populations. Still, there has been very little evidence about patient-oriented short-term outcomes (myocardial infarction, stroke, heart failure, death, and ED revisits). Clinical Question: Among adult ED patients discharged with a diagnosis of hypertension and not on antihypertensive therapy, is an ED discharge prescription for an oral antihypertensive medication associated with a lower 30-day risk of severe hypertension-related adverse events, death, or ED revisits? Reference: Todd et al. Antihypertensive prescription is associated with improved 30-day outcomes for discharged hypertensive emergency department patients. J Am Coll Emerg Physicians Open. 2024 Population: Adult patients (≥18 years) seen and discharged from an ED within a single hospital system with a primary or secondary ED discharge diagnosis of essential (primary) hypertension and hypertensive urgency without prior treatment for hypertension during the previous 18 months. Excluded: Patients admitted to the hospital or to ED observation. Those who died in the ED. Patients without documented elevated blood pressure (BP <140/90). Pregnant patients. ED stay >48 hours. Anyone prescribed an antihypertensive in the 18 months prior. Patients with a severe adverse event (AE) that were already present at ED discharge. Visits with missing gender or race data. Exposure: Receiving a prescription for an oral antihypertensive medication at ED discharge. Comparison: Discharged hypertensive ED patients meeting the same inclusion/exclusion criteria who did not receive an antihypertensive prescription at ED discharge. Outcome: Primary Outcome: Severe composite adverse events from hypertension within 30 days of ED discharge (Acute aortic catastrophe, Acute heart failure, Myocardial infarction, Hemorrhagic stroke, Ischemic stroke or Hypertensive encephalopathy) Secondary Outcomes: All-cause death within 30 days of ED discharge and ED revisit within 30 days of ED discharge. Type of Study: Retrospective observational cohort study Authors’ Conclusions: “Prescription antihypertensive therapy for discharged ED patients is associated with a 30-day decrease in severe adverse events and ED revisit rate.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? YES Did the authors use an appropriate method to answer their question? YES Was the cohort recruited in an acceptable way? YES Was the exposure accurately measured to minimize bias? UNSURE Was the outcome accurately measured to minimize bias? UNSURE Have the authors identified all important confounding factors? NO Was the follow-up of the subjects sufficient? UNSURE How precise are the results? YES Do you believe the results? YES Can the results be applied to the local population? YES Do the results fit with other available evidence? YES Who funded the trial? The study is explicitly described as unfunded research. Did the authors declare any conflicts of interest? NO Results: After applying the inclusion and exclusion criteria, they had 93,512 ED visits with a discharge diagnosis of hypertension. The mean age was 59 years, 57% female, 59% white, 10% received antihypertensive treatment in the ED before discharge, and 5% received an antihypertensive prescription at ED discharge. Patients prescribed antihypertensives at discharge were younger, more often male and Black, had higher systolic and diastolic blood pressure, lower comorbidity burden, were more likely to have received antihypertensives in the ED, and less likely to have prior heart failure. Key Result: One in 20 hypertensive ED patients received an antihypertensive prescription at discharge; among those who did, the adjusted odds of severe 30-day adverse events and ED revisits were substantially lower, with no difference in 30-day mortality compared with those who did not receive a prescription. Primary Outcome: Severe adverse events within 30 days 0.7% untreated vs 0.2% treated aOR 0.224 (95% CI; 0.106 to 0.416, p<0.001) Number needed to treat (NNT) 183 (95% CI; 161 to 247) to prevent one adverse event. Secondary Outcomes All cause death at 30 days: No statistical difference between groups (5 deaths in treated vs 105 untreated, aOR 1.445, 95% CI; 0.476–3.583, p=0.467). ED revisit within 30 days: Fewer in the treated group (10% vs 16%). Adjusted aOR 0.610 (95% CI; 0.547 to 0.678, p<0.001). NNT 18 (95% CI 16 to 23) to prevent one ED revisit. Individual Adverse Events: Antihypertensive therapy was significantly associated with decreased odds of acute heart failure (aOR 0.183, 95% CI; 0.056 to 0.441). No statistical difference in aortic catastrophe, MI, ischemic stroke, hemorrhagic stroke, and hypertensive encephalopathy, with some components having zero events in the treated group. 1. Residual Confounding: This is an observational treatment study, not a randomized trial, so the decision to prescribe is influenced by physician judgment and patient factors. Treated patients were younger, had less comorbidity, and were more likely to have received antihypertensives in the ED and to get follow-up prescriptions later. This suggests that they differed systematically from untreated patients. Even with multivariable adjustment and inverse probability weighting, unmeasured factors such as medication adherence, health literacy, or clinician concern could both drive the decision to treat and influence the likelihood of good outcomes. 2. Composite Endpoint: Death, severe adverse event or....ED revisit. That's kind of like a composite endpoint of you die, you have a myocardial infarction, or you sprain your ankle. As you would expect, the vast majority of patients who met one of these criteria (14,208 out of 14,978, almost 95%) had repeat ED visits. There was no significant difference in deaths. While there was a statistically significant difference in severe adverse events, the NNT to prevent one was 183,

Date: November 27, 2025  Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: You are looking after a 65-year-old man who appears to be in septic shock. He presented after five days of fever and cough, and is now severely lethargic and hypotensive on arrival. You give him antibiotics and IV fluids immediately, but an hour later, his lactate comes back at 5, and you need to start norepinephrine to keep his MAP above 65. You put in a call to the intensive care unit (ICU) to get him transferred, and the intensivist asks you whether you have started personalized hemodynamic resuscitation targeting capillary refill time. You don’t want to sound dumb, but what the heck is personalized hemodynamic resuscitation protocol targeting capillary refill time? Background: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is the most severe end of that spectrum. Patients with sepsis have persistent hypotension requiring vasopressors to maintain MAP ≥65 mm Hg and a lactate >2 mmol/L despite adequate volume resuscitation (Sepsis‑3). In high-income countries, mortality has fallen but remains substantial.  In many settings, mortality can be between 30% to 70%. High-quality ED care requires early recognition, IV antibiotics, source control, hemodynamically directed fluids, and vasopressors. The management of septic shock has changed dramatically since the time that Ken and I started practice. We went through a period in which a very aggressive bundle of care was proposed, based on work by Dr. Emanuel Rivers, published in the NEJM in 2001. Then, we ran big trials on the components of that bundle, and found that none of them helped individually (ARISE, ProCESS & ProMISe). It was clear that these patients benefited from close attention and clinical reassessments, but aside from early antibiotics, the exact interventions needed were unclear. For a while, many people focused on trending lactate levels. We then saw the original ANDROMEDA SHOCK study, which showed that a resuscitation strategy focused on clinical assessments of capillary refill time was at least as good as a strategy focused on trending lactates. We have been left with the question of exactly how to improve capillary refill and which other targets are important. There has been a question about whether a higher MAP target might help (SGEM#90), especially in elderly patients with more baseline hypertension.  But the recent OPTRESS study showed worse outcomes with a higher MAP target in elderly septic shock patients. Therefore, aside from the consensus that providing early antibiotics is a good idea, there remain many questions about the ideal initial resuscitation strategy for septic shock patients. Clinical Question: In adult patients with septic shock, can death, duration of vital support, and/or hospital length of stay be improved by a “personalized hemodynamic resuscitation protocol targeting capillary refill time? Reference:  Hernandez et al. Personalized Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial. JAMA. 2025 Oct Population: Adults (≥18 y) with septic shock per Sepsis‑3 (vasopressors after ≥1 L IV fluid and lactate >2 mmol/L), within 4 hours of shock onset. Key Exclusions: >4 h from shock onset; anticipated surgery or dialysis within 6 h; expected survival <90 days; refractory shock; DNAR; Child‑Pugh B/C; severe ARDS; active bleeding; pregnancy; inability to assess CRT (peripheral vascular disease, hypothermia, very dark skin tone, Raynaud phenomenon). Intervention: A personalized hemodynamic resuscitation protocol targeting capillary refill time (CRT) using a 6-hour stepwise algorithm (see below). Comparison: Usual care per local protocols/guidelines. Outcome: Primary Outcome: A hierarchical composite tested with a stratified win ratio of: (1) 28-day all-cause mortality, then (2) duration of vital support (time requiring cardiovascular, respiratory, or kidney support) through day 28, then (3) hospital length of stay through day 28. Secondary Outcomes: Secondary outcomes were each of the three components of the primary outcome. Trial: This is a pragmatic, multi-center, open-label, randomized controlled trial. Authors’ Conclusions: “Among patients with early septic shock, a personalized hemodynamic resuscitation protocol targeting capillary refill time was superior to usual care for the primary composite outcome, primarily due to a lower duration of vital support.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Yes The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Unsure Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Unsure The treatment effect was sufficiently large and precise to be clinically significant. Unsure Financial conflicts of interest. The researchers at each study site had to get their own fund, so this was truly researcher-driven. Although a few of these researchers have ties to industry, they do not seem to have any obvious financial conflicts of interest that would be relevant to this protocol. Results: They randomized 1,501 patients and were able to analyze 1,467. The median age was ~66 years, and 43% were female. The severity of sepsis was an APACHE II of ~18 and a SOFA of 8. Sources of infection were ~48% abdominal, ~20% respiratory, and ~20% urinary. Baseline supports included invasive ventilation ~48%, norepinephrine 100% (median ~0.21 to 0.23 µg/kg/min). Lactate median ~3.6 mmol/L. Median time from shock criteria to randomization was 2 hours (IQR 1 to 3). Key Results: Compared with usual care, CRT‑PHR produced a statistically significant advantage on the hierarchical composite, driven mainly by shorter duration of vital support, while 28‑day mortality was nearly identical between groups. Primary Outcome: Based on their stratified win ratio analysis of their composite outcome, there were 131,131 wins for the CRT-PHR group and 112,787 wins for the usual care group, resulting in a win ratio of 1.16 (95% CI 1.01-1.33, p=0.04) Secondary Outcomes:  No statistical difference in mortality (26.5% vs 26.6%, p=0.91). There was a statistical decrease of 1 day in mean vital support free days (16.5 vs 15.4). Vital sign support free days is also a composite outcome. They don’t report the specific components of this outcome, but based on the supplementary material, there doesn’t seem to be any real difference in the use of mechanical ventilation or vasopressors, and so the entire difference in this trial might come down to a 1-day difference in renal replacement therapy. There was no statistical difference in hospital length of stay (15.3 vs 16.2). 1. Unmasked Trial with Subjective Outcome Changes: Open-label trials increase the risk of performance bias. Mortality is an objective outcome and was completely unchanged here. The part of the component outcome that changed was “vital support free days”. However, treatment decisions are highly subjective and can be influenced by treatments the patient has already received. Therefore, this outcome is at high risk of bias in an unmasked trial. 2. Composite Outcomes: Composite outcomes have been discussed on the SGEM several times. They are endpoints in clinical research that combine multiple individual events. In this trial, they combined all-cause mortality, vital support and length of stay into a single measure to capture the overall effect of the intervention. Composite outcomes can be useful when individual events are too rare to provide adequate statistical power, allowing researchers to detect treatment effects with smaller sample sizes or shorter follow-up. However, composite outcomes must be interpreted cautiously because the components may vary greatly in clinical importance or frequency [1,2,3].  In addition, the trial’s reported benefit may be driven largely by less important or more common components rather than the outcomes that matter most to patients.  In this ANDROMEDA SHOCK-2 trial, there was no 28-day mortality benefit (26.5% vs 26.6%; HR 0.99), but there was a statistical difference in fewer days of vital support. Performing a hierarchical composite analysis gave a win ratio was 1.16 (95% CI 1.02–1.33; P=0.04). This means a net advantage for the CRT‑personalized resuscitation strategy. 3. Lipstick on a Pig? One of the criticisms of composite outcomes is that each outcome is valued the same. Changing the analysis into a hierarchical model with pre-specified outcomes of importance attempts to address this limitation (death first, then major morbidity and then resource utilization). Analysis typically compares each patient in the intervention arm with each patient in the control arm (or matched pairs) and determines a “win,” “loss,” or “tie” based on the highest‑priority endpoint on which the pair differs. Only if tied at that level does the comparison proceed to the next level in the hierarchy. The net effect is summarized as a win ratio (or a “stratified win ratio,” if stratified by baseline risk). The number of wins for the intervention divided by the number of wins for control (values >1 favour the intervention).

Date: Dec 17, 2025 Reference: Pagnini F, et al. Unexpected events and prosocial behavior: the Batman effect. npj Mental Health Research. November 2025 Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine physician at Children’s National in Washington, DC. You may also know him as the host of SGEM Peds. Case: It’s been a dark, cold day in Gotham City. You’re finally on the metro heading home after a long shift. The train is packed, and you’re standing, crammed uncomfortably among all the other citizens eager to get home. Outside, you see the holiday lights and decorations, trying valiantly to shine through the flurries of snow. At the next stop, you see a visibly pregnant passenger board the crowded train car. She shuffles in and stands, holding the rail. No one around her moves. No one gets up to offer their seat. Hardly anyone even notices. You pull your coat a bit tighter around you and wonder: What’s it going to take to nudge people to be a little more helpful? Background: Prosocial behaviour is something we rely on every shift but hardly ever discuss explicitly. Psychologists typically define it as voluntary actions aimed at helping others. Examples include holding a door open, donating money, giving up your seat, or stepping in to assist a stranger. It’s an umbrella term that covers everything from simple everyday kindness to extraordinary acts of altruism. The world just saw an extraordinary example of prosocial behaviour in the Bondi Beach attack ‘hero’, Ahmed Al Ahmed. Motivations vary: empathy and concern for others, a desire to follow social norms, expectations of reciprocity, and even a wish to avoid guilt all influence prosocial behaviour. Prosocial behaviour has traditionally been studied in several primary ways. In the lab, researchers use economic games (such as dictator, ultimatum, and public goods games), staged helping tasks (such as picking up dropped pens or assisting with a “broken” computer), or vignette-based scenarios (“Would you stop to help?”). In real-world settings, classic bystander studies explore whether people intervene when someone seems in need and what situational factors (crowding, diffusion of responsibility, perceived danger) influence their decision to act or remain passive. Throughout all approaches, a key theme is that context plays a crucial role: the same individual may assist in one situation but ignore someone in another. Over the past decade, there has been increasing interest in how subtle environmental cues influence prosocial behaviour. Mindfulness research indicates that when people focus on the present moment, they may be more inclined to notice others’ needs and respond accordingly, although the evidence remains modest and not definitive. Another area of study examines "social primes." For example, images of superheroes can temporarily boost helping intentions and small acts of assistance. A related body of research on the “pique technique” demonstrates that unusual, unexpected events or requests can disrupt automatic “no” responses and increase compliance or helping, likely by pulling people out of autopilot. The “Batman effect” study we explore today extends these ideas into real-world scenarios. Could an unexpected disruption, such as a person dressed as Batman, increase a specific prosocial behaviour? For an emergency physician accustomed to crowded waiting rooms and chaotic departments, it’s an intriguing yet potentially significant question: can small, harmless environmental “shocks” encourage people to do the right thing a little more often without anyone ever having to take a mandatory module on ethics? Clinical Question: Among passengers on a crowded metropolitan subway, does the presence of an unexpected event (a person dressed as Batman) increase the likelihood that someone offers their seat to a pregnant-appearing woman, compared with no Batman present? Reference: Pagnini F, et al. Unexpected events and prosocial behavior: the Batman effect. npj Mental Health Research. November 2025 Population: Passengers in crowded cars on the Milan underground metro. Intervention: Presence of someone dressed as Batman (~3 meters away, no interaction with an experimenter pretending to be a visibly pregnant woman). Comparison: Identical set-up without Batman Outcome: Whether the seated passenger offered their seat to the (pretend) pregnant woman during a single-stop ride Type of Study: Quasi-experimental, non-randomized controlled field study. Both conditions were conducted simultaneously in different train cars and different areas of the platforms. Authors’ Conclusion: “This study suggests that unexpected events can increase prosocial behavior by momentarily disrupting automatic attention patterns and fostering situational awareness. These findings open new avenues for understanding the environmental and cognitive mechanisms underlying prosociality, and suggest potential applications for promoting kindness and cooperation in everyday settings—extending the “Batman effect” to nonsuperheroes as well.” Quality Checklist for Quasi-Experimental Studies: Is it clear what is the ‘cause’ and what is the ‘effect’? Yes Were the participants included in any comparisons similar? Unsure  Were participants in any comparisons receiving similar treatment/care other than the exposure? Yes Was there a control group? Yes Were there multiple measurements of the outcome both pre and post the intervention/exposure? No Was follow-up complete, and if not, were differences adequately described and analyzed? Yes Were the outcomes of participants in any comparisons measured in the same way? Yes Were outcomes measured in a reliable way? Unsure  Was appropriate statistical analysis used? Yes Results: They conducted 138 observations (70 control and 68 experimental with Batman). Most who offered up their seat were women (~68%) with a mean age of approximately 42 years. Key Result: Passengers were roughly three times more likely to give up their seat for a pregnant-appearing woman when Batman was present on the train compared with when he was not. Primary Outcome: Offering a seat to the pregnant woman 38% control vs 67% Batman Odds ratio (OR) = 3.39, p < 0.001 They also conducted brief follow-up interviews with the passengers who gave up their seats and asked whether they had seen Batman. Many spoke about recognizing pregnancy, social norms, education or safety. Nobody directly admitted to giving up their seat because Batman was there. In fact, 44% of those interviewed stated they didn’t see Batman at all. 1. Hawthorne Effect: When discussing this type of field experiment, it is important to mention the Hawthorne effect, which is the idea that people change their behaviour simply because they know they are being observed. In this study, a designated observer recorded whether passengers offered their seat to the pregnant woman. It is not specified how the observer tried (or did not try) to blend into the environment. It is possible that some passengers realized they were being observed, which could have influenced their actions. 2. Confounding: We applaud the authors for attempting to avoid confounding by concurrently conducting experiments with two research teams in different train cars and areas of the platform. The train cars also had to have all seats occupied with no more than five people standing between seats. Ultimately, this was not a randomized experiment. While they looked at Batman vs No Batman scenarios, that may not be the only thing that differs amongst the groups represented in their respective train cars, which was not measured or reported. In an exaggerated example, what if the car with Batman was full of nuns while the other car had a more heterogeneous smattering of society? Did people give up their seats because Batman was there or because they were or were not nuns (assuming that nuns are more charitable)? We also don’t know if the behaviour of the “pregnant” experimenter changed at all between scenarios. Did she always choose to stand in the same place? Did she make or avoid eye contact with the people around her? Were there other environmental factors that made her easier or more difficult to notice? 3. Outcome Measurement: The outcome of interest was the number of people who gave up their seats to the pregnant woman. Based on the methods, it looks like there was only one observer. The study findings may have been more robust if they had more than one observer and reported inter-rater reliability. I’m reminded of the selective attention test, where the viewer is tasked with counting how many times players pass a ball without noticing the gorilla that walks in and out of the frame. 4. Loss to Follow Up: Among the 138 observations, 70 instances of prosocial behaviour were observed. Of those, only 52 (74%) were interviewed during follow-up. This makes us wonder: What about the people who weren’t interviewed? Would they have provided us with more insight or breadth about their reasons for giving up the seat? Would some of the people who weren’t interviewed in the experimental design have stated that they saw Batman? 5. Generalizability: The experiment was conducted in the Milan metro system. There are likely differences in cultural or societal norms that make the findings of this study less generalizable to all transit systems worldwide. One example may be that the number of stops or the distance between stops varies. Shorter distances between stops and more frequent stops could encourage more people to give up their seats to pregnant women as their stop approaches. Is it actually the Batman Effect? This threat to validity hurts me a little bit to admit…because my confirmation bias says “Of course it was the presence of Batman who was responsible for people doing good!” But I mean, who is Batman?

Reference: Binder ZW et al. “Ultrasound-Guided Nerve Block for Pediatric Femur Fractures in the Emergency Department: A Prospective Multi-Center Study.” Academic Emergency Medicine, 2025. Date: November 24, 2025 Dr. Lauren Westafer Guest Skeptic: Dr. Lauren Westafer is an Associate 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 9-year-old boy presents to the emergency department after a trampoline injury. He was at a party with his friends and they were all bouncing together and competing to see who could bounce the highest. The boy fell down on his right leg and a friend accidentally landed on it. On your exam, the boy is in significant pain and has a deformity of his right leg. You do not note any additional injuries. X-rays confirm a mid-shaft femur fracture. You administer some IV morphine, but the boy is still whimpering in pain. One of the other attending physicians on shift who happens to be an ultrasound enthusiast, suggests using an ultrasound-guided nerve block as a way to manage the boy's pain. The boy’s parents ask “What is that?” Background: Femur fractures are one of the most painful injuries in pediatric patients and frequently require hospital admission for definitive treatment, often with long ED stays prior to operative management. Traditional pain management for these injuries relies heavily on IV opioids, which have well-documented side effects including nausea, respiratory depression, and sedation. Increasing public awareness of the opioid crisis has also led to growing parental concern over opioid exposure in children. There is growing interest in opioid-sparing pain control methods. The fascia iliaca compartment nerve block (FICNB) is a regional anesthesia technique that targets the femoral nerve and adjacent sensory nerves to provide localized pain relief. While landmark-based FICNB techniques have been used successfully in adult patients, recent studies suggest that ultrasound guidance improves the accuracy and safety of these procedures. However, evidence on the effectiveness and safety of ultrasound-guided FICNB in pediatric patients, particularly when performed by emergency physicians in real-world ED settings, remains limited.  Clinical Question: In children with femur fractures, is ultrasound-guided FICNB more effective at reducing pain compared to systemic analgesia? Reference: Binder ZW et al. “Ultrasound-Guided Nerve Block for Pediatric Femur Fractures in the Emergency Department: A Prospective Multi-Center Study.” Academic Emergency Medicine, 2025. Population: Children aged 4–17 years presenting to the ED with isolated, acute femur fractures. Excluded:  Patient with neurovascular compromise, multi-trauma, GCS ≤13, bilateral fractures, allergy to anesthetics, prisoners, pregnancy. Intervention: Ultrasound-guided fascia iliaca compartment nerve block (FICNB) performed with ropivacaine or bupivacaine Comparison: Systemic analgesia administered at discretion of ED treating team Outcome: Primary Outcome: Reduction in pain intensity at 60 minutes using the Faces Pain Scale–Revised (FPS-R). Secondary Outcomes: Reduction in pain at 240 minutes, opioid consumption (oral morphine equivalents per hour), occurrence of adverse events, and emergency department (ED) length of stay. Trial: Prospective multi-center observational study conducted at 12 pediatric emergency departments in the US and Australia. Some sites performed FICNB. Other sites did not. Dr. Zachary Binder Guest Author: Dr. Zachary Binder is a pediatric emergency medicine attending physician at UMass Memorial Health and Associate Professor at UMass Chan Medical School. He is the Director of Point-of-Care Ultrasound for the Department of Pediatrics and the medical school. Authors’ Conclusions: Children who received FICNB had greater reductions in pain intensity and required less opioid medication than those who did not. This is the largest prospective study evaluating the ultrasound-guided FICNB performed on children in the ED, and its findings support the procedure’s use for pediatric femur fracture pain management. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes.  Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes.  How precise are the results? Fairly precise Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes.  Funding of the Study: No financial conflicts of interest Results: They included a total of 114 participants (54 in the FICNB group and 60 in the non-FICNB group).  The mean age was ~10 years old, with ~20% female. Fractures were mostly displaced (91% vs 83%), while open fractures were rare (~2%). Most had received opioids before enrollment (96% vs 88%).  FICNBs were performed by attendings (37%), fellows (33%), or residents (30%) under supervision. Half were performed or supervised by attendings with advanced POCUS training. Key Results: Children who received FICNB had greater reduction in pain compared to those who did not, without more adverse events or longer ED LOS. Primary Outcome (Pain reduction at 60 min) There was a mean decrease of 3.8 points (95% CI, 3.1 to 4.6) in the FICNB group compared to a decrease of 0.8 points in the non-FICNB group (95% CI, -0.2 to 1.9).  That was a difference of 3.0 (95% CI, 1.7 to 4.3).  Secondary Outcomes When it came to pain reduction at 240 min, there was a mean decrease of 3.6 points (95% CI, 2.6 to 4.5) in the FICNB group vs. 1.7 points (95% CI, 0.7 to 2.7) in the non-FICNB group. That was a difference of 1.9; (95% CI, 0.5 to 3.2). The FICBN also received less opioids after enrollment measured as oral morphine equivalents per hour (OME/hr). This was 0.3 in the FICBN group vs. 1.1 in the non-FICBN group). This was a difference of 0.8 (95% CI, 0.4 to 1.1). ED length of stay in both groups was 6.1 hours with overlapping 95% CI. There was not much difference in adverse events between the two groups (5.6% FICNB vs 8.3% non-FICNB), with no serious complications attributable to FICNB. One patient in the FICNB group had apnea but had also received ketamine, fentanyl and midazolam.    Listen to the SGEM podcast to hear Zack respond to our five nerdy points. Selection Bias Twelve sites were included. The proportion of physicians able to perform the nerve block ranged from 25-100% of the faculty. There were four sites that did not routinely perform FICNB. For the sites that did perform the nerve block, it was only performed when someone trained to do it was on shift (which makes sense). Patients may also have been missed for other reasons such as maybe it was too busy on shift or there was a fast disposition from ED to the operating room. However, this also means that there is a group of eligible kids that may have been missed with this convenience sampling. How do you think this selection bias may have impacted the results of the study? Performing FICNB We can’t imagine that a young child is going to be thrilled seeing a long needle being introduced to the leg that is already broken. How do you do this practically? Are you having to give any additional medications for anxiolysis prior to this? Are you worried about the patient moving during this process? Any tips on how to fit this into the workflow of a busy ED shift? One other thing that we were looking for was whether or not all of these blocks were successfully placed on the first attempt or did some require multiple attempts? Ultrasound Training and Competencies We were impressed that in this study, the nerve block was performed by a mix of attending physicians (37%) and fellows and residents under supervision. What does it take to train someone to perform this nerve block? How do you determine they are capable enough to be credentialed? Generalizability It’s mentioned in the paper that four of the 12 sites involved in this project did not routinely perform FICNB. It’s also mentioned that at some of these sites, not performing FICNB would be considered substandard care. This is quite a variation even amongst academic children’s hospitals which may make this practice less generalizable to the community or rural settings.  What do you think are some of the biggest barriers and challenges in having this practice be adopted more widely? Is it the lack of trained staff? Buy-in from orthopedic colleagues? Patient and Family Experience While the primary outcome of pain reduction was very patient-oriented, we can’t help but wonder, did you collect any additional data about the experience of patients or families? Were they overall satisfied with the care they received nerve block or not? Did any express preference for nerve block or systemic analgesia? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion. SGEM Bottom Line: Ultrasound-guided fascia iliaca compartment nerve blocks were associated with clinically meaningful pain reduction and less opioid use for pediatric femur fractures in the ED without prolonging length of stay.

Date: December 4, 2025 Guest Skeptic: Dr. Jestin Carlson – Long-time listener, second-time guest.   Reference: Reinaud et al. Reporting of Noninferiority Margins on ClinicalTrials.gov: A Systematic Review. JAMA Netw Open. 2025 Case: You are working with a resident who asks you about a new thrombolytic they heard about on the SGEM for acute ischemic stroke.  This new treatment was found not to be inferior to the existing thrombolytic, but they are not sure how the paper reached that conclusion.  You start to discuss noninferiority margins when the resident asks you, “Are the noninferiority margins reported on ClinicalTrials.gov consistent with the final publications?” Background: A non-inferiority (NI) trial asks whether a new strategy is “not unacceptably worse” than an established, effective strategy by more than a pre-specified amount. The non-inferiority margin (Δ) or delta is the largest loss of effectiveness we would tolerate in exchange for another advantage (lower cost, easier logistics, fewer adverse effects). Regulators and methods groups emphasize that Δ must be clinically justified, pre-specified, and not chosen after seeing the data. The Δ is then tested using a one-sided hypothesis procedure or, equivalently, by checking whether the confidence interval for the treatment difference stays within Δ. For example, a new medicine to treat hypertension lowers patients’ systolic blood pressure by 1 point more than the standard treatment but causes gastrointestinal (GI) upset in 50% of patients.  That difference may be statistically significant, but clinically it doesn’t result in a net benefit for the patients since so many of them get GI upset.  Ideally, the noninferiority margins should be set up before the trial is conducted to minimize bias.  Many modern ED trials rely on NI logic (TNK vs tPA for stroke, non-operative treatment of appendicitis, Simple Aspiration versus Drainage for Complete Pneumothorax, etc).  However, prior work suggested poor reporting of noninferiority margins with reporting rates as low as 2.6% for studies published between 2012 and 2014.  That was over 10 years ago...hopefully we have improved since then.  Clinical Question: What proportion of registered noninferiority randomized trials report the noninferiority margin at registration, and how consistent are margins between ClinicalTrials.gov and corresponding publications? Reference: Reinaud et al. Reporting of Noninferiority Margins on ClinicalTrials.gov: A Systematic Review. JAMA Netw Open. 2025 Population: All registered non‑inferiority trials on ClinicalTrials.gov with primary completion 2010–2015 (Stage 1) and all first‑posted 2022–2023 (Stage 2). Excluded: Nonrandomized, single-arm, phase 1–2/2–3, diagnostic/screening trials where noninferiority was only a secondary outcome. Exposure: Presence of a prespecified noninferiority margin reported on ClinicalTrials.gov (at registration / during enrollment / after primary completion / in posted results). Comparison: Descriptive contrasts across timepoints and between the registry and corresponding publications (consistency). Outcome: Primary Outcome: Proportion reporting the noninferiority margin at registration on ClinicalTrials.gov. Secondary Outcomes: Timing of first reporting (registration, during enrollment, after completion, or in posted results); proportion reporting margin in posted results; proportion reporting margin in the corresponding publication; justification of margin; consistency between registry and publication; reporting of primary analysis population and Type I Error. Type of Study: A systematic review of registered randomized trials’ methods reporting. Authors’ Conclusions: “Reporting of the noninferiority margin on ClinicalTrials.gov was low (3.0% in 2010–2015 sample, 9.2% in 2022-2023 sample). Because margins are central to design and interpretation, mandatory reporting of trial design and the noninferiority margin at registration would improve transparency and reliability of noninferiority trial results.” Quality Checklist for Systematic Review: Was the main question clearly stated? Yes Was the search detailed and exhaustive? Yes  Were the inclusion criteria appropriate? Yes Included studies sufficiently valid? Yes Results similar from study to study? Yes Any financial conflicts of interest? Authors do not report any financial conflicts of interest. Results: In the 2010 to 2015 cohort (n=266), 60% were industry‑funded; most evaluated drugs/biologics (~67%); parallel‑arm designs predominated (94%); open‑label was common (49%); adults‑only accounted for 74%; and the median planned sample size was 304 (IQR 63 to 545). The 2022 to 2023 cohort (n=327) showed similar patterns with more adult-only studies (83%) and a median planned sample size 228 (IQR 50 to 406). Key Result: Very few trials pre-specified a Δ at registration, a super majority reported a Δ in their publication and registry‑to‑publication consistency could only be evaluated in a handful of studies. 2010 to 2015 sample (n=266) Only 8 trials (3%) reported the planned noninferiority margin at registration. 31 trials (11.7%) first reported a margin after registration (11 during enrollment; 20 after primary completion). Of 132 trials with results posted on ClinicalTrials.gov, 79 (59.8%) reported the noninferiority margin in the posted results. Corresponding publications were found for 208 trials (2010–2015 sample); 196/208 (94.2%) publications reported the noninferiority margin, and 86/196 (41.3%) justified it. 2022 to 2023 sample (n=327) 30 trials (9%) reported the margin at registration (a modest improvement but still low); only 6 of these justified. When margins were reported in both the registry and the publication, they were identical in the 5 trials that reported margins at registration and in publication; margins in posted results and publications were consistent for all but 1 of 63 trials. Registry Transparency: ClinicalTirals.gov lacks a mandatory, structured field for trial design type and noninferiority margin. The authors suggest mandatory fields to prevent untraceable post-hoc margin changes. Building and maintaining trust in the scientific literature depends on ensuring we are honest and transparent in the scientific process.  This includes transparency in registration.  Potential for Bias: Post-hoc or late specification of margins can bias conclusions. A margin change after seeing the data can turn a noninferior result from “fail” to “pass”. This would be like p-hacking or HARKing (hypothesizing after results are known). Overinterpreting Non-inferiority Trials: The goal of non-inferiority trials is exactly that...to determine if one treatment is not inferior to another. It does not prove whether the treatment is effective.  In addition, even if margins are pre-specified, they can be clinically meaningless. Readers still need to appraise whether the Δ represent something the patient would consider non-inferior.  Single Trial Registry: This study used a single registry (ClinicalTrials.gov) and did not search the study protocols. There are many registries where clinical trials can be registered, including the Australian New Zealand Clinical Trials Registry, the Chinese Clinical Trial Registry and EU Clinical Trials Register, to name a few.  How these results generalize to other registries is unknown. Ensuring Consistency with Reporting: FDA guidance and the CONSORT extension for noninferiority trials emphasize pre-specification and justification of margins. We should expect this in both registration and publication.  In addition, journals, editors, and reviewers may insist that the author report not only the margins at the time of publication but also whether the margins were published at the time of registration.  Comment on the Authors’ Conclusion Compared to the SGEM Conclusion: We generally agree with the authors’ conclusions.  SGEM Bottom Line: Non-inferiority margins need to be pre-specified, justified, and clinically acceptable, and this new review shows we often can’t verify that from the trial registry alone. Case Resolution: You tell the resident that when you read a noninferiority trial, check the publication for margin justification, when possible, verify pre-specification in the trial registry or protocol and reflect on whether the margin is clinically relevant. Treat noninferiority claims cautiously if the margin is not prospectively registered. Clinical Application: Be skeptical when reading the results of a non-inferiority trial and cross-check them against what is reported on clinicaltrials.gov if it was registered there.  What Do I Tell the Patient? N/A Keener Kontest: Last week’s winner was Brad Roney. He knew the pain was defined by the International Association for the Study of Pain (IASP) as: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Listen to the SGEM podcast for this week’s question. If you know, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode. Other FOAMed: First10EM - You Don't Understand Non-Inferiority Trials (and neither do I) Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.   Additional Readings & Resources: D'Agostino RB Sr, Massaro JM, Sullivan LM. Non-inferiority trials: design concepts and issues - the encounters of academic consultants in statistics. Stat Med. 2003 Jan 30;22(2):169-86. doi: 10.1002/sim.1425. PMID: 12520555. Kaul S, Diamond GA. Good enough: a primer on the analysis and interpretation of noninferiority trials. Ann Intern Med. 2006 Jul 4;145(1):62-9.

Date: November 26, 2025 Reference: Ray et al. Emergency Department Visit Frequency Among Adults with Chronic Abdominal Pain: Findings From the 2023 US National Health Interview Survey. AEM November 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 PaperinaPic infographics.   Case: You are mid-shift in what feels like the never-ending winter of emergency medicine, and you hear the sigh as your resident picks up the chart of the next patient to be seen. Wondering if the resident requires coffee or support, you ask what is wrong. “I’m good, it’s just this is the third patient with acute worsening of abdominal pain they’ve had for years that I’ve seen this week. What’s going on?” Background: Abdominal pain is a frequent reason for presentation to the emergency department (ED), generating over 13 million visits in the US in 2022. As emergency care providers, we are taught to think of the worst-case diagnoses (aneurysmal, ischaemic, an ectopic pregnancy, appendicitis, etc). Once the “bad stuff” is excluded, it’s tempting to breathe a sigh of relief and “not my concern”. However, there is an estimated population prevalence of chronic abdominal pain of around 22 per 1,000 person-years. According to the International Association for the Study of Pain, this is defined as abdominal pain without a clear diagnostic explanation that lasts for 3 months or more. Often, patients with these symptoms have been diagnosed with “functional” abdominal pain, although more recent terminology uses “Disorders of Gut-Brain Interaction”. Managing patients with acute-on-chronic pain syndromes in the ED can be very challenging, particularly if continuity of care is lacking for their chronic condition. This has been addressed to some extent by the GRACE-2 guidance on managing recurrent low-risk abdominal pain, which de-emphasizes repeated routine imaging and recommends opioid-minimizing strategies for symptom management. Clinical Question: Do people with chronic abdominal pain have higher rates of ED utilization than those without? Reference: Ray et al. Emergency Department Visit Frequency Among Adults with Chronic Abdominal Pain: Findings From the 2023 US National Health Interview Survey. AEM November 2025. Population: Adult respondents to the National Health Interview Survey 2023 who completed the question on demographics, pain, healthcare seeking behaviours, disability, mental health, past medical history and social determinants of health. Exclusion: The entire survey excludes people without a permanent household address, active-duty military personnel or civilians on military bases, and residents of long-term care facilities. For this study, the authors also excluded people reporting a history of cancer, Crohn’s disease and ulcerative colitis and those who were pregnant. Exposure: Chronic abdominal pain (CAP) was defined by the authors as reporting pain “most days” or “every day” over the prior three months, and being “bothered by” abdominal, pelvic or genital pain “somewhere between a little and a lot” or “a lot” over the prior three months. Comparison: Adults without chronic abdominal pain. Outcomes: Primary Outcome: ED visits in the prior 12 months. Secondary Outcomes: Mental health status, physical comorbidities, disability, and social determinants of health. Type of Study: Secondary analysis of a cross-sectional interview study. Dr. Michael Ray This is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Michael Ray is an Assistant Research Professor, Department of Emergency Medicine at George Washington University School of Medicine & Health Sciences. Known as a pain researcher. Clinically practiced as a chiropractor in an outpatient setting, which led to an interest in chronic pain and transition to academia. Authors’ Conclusions: This nationally representative analysis suggests that individuals with CAP have significantly higher ED utilization and face greater burdens of disability, mental health conditions, comorbidities, and SDOH-­related barriers. These findings highlight the potential value of addressing BioPsychoSocial factors to reduce ED reliance and support comprehensive care for CAP patients. 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? Unsure Have the authors identified all important confounding factors? Unsure Was the follow-up of subjects complete enough? N/A How precise are the results? The numbers are large, so they are likely to be reasonably precise, but formal measures of uncertainty, such as credible intervals, aren’t presented in the paper. Do you believe the results? Yes  Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Funding of the Study? National Research Scientist Award via George Washington University, and the Authors declared no conflicts of interest. Results: Just over 4.5 million (2.8%) of the nearly 163 million respondents reported Chronic Abdominal Pain. The chronic abdominal pain group had higher proportions of female sex (66% vs 50%) and age 55 to 64 (23% vs 15%), with similar race/ethnicity distribution. Key Result: Reporting Chronic Abdominal Pain was associated with an increased frequency of ED attendance. Primary Outcome: 1% of people with CAP reported one ED visit over the last 12 months, compared to 11.7% of people without. 16.9% had visited 2 to 4 times compared with 5.2%. Secondary Outcomes: Chronic abdominal pain was associated with increased incidence of anxiety, depression, physical comorbidities, challenges accessing healthcare, economic instability and limitations in social and employment function. Recall Bias: By conducting a secondary analysis of the US National Health Interview Survey, you are obviously limited by how the original survey's designers chose to collect the data. Much of the data depends on patients’ recollections, which we know can be flawed. People who go to the ED with their pain may well remember the days of pain more clearly than those who did not or could not seek healthcare. Do you have any information or a sense of how the NHIS measures up against other cohorts where the data can be triangulated Exclusions & Missing Data: The dataset includes many potential confounding factors, such as comorbidities and some social determinants of health. However, the entire survey excludes people without a permanent household address, and there doesn’t seem to be information around alcohol or substance use, which could plausibly be associated with chronic pain and contact with healthcare. How much do you think that challenges your findings? Outcome Measurement: The NHIS does not link ED visits to a specific presenting complaint, so some “excess” ED use among chronic abdominal pain respondents may reflect unrelated issues. In addition, modelling excluded asthma and injury. Excluding injury makes sense, but why exclude asthma? Multiple Comparisons: You acknowledge in the paper that the multiple comparisons you have done increase your risk of Type 1 error. This is where you find something that meets the criteria for statistical significance purely by chance. However, you deliberately chose not to apply a statistical adjustment, such as a Bonferroni correction. Could you talk us through that? Residual & Bidirectional Confounding: Although models adjusted for demographics, disability, mental health, PMH, and SDOH, unmeasured or imperfectly measured factors (access to specialty care, pain catastrophizing, prior imaging availability) could partly explain the associations. You note complex bidirectional relationships among CAP, mental health, disability, and SDOH that a cross-sectional model cannot fully resolve, which is an inherent limitation of observational designs. What do you think its implications might be for the individual patient and care provider? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We broadly agree with the authors’ conclusions, but would emphasize the need to be very cautious about inferring causation in either direction. SGEM Bottom Line: Adults reporting chronic abdominal pain report more ED attendances than those without, and report higher levels of physical, psychological and social comorbidities. Dr. Kirsty Challen Case Resolution: You empathize with your resident, noting that it can be frustrating when patients present to the ED with chronic problems. However, you help her frame this in the context of the impact on multiple areas of the patient’s life of chronic pain. Clinical Application: ED providers should recognize that people presenting with chronic abdominal pain are more likely to have physical and psychological comorbidities and be disadvantaged in terms of social determinants of health. What Do I Tell the Patient? We know that patients with chronic abdominal pain often have challenges in other parts of their lives. Is there anything else we can help with? Keener Kontest: The last episode’s winner was Scott Luce. He gave four examples of c-collars with geographic locations from the US (Aspen, Philly, Miami Jr and NY Ortho). Listen to the SGEM podcast for this week’s question. If you know, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode. Now it is your turn, SGEMers. What do you think of this episode on chronic abdominal pain and ED utilization?

Date: November 8, 2025 Reference: Millin M, et al., Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries – A NAEMSP Comprehensive Review and Analysis of the Literature, Prehospital Emergency Care, Aug 2025. Guest Skeptic: Clay Odell, BSN, NRP, RN, is a Paramedic Firefighter with Newport (NH) Fire-EMS. He is a past Chief of the NH Bureau of Emergency Medical Services. Previous positions he held are Trauma System Coordinator for the State of NH, Executive Director of Upper Valley Ambulance in Fairlee VT, and a flight crew member at Dartmouth Hitchcock Advanced Response Team. Clay has been a paramedic since 1985 and has been a registered nurse since 1997. Case: Your EMS unit responds to a 911 call for a hunting accident. You arrive to find the patient sitting on the tailgate of his truck. He tells you he fell out of his deer stand, approximately 20 feet, landing on his head. He walked out of the woods about a mile after the fall. His chief complaint is head and neck pain. He has a Glasgow Coma Scale (GCS) score of 15, a hematoma and laceration above his left eye, and he is quite tender over the cervical spine region. You observe your colleagues trying to apply a rigid cervical collar without moving the patient’s neck. It goes about as well as usual, meaning the patient's head is moved a bit. Maybe more than a bit. He then decides he hates the collar and rips it off. He adamantly refuses all attempts to apply a soft collar or improvised towel roll. On arrival at the trauma center, you give a handoff report, and the team leader demands to know why the patient is not in a collar. The patient overhears this and rather profanely informs everyone, "you ain't putting no *F-ing* collar on me". Background: Prehospital care for suspected SCI has two competing imperatives, limiting secondary cord injury while avoiding iatrogenic harm. Historically, EMS prioritized rigid immobilization (long backboard + rigid cervical collar) based on the fear that post-injury movement could precipitate delayed neurologic deterioration. In the last two decades, emergency care has shifted toward selective spinal motion restriction (SMR) and earlier collar removal when appropriate. This reflects a better understanding of risk, test performance, and harms from prolonged immobilization. In the ED, validated decision tools (NEXUS and Canadian C‑spine Rule) help identify very‑low-risk patients who do not need imaging; when imaging is needed, modern multidetector CT outperforms plain radiography for clinically significant cervical spine injury (CSI). A large Western Trauma Association cohort (10,276 patients) found CT sensitivity of 98.5% with a negative predictive value of ~100% for clinically significant injuries. The misses were rare and occurred in patients with focal neurologic deficits, who then warranted an MRI [1]. Prehospital protocols increasingly emphasize minimizing time on a backboard and avoiding prolonged collar use because of pressure injury and other morbidities. A systematic review by the East Association for the Surgery of Trauma (EAST) supports collar removal after a negative high-quality CT in an obtunded adult. They highlight the downstream harm from extended immobilization without added benefit [2]. Pediatrics and geriatrics remain special populations. NEXUS shows high sensitivity in children, though confidence intervals are wider in the very young.  Clinicians should have a low threshold for imaging in older adults, who are vulnerable to serious cervical spine injuries from low-energy mechanisms [3]. Clinical Question: In trauma patients with potential SCI, what is the evidence that post‑injury movement causes delayed neurologic deterioration, and what are the benefits and harms of prehospital spinal immobilization and SMR? Reference: Millin M, et al., Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries – A NAEMSP Comprehensive Review and Analysis of the Literature, Prehospital Emergency Care, Aug 2025. Population: Human (and some animals) with potential spinal cord injuries that addressed one of four predefined questions(pathophysiology of delayed neurologic injury, harms of immobilization, effectiveness of immobilization/SMR at limiting movement, and the relationship to delayed neurological injury). Exclusions: Manikin/simulation‑only studies, abstracts without full publication, editorials, other reviews/meta-analyses, guidelines, book chapters, and non-English full manuscripts. Intervention: Prehospital spinal immobilization (long backboard + cervical collar) and SMR (cervical collar ± vacuum splint/ambulance cot) Comparison: No immobilization vs immobilization or alternative immobilization strategies. Outcome: Primary Outcome: Effectiveness of immobilization/SMR at limiting movement and relationship to delayed neurological injury. Secondary Outcomes: Harms of immobilization/SMR (airway/respiratory compromise, raised ICP, pressure ulcers, delays to care, increased imaging, pain), and associations between hypoperfusion/hypoxia and worse neurologic outcomes. (See Tables 2-4 summarized in the paper.) Type of Study: Comprehensive review with no meta-analysis Authors’ Conclusions: There are no data in the published literature to support spinal immobilization and spinal motion restriction as standard of care. Efforts aimed to reduce the use of cervical collar should be considered, and the use of backboards and full body vacuum splint should be limited to the point in time of active patient extrication.  Quality Checklist for Therapeutic Systematic* Reviews: (Yes/No/Unsure) * This is the list we use for SR, while the study in question was called a “Comprehensive Review.” The main question being addressed should be clearly stated. Yes The search for studies was detailed and exhaustive. Yes Were the criteria used to select articles for inclusion appropriate? Yes Were the included studies sufficiently valid for the type of question asked? Unsure Were the results similar from study to study? No Were there any financial conflicts of Interest? No Results: The review synthesized 115 manuscripts spanning prehospital and hospital settings, adult and pediatric populations, and diverse geographies and time periods. The authors did not pool a single set of patient demographics due to the heterogeneity of designs and questions. Key Results: No definitive evidence that routine immobilization/SMR prevents delayed neurologic injury, while harms are common. Primary Outcome: Limiting movement (biomechanical surrogates) results are mixed. No randomized trials were found showing that collars/boards prevent secondary spinal cord injury. In the best-known observational comparison (immobilized vs. not), immobilization was associated with more neurologic disability. A before-and-after system study (moving from routine backboards to SMR) found no increase in delayed deficits. Secondary Outcomes: Harms were common with negative airway/respiratory effects, increased ICP,skin breakdown, delays in care, increased imaging, and pain. Dr. Millin is an emergency and EMS physician, retired from full-time faculty at Johns Hopkins University in Baltimore, and now runs a non-profit wilderness EMS agency in Maryland. He is also the lead author of this comprehensive review, and we asked him five nerdy questions.  Heterogeneity: The review necessarily combined diverse designs (case series, retrospective cohorts), different exposures (movement vs perfusion/hypoxia), and varied outcomes (motion metrics vs patient-important neurologic outcomes). Such heterogeneity limits inferences, and the authors appropriately did not attempt to meta-analyze the data. Risk‑of‑Bias: While selection and abstraction processes are detailed, the report does not describe a formal risk‑of‑bias (RoB) tool. This is a common expectation in systematic reviews. They could have used the ROBINS‑I, which helps assess the risk of bias in the results of non-randomized studies that compare the potential benefit and harm of two or more interventions [4]. Without a structured RoB assessment, confidence in causal interpretations is limited. Screening: The title/abstract was screened by a single reviewer. This may increase the chance of missed eligible studies. Best practice is for two independent reviewers to screen titles and abstracts and to review full texts independently, resolving discrepancies through discussion or a third reviewer. This process improves the validity, transparency, and reproducibility of systematic reviews [5,6,7]. Language & Publication Bias: The authors limited their search to English-language full texts. This can introduce language bias. In addition, narrative syntheses with small or observational studies are also vulnerable to publication bias, with negative studies less likely to be published. Surrogates Outcomes. Several included papers focus on movement reduction as a surrogate for patient-important outcomes (neurologic deficits). Surrogate-oriented outcomes (SOO) do not reliably translate into patient-oriented outcomes (POOs). Comment on Authors’ Conclusion Compared to SGEM Conclusion:  I, Clay Odell, believe the results, and I think this is likely as good evidence as we’re ever going to get regarding the clinical utility (or not) of cervical collars. This may be sufficient evidence for some EMS medical directors to reduce the emphasis on c-collars, but there will remain skeptics. I wonder if the NAEMSP will adopt these conclusions into their official position statement. We agree that routine, prolonged immobilization is not evidence-based and carries harm, and that minimizing backboard time is good practice. We would frame the conclusion more cautiously and prioritize oxygenation/perfusion, use manual stabilization/SMR selectively,

Date: November 12, 2025 Reference: Taccone et al. Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury The TRAIN Randomized Clinical Trial. JAMA 2024 Guest Skeptic: Dr. Alex Weiler is an Emergency Department staff physician in the Peterborough Regional Health Centre and is an associate professor with Queen's University Department of Family Medicine.  This podcast was recorded live at the Kawartha EM Conference in beautiful Peterborough, Ontario.   Case: A 48-year-old woman presents with a sudden, severe headache and brief loss of consciousness. CT/CTA confirms aneurysmal subarachnoid hemorrhage (SAH). She is coiled and admitted to the intensive care unit (ICU) with an external ventricular drain. On ICU day 3, Hb is 8.4 g/dL (or as we say in Canada 84 g/L), she is not actively bleeding, Glasgow Coma Scale (GCS) of 10 with fluctuating attention, and her expected ICU stay is clearly >72 hours.  Background: Acute brain injury (ABI) can occur for a variety of reasons, including aneurysmal SAH (like in this case) or trauma. Anemia is common in patients with ABI and can worsen cerebral hypoxia. For decades, ICU transfusion practice drifted toward “restrictive” triggers (Hb <7 g/dL or <70g/L) based on trials in mixed ICU populations. However, brain-injured patients may not behave like the average ICU patient. The brain is uniquely sensitive to oxygen delivery, and secondary ischemia strongly predicts poor neurological outcomes. Small single-center studies and physiologic work suggested higher hemoglobin could improve brain tissue oxygenation; however, prior randomized evidence has been sparse or inconclusive in discrete ABI subgroups (traumatic brain injury [TBI], SAH), leaving real uncertainty about the optimal transfusion threshold for this population. The TRAIN trial was designed to answer a practical question that matters at the bedside: in adults with ABI who are anemic but not exsanguinating, does a liberal transfusion strategy improve downstream neurological outcomes compared with a restrictive strategy? Clinical Question: In adults with acute brain injury (TBI, aneurysmal SAH, or ICH) who are anemic (Hb <90 g/L), does a liberal RBC transfusion threshold (transfuse when Hb <90 g/L) compared with a restrictive threshold (transfuse when Hb <70 g/L) improve 6-month neurological outcomes? Reference: Taccone et al. Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury The TRAIN Randomized Clinical Trial. JAMA 2024 Population: Adults (18 to 80) in 72 ICUs across 22 countries with TBI, SAH, or ICH. They needed to have an Hb <90 g/L within 10 days of injury and an expected ICU stay of ≥72 hours. Exclusions:Hb >90 g/L, GCS 3 with fixed/dilated pupils, GCS >13 at randomization, active bleeding, expected ICU stay <3 days, prior neurological disease, pregnancy, inability to receive transfusion; others are listed in the flow diagram. Intervention: Liberal strategy (transfuse when Hb <90 g/L for 28 days). Comparison: Restrictive strategy (transfuse when Hb <70 g/L for 28 days). Outcome: Primary Outcome: Unfavourable neurological outcome at 180 days, GOS‑E 1 to 5 (death to severe disability). Secondary Outcomes: 28-day mortality; composite of death or organ failure at day 28; organ failure; ICU/hospital LOS; distribution (“shift”) of GOS‑E; prespecified serious adverse events (cerebral ischemic events, VTE, infections, TRALI, anaphylaxis). Type of Study: A multicenter, pragmatic, parallel group, open-label, RCT Authors’ Conclusions: “Patients with acute brain injury and anemia randomized to a liberal transfusion strategy were less likely to have an unfavorable neurological outcome than those randomized to a restrictive strategy.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the ED. 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. No  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. Unsure Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Yes Financial conflicts of interest. Funded by non-profit sources, and the sponsors had no role in design/analysis/reporting. Minor author disclosures unrelated to the intervention were reported. Results: 820 completed the trial, with 806 having the primary outcome (393 liberal; 413 restrictive). Mean age 51 and 46% women. The type of brain injury was ~59% TBI, 23% SAH, 18% ICH overall. GCS at randomization was 6 [IQR 3–8] and was Hb 85 g/L [IQR ~80 to 88]. A median of two units (IQR 1–3) were transfused in the liberal vs 0 units (IQR 0–1) in restrictive, giving an absolute mean difference 1.0 unit (95% CI 0.87–1.12). Key result:  A liberal threshold (Hb <90 g/d) reduced unfavourable neurological outcome at 180 days compared with a restrictive (Hb <70 g/L). Primary Outcome: Unfavourable GOS E 1–5 at 180 days was 63% liberal vs 73% restrictive ARR 10% (95% CI 3.6–16.5) RR 0.86 (95% CI 0.79–0.94), p=0.002. NNT 10 to prevent one additional unfavourable outcome Secondary Outcomes: No statistical difference in 28-day mortality: 21% liberal vs 23% restrictive; RR 0.95 (95% CI 0.74–1.22) No statistical difference in the composite outcome of death/organ failure at day 28, organ failure, or ICU LOS Serious adverse events were similar between groups 1. Performance Bias: Bedside teams knew the assignment (open-label), which can bias outcomes even with masked assessors. The investigators acknowledge awareness of group assignment and incomplete assessment of co-interventions as a limitation.  2. Detection Bias: Cerebral infarction was identified at clinicians’ discretion rather than by systematic imaging, risking underascertainment bias (detection bias). The authors appropriately called the serious adverse event (SAE) data exploratory. 3. Analysis Bias: The primary analysis excluded patients who withdrew consent post‑randomization (modified Intention-to-Treat analysis [mITT]). While common, exclusion after randomization can erode the protection of randomization. A pure ITT analysis better preserves unbiased comparisons. Attrition and missing data can bias estimates (the authors did perform sensitivity analyses, which were consistent). 4. Heterogeneous Acute Brain Injury Etiologies: Pooling TBI, SAH, and ICH increases generalizability but risks effect modification across pathologies. Subgroup analyses largely aligned, but power for interaction is limited. We need to be skeptical of subgroup findings because of multiplicity and low power.  5. Non‑Standardized Neuroprognostication: Prognostication practices were not standardized across centers, which can influence functional outcomes and mortality decisions. The authors correctly note this as a limitation. While mortality was similar between groups, this can mitigate but not eliminate this potential bias. Comment on the Authors’ Conclusion Compared to the SGEM Conclusion: We generally agree with the authors’ conclusions. SGEM Bottom Line: An anemic brain is not a happy brain. In adults with acute brain injury and Hb ≤90 g/L, targeting a 90 g/L transfusion threshold modestly improved 6-month functional outcomes vs a 70 g/L trigger, without a mortality signal and with fewer cerebral ischemic events. Case Resolution: This patient’s Hb was 84 g/L. Therefore, we suggest giving her a transfusion of one unit of packed red blood cells to keep her Hb ≥ 90 g/L. Dr. Alex Weiler Clinical Application We need to remember that this applies to: Adults (18–80) with ABI (TBI, aneurysmal SAH, ICH) in the first 10 days, not actively bleeding, expected to require ICU care ≥72 h, and with Hb between 70 to 90 g/L. Outside of this group (massive hemorrhage, exsanguination, pregnancy, severe comorbidity extremes), extrapolate cautiously. When Hb drops below 90 g/L in eligible ABI patients, it’s reasonable to transfuse RBCs to target at least this threshold, aiming to reduce unfavourable neurological outcomes by ~10%. Use shared decision-making with neurocritical care about triggers, especially if there is clinical concern for cerebral ischemia. Don’t expect a 28-day mortality benefit or shorter ICU stays. The signal here is better functional recovery, not survival. And don’t forget to maintain standard ABI bundles (BP, oxygenation/ventilation, fever control, DVT prophylaxis). What Do I Tell the Patient/Family?  After a brain injury, the brain needs plenty of oxygen to heal. The oxygen is carried in the blood by hemoglobin. When hemoglobin levels are too low, the brain may not get enough oxygen, which can make recovery harder. Your hemoglobin is too low. We recommend a blood transfusion now to bring the hemoglobin up to a safer range. This is part of our effort to give the brain the best chance to heal. Keener Kontest: Last week’s winner was Steven Stelts from NZ. He knew the pending legislation to address HCW violence is the Save Healthcare Workers Act (H.R. 3178 / S. 1600), which would establish federal criminal penalties for assaulting healthcare workers.  Listen to the SGEM podcast for this week’s question. If you know, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode. Remember to be skeptical of anything you learn,

Date: October 17, 2025 Dr. Kristen Panthagani Guest Skeptic: Dr. Kristen Panthagani is an emergency medicine resident and Yale Emergency Scholar at Yale New Haven Hospital. She’s a physician-scientist, having completed her MD/PhD at Baylor College of Medicine. She’s also well known as a science communicator, creator of You Can Know Things which helps explain science in a way everybody can understand, with an emphasis on addressing health rumors and explaining evidence-based medicine. This SGEM Xtra is inspired by piece in the New England Journal of Medicine titled, Training Health Communicators-The Need for a New Approach. It covers the shifting landscape of how and where people are getting health information, specifically social media. It also provides some key competencies to keep in mind as we train healthcare professionals and scientists to communicate in these spaces. The idea of "social media" has existed for a long time. Check out the book Writing on the Wall by Tom Standage to learn more. We last covered the topic of science communication on a SGEM Xtra with Sarah Mojarad where she gave us five tips for science communication. Today we have five themes from your article to discuss. Listen to the SGEM Xtra podcast to hear Dr. Panthagani discuss these themes in detail. Shifting Information Sources People’s habits are changing. They are going to different sources to get health information, and we have to adapt and evolve to stay relevant. The idea of "talk with your doctor if you have questions" is often impractical if people cannot get timely appointments in clinic. Websites for universities and organizations can be reputable sources, but health information is not always presented at the recommended health literacy level. People are not fans of the top-down, “I am the high and mighty institution or organization. Let me tell you what to do” approach anymore. So where are people turning for health information? People are increasingly getting their information from social media. Over half of adults in the US report getting health information from social media. It is unlikely that we can simply tell people to stop using social media for this purpose.   Putting a Face to the Message How can we harness social media? The typical dry and stiff presentation with text-heavy slides at a scientific conference is unlikely to grab people’s attention. People gravitate toward authenticity. A more raw, informal style may be resonate more compared to a polished, rehearsed message "Be a real person." These were tips about style of communication. What tips do you have for creating content? If it's boring to you, it's probably boring for your audience. Don't do stuff you hate. If you like writing, don't create reels. Find ways to write articles, commentary, Substack, etc. You don't have to do it all. Bidirectional Communication Traditional health communication has been top-down from institutions/organizations to the consumer. There is a difference between information dissemination versus communication. Information dissemination is one direction. Communication is bi-directional Listen to the audience Be careful that the scientific understanding of a term (ex. "immunity") may not be the colloquial understanding. Data is not enough. Unite over shared values. Bidirectional communication requires time and effort. Don't feel obligated to respond to every comment. Read the comments to gauge understanding and identify points of confusion. Acknowledging Uncertainty This is a sore spot when it comes to the communication that came during the Covid-19 pandemic. We have to acknowledge that this was a really tough time. We confronted a novel disease and pathogen. The language around topics like vaccines, social distancing, masking, did not really acknowledge that these interventions are not perfect. Guidance changed based on new and emerging data. This is difficult and requires balancing the simplicity of the message with the nuance. We did not do a good job communicating nuance and uncertainty in the early data. How will the public receive scientists acknowledging uncertainty when there are other voices (who may lack knowledge or expertise) proclaiming their message loudly and confidently? People may appreciate nuance more than we give them credit for. Sometimes saying, "I don't know" can actually built trust. Be Nice Dr. Panthagani has a Substack article about why criticizing “anti-vaxxers” backfires. In it she brings up a distinction between shame and guilt from research Brene Brown. Guilt focuses on the behavior and the decision. Shame attacks the character of the person.  Not surprisingly, making people feel stupid, calling them stupid, or being quick to label them doesn’t really work when it comes to effective science communication. Using shame-based methods makes things worse Find ways to connect over shared values. Keep in mind Graham’s hierarchy of disagreement. We want to be refuting the central point that is being made and do so respectfully. We can disagree without being disagreeable. 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 10 years to less than 1 year using the power of social media. So, patients get the best care, based on the best evidence. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. References: Rooney MK, Santiago G, Perni S, et al. Readability of patient education materials from high-impact medical journals: a 20-year analysis. Journal of Patient Experience. 2021;8:2374373521998847. doi:10.1177/2374373521998847 Mishra V, Dexter JP. Comparison of readability of official public health information about covid-19 on websites of international agencies and the governments of 15 countries. JAMA Network Open. 2020;3(8):e2018033. doi:10.1001/jamanetworkopen.2020.18033 https://www.kff.org/public-opinion/kff-health-information-and-trust-tracking-poll-health-information-and-advice-on-social-media/

Date: October 30, 2025 Reference: Boes et al. Prevalence of violence against health care workers among agitated patients in an urban emergency department. October 2025 AEM 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: It's 7:34 pm. You just took a sip of your portable espresso machine coffee from your favourite Batman cup. It's been 34 minutes into your Tuesday overnight shift. Things are a little crazy, but you are proud of yourself for getting your day colleague out on time. Just then, your second-year resident walks briskly towards you and sits down next to you, an air of fluster about her. She is trying to keep her cool, but you can see her hands are trembling as she is putting in orders for the patient she just saw. You ask her what's up, and she responds, "The intoxicated patient in bed 12 just threatened to punch me when I told him I couldn't give him more pain medications. He said pretty awful things about me, called me names, and cursed at me... they called over security... but I still feel a little shook up about it... " She looks down and shakes her head, and then looks back at you and asks, "How often does this actually happen? Violence against us?" Background: Violence toward clinicians is not a rare event in the ED but rather a predictable occupational hazard. The Canadian Association of Emergency Physicians (CAEP) has called ED violence “unacceptable,” urging a system-wide, zero-tolerance culture and coordinated mitigation efforts across hospitals, EMS, and law enforcement. Their formal CAEP Position Statement on violence in the ED summarizes scope, risk factors, and policy recommendations for prevention and reporting [1]. In the US, the American College of Emergency Physicians (ACEP) maintains a consolidated resource hub on ED workplace violence, including policy statements and advocacy for federal legislation (OSHA standards and the SAVE Act) to mandate prevention programs and establish penalties for assaults on healthcare workers. ACEP’s 2022-member poll found 85% of respondents reported violence had increased in their ED over the prior five years, with 45% saying it had greatly increased. The 2024 follow-up highlighted that >90% feared threats or attacks in the prior year. These data align with the day-to-day experience of emergency physicians and underscore persistent underreporting and inadequate institutional responses [2]. Both CAEP and ACEP emphasize practical approaches such as environmental design, staffing and security policies, de-escalation training, standardized reporting, and partnerships with law enforcement. At the same time, they reject the idea that violence is “part of the job.” Clinical Question: Among ED patients with, what is the prevalence of violent events against health care workers, and how does that compare with events formally reported to the hospital? Reference: Boes et al. Prevalence of violence against health care workers among agitated patients in an urban emergency department. October 2025 AEM Population: ED patients from a locked observation unit at Hennepin County Medical Center (Minneapolis, MN). Exclusions: Patients known to be in custody at the time of the encounter were excluded from data collection. Exposure: Agitation, defined as an Altered Mental Status Score (AMSS) ≥ +1 (range from −4 to +4). Observers then recorded whether the encounter included verbal abuse, a threat of violence, or a violent act against a health care worker. Comparison: N/A Outcome: Primary Outcome: Assault against any health care worker, defined by Minnesota state statute as an act with intent to cause fear of immediate bodily harm or death, or intentional infliction/attempt to inflict bodily harm. Secondary Outcomes: Verbal abuse of health care workers by agitated patients (distinct from threats), defined as harsh/insulting/derogatory language or gestures intended to frighten, humiliate, or belittle. Type of Study: A secondary analysis of two prospective, observational studies conducted in the ED setting. This is an SGEMHOP, and we are pleased to have the lead author on the episode, Dr. Brian Driver. He is a faculty emergency physician and Director of Clinical Research in the Department of Emergency Medicine at Hennepin County Medical Center. Authors’ Conclusions: “Verbal abuse, threats of assault, and violent acts occurred frequently in ED patients with agitation and were underreported.” 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? Unsure  Do you believe the results? Yes Can the results be applied to the local population? Unsure  Do the results of this study fit with other available evidence? Yes Funding of the Study. None is stated in the manuscript, while the authors declare no conflicts of interest. Results: Across 17,873 screened encounters, 4,609 (26%) involved agitation (AMSS ≥ +1). Alcohol or drug intoxication was present in 4,108 (89%) encounters. Among agitated patients, the median age was ~36 to 39 years, about 50% were male, and the cohort included a substantial proportion of Black, non-Hispanic patients (40–46% across violence strata). The study took place in a locked ED observation unit within an urban safety‑net hospital with ~100,000 annual visits. Key Result: Among agitated ED encounters, assaults were common, formal reports of verbal abuse were rarely reported, while most violent acts were reported. Only 0.5% (9/1,786) of verbal-abuse events and 61.9% (224/362) of violent acts were formally reported to the hospital. Listen to the SGEM podcast to hear Brian answer our five nerdy questions. External Validity: This was a single-center analysis in a locked ED observation unit that preferentially rooms patients with suspected intoxication. While you suggest similar patients would otherwise be mixed in general ED beds, concentrating intoxicated, agitated patients may change the observed prevalence and risk environment. Measurement Bias and Lack of Inter-Rater Reliability. Trained observers used standardized definitions, but inter-rater reliability was not reported, and observers were embedded in the clinical setting (not blinded), which can introduce observation/expectation bias. This is particularly important for subjective constructs like “verbal abuse.” Comparator Misalignment & Underreporting Bias: The “formal report” comparator aggregated events from anywhere in the ED, not just the studied unit or only agitated patients. Using the same denominator (n=4,609) overestimates reporting percentages and biases toward the null in observed–reported differences. Institutional reporting is also known to be incomplete. Don't these differences limit the interpretation of the magnitude of underreporting?  Ascertainment Constraints: The authors note constraints such as language limitations (inability to capture some non-English events), areas not observed (triage), and binary counting at the encounter level (not tallying multiple events per visit). Each can attenuate or distort true prevalence. Could this not systematically shift some of the point estimates? Descriptive Design: As a prevalence study, it does not adjust for potential drivers of violence (staffing, throughput, intoxication level, and de-escalation availability), limiting inference about determinants or modifiable factors. These confounders make it challenging to know how best to address the problem of violence based on this data set. Comment on the Authors’ Conclusion Compared to the SGEM Conclusion: We generally agree with the author that the rate of violence in agitated patients against health care workers is high and under-reported. SGEM Bottom Line: Violence against ED staff is common and substantially underreported, especially for verbal abuse. Dr. Suchi Datta Case Resolution: You tell your resident that, sadly, her experience is not singular and that violence against healthcare workers is a problem, especially amongst agitated patients. You encourage her to report the incident, as there needs to be more documented encounters to help facility advocacy on a systemic level. You also provide her with some resources to help process her trauma. She is very thankful and goes on to talk to you about how the encounter made her feel. You take a walk outside to the trauma bay and, after some breathing exercises, feel strong enough to come back and continue running the ED the rest of the night. Clinical Application: Be careful around agitated patients. Make sure you accurately report incidents of violence. We need to advocate for systemic changes to protect healthcare workers as per ACEP and CAEP. This includes more robust prevention, reporting, and accountability. Violence should not be part of our job. What Do I Tell My Patient? N/A Keener Kontest: Last week’s winner was Dr. Steven Stelts from New Zealand. He knew Magnesium got its name from Magnesia, a region in Thessaly, Greece. This is an area known in ancient times for its deposits of minerals and stones containing magnesium. Listen to the SGEM podcast for this week’s question. If you know, then send an email to  thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode. Now it is your turn, SGEMers.