The Skeptics Guide to Emergency Medicine

Reference: Cohen et al; SUSPECT study group. Can we avoid casting for suspected scaphoid fractures? A multicenter randomized controlled trial. J Orthop Traumatol. 2025 Date: May 1, 2025 Guest Skeptic: Dr. Matt Schmitz is an orthopedic surgeon specializing in Adolescent Sports Medicine and Young Adult Hip Preservation. He practices at the Rady Children’s Hospital in San Diego and is Professor of Orthopedics at UC San Diego. Case: A 48-year-old woman presents to the emergency department (ED) with left wrist pain after slipping on a wet pavement while walking into work. It was a FOOSH injury (fall on out-stretched hand). She did not lose consciousness and was able to drive herself to the ED, but she reports increasing wrist pain with movement. She rates the pain as 6/10 and notes it’s worse with lifting or rotating the wrist. She denies numbness, weakness, or swelling of the fingers. No previous wrist fractures or injuries. On inspection, she has no obvious deformity and minimal swelling at the wrist. The examination reveals tenderness in the anatomical snuffbox and over the scaphoid tubercle. Her range of motion is decreased due to pain, especially with radial deviation and wrist extension. Sensation and cap refill intact; radial pulse present. Plain radiographs (PA, lateral, scaphoid view) show no fracture. Background: Scaphoid fractures are a common injury seen in the ED but can represent a challenge to diagnose, even for experienced clinicians. The scaphoid injury is the most frequently fractured carpal bone, typically occurring after a fall onto an outstretched hand (FOOSH) in young, active individuals. The clinical dilemma arises when there is a high suspicion of fracture based on mechanism and physical exam (especially tenderness in the anatomical snuffbox), but the initial radiographs appear normal. An excellent SRMA on the history, physical exam, and imaging for scaphoid fractures was done by Carpenter et al AEM 2014. On SGEM#420, we wanted to know what to do with a patient who presents with a FOOSH injury and has a normal x-ray. Specifically, are there clinical exam findings that can help rule in/rule out a scaphoid fracture? The bottom line was there was no single physical examination maneuver that could reliably rule out an occult scaphoid fracture. Given this dilemma, ED physicians have erred on the side of caution. If a fracture is not radiographically visible, the patient is immobilized and referred for follow-up imaging in 10 to 14 days or orthopedic review. This conservative approach stems from the significant morbidity associated with missed scaphoid fractures, including non-union and avascular necrosis. However, this “cast first, confirm later” philosophy has led to over-treatment in most cases. Studies estimate that only 10–20% of patients with clinical suspicion of a scaphoid fracture and normal initial X-rays have a fracture confirmed on follow-up imaging. With this context, a new wave of research has emerged, questioning whether immediate casting is necessary or whether selective immobilization and early reassessment may be equally safe and more patient-centred. This ongoing debate challenges emergency physicians to balance the risks of under-treatment with the harms of unnecessary immobilization, time off work, and healthcare costs. Clinical Question: Can patients with suspected scaphoid fractures and normal initial radiographs be managed without casting, using a brief period of bandaging and reassessment? Reference: Cohen et al; SUSPECT study group. Can we avoid casting for suspected scaphoid fractures? A multicenter randomized controlled trial. J Orthop Traumatol. 2025 Population: Adults presenting to the ED with a clinical suspicion of scaphoid fracture but normal initial radiographs. Intervention: 3-day bandaging followed by reassessment. Comparison: Traditional 2-week casting with thumb spica. Outcome:

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

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

Reference: Muldowney et al. A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting. Ann Emerg Med. 2025  Date: April 24, 2025 Guest Skeptic: Dr. Howie Mell received his Medical Doctorate (MD) from the University of Illinois at Chicago, College of Medicine at Rockford. Prior to that, he received a Master of Public Health (MPH) degree emphasizing Environmental and Occupational Health from the University of Illinois at Chicago, School of Public Health, while serving as a firefighter/paramedic in the Chicago suburbs. He completed his residency in emergency medicine at the Mayo Graduate School of Medicine, Rochester, Minnesota. Dr. Mell is board-certified by the American Board of Emergency Medicine in both Emergency Medicine (EM) and Emergency Medical Services (EMS) Medicine. He is a Fellow of the American College of Emergency Physicians (FACEP). Dr. Mell serves as an Ambassador Emergency Physician for Vituity (formerly CEP-America), and he is currently assigned to Schneck Medical Center in Seymour, Indiana (John Cougar Mellencamp’s “Small Town”). Case: You’re an experienced paramedic working a busy night shift in an urban EMS system. Dispatch sends you to a call for a 35-year-old male found acting erratically in a public park. Upon arrival, you find him disoriented, agitated, and combative. Bystanders report that he has been using methamphetamine and alcohol. The patient is uncooperative, making verbal de-escalation ineffective. Physical restraint is needed for transport. Your EMS protocol allows for pharmacologic sedation with either midazolam (1 to 5 mg IV/IM, repeat every 2 to 5 minutes as needed) or ketamine (5 mg/kg IM, max 500 mg). The patient is tachycardic (HR 122 bpm), hypertensive (BP 156/96 mmHg), and has a Glasgow Coma Scale (GCS) score of 12. You need to act quickly for scene safety and the patient's well-being. Background: Acutely agitated patients in the pre-hospital setting present a unique challenge for emergency medical services (EMS). Agitation can stem from various underlying conditions, including psychiatric disorders, substance intoxication, metabolic disturbances, traumatic brain injury, or postictal states​. If not managed appropriately, severe agitation can escalate, leading to self-harm, harm to others, or interference with necessary medical care. Initial management emphasizes verbal de-escalation techniques, which should always be attempted first. However, when these strategies fail, pharmacologic sedation may be necessary to ensure the safety of both the patient and pre-hospital providers. The choice of sedative agent is a critical decision. The paramedic must balance the need for rapid sedation with the risk of adverse effects, including respiratory depression and cardiovascular instability​. Benzodiazepines, such as midazolam, have historically been used for pre-hospital sedation due to their anxiolytic and muscle-relaxant properties. However, their use is associated with risks such as respiratory depression and paradoxical agitation. In recent years, ketamine has gained popularity due to its rapid onset, potent dissociative properties, and preservation of airway reflexes​. Despite its advantages, ketamine is not without concerns, including the potential for emergence reactions, increased blood pressure, and the need for airway management in some cases. Current guidelines lack consensus on the optimal pharmacologic approach, leading to significant variation in practice across EMS systems. The ongoing debate surrounding the best sedation strategy highlights the need for robust clinical research to guide evidence-based practice. A newly published study aims to address this knowledge gap by comparing ketamine and midazolam in the out-of-hospital setting, shedding light on their relative efficacy and safety. Clinical Question: In prehospital patients requiring pharmacologic sedation for acute behavioural disturbance,...

Reference: Kareemi et al Artificial intelligence-based clinical decision support in the emergency department: a scoping review. AEM April 2025. Date: April 15, 2025 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. Case: It may be April, but as you sit in your departmental meeting with your emergency physician colleagues, you all note that the winter “surge” of patients hasn’t stopped. The decision fatigue at the end of shifts is as present as ever. “Surely AI will be making some of these decisions better than us soon?” says one of your colleagues, only half joking. Another colleague chips in that the medical students at the nearby university have been warned against using ChatGPT to create differential diagnoses and you are left wondering whether AI might be “working” in the ED soon. Background: Emergency departments can be a high-pressure environment. Clinical decisions must be made quickly and accurately, often with incomplete information. Clinical decision support (CDS) tools aim to address this challenge by offering real-time, evidence-informed recommendations that help clinicians make better diagnostic, prognostic, and therapeutic decisions. CDS spans a wide spectrum from traditional paper-based clinical decision rules to smartphone apps (MDCalc) to more integrated systems into electronic health records (EHRs). These tools function by combining patient data with expert-driven algorithms or guidelines to inform care pathways. They can help determine disease likelihood, risk stratify patients and even guide resource utilization such as imaging or admission decisions​. Recent years have seen a growing interest in applying artificial intelligence (AI), particularly machine learning (ML), to CDS. Unlike traditional "knowledge-based" CDS that relies on literature-based thresholds, AI-driven tools derive patterns from large datasets ("big data") to identify associations and make predictions. These "non–knowledge-based" systems promise to augment human decision-making by uncovering insights that might be overlooked by clinicians or static rules​. However, the majority of AI-based CDS (AI-CDS) tools remain in early development. Few have been rigorously tested in the ED, and even fewer have demonstrated improvements in patient outcomes or clinician workflow. Despite FDA clearance for some tools, evidence for real-world impact remains limited​. Emergency physicians are right to approach this technology with skeptical optimism. We will need to balance the transformative potential of AI with a critical eye toward evidence, safety, and usability. Clinical Question: (1) What is the current landscape of AI-CDS tools for prognostic, diagnostic, and treatment decisions for individual patients in the ED? and (2) What phase of development have these AI-CDS tools achieved? Reference: Kareemi et al Artificial intelligence-based clinical decision support in the emergency department: a scoping review. AEM April 2025. Population: Studies involving AI or ML-based clinical decision support tools applied to individual patient care in the ED, published 2010 - 2023. Excluded: Models that assessed a specific test (e.g. imaging) without clinical context, administrative or operational outcomes (e.g. patient census), models involving irrelevant data (e.g. vignettes or data not available following the emergency assessment), length of stay as a primary outcome, studies without full text or abstract in English. Intervention: AI- or ML-based clinical decision support tools used during patient care in the ED. Comparison: Not applicable for a scoping review. However, the review identified whether studies involved any comparison with usual care, clinician judgment, or non-AI tools. Outcomes: The review didn’t focus on a single outcome but instead categorized studies by their targeted clinical decision task—diagnosis, prognosis, disposition, treatment,

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

The discussion dives into the myth that non-urgent patients are the primary cause of emergency department crowding. Misconceptions surrounding this issue are debunked, illustrating the risks of diverting patients who might have serious conditions. The conversation critiques traditional approaches, labeling them as ineffective solutions and calling for evidence-based strategies. It emphasizes the need for comprehensive solutions that address deeper healthcare system flaws, rather than just treating the symptoms of overcrowding.

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

Nicholas Peoples, a standout medical student from Baylor College of Medicine with a rich background in global health, dives into the pressing issue of citation errors in biomedical literature. He reveals that up to 40% of citations may reference non-existent studies, undermining clinical practice. The conversation highlights the role of AI in enhancing citation accuracy and the urgent need for accountability among researchers. They also discuss the cultural shift necessary in academia to ensure integrity and trust in scientific research.

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