The Skeptics Guide to Emergency Medicine

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.

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),

Reference:  Boutin A, et al. Removable Boot vs Casting of Toddler’s Fractures: A Randomized Clinical Trial. JAMA Pediatr. Published April 2025. Date: July 23, 2025 Dr. Andrew Tagg Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder and website lead of Don’t Forget the Bubbles (DFTB). Case: A two-year-old boy presents to your pediatric emergency department (ED) with a limp and refusal to bear weight. His parents aren’t exactly sure what happened. They were at the park and suspected that he might have twisted his leg coming down a slide. On your exam, he does not have a fever. He does not have any swelling or deformity of his bilateral lower extremities. You order X-rays, which confirm a nondisplaced spiral fracture of the distal tibia, a classic toddler’s fracture. After you disclose his diagnosis, his worried parents ask you, “A fracture? Does that mean it’s broken? Will he need to get a cast? He’s such an active little guy, typically.” Background: Toddler’s fractures are subtle, nondisplaced spiral fractures of the tibia. They typically occur in children between the ages of 9 months and 4 years. They often present in children who are just beginning to walk, hence the term “toddler’s fracture.” These kids can come in with inability to bear weight, a limp, or nonspecific pain. Another challenge is that the history you get may or may not help guide you. These injuries usually result from low-energy trauma, such as a twisting injury during a fall. That can happen multiple times a day when you’re learning to walk! The mechanism of injury is so subtle sometimes that parents or caretakers may not recall any inciting event. The findings on X-ray can be quite subtle as well. AP and lateral views may reveal a very small hairline fracture that’s easily missed. In some situations,  X-rays will be negative despite clinical exam findings suggestive of a toddler’s fracture. In those situations, repeated X-rays in a week or so can show some evidence of periosteal reaction. The traditional management has included immobilization with a long leg or short leg cast, based on the belief that toddlers are unlikely to limit activity independently and require rigid immobilization to promote healing and pain relief. However, growing concerns about the discomfort, skin breakdown, need for follow-up visits, and potential complications from casting have led to interest in less restrictive treatments. such as removable walking boots. Clinical Question: In children with radiographically confirmed toddler’s fractures, is treatment with a removable walking boot noninferior to a circumferential cast? Reference:  Boutin A, et al. Removable Boot vs Casting of Toddler’s Fractures: A Randomized Clinical Trial. JAMA Pediatr. Published April 2025. Population: Children aged 9 months to 4 years with radiograph-visible tibial toddler’s fractures seen in 4 Canadian pediatric emergency departments. Exclusion: Presented more than 5 days after injury or had an increased risk for pathological fracture or delayed healing Intervention: Removable prefabricated walking boot. Parents were told to use the boot for one week, then use it as needed for symptoms for up to three weeks. This was based on caregiver discretion, with no scheduled follow-up. Comparison: Standard circumferential casting. This varied across sites: Two sites did a long-leg splint in the ED, followed by a fiberglass cast. Another site did a short or long leg splint/cast in the ED, followed by a long leg fiberglass cast. The final site placed a short-leg splint in the ED, followed by a short-leg fiberglass cast. The casts were applied within seven days of the ED visit. Two sites had casts that were peelable, meaning they could be removed by caregivers at home. The other two sites had patients return to the clinic for cast removal. Outcome:

Date: October 10, 2025 Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department.  Case: A 37-year-old man presents to the emergency department (ED) with severe right-sided flank pain.  The pain started about eight hours ago as a vague discomfort in his right flank, but it has gotten progressively worse and now is radiating to his groin. Patient reports nausea, an increased urge to urinate and noticing blood in his urine on one occasion. The patient denies prior medical or surgical history. Upon ED arrival, his vital signs are normal. Physical examination revealed a stated age patient in distress due to severe right flank pain, prominent right-sided costovertebral angle tenderness, and absence of abdominal tenderness or guarding. While strongly considering renal colic in differential diagnosis and reaching for the bedside ultrasound, you are wondering if a single dose of a non-steroidal anti-inflammatory (NSAID) will be enough to relieve this patient’s pain, or should you add Magnesium or Lidocaine? Background: Renal colic is a common and extremely painful emergency department (ED) complaint encountered in the ED that frequently recurs. The nonsteroidal anti-inflammatory drugs (NSAIDs) given intravenously or intramuscularly (IM) are frequently used as first-line therapy. However, about 30% of ED patients receiving NSAIDS require rescue analgesia in the form of opioids. Opioid use, though effective, is limited at times due to the potentially dangerous adverse effects. Thus, there might be a role for other non-opioid classes of drugs to be co-administered with NSAIDs for relief of renal colic. Magnesium sulfate (MgSO₄) has been suggested as a possible treatment option. It may blunt ureteral smooth muscle spasm by antagonizing calcium influx in smooth muscle and by N‑methyl‑D‑aspartate (NMDA) receptor antagonism. These are mechanisms that can reduce visceral pain and augment other analgesics. Small ED trials and meta‑analyses suggest MgSO₄ can reduce pain scores and opioid use in renal colic, though the evidence base has been limited and heterogeneous [1]. Another suggested treatment modality for renal colic is intravenous lidocaine. We looked at this treatment on SGEM#202 and were unimpressed with the efficacy. Systemic lidocaine blocks voltage‑gated sodium channels and appears to modulate central sensitization and visceral pain pathways. In ED populations, systematic reviews indicate IV lidocaine offers variable analgesia with a mixed signal for benefit, and renal colic–specific RCTs suggest it may be inferior to ketorolac and best considered (if at all) as part of a multimodal strategy rather than as monotherapy [2]. Clinical Question: In adult ED patients with suspected renal colic receiving IM diclofenac, does adding IV magnesium sulfate or IV lidocaine increase the proportion achieving ≥50% reduction in pain at 30 minutes compared to a saline placebo? Reference: Toumia M, Sassi S, Dhaoui R, et al. Magnesium Sulfate Versus Lidocaine as an Adjunct for Renal Colic in the Emergency Department: A Randomized, Double-Blind Controlled Trial. Ann Emerg Med 2024 Population: The study enrolled adults aged 18 to 65 years with suspected acute renal colic and a pain score of 5 or more on a 10-point numerical rating scale (NRS). Exclusions: Pregnancy/breastfeeding; NSAID, MgSO₄, or lidocaine contraindication or allergy; renal/hepatic dysfunction; analgesic use in prior 6 h; bleeding diathesis or GI hemorrhage; significant CAD/arrhythmia; seizures; peritoneal signs; altered mental status; anticoagulation; hemodynamic instability; morphine allergy. Intervention: All patients received 75 mg IM diclofenac. The intervention groups then received either 1g IV MgSO₄ (10 mL) over 2-4 minutes or 1.

Date: October 3, 2025 Reference: Doheim et al. Meta-Analysis of Randomized Controlled Trials on IV Thrombolysis in Patients With Minor Acute Ischemic Stroke. Neurology 2025 Guest Skeptic: Dr. Casey Parker is a Rural Generalist, Evidence-based medicine enthusiast and Ultrasound Nerd. This episode was recorded live, in beautiful Broome, Australia, at the Spring Seminar on Emergency Medicine (SSEM 2025). You can get copies of the slides used in the presentation at this LINK. You can also watch the episode on YouTube. Case: Dani is a recently retired emergency department (ED) doc who has spent the last year travelling the world, playing banjo & sharing time with family and friends. This morning, whilst eating a breakfast of eggs and ham, Dani had a sudden onset of right-hand weakness and difficulty speaking. Dani’s family called 000 (911 in North America), and she was taken to the ED within one hour. On arrival at your medium-sized rural ED, Dani is assessed by the “Stroke Team aka, you” as having mild motor weakness in the right hand and mild dysarthria. Dani is given an NIHSS score of 4. A rapid CT and CTA is quickly reported as “no acute large vessel occlusion” and “No intracranial bleed and no established cortical infarction”. You know that many centers in the city are offering intravenous tPA for patients with acute ischemic stroke.  You wonder if Dani should get a dose?  Background: Minor ischemic strokes (MIS), often defined by NIHSS ≤5, are very common, with roughly half of all ischemic strokes presenting with mild deficits. Despite the mild presentation, these strokes are not always benign. About 30% of patients with initially minor stroke symptoms end up significantly disabled (unable to walk independently) at 90 days [1].  In short, a small stroke can still have a big impact on a patient’s life if it isn’t effectively treated or if it progresses. Dr. Daniel Fatovich There have been gallons of ink spilled in the discussion of the stroke literature, with much debate on previous SGEM episodes about the relative risks and benefits of IV thrombolytic therapy for acute strokes. Drs. Ken Milne and Danny Fatovich have earned themselves the title of “non-expert EM contrarians” when discussing the literature around acute ischemic stroke management with Neurologists all over the world. IV thrombolysis (tissue plasminogen activator [tPA], or newer Tenecteplase [TNK]) is a well-established therapy for acute ischemic stroke based on some questionable evidence [2-6]. However, its role in mild strokes has been hotly debated. On one hand, treating early might prevent a minor stroke from evolving or causing hidden disability. On the other hand, tPA carries a risk of intracerebral hemorrhage, and many minor stroke patients recover well without aggressive intervention. Guidelines have wrestled with this nuance: current recommendations endorse tPA for mild strokes that have clearly disabling deficits, but advise against tPA for mild non-disabling strokes [7]. The core controversy is whether the potential functional benefit in MIS is worth the bleeding risk if the patient is already doing okay. Things changed 10 years ago after Mr. CLEAN was published. It showed that endovascular interventions (EVT) for acute large vessel occlusions (LVOs) could have impressive results (NNT of 7). However, the role of IV thrombolytics for minor stroke syndromes remains unclear and controversial.  Legendary (now-retired) ED Dr. Joe Lex once stated, “If I can kick the syringe outta’ your hand – then don’t give me the tPA!”  Was Joe right? Before 2019, practice varied widely. Some neurologists treated almost any stroke within the window, reasoning that “time is brain” even for mild deficits, while others were more conservative. Observational studies yielded mixed signals. Several studies suggested that thrombolysis in mild strokes improves the chance of an excellent outcome at discharge or 90 days, while others showed minimal benefit.

Reference:  George S, et al. Effectiveness of nasal high-flow oxygen during apnoea on hypoxaemia and intubation success in paediatric emergency and ICU settings: a randomised, controlled, open-label trial. Lancet Respir Med. March 2025 Date: July 10, 2025 Guest Skeptic: Dr. Spyridon Karageorgos is a Pediatric Chief Resident at Aghia Sophia Children’s Hospital, Athens, Greece and faculty of the Pediatric Emergency Medicine MSc at Queen Mary University in London. Case: A two-year-old boy presents in the emergency department (ED) with severe respiratory distress and hypoxemia. You attempt to use some non-invasive forms of respiratory support, but he continues to have significant work of breathing and retractions. His mental status begins to decline, and he appears much sleepier than before. The team makes the decision to intubate him. You follow the steps of the pre-intubation checklist and pre-oxygenate him with 100% FiO2. As the sedative and paralytic for intubation are given, the respiratory therapist asks, “Do you also want to use nasal high flow (NHF) for apneic oxygenation during intubation?”  Background: Managing hypoxia in pediatric patients in EDs and intensive care units (ICUs) remains a challenge. Hypoxia can arise from various causes, including bronchiolitis, pneumonia, asthma, or undifferentiated respiratory failure. Ensuring timely and effective oxygenation is critical to stabilizing these patients and preventing progression to respiratory failure or cardiac arrest.  NHF oxygenation has gained traction as a respiratory support modality in both ED and ICU settings. NHF delivers humidified and heated oxygen at high flow rates, which typically exceed the patient’s inspiratory flow through nasal cannula. This mechanism not only improves oxygenation but can also help reduce the work of breathing by flushing anatomical dead space and providing some degree of positive end-expiratory pressure (PEEP). The use of NHF is considered less invasive than continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) or mechanical ventilation. It is usually better tolerated, especially by children. The use of NHF has expanded into general pediatric practice, especially for treating conditions like bronchiolitis and other forms of acute respiratory distress. But, its comparative efficacy to standard oxygen therapy in various clinical settings and patient populations remains a subject of ongoing investigation. While we would always prefer a controlled intubation, sometimes the patients we see in the ED are unstable and need to be intubated emergently. We often try to pre-oxygenate prior to intubating to maximize oxygen reserves. Previous studies have suggested that the use of NHF may reduce the risk of hypoxemia and improve first-attempt intubation . However, randomized controlled trials evaluating this practice in the pediatric population are limited. Clinical Question: In children requiring emergency intubation, does the use of nasal high-flow oxygen for apneic oxygenation reduce hypoxemia and increase the rate of successful first-attempt intubation compared to standard care? Reference:  George S, et al. Effectiveness of nasal high-flow oxygen during apnoea on hypoxaemia and intubation success in paediatric emergency and ICU settings: a randomised, controlled, open-label trial. Lancet Respir Med. March 2025 Population: Children aged 1 month to 15 years with acute hypoxic respiratory failure (SpO₂ <92% on room air) requiring emergency endotracheal intubation in EDs and pediatric and neonatal ICUs across Australia, New Zealand, and Switzerland. Exclusion: Primary nasal intubation, blocked nasal airways, elective endotracheal tube change, intubation required immediately for loss of cardiac output or respiratory arrest, location of intubation outside of ED or ICU, death Intervention: Nasal high-flow oxygen at 2L/kg/min during the apneic phase of intubation....

Date: September 18, 2025 Guest Skeptic:  Dr. Neil Dasgupta is an Emergency Medicine (EM) physician and emergency department (ED) intensivist from Long Island, NY. He is the Vice Chair of the ED and Program Director of the EM residency program at Nassau University Medical Center in East Meadow, NY.  Reference:  Doupnik et al. Impact of telemental health on suicide prevention care in U.S. emergency departments. AEM Sept 2025 Trigger Warning: The following case scenario discusses suicide and self-harm. If you or someone you know is at risk, seek immediate help (dial 911/999/112 as appropriate, or 988 in the US/Canada for suicide & crisis support). Resources:  Substance Abuse and Mental Health Services Administration (SAMHSA) National Alliance on Mental Illness (NAMI) American Foundation for Suicide Prevention (AFSP) Case: It’s 23:15 on a Tuesday in a 10-bed rural emergency department (ED) that serves as the community’s sole hospital. A 37-year-old male arrives with a friend after texting that they “can’t do this anymore.” The friend is concerned because he has access to firearms. Triage vitals are stable. The nurse uses the ED’s standard suicide‑risk screen, which is positive. The nurse activates the service’s 24/7 telemental‑health workflow. A video cart is wheeled into the room, and a remote clinician joins the conversation. Background: Delivery of quality mental health care is one of the major difficulties affecting our EDs. Caring for these patients presents a particular kind of challenge, since establishing rapport with the patient, getting a detailed history, gathering collateral information from others, overcoming possible intoxications or toxidromes, requiring staff for continuous observation and treating physical injuries can require substantial levels of time and skills.  In addition, suicide remains a leading cause of death, and EDs are a frequent point of contact for people in crisis. Many of these encounters involve complex psychosocial factors, limited outpatient capacity, and time-sensitive safety planning. The stakes are high, and what happens in the ED can shape risk in the hours to days after discharge. As emergency physicians, we balance therapeutic alliance, thorough risk assessment, and efficient disposition in an environment built primarily for acute medical care, not longitudinal mental health follow-up. Frustration often occurs due to limited resources, high volumes, inpatient boarding and overcrowding; it can seem impossible for an ED physician to provide compassionate, nuanced, complete psychiatric care. Patients utilize the ED for mental health care because they often do not have a choice.  Sometimes that lack of choice stems from a report of suicidal thoughts, which in most communities represents a lack of capacity to make medical decisions, and EMS systems are required to transport these patients for emergent psychiatric care.  In many communities, especially in areas that have less robust access to health care in general, there are profound administrative, financial and systemic barriers to creating or maintaining a functional level of mental health care infrastructure, profoundly overburdening the services that exist and pushing those needs onto the local emergency departments.  Telemedicine (particularly telepsychiatry and broader telemental health) has become a pragmatic way to expand access to mental health expertise. This has accelerated with the pandemic-era virtual care. Programs vary widely, with some providing on-demand psychiatric prescribers, while others lean on social work, psychology, or case management. Integration with the ED team and the electronic health record (EHR) can be excellent in some settings and minimal in others. Despite legislative progress in the US, including the Affordable Care Act and the Addiction Equity Act, reimbursements remain poor for the care of such patients, severely limiting access to care.

Date: Sept 16, 2025 Reference: Prada et al. Evaluation of the evidence on acetaminophen use and neurodevelopmental disorders using the Navigation Guide methodology. Environ Health. August 2025 Guest Skeptic: Dr. Andrew Martin is an emergency physician practicing in Jacksonville, Florida.  Case: A 27-year-old at 24 weeks’ gestation presents to the emergency department (ED) with fever (38.6 °C), myalgias, and sore throat. She took 650 mg of acetaminophen (Tylenol) six hours ago with partial relief. She hesitated to repeat the dose after reading online posts about “Tylenol and autism.” She has no abdominal pain, no vaginal bleeding, and normal fetal movement. Vitals otherwise stable; pharynx erythematous, no exudate. She asks, “Is it safe to take another dose, or could this hurt my baby’s brain later?” Background: Acetaminophen (paracetamol) is the most used analgesic–antipyretic in pregnancy. A recent prospective cohort study suggests ~40 to 65% of pregnant people report using it. They are typically using acetaminophen for headache, myalgias, or fever, with most use being short and intermittent. Alternatives, particularly non-steroidal anti-inflammatory drugs (NSAIDs), carry well-described fetal risks in late gestation. This is one of the reasons why acetaminophen remains the default first-line choice [1,2]. Biologically, acetaminophen crosses the placenta and achieves fetal levels like maternal levels, making the developing brain theoretically exposed during critical windows [3]. This has motivated a large observational literature examining whether prenatal exposure is linked to later neurodevelopmental outcomes such as ADHD and autism. Meta-analyses generally report small associations (summary effects around 1.2 to 1.3) and signal stronger effects with longer duration of use, though heterogeneity in exposure measurement and outcome ascertainment is substantial.  Professional bodies, including the American College of Obstetricians and Gynecologists (ACOG) and the Society of Obstetricians and Gynecologists of Canada [SOGC], continue to recommend acetaminophen for appropriate indications at the lowest effective dose and shortest duration. At the same time, they do acknowledge ongoing research and the limitations of observational data (including confounding by indication). For emergency clinicians, the practical tension is familiar. The dilemma is that untreated maternal fever and significant pain can themselves harm pregnancy, yet patients are increasingly asking about possible long-term neurodevelopmental potential harms of using acetaminophen.  Clinical Question: Is acetaminophen exposure during pregnancy associated with ADHD, ASD, or other neurodevelopmental disorders (NDDs) in children? Reference: Prada et al. Evaluation of the evidence on acetaminophen use and neurodevelopmental disorders using the Navigation Guide methodology. Environ Health. August 2025 Population: Observational studies assessing children of pregnant individuals for neurodevelopmental outcomes. Excluded: Postnatal exposures, non-human studies for the primary analysis, non-original publications, and duplicate reports from the same cohort. Exposure: Prenatal acetaminophen (maternal self-report, biomarkers such as meconium/cord blood, or medical records/prescription registries). Comparison: Children who were not exposed prenatally to acetaminophen, or those exposed to alternative analgesics. Outcome: Primary Outcome: NDDs (particularly ADHD and ASD) and related symptomatology measured by clinical diagnoses, medication use, or validated behavioural scales. Secondary Outcomes: Timing and dose–response patterns, broader cognitive/behavioural domains (language & executive function), and triangulation across design types. Type of Study: Systematic review using the Navigation Guide methodology with a qualitative synthesis (no meta-analysis) due to substantial heterogeneity.

Date: August 12, 2025. This is an SGEM Xtra, and today, we’re putting on our conference lanyards and boarding passes to talk about one of the most exciting events in the global EM calendar, IncrEMentuM 2026. For those who did not attend IncrEMentuM 2025, it set the bar incredibly high. From the moment delegates walked into the venue in Murcia, Spain, there was a buzz that felt like the early days of SMACC. The conference felt electric, global, and unapologetically fun. The talks were short, sharp, and full of energy, blending the best evidence with stories you’d remember long after the conference ended. On-stage simulations pushed the boundaries of what a medical conference could be, while debates in the concourse were full of healthy skepticism. Between sessions, the networking was amazing. One minute you could be sipping coffee next to EM legend Scott Weingart, and the next minute swapping resuscitation hacks with a new friend from across another continent. And, of course, the Spanish hospitality shone through. Paco, Carmen and the whole Incrementum team made everyone feel welcome, well fed, and everyone left wanting more. Well, you are in luck. Lightning is going to strike again on April 22 to 24, 2026, back in beautiful Murcia. Today, I am joined by three amazing Canadian EM physicians and educators who will be presenting in Murcia. Dr. Sara Gray has been known to run codes with the grace of a symphony conductor. Dr. Chris Hicks is like the Yoda of resuscitation: wise, calm, and occasionally cryptic. And finally, Dr. David Carr, the master of pearls, pitfalls, and the occasional “I-can’t-believe-that-just-happened” story. Having these three superstars on the SGEM reminds me of what a deep bench of medical educators we have in Canada. We are consistently punching above our weight in the #MedEd world. Today's podcast is not about Canada but rather the amazing things Spanish EM educators are doing. Five Questions for the Panellists Listen to the SGEM Xtra podcast to hear Sara, Chris and David respond. What can people expect from IncrEMentuM 2026? How is it different from your typical EM conference with endless PowerPoint karaoke & bad coffee? How does IncrEMentuM compare to the SMACC conferences? What will each of you be bringing to the stage in 2026 in Murcia? Beyond the great talks, why should someone hop on a plane to Murcia, and what are you looking forward to the most? IncrEMentuM 2026: April 22 to 24 in Murcia, Spain. Be prepared or be unprepared. Come for the evidence, stay for the tapas, and leave with new skills, new friends, and maybe a few “you-had-to-be-there” stories. The SGEM will be back with a structured critical appraisal, trying to cut the knowledge translation (KT) window from over ten years to less than one year, using the power of social media, so patients get the best care, based on the best evidence. Recuerda ser escéptico de todo lo que aprendas, incluso si lo escuchaste en The Skeptics’ Guide to Emergency Medicine.

Date: August 12, 2025 Article: FDA Approved and Ineffective by Jeanne Lenzer and Shannon Brownlee. June 5, 2025. The Lever. Jeanne Lenzer Guest Skeptic: Jeanne Lenzer is a long-time medical investigative journalist and returning SGEM guest. Her previous work, including the book The Danger Within Us, explored how conflicts of interest and weak evidence can endanger patient care. In this new project with The Lever, Jeanne analyzes how the FDA approves drugs that often don’t meet basic efficacy standards. I think many people assume that if a treatment is FDA-approved, surely it must work. However, people may be shocked to find out about the FDA’s drug approval process and how ineffective or harmful medications make it to market. Most patients and doctors have no idea that the FDA has quietly flipped the drug approval process on its head by putting most drugs on the market before they are shown to be safe or effective, with the promise that they will do those studies after they are on the market. Studies have shown that once a drug is on the market, patients do not want to enter or remain in clinical trials because they are convinced they’re being deprived of a proven treatment, and failure to enroll sufficient patients is one reason postmarket studies are delayed or never conducted. Once a drug is on the market, the FDA can require postmarket testing, but the due dates are often set so many years in the future that the patent will have run out. Take the controversial new Alzheimer’s drug, Leqembi, which causes brain bleeds, swelling and death. The manufacturer is required to conduct safety studies and report annually to the FDA.  However, neither the FDA nor the company will release the safety data until the final report is due. This will be in 2036, 13 years after it’s been on the market. This can be considered a guaranteed win for Pharma and a bad deal for patients. The FDA has fallen so low that the agency introduced a new term, “dangling approvals” for drugs approved before clinical benefit was proved and then allowed to remain on the market even after the post-marketing studies fail. Richard Pazdur, head of oncology at the FDA, defended the agency’s refusal to order certain cancer drugs off the market even after their post-market studies failed, saying “A failed trial, doesn’t mean a failed drug.” Well, true and true, but the idea is that drugs were supposed to be proven to work before they go on the market, not after. And with Pazdur’s and the FDA’s reasoning, any bad drug could remain on the market forever. And a few have. A two-year investigation by Lenzer and Brownlee found 429 FDA approvals (2013–2022) where the majority of drugs were authorized on inadequate evidence of effectiveness, with heavy reliance on surrogate outcomes, frequent lack of replication, and slow/absent confirmatory trials. The highlighted real-world harm and cost and call for regulators and clinicians to re-center on patient-oriented outcomes (POO) before widespread adoption. The article gives a few stories about FDA-approved drugs that turned out to cause harm without any benefit. One example was the drug Elmiron: Elmiron (pentosan polysulfate sodium) was approved in 1996 by the FDA for interstitial cystitis (chronic bladder pain) FDA approval was given without solid evidence of effectiveness FDA allowed approval on the condition that a follow-up study be done to confirm efficacy The follow-up study took 18 years to complete and showed no benefit over placebo Despite this, Elmiron remained on the market Not just a lack of benefit, but there were reported cases of harm Elmiron was associated with cases of a rare eye disease called pigmentary maculopathy that resulted in vision loss or blindness. It was also associated with severe colitis and dozens of deaths Bottom line is a drug with no proven benefit and significant harms stayed on the market for nearly 30 years