The Skeptics Guide to Emergency Medicine

Dr. Brandon Ho, a pediatric emergency medicine fellow at Children’s National Hospital, discusses the significant challenges in accurately triaging pediatric patients. He reveals concerning trends of misclassifying seriously ill children and the implications for patient care. The conversation covers the limitations of the Emergency Severity Index (ESI), biases in triage assessments, and the importance of effective communication. Ho also explores innovative solutions like AI and machine learning to enhance triage accuracy and improve health outcomes for young patients.

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.

In this discussion, Dr. Lauren Westafer, an Assistant Professor and pulmonary embolism expert from the University of Massachusetts Medical School, delves into the nuances of D-dimer testing. She highlights the challenges of ruling out pulmonary embolism (PE) in high-risk patients, spotlighting striking findings from recent research. The conversation critically assesses the reliability of D-dimer levels and biases in existing studies, urging a need for reevaluation of testing strategies for better outcomes in emergency medicine.

Dr. Aaron Skolnik, an Assistant Professor at Mayo Clinic and critical care expert, dives into the complexities of diagnosing sepsis. He highlights a critical case of a 62-year-old man with severe symptoms and discusses the limitations of current biomarkers. The conversation centers on monocyte distribution width (MDW) as a promising but not yet routine diagnostic tool for sepsis in emergency settings. Skolnik also examines biases in sepsis studies, underscoring the importance of clinician judgment in making accurate diagnoses.

Dr. Ross Prager, an Intensivist and adjunct professor, dives into the transformative role of AI in clinical research. He discusses how AI can enhance everything from study design to data analysis, but emphasizes the importance of collaboration for success. Ethical challenges, such as privacy risks and biases in AI models, are explored, along with the necessity of maintaining research integrity. Ultimately, the conversation reveals a future where AI revolutionizes patient-centered care while demanding vigilance from researchers.

In this engaging discussion, Dr. Tabitha Cheng, a board-certified emergency medicine physician with a focus on pediatric injuries, is joined by Dr. Caleb Ward and Dr. Julie Leonard, experts from the PECARN Network. They delve into the challenges of diagnosing cervical spine injuries in children post-accident and present a new three-tiered risk stratification system for imaging. The conversation emphasizes the importance of minimizing unnecessary radiation exposure and rethinking traditional emergency protocols, promoting a collaborative approach in pediatric care.

Dr. Jestin Carlson, a prominent figure in emergency medicine education, discusses the importance of engaging learning experiences, showcasing a dynamic course that reviews over 200 medical articles in exciting locales. The conversation shifts to the intricacies of ROC curves, emphasizing their role in evaluating medical tests while uncovering issues like p-hacking. Carlson advocates for transparency in research and stresses the need to consider various factors in clinical models, urging a skeptical approach to medical literature to improve patient care.