The Skeptics Guide to Emergency Medicine

Date: June 16, 2023 Reference: Reed et al. Pilot Testing Fentanyl Test Strip Distribution in an Emergency Department Setting: Experiences, Lessons Learned, and Suggestions from Staff. AEM June 2023 Guest Skeptic: Dr. Lauren Westafer is an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for Annals of Emergency Medicine. Case: A 27-year-old right hand dominant patient presents to the emergency department (ED) with a 2.5 cm left forearm abscess. They have no fever, chills, or signs of compartment syndrome. You perform an incision and drainage of the abscess with significant improvement in pain. The patient reports injection use of opioids, last use was a few hours ago. The patient currently has no signs of withdrawal and is interested in potentially starting on methadone; however, the patient is not ready to start the medication right now. Background: We have addressed the issue of substance use disorder a few times on the SGEM. This included looking at alcohol misuse and opioid misuse. SGEM#55: Drugs in My Pocket (Opioids in the Emergency Department) SGEM#241: Wake Me Up Before You Go, Go – Using the HOUR Rule SGEM#264: Hooked on a Feeling - Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain SGEM#313: Here Comes a Regular to the ED SGEM#374: Bad Habits – Medications for Opioid Use Disorder in the Emergency Department Rises in opioid overdose deaths have been attributed, at least in part, due to increases in fentanyl contaminating the illicit opioids in the United States. EDs are an important touch point for individuals with opioid use disorder (OUD), given the number of encounters for overdose and complications associated with drug use. Although some patients may be ready for medication such as buprenorphine or methadone, which can be initiated in the ED, some patients may not be ready for either medication. In these cases, harm reduction practices, strategies that mitigate complications from drug use, are critical. Fentanyl test strips (FTS) have been suggested as one harm reduction strategy to reduce opioid overdose deaths. The American College of Emergency Physicians (ACEP) endorses greater harm reduction education for emergency physician . Fentanyl test strips can be used by people who use drugs (PWUD), prior to use, to detect the presence of fentanyl. Individuals can then use that information to decide if or how much of the drug to use. Clinical Question: What are the perspectives of clinicians and other staff distributing fentanyl test strips to people who use drugs in an ED setting? Reference: Reed et al. Pilot Testing Fentanyl Test Strip Distribution in an Emergency Department Setting: Experiences, Lessons Learned, and Suggestions from Staff. AEM June 2023 Study design: This was a qualitative study assessing staff perceptions of a pilot of distribution of fentanyl test strips. Staff meeting inclusion criteria (below) were invited to participate and rec Population: English speaking ED clinician (physician, nurse, advanced practice provider, technician, social worker, certified recovery specialist) distributing fentanyl test strips through the pilot program. Intervention: Interviews at two points in time, three weeks and three months after distribution of FTSs began Comparison: Not applicable Megan Reed PhD This is an SGEMHOP episode, and it is my pleasure to introduce Dr. Megan Reed. She is a PhD with a Master’s in Public Health. Megan currently works at the College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA. Authors’ Conclusions: “Implementing FTS distribution may improve patient rapport while providing patients with tools to avoid a fentanyl overdose. Participants generally reported positive experiences distributing FTS within the ED but the barriers they identified limited opportunities to make distribution more integrated into their workflow. EDs considering this intervention should train staff on FTS, how to identify and train patients, and explore mechanisms to routinize distribution in the ED environment.” Quality Checklist for Randomized Clinical Trials: Was there a clear statement of the aims of the research? Yes Is a qualitative methodology appropriate?  Yes Was the research design appropriate to address the aims of the research? Yes Was the recruitment strategy appropriate to the aims of the research?  Yes Was the data collected in a way that addressed the research issue? Yes Has the relationship between researcher and participants been adequately considered? No Have ethical issues been taken into consideration? Yes Was the data analysis sufficiently rigorous? Unsure Is there a clear statement of findings? Yes How valuable is the research? Valuable Funding/COI: Funding from Bloomberg Philanthropies and the authors declare no potential conflict of interest. Results: There were 21 ED staff who participated in the qualitative review (7 residents, 4 attendings, 6 nurses, 2 recovery specialists, 1 social worker and 1 technician).  The mean age was 35 years, 57% were male and 76% were not at all familiar with FTS. Key Result: All participants endorsed the utility of FTS distribution in the ED Five Themes from the Interviews: Strategies to approach patients about FTS Patient reactions to FTS Dynamics between patients and participants Staff support and stigma Challenges of FTS distribution in the ED Listen to the podcast to hear Megan answer each our five nerdy questions. You can also click on the link to the YouTube video on How to Use FTS and How to Distribute FTS in the ED. 1. Reflexivity: Reflexivity is a key component of rigor in qualitative studies. Reflexivity involves a qualitative researcher examining their own judgments, practices, and belief systems during the data collection process to identify any personal biases that may have incidentally affected the research. In what was reflexivity addressed in the analysis? 2. Social Desirability Bias: We have talked often on the SGEM about various forms of bias. Bias being defined as something that systematically moves us away from determining the best point estimate of an observed effect size. In qualitative research, a major bias that is omnipresent is social desirability bias. This bias is when participants will often tell you what they think you want to hear. What degree do you think this might have been present? What efforts did you undertake to try to avoid this bias? 3. Qualitative Analytic Technique: There are several options for analysis in qualitative studies – grounded theory, thematic analysis, etc. Qualitative content analysis is less commonly used in healthcare and implementation research. Often then a manifest (what participants say) or latent (what participants intended to say) approach is chosen. How did you choose your approach? 4. Qualitative Rigor: Rigor in qualitative studies has been widely described based on the following criteria: credibility, dependability, transferability, and confirmability (instead of validity and generalizability). What did you do in this study to ensure qualitative rigor on these points? 5. Balancing Perspectives: In qualitative studies, participants will sometimes report the experiences or perspectives of others. Since this study did not interview the patients who were approached as potentially receiving fentanyl test strips, it is impossible to understand their perspectives. How do you balance this tension? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions. SGEM Bottom Line: Although the clinical impact of fentanyl test strips is uncertain, staff led distribution in the ED appears feasible. Case Resolution: You prescribe antibiotics for the mild cellulitis around the abscess. You provide take home naloxone and discuss harm reduction techniques including rotating injection sites, where to access new needles, use of alcohol pads, and potential for fentanyl test strips. Dr. Lauren Westafer Clinical Application: Although the clinical utility of fentanyl test strips in an undifferentiated population of people who use drugs in the ED is unknown, there are several barriers to implementing this intervention in the ED. What Do I Tell the Patient? Until you are ready to stop using drugs, there are several things you can do to reduce your risk of getting very sick, a bad infection, or dying. One of the things you may be interested in are test strips, which can detect fentanyl. If the drugs test positive for fentanyl, you are at increased risk of overdose. Keener Kontest: Last weeks’ winner was John Carter. He knew etomidate was published as a novel hypnotic agent in 1965.Listen to the episode to hear this weeks' question. If you think you know the answer then send an email to TheSGEM@gmail.com with "keener" in the subject line. SGEMHOP: Now it is your turn SGEMers. What do you think of this pilot study of distributing FTS to OUD patients in the ED? Tweet your comments using #SGEMHOP. What questions do you have for Megan and her team? Ask them on the SGEM blog. The best social media feedback will be published in AEM. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Dr. Amy Drendel, a pediatric emergency medicine physician and researcher at Children’s Wisconsin, discusses an intriguing case of a 14-year-old boy with sickle cell disease facing a painful vaso-occlusive episode. She highlights the promising role of intranasal fentanyl in improving pain management and expediting discharge from emergency departments. The conversation dives into the challenges of opioid administration, the potential efficiencies of intranasal versus intravenous methods, and the need for further research to enhance care for pediatric patients.

Date: June 6th, 2023 Reference: Pines, Raja, Bellollo and Carpenter. Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules 3rd Edition Dr. Jesse Pines Guest Skeptic: Dr. Jesse Pines is the Chief Clinical Innovation at US Acute Care Solutions and a Clinical Professor and George Washington University and Professor of Emergency Medicine at Drexel University. In this role, he focuses on developing and implementing new care models including telemedicine, alternative payment models, and clinical programs involving new technology at USACS.  Jesse has been on the SGEM before including these two episodes: SGEM#308: Taking Care of Patients Everyday with Physician Assistants and Nurse Practitioners SGEM#316: What A Difference An A.P.P. Makes? Diagnostic Testing Differences Between A.P.P.s and Physicians Please consider listening to the SGEM Xtra podcast with Jesse discussing the 3rd edition of Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules. I was honoured to be asked to write the foreword to this latest edition. Foreword Emergency physicians are many things but one of the most important things we try to be is great diagnosticians. Every shift we use limited information in a busy, chaotic environment to make decisions. Sometimes those decisions can mean life or death and need to be made quickly. We strive to be the best at exercising this important responsibility. This is the book that can help clinicians achieve that goal. The first and second edition of Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules is a resource I have used regularly through my career. It has made me a better diagnostician and better physician. Questions come up on every shift as to what evidence supports our actions. This fantastic book provides answers to those questions in a brief and helpful way. I am often accessing it for my own needs and as an educational resource for students. The third edition contains the foundational elements of providing excellent evidence-based medicine (EBM) care. The authors start by discussing diagnostic testing in the emergency department (ED). They explain the epidemiology and statistics behind diagnostic testing. They appropriately emphasize that clinical decision instruments are tools to guide care, not rules to dictate care. They touch upon the additional responsibility of being good stewards given the realities of limited resources. They also provide a chapter to help clinicians understand the direction of bias in diagnostic research. The third edition covers dozens of common and deadly conditions clinicians are faced with in the ED. This includes chapters on pediatrics, geriatrics, cardiac, neurological, surgical, trauma, infectious disease, and other conditions. There are four new chapters in the latest edition of the book: Skin and Soft Tissue Infection, Shared Decision Making, Cognitive Bias and Telemedicine Diagnosis. There are all wonderful additions to the book. My favourite new chapter is the one discussing Shared Decision Making (SDM). SDM goes beyond informed consent and recognizes the autonomy and agency of patients. We are making important decisions that must consider patients values and preferences. This is one of the three pillars of EBM. While we may be the experts at clinical medicine, patients are experts of their own personal experience. There are many examples of where SDM can be utilized in the ED with my clinical experience to enrich the therapeutic patient-physician alliance. If you want to provide patients the best care, based on contemporary evidence then this is your book. Previous Books Highlighted on the SGEM SGEM Xtra: Message in a Book by the SGU SGEM Xtra: Don’t Give Up – The Power of Kindness with Brian Goldman SGEM Xtra: The Danger Within Us SGEM Xtra: Relax – Damm It! SGEM Xtra: Season 1 to 10 PDF Books 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 ten years to less than one 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. Further Reading: SGEM#3: To X-ray or not to X-ray (Ottawa Ankle Rule) SGEM#5: Does Johnny “kneed” an X-ray? (Ottawa Knee Rule) SGEM#48: Thunderstruck (Subarachnoid Hemorrhage) SGEM#88: Shock Through the Heart (Ottawa Aggressive Atrial Fibrillation Protocol) SGEM#106: O Canada- Canadian CT Head Rule for Patients with Minor Head Injury SGEM#170: Don’t Go Breaking My Heart – Ottawa Heart Failure Risk Scale SGEM#201: It’s in the Way That You Use It – Ottawa SAH Tool SGEM#266: Old Man Take a Look at the Canadian CT Head Rule I’m a Lot Like You Were SGEM Xtra: Ian Stiell – Legend of Emergency Medicine Kohn MA, Carpenter CR, Newman TB. Understanding the direction of bias in studies of diagnostic test accuracy. Acad Emerg Med. 2013 Nov First10EM: Clinical Decision Rules are Ruining Medicine

Date: June3, 2023 Reference: Kotani et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. Journal of Critical Care April 2023 Guest Skeptic: Dr. Amber Gombash is an emergency physician in Concord, NC. Case: You have a critically ill patient that you are preparing to intubate and wonder if the use of etomidate as your induction agent increases mortality. Missy Carter Background: Intubation is something we have a covered a few times on the SGEM. There was an episode with Physician Assistant (PA) Chip Lange on the use of POCUS to confirm tube placement (SGEM#249). This got some feedback from our friend Scott Weingart over at EMcrit. Our usual go to guest skeptic for airway has been paramedic and PA Missy Carter (SGEM#247, SGEM#271 and SGEM#396). One aspect that has not been well covered on the SGEM is the choice of induction agent when intubating patients. There was an episode 10 years ago looking at the use of etomidate in septic patients (SGEM#44). It was a SRMA reporting an associated increase in adrenal insufficiency and all-cause mortality with the use of etomidate to intubate septic patients. A more recent SGEM episode looked at an unblinded single centre randomized trial comparing etomidate vs ketamine in adult patients requiring emergency endotracheal intubation (SGEM#356). The primary outcome was an 8% absolute increase in all-cause mortality at seven days for patients allocated to the etomidate group. This outcome was no longer statistically different at 28 days. There were multiple issues with this trial including a lack of masking (blinding), selection bias and the primary outcome measure of all-cause mortality at 7 days. Etomidate is often used as the induction agent in critically ill patients due to its fast onset and hemodynamically neutral nature. However, it is hypothesized that etomidate may increase the risk of organ dysfunction and death by the suppression of cortisol production through inhibition of 11-beta-hydroxylase. This goes back to at least 2009 the Ketased study. That trial found that in a critical care setting there was an increase adrenal insufficiency in the group receiving etomidate. There are now multiple randomized trials studying the effect of etomidate as an induction agent on adrenal function and mortality. These studies have reported mixed results—with some finding a statistically significant increase in mortality. There was a SRMA in 2021 that reported an associated increase in adrenal suppression and mortality with etomidate. However, this review combined high-level studies (five randomized controlled trials) with low-level studies (nine post hoc and 15 retrospective studies). Clinical Question: Does etomidate used as an induction agent cause an increased mortality in critically ill adults? Reference: Kotani et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. Journal of Critical Care April 2023 Population: Critically ill adults undergoing emergency endotracheal intubation for critical illness Exclusions: Pediatric patients < 15 years old, etomidate as an infusion (rather than induction/bolus dose), non-randomized trials, systemic reviews, commentaries/editorials and literature reviews, studies not addressing the review question Intervention: Etomidate Comparison: Any other induction agent Ketamine (4 studies), midazolam (4 studies), thiopental (1 study), ketamine + midazolam (1 study), ketamine + propofol admixture (1 study) Outcome: Primary Outcome: Mortality at the main timepoint defined by trial authors Timepoint: Intensive care unit (1 study), Hospital (5 studies), 24 hours (1 study), 7 days (1 study), 28 days (2 studies), 30 days (1 study) Secondary Outcome: Development of adrenal insufficiency Authors’ Conclusions: “This meta-analysis found a high probability that etomidate increases mortality when used as an induction agent in critically ill patients with a number needed to harm of 31.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. No The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Yes There was low statistical heterogeneity for the primary outcomes. Yes The treatment effect was large enough and precise enough to be clinically significant. Unsure Results: The authors identified eleven randomized trials that fulfilled their inclusion and exclusion criteria. These trials include a total of 2,704 patients. Of the eleven studies, the comparator was ketamine in four studies, midazolam in four studies, thiopental in one study, ketamine + midazolam in one study, and ketamine + propofol mixture in one study. Key Result: There is a high probability that etomidate increases mortality when used as an induction agent in critically ill patients. Primary Outcome: All-cause mortality Etomidate increased mortality at the main timepoint defined by trial authors in 319/1359 (23%) vs comparator 267/1345 (20%) This gives an NNH of 31 Risk ratio = 1.16 (95%CI; 1.01-1.33, P = 0.03), 1% probability of any increase, 92.1% probability of a 1% increase (NNH <100) Secondary Outcome: Adrenal insufficiency Etomidate increased development of adrenal insufficiency in 147/695 (21%) vs comparator 69/686 (10%) RR = 2.01 (95%CI; 1.59-2.56), P = <0.001, 1. Risk of Bias: Out of the eleven studies, five were graded as low risk bias, five had some concerns and one as high risk; the highest risk weighted only 0.6%. Most of the large trials included in this study were open label (Machett 30%, Punt 11% and Powers 16%). The other large, randomized trial was a single blinded trial by Jabre making up 24% of the data set. This lack of masking could have introduced bias into the results. Bias being defined as something that systematically moves us away from the “truth”. Truth being the best point estimate of the observed effect size. 2. Mortality Outcome: The included trials used a wide range of timepoints for all-cause mortality. It ranged from as short as 24 hours (Powers WF 2021) to as long as 30 days (Driver B 2014). Five studies were hospital mortality, and one study was intensive care unit (ICU) mortality. The authors did request mortality data at a longer timepoint from original trials but unfortunately did not get responses. 3. Loss of Statistical Significance: If you include the secondary outcome of 28-day all-cause mortality data from the Matchett trial which represented 30% (801/2704) of the SRMA data the statistical difference goes away. The RR was 1.07 (95% CI 0.95 to 1.21). It’s good to remember the potential biases in the original trials. We already mentioned that the Matchett trial was an open-label trial. There were additional concerns of it being a single centre with the code blue team being run by anesthesiologists. The patients in the Matchett trial were also not included consecutively.  More than 1,000 patients were excluded from the trial with 800 due to “clinical circumstances, clinician preference for usual care”. The trial only had 801 patients total with 800 being excluded for seemingly subjective reasons.This raises the concern of selection bias that cannot be controlled for in the SRMA. There is also the issue of survival and survival with good neurologic function. We saw this with the PARAMEDIC2 trial. That 2018 NEJM RCT reported an increase in survival to hospital and survival to hospital discharge in patients with out-of-hospital cardiac arrests (OHCAs). However, there was no statistical difference in good neurologic outcome at hospital discharge or at three months (SGEM#238). 4. Lots of Different Controls/Comparators: These trials did not just compare etomidate to one other induction agent like ketamine but rather to a variety of agents. When comparing etomidate with just ketamine the data still demonstrated an increase in mortality with etomidate (RR 1.18 [95% CI 1.02 to 1.37]). Interestingly the I2 measure for heterogeneity in this subgroup analysis was 30% while the overall statistical heterogeneity for etomidate vs any other induction agent was reported at 0%. 5. Different Patients: These were not just ED patients. Some were from out-of-hospital, some were ED patients, and some were from the ICU. There was also a diversity of critically ill patients (medical and surgical patients). Some patients had more cardiovascular morbidities than other patients. This might make the results more generalizable but could also mean that the results do not apply to the individual patient. This gets back to the EBM Venn diagram of the literature informing care, using good clinical judgment, and considering patient values/preferences. This moderate level evidence suggests an increase in mortality using etomidate. However, not at the longest follow-up available and does not give information on survival with good neurologic function.  Comment on Authors’ Conclusion Compared to SGEM Conclusion: We would have been less definitive and more uncertain with our conclusions. The data suggests a single dose of etomidate may increase mortality in the short-term setting for critically ill adults although further research is needed to determine its effects on long-term mortality. SGEM Bottom Line: It's still uncertain if using etomidate as an induction agent decreases the patient-oriented outcome of survival with good neurologic function in critically ill patients requiring emergent endotracheal intubation. Case Resolution: As you prepare to intubate your critically ill patient,

Date: May 10, 2023 Reference: Harhay MO, et al. A bayesian interpretation of a pediatric cardiac arrest trial (THAPCA-OH). NEJM Evidence. 2023. Guest Skeptic: Dr. Kat Priddis is a paediatric emergency medicine consultant and trauma director at Watford General Hospital. She is part of the Don’t Forget the Bubbles team and faculty at Queen Mary University in London where she teaches part of the Paediatric Emergency Medicine MSc. Dr. Kat Priddis Case: You are working at the community emergency department (ED) when you receive a call from the local Emergency Medicine Service (EMS) team that they are bringing a 2-year-old boy who had a cardiac arrest at home. He had been having some upper respiratory symptoms in the previous days. Parents found him in bed that morning blue and unresponsive. They started cardiopulmonary resuscitation (CPR) until EMS arrived.  Upon arrival at the ED, your team promptly begins high quality CPR and manages to obtain return of spontaneous circulation. As you are mentally running through your checklist for post-arrest care and preparing to transfer the patient, a team member tells you that there are potentially two hospitals in the area who may be able to accept the patient. One of the hospitals has a pediatric intensive care unit (PICU) that has the capability to perform therapeutic hypothermia but it’s further away. Which hospital should you transfer the patient to? Background: Therapeutic hypothermia in cardiac arrest has been covered on the SGEM multiple times, all the way back to SGEM #21 and SGEM #54 and most recently in SGEM #391. Ken and Justin Morgenstern of First10EM provided a very nice summary of the history of therapeutic hypothermia that you can check out, so we won’t belabor the point. Other therapeutic hypothermia trials included Target Temperature Management or TTM trial (SGEM #82), HYPERION (SGEM #275), TTM2 (SGEM #336). However, we have not covered the Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest (OHCA) in Children or THAPCA-OH published in the New England Journal of Medicine in 2015. We’re adding on a second paper looking at the Bayesian interpretation of the original study.  Clinical Question: Does therapeutic hypothermia provide any benefit in neurobehavioral outcomes and survival in out-of-hospital pediatric cardiac arrest? Original trial: Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Engl J Med. 2015. Reference: Harhay MO, et al. A bayesian interpretation of a pediatric cardiac arrest trial(THAPCA-OH). NEJM Evidence. 2023. Population: 295 pediatric patients (ages greater than two days to less than 18 years) hospitalized in PICUs at 38 children’s hospitals, who were admitted after OHCA.  Excluded: Inability to randomize within 6 hours of ROSC, Glasgow Coma Scale (GCS) motor score of 5 or 6, decision to withhold aggressive treatment by clinical team, traumatic arrest Intervention: Therapeutic hypothermia (target temperature 33°C).  Comparison: Therapeutic normothermia (target temperature 36.8°C) Outcome:  Primary Outcome: Survival with good neurobehavioral outcome at 12 months. Outcome defined by Vineland Adaptive Behavior Scales (VABS-II) of 70 or higher (this is a scale from 20 to 160 with higher scores associated with better function) Secondary Outcomes: Survival at 12 months and change in neurobehavioral function Other Outcomes: Global cognitive score, blood product use, infection, serious arrhythmias through 7 days, 28-day mortality Trial: Multinational unmasked randomized clinical trial  Authors’ Conclusions Original Paper: “In comatose children who survive out-of-hospital cardiac arrest, therapeutic hypothermia, as compared to therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year.” Authors’ Conclusions Bayesian Interpretation Paper: “There is a high probability that hypothermia provides a modest benefit in neurobehavioral outcome and survival at 1 year.” 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).  No 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. Unsure.  Financial conflicts of interest. Some investigators reported consulting fees from biomedical companies, but it did not seem there were obvious conflicts of interest. Results: 1,355 patients were screened and met inclusion criteria. 475 were eligible. 295 underwent randomization with 155 in the hypothermia group and 140 in the normothermia group. Median age was two years of age and two-thirds were male.  A higher percentage of the patients in the normothermia group had asystole as their initial rhythm (62% vs 55%), had a cardiovascular event as the cause of their arrest (13% vs 9%), and still required chest compression at time of arrival to the first hospital (73% vs 64%).  Key Results (Original Paper): Therapeutic hypothermia did not have significant benefit on survival with good neurological function compared to normothermia. Key Result (Bayesian Analysis): There is a high probability that therapeutic hypothermia can have some benefit in survival with good neurological function compared to normothermia. From the Original THAPCA-OH Study Primary Outcome:  Survival at one year with VABS-II scores ≥70 was not significantly different (p=0.14) between the two groups. Secondary Outcomes: Survival at one year with change in VABS-II score from baseline was not significantly different between the two groups (p=0.13) There were no statistically significant differences in blood product use, arrhythmias, infections, or all-cause mortality at 28 days. From the Bayesian Interpretation Probability of benefit from hypothermia was 94% for both neurobehavioral outcomes and survival at one year. 1) Selection Bias: There were a lot of exclusion criteria in the original THAPCA-OH study that may have led to selection bias. Two of the reasons why patients were excluded included: clinician judgment to withhold treatment and family not approached for consent because the doctor thought participation was not appropriate. These are highly subjective exclusion criteria Additionally, we could not figure out why patients with GCS motor scores of 5 or 6 were excluded. Were they too “healthy?” This is especially odd because they also simultaneously excluded patients with poor function based on VABS-II score of <70 or Pediatric Overall Performance Category or Pediatric Cerebral Performance Category scores. Were they trying to find those Goldilocks patients who were “just right?” 2) Masking and Confounders: The trained interviewer who collected the VABS-II score was masked to group allocation, but they were unable to mask the treatment team to the intervention. Additionally, the clinical teams had control over all other aspects of treatment outside of the temperature goals. This lack of masking may have impacted how patients were treated based on their assigned group.  For the patients who died while in the hospital or within 28 days, around 40% in both groups had a cause of death attributed to withdrawal of care for poor neurologic prognosis. This study was looking at the effects of hypothermia vs normothermia on survival and neurologic outcomes so excluding these patients when poor neurologic outcome is not assured may also affect the results.  3) P-Values: There are several definitions for what a p-value is and what it is not [1-3]. The cutoff of 0.05 is arbitrary. It was proposed by Ronald Fisher back in 1925, and we’ve used it since to determine whether something is “statistically significant.” Other fields use different p-value thresholds to determine significance. Something can be not clinically significant but still be statistically significant or vice versa. Is it really that dichotomous? When a p value crosses a pre-specified significance threshold, we are tempted to say that there is no difference between the two interventions, but that is not really accurate. There can still be a difference, but it just is not statistically different. 4) Bayesian Approach and Definitions: The SGEM covered a bit of Bayesian statistics on an SGEM Xtra with Dr. Dan Lane. If we look at the numbers from the THAPCA-OH study without considering p-values, it very much looks like there is a difference between therapeutic hypothermia vs. normothermia. The hypothermia group had 20% good neurobehavioral outcomes compared to the 12% in the normothermia group. Bayes’ theorem is described as “revising prediction in light of relevant evidence.” In many ways, this reflects our clinical thinking. We consider what the previous evidence has demonstrated when considering new evidence. Bayesian statistics looks at the trial in probabilistic terms. It looks at previous data (also called priors).  Noninformative Priors: There is no prior existing data, meaning that we only consider the observed trial data, and every effect is possible. This helps you to pick up on small improvements.

Join Dr. Jonathon Edlow, a Harvard emergency medicine professor, and Dr. Peter Johns, a seasoned emergency physician with a passion for vertigo education. They discuss the GRACE-3 guidelines, emphasizing the complexities of diagnosing acute dizziness and the importance of comprehensive history-taking. The duo critiques traditional methods and advocates for an algorithmic approach to enhance diagnostic accuracy. They delve into vital techniques for managing Benign Paroxysmal Positional Vertigo and highlight the necessity of ongoing training for emergency physicians in effectively evaluating vestibular disorders.

Dr. Brooks Walsh, an emergency physician and former paramedic, delves into the complex topic of excited delirium, revealing its historical roots dating back nearly 200 years. He critiques the term's racial biases and calls for a re-evaluation of its application in emergency medicine. Walsh emphasizes the need for diversity in decision-making to improve patient outcomes and discusses the challenges in translating research into practice. He advocates for better communication strategies in high-stress situations, aiming to foster equity in medical care.

Date: April 26, 2023 Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You are moonlighting at the Veterans Administration emergency department (ED) and are caring for an Iraq veteran complaining of post-traumatic stress disorder (PTSD) and severe anxiety. You desire a psychiatric consult and learn that you don’t have in-person consult availability at this facility, but instead use telehealth services. You wonder about how this compares to an in-person consult. Background: Mental health and behavioral complaints are common in the ED, but a shortage of mental health providers results in high numbers of patients requiring transfer, some of whom may have been appropriate for discharge. Telemental health (TMH) has been shown in settings outside the Veterans Administration (VA) to increase access to mental health providers, increase the proportion of patients discharged home, and decrease the number of patients transferred. However, what’s not well studied is the effect of TMH on post-evaluation utilization and processes of care such as medication changes, disposition, length of stay, involuntary holds, and use of chemical or physical restraints. Clinical Question: What is the effect of TMH, versus in-person consult, on 30-day outcomes and processes of care during the visit? Reference: Han et al. The effect of telemental versus in-person mental health consults in the emergency department on 30-day utilization and processes of care. AEM April 2023 Population: Veterans presenting to VA medical center (VAMC) EDs and urgent care centers (UCC) Intervention: Telemental health consult administered via iPad and Apple FaceTime software Comparison: In-person mental health consultation Outcome: Primary Outcome: Composite of 30- day return ED visits, 30-day return hospitalization after the index ED visit, and death from any cause. Secondary Outcomes: Number of medications changed, disposition, length of stay, involuntary hold, use of parenteral benzodiazepines or haloperidol, and use of physical restraints or seclusion Type of Study: Exploratory retrospective cohort study Dr. Jin Han This is an SGEMHOP episode which means we have the lead author on the show.  Dr. Jin Han is an emergency physician with Vanderbilt University Medical Center in Nashville TN, and a researcher with the Geriatric Research, Education, and Clinical Center at the Tennessee Valley VA Healthcare System. Authors’ Conclusions: “TMH was not significantly associated with the 30-day composite outcome of return ED/UCC visits, rehospitalizations, and death compared with traditional in-person mental health evaluations. TMH was significantly associated with increased ED/UCC length of stay and decreased odds of placing an involuntary psychiatric hold. Future studies are required to confirm these findings and, if confirmed, explore the potential mechanisms for these associations.” 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/is the estimate of risk? Fairly narrow CIs Do you believe the results? Yes Can the results be applied to the local population? No Do the results of this study fit with other available evidence? Yes Funding/COI: Grant from the Office of Rural Health of the Veterans Health Administration and National Center for Advancing Translational Sciences. There were no declared COIs. Results: They identified 496 veterans that met inclusion criteria. The mean age was 55, almost 90% were male and 27% were rural. High-risk chief complaint (suicidal ideation, homicidal ideation, agitation, or psychosis) was 29%. Of the cohort, 70% received TMH and 30% received in-person mental health evaluations.  Key Results: No statistical difference in the primary outcome between TMH and in-person mental health evaluation. Primary Outcome: Composite 30-day return visits, rehospitalizations, deaths 4% TMH vs 17.3% In-Person: aOR 1.47 (95% CI; 0.87 to 2.49) Listen to the SGEM podcast to hear Jin answer our five nerdy questions. 1. External Validity: As with most VA studies, the cohort consisted mostly of middle-aged men. How much do you think this limits the external validity to other populations outside of the VA? 2. Baseline Demographics: There were several demographic differences between patients who received TMH and those who received an in-person consult. Do you have any thoughts as to why that occurred? 3. Primary Outcome: Your primary outcome is a composite outcome, but you separated out the individual components for the exploratory outcomes. Can you explain why you used the composite for your primary? 4. Lost to Follow-Up: We could not find mention of patients being lost to follow up, which could introduce bias if 30-day outcomes aren’t accurate. Were there any patients lost to follow up? 5. Length of Stay: The results show longer length of stays and decreased use of involuntary holds in the telemental health group. Why do you think that occurred? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusions but are concerned about the external validity of the findings. SGEM Bottom Line: Telemental health consults did not significantly change the primary outcome but did have some interesting process differences when compared with in-person consults in the American Veteran’s Administration system. Case Resolution: You connect to a TMH provider who assesses your patient, makes some medication changes, and discharges the patient home to follow up within a week. Dr. Corey Heitz Clinical Application: Telemental health may serve as a good option for mental health consultation when in-person evaluation isn’t available. What Do I Tell the Patient? “I’m going to set you up for a mental health evaluation. You’ll talk to a provider, but they won’t be here in the building. Instead, we’re going to use a videoconferencing app.” Keener Kontest: Last weeks’ winner was Dr. Kay Dingwell from PEI. She knew T’Pau was the name of the respected Vulcan leader in Star Trek the Original Series episode called Amok Time. Listen to the podcast to hear this weeks' question. If you think you know the answer, send an email to TheSGEM@gmail.com with “Keener” in the subject line. The first correct answer will receive a cool skeptical prize. SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on telemental health? What questions do you have for Jin and this team? Tweet your comments using #SGEMHOP or post your feedback on the SGEM blog. The best social media feedback will be published in AEM.   Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

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