The Skeptics Guide to Emergency Medicine

Date: April 16th, 2022 Reference: Blom et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021 Guest Skeptic: Dr. Matt Schmitz, Pediatric Orthopedics, Adolescent Sports Medicine and Young Adult Hip Preservation Surgeon at San Antonio Military Medical Center in Texas. Disclaimer: The views and opinions of this blog and podcast do not represent the United States Government or the US Military. Case: A 55-year-old man comes into the emergency department (ED) for increasing knee pain and decrease in function. He’s had an anterior cruciate ligament (ACL) repair and used to run marathons. However, he is finding it more difficult to even put his socks on. Physical exam shows varus deformity at the knee, decreased range of motion, crepitus, no locking and neurovascularly intact distal. X-rays show severe, tri-compartment arthritis. Background: Musculoskeletal complaints are one of the most common presentations to emergency departments. Often emergency physicians are assessing, treating, and answering patients question about orthopedic surgical procedures. How good is the evidence for the most common elective procedures? Before we answer that question, let’s remind everyone that only a small number (2.8%) of interventions published in SRMA and relevant to emergency medicine have unbiased and strong evidence for improved outcomes (SGEM#361). This is a broader problem in medicine. Tricoci et al. JAMA Feb 2009 looked at the ACC/AHA guidelines from 1984 to 2008. They found 53 guidelines with 7,196 recommendations. Only 11% of recommendations were considered Level A, 39% were Level B and 50% were Level C. An update was published by Fanaroff et al in JAMA 2019. The level of high-quality evidence had not changed much when looking at the ACC/AHA guidelines from 2008-2018. There were 26 guidelines with 2,930 recommendations. Now Level A recommendations were down to 9%, Level B 50% and Level C 41%. Time to turn our skeptical eye to the evidence for elective orthopaedic procedures. Clinical Question: What is the effectiveness of common elective orthopaedic procedures compared with no treatment, placebo, or non-operative care? Reference: Blom et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021 Population: Meta-analyses of randomised controlled trials Exclusions: Network meta-analyses (when pairwise meta-analyses were available), narrative reviews, systematic reviews that did not pool data or do a meta-analysis, and meeting abstracts Intervention: Surgery Comparison: No treatment, placebo, or non-operative care Outcome: Quality and quantity of evidence behind the ten most common elective orthopaedic surgeries and comparisons with the strength of recommendations in relevant national clinical guidelines. Authors’ Conclusions: “Although they may be effective overall or in certain subgroups, no strong, high quality evidence base shows that many commonly performed elective orthopaedic procedures are more effective than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable.  Yes/Unsure The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. Yes The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Yes There was low statistical heterogeneity for the primary outcomes. Unsure The treatment effect was large enough and precise enough to be clinically significant. Yes, No and Unsure Results: The ten most common elective orthopaedic procedures were identified using a literature search,

Date: April 7th, 2022 Reference: Wong et al. Sensitivity of diffusion-weighted magnetic resonance imaging in transient global amnesia as a function of time from symptom onset. AEM April 2022 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. Case: A 65-year-old man presents to your emergency department with his wife. She tells you that he woke up normally this morning, but after breakfast he began asking the same questions repetitively and was amnestic to the answer, seemingly unable to form new memories. He remained completely awake and alert and otherwise appeared well.  There was no history of recent trauma, infectious symptoms, or any other illness.  Background: Transient global amnesia (TGA) is an idiopathic acute neurological disorder that presents with sudden onset anterograde memory loss. It was first described as a syndrome in 1956 by Courjon and Guyotat and also by Bender [1,2].  Fisher and Adams formally described as TGA in 1964 [3]. The usual presentation is a patient between 50 and 70 years of age who are cognitively and neurologically intact but asking repetitive questions, unable to form new memory. Symptoms do not last very long and resolve within 24 hours. The incidence has been reported as 23.5 per 100,000 people per year [4] and is more common in people who get migraine headaches [5]. TGA is often precipitated by physical or emotional stressors, pain, the Valsalva maneuver, hot or cold-water immersion or sexual intercourse [6] Diagnosing TGA combines items put forward by Hodges and Warlow and Caplan [7-9]. This results in seven diagnostic criteria for TGA. Diagnostic Criteria for Transient Global Amnesia Attack is witnessed Clear-cut anterograde amnesia during the attack No neurologic symptoms or signs during the attack other than amnesia (no clouding of consciousness or loss of personal identity) No neurologic physical examination findings others than anterograde amnesia Memory loss is transient (resolution within 24 h) No epileptic features and no active epilepsy (defined as no seizure within 2 years or on antiepileptic medication) No recent head injury A diagnostic algorithm has been published for patients with sudden onset of anterograde amnesia [6]. Included in this differential is transient epileptic amnesia, transient ischemic attack, stroke, metabolic disorders, psychogenic disorders, and post traumatic amnesia. The workup can include laboratory testing, EEGs, ECGs, echocardiogram and advanced neuroimaging. Clinical Question: What is the sensitivity of diffusion-weighted magnetic resonance imaging (DW-MRI) as a function of time from symptom onset compared to clinical diagnosis of TGA? Reference: Wong et al. Sensitivity of diffusion-weighted magnetic resonance imaging in transient global amnesia as a function of time from symptom onset. AEM April 2022 Population: Adult patients 16 years of age and older with a diagnosis of TGA based on the existing clinical criteria Intervention: Evaluation with DW-MRI at varying time intervals post symptom onset Comparison: No comparison as no studies of patients without DW-MRI were included Outcome: Sensitivity of DW-MRI in diagnosis of TGA Dr. Matt Wong This is a back-to-back SGEMHOP episode. We did the March episode at the end of last month and the April episode is the first week of this month. We are pleased to have the lead author on the show. Dr. Matthew Wong is an emergency physician and educator at Beth Israel Deaconess Medical Center, and an Assistant Professor at Harvard Medical School. Authors’ Conclusions: “DW-MRI lesions are uncommon in patients with TGA early after symptom onset, but the sensitivity (i.e., positivity rate) of DW-MRI increases with time. Despite the limited quality of existing evidence, obtaining an early DW-MRI in patients with clinical diagnosis of TGA in the acu...

Date: March 31st, 2022 Reference: Butt et al. Take-Pause: Efficacy of mindfulness-based virtual reality as an intervention in the pediatric emergency department. AEM March 2022 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 is a pulmonary embolism and implementation science researcher. Lauren won the 2021 SAEM FOAMed Excellence in Education Award. Case: A 15-year-old male presents to the pediatric emergency department (ED) with right ankle pain sustained while twisting his ankle during dance practice. The right ankle is swollen and tender. He rates his pain a 5 on the FACES scale and is awaiting examination by the treating clinician. Background: Pediatric emergency department (ED) visits and related procedures can invoke pain and anxiety among children. Patients who experience adequate pain relief during their ED stay have significant reductions in distress, improved rapport with their physician, improved intent to comply with discharge instructions and higher levels of personal and caregiver satisfaction. Children represent one group of patients that are less likely to receive adequate analgesia (Brown et al, Selbst and Clark). This phenomenon is known as oligoanalgesia or poor pain management through the underuse of analgesia. Dr. Anthony Crocco We have covered pediatric pain with PEM super hero Dr. Anthony Crocco on SGEM#78 who did a RANThony on this issue. Dr. Samina Ali is a PEM super (s)hero who was on SGEM#242 looking at intranasal (IN) ketamine vs fentanyl on pain reduction for extremity injuries in children. The bottom line from that trial was IN ketamine appears to be non-inferior to IN fentanyl for efficacy, but with more adverse events. Many clinicians utilize distraction techniques to reduce pain and anxiety in children during their ED visits [4]. However, there are no prospective randomized trials using virtual reality (VR) as a distraction technique while awaiting physician evaluation. Clinical Question: Does a 5-minute virtual reality program reduce situational anxiety in the pediatric ED? Reference: Butt et al. Take-Pause: Efficacy of mindfulness-based virtual reality as an intervention in the pediatric emergency department. AEM March 2022 Population: Patients ages 13-17 years who presented to the pediatric ED with mild to moderate acute pain (pain score 2-6 on FACES pain scale) Exclusions: Patients with developmental delays, inability to speak English, prone to motion sickness, significant visual/hearing impairment, pregnancy, parental refusal, received analgesic ≤4 hours prior to ED arrival, or inability to use the pain scale. Intervention: Virtual reality “Take Pause” program for 5 minutes Comparison: Passive distraction technique with hospital-owned iPad with pre-downloaded age-appropriate games for 5 minutes Outcome: Primary Outcome: Difference in the change in situational anxiety level between groups 15 minutes after intervention using the Spielberger State – Trait Anxiety Inventory (STAI: Y-6 item) Secondary Outcomes: Mean difference in pain score on the FACES scale, heart rate, respiration rate from baseline to 15 minutes after intervention Trial: Prospective, randomized, single-blind trial Mahlaqa Butt This is an SGEMHOP episode which means we have the lead author on the show. Mahlaqa Butt, MPH is a third-year medical student at New York Institute of Technology-College of Osteopathic Medicine and a clinical research associate at the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn NY. She has co-authored 11 peer-reviewed emergency medicine research publications primarily focused on opioid-free pain management in the ED. She will be pursuing a residency in emergency medicine this fall. Authors’ Conclusions: “Take-Pause,

Date: March 26th, 2022 Guest Skeptic: Professor Melanie Trecek-King Associate professor of biology at Massasoit Community College in Massachusetts. Founder and creator of Thinking Is Power. Reference: Trecek-King M.A Life Preserver for Staying Afloat in a Sea of Misinformation.  Skeptical Inquirer March/April 2022 Prof Trecek-King This is an SGEM Xtra episode. I met Melanie through our online interactions on Twitter. She posts excellent tweets about critical thinking. I then discovered her amazing website called Thinking is Power. We also discovered through our social media interactions that were were both Feynman fans. I asked Melanie to come on the show and discuss her recent article in Skeptical Inquirer and explain the acronym she created called FLOATER. Melanie explains that FLOATER grew out of James Lett’s “A Field Guide to Critical Thinking” (Lett J. Skeptical Inquirer 1990), in which he summarized the scientific method with the acronym FiLCHeRS (Falsifiability, Logic, Comprehensiveness of evidence, Honesty, Replicability, and Sufficiency of evidence). The FLOATER acronym stands for Falsifiability, Logic, Objectivity Alternative explanation, Tentative conclusion, Evidence, and Replicability. This was the basis for her article in Skeptical Inquirer. Melanie published her first article in the January/February edition called "Teach Skills, Not Facts". Listen to the SGEM Xtra podcast to hear Melanie explains each of the seven tools/rules that make up the FLOATER acronym. Tool 1: Falsifiability It must be possible to think of evidence that would prove the claim false. It seems counterintuitive, but the first step in determining if a claim is true is to determine if you can prove it wrong. Tool 2: Logic Arguments for the claim must be logical. They can be deductive or  inductive arguments. We should try and not commit logical fallacies when arguing positions. Tool 3: Objectivity The evidence for a claim must be evaluated honestly. Tool 4: Alternative Explanations Other ways of explaining the observation must be considered.  Tool 5: Tentative Conclusions In science, any conclusion can change based on new evidence. Tool 6: Evidence The evidence for a claim must be reliable, comprehensive, and sufficient. Tool 7: Replicability Evidence for a claim should be able to be repeated. We have a reproducibility crisis in science.  We ended this SGEM Xtra show with a quote from Marie Curie. I think Melanie is an amazing skeptic and educator. It was an absolute pleasure to have her on the show as the guest skeptic. 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 Additional Readings: Kahan et al. Science Curiosity and Political Information Processing. Political Psychology. January 2017 Kahan DM. Why Smart People Are Vulnerable to Putting Tribe Before Truth. Scientific America. December 2018 Trecek-King M. Teach Skills, Not Facts. Skeptical Inquirer. January/February 2022

Date: March 3rd, 2022 Reference: Macnow et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatrics 2021 Guest Skeptic: Dr. Catherine Varner is an Assistant Professor and Clinician Investigator in the Department of Family and Community Medicine at the University of Toronto. She is an emergency physician at Mount Sinai Hospital and a Clinician Scientist and the Deputy Director of the Schwartz-Reisman Emergency Medicine Institute. Dr. Varner's research interests are in concussion and pregnancy care in the ED. Case: An 18-year-old female presents to the emergency department (ED) after falling off a moving snowmobile and hitting her head on the ground. It was a witnessed fall; she was wearing a helmet at the time and there was no loss of consciousness. There were no other injuries reported and she is found to have a GCS score of 15 after the injury. The Acute Concussion Evaluation–Emergency Department (ACE-ED) Tool is used, and she scores a 2 for headache and feeling foggy. She knows about taking it easy physically for the next couple of days but wonders if she must stay off her computer as well? Background: Concussions or mild traumatic brain injury (mTBI) are commonly diagnosed in the Emergency Department (ED). Most patients recover within the first week; however, 15-30% of patients develop persistent post-concussive symptoms. An issue that often comes up with minor head injuries is do we need to get advanced imaging. A paper by Dr. Ian Stiell and his group gave us a tool to help us decide who to scan with the now infamous clinical decision instrument called the Canadian CT Head Rule [1]. This classic paper was published in Lancet 2001 and reviewed on SGEM#106. Another issue that comes up is whether children need strict rest after a concussion. SGEM#112 reviewed a small study by Thomas et al published in Pediatrics 2015 asking if there was a benefit to recommending strict rest after a child has a concussion [2]. The bottom line from that episode was that in children with concussion, two days of rest followed by a gradual return to activity is preferred over five days of rest followed by a gradual return to activity. The longer strict rest period appears to cause more post-concussive symptoms. Our episode together looked at the impact of light exercise in adults with mild concussions on the likelihood of developing persistent symptoms up to 30 days following their injury (SGEM#331). We found there was not a statistical difference between light activities like walking and 48 hours of rest with gradual return to activity as tolerated. Our conclusions were that early light exercise may be encouraged as tolerated at ED discharge following mTBI, but this guidance is not sufficient to prevent persistent concussion symptoms [3]. The Acute Concussion Evaluation–Emergency Department (ACE-ED) tool is an instrument used by ED clinicians to diagnose a concussion and identify risk factors for prolonged recovery. It is both helpful for diagnosis and future management of symptoms. When a patient is recovering from a concussion, whether you are using ACE or another symptom scoring tool like the Postconcussion Symptom Scale or the Rivermead Post-concussion Symptom Questionnaire, future health care providers caring for the concussion patient may refer to the quantitative assessment of the patient’s symptoms in the acute phase of the injury. Clinical Question: Does screen time in the first 48 hours after concussion have an impact on the duration of concussive symptoms? Reference: Macnow et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatrics 2021 Population: Patients aged 12 to 25 years presenting to the emergency department within 24 hours of sustaining a concussion according to the Acute Concussion Evaluation–Emergency Department (ACE-ED) tool (Giola et al 2008)

Date: February 24th, 2022 Reference: Parish et al. An umbrella review of effect size, bias, and power across meta-analyses in emergency medicine. AEM 2021 Guest Skeptic: Professor Daniel Fatovich is an emergency physician and clinical researcher based at Royal Perth Hospital, Western Australia. He is Head of the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research; Professor of Emergency Medicine, University of Western Australia; and Director of Research for East Metropolitan Health Service. Case: A resident has been following the literature over their four years of training. They have already seen several things come into fashion and go out of fashion during this short time. This includes therapeutic hypothermia for out-of-hospital cardiac arrest (OHCA), tranexamic acid (TXA) for epistaxis and electrolyte solutions for mild pediatric gastroenteritis. They wonder how strong the evidence is for much of what we do in emergency medicine. Background: There are many things in medicine that could be considered myth or dogma. We have covered some of these over the 10 years. Topical anesthetic uses of 24-48 hours for mild cornea abrasions will cause blindness- No (SGEM# 315) Epinephrine for adult out-of-hospital cardiac arrests (OHCAs) results in better neurologic outcomes – No (SGEM#238) TXA for intracranial hemorrhage, isolated traumatic brain injury, post-partum hemorrhage or gastrointestinal bleed results in better primary outcomes - No (SGEM#236, SGEM#270, SGEM#214, and SGEM#301) Therapeutic hypothermia in adult OHCA saves lives – No (SGEM#336) Electrolyte solutions are needed in mild pediatric gastroenteritis - No (SGEM#158) A lot of medical practice is based on low quality research. Tricoci et al. JAMA Feb 2009 looked at the ACC/AHA guidelines from 1984 to 2008. They found 53 guidelines with 7,196 recommendations. The results were only 11% of recommendations were considered Level A, 39% were Level B and 50% were Level C. The definitions used for each level of evidence are as follows: An update was published by Fanaroff et al in JAMA 2019. The level of high-quality evidence had not changed much when looking at the ACC/AHA guidelines from 2008-2018. There were 26 guidelines with 2,930 recommendations. Now Level A recommendations were down to 9%, Level B 50% and Level C 41%. This lack of evidence is not isolated to cardiology. A recent study looked at the top ten elective orthopaedic procedures. It was an umbrella review of meta-analyses of randomized control trials (RTCs) or other study designs if no RCTs existed (Blom et al BMJ 2021). The comparison was the clinical efficacy of the most common orthopaedic procedures with no treatment, placebo, or non-operative care. The primary outcome was the quality of the evidence for each procedure. Only two out of ten common procedures, carpal tunnel decompression and total knee replacement, showed superiority over non-operative care. Clinical Question: What is the effect of faults such as underpowered studies, flawed studies (i.e. methodologic and statistical errors, poorly designed studies) and biases in the field of therapeutic interventions in the emergency medicine literature? Reference: Parish et al. An umbrella review of effect size, bias, and power across meta-analyses in emergency medicine. AEM 2021 Population: SRMAs 1990-2020 in the top 20 journals under the google scholar subcategory: emergency medicine; emergency medicine meta-analyses from JAMA, NEJM, BMJ, The Lancet, and the Cochrane Database of Systematic Reviews; emergency medicine topics across all PubMed journals; and an extraction of all studies from the Annals of Emergency Medicine Systematic Review Snapshots (SRS) series. Exclusions: Articles were excluded if they did not include a quantitative synthesis (meta-analysis); did not contain at least two summarized studies; did not make a comparison between ...

Date: February 21st 2022 Reference: Kim et al. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. AEM February 2022. Guest Skeptic: Dr. Kirsty Challen (@KirstyChallen) is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). She is Chair of the Royal College of Emergency Medicine Women in Emergency Medicine group and involved with the RCEM Public Health and Informatics groups. Kirsty is also the creator of the wonderful infographics called #PaperinaPic. Case: You are in discussion with your emergency department (ED) manager about the number of patients boarding for hours to days and you are both aware that many of these patients are attending with mental health crises. You wonder whether a model of care involving a specifically designed unit would improve their patient experience and ED boarding times. Background: We have covered mental health issues only a few times on the SGEM. The latest SGEM Xtra was a very powerful episode with Dr. Tim Graham sharing his story of burnout, anxiety, and depression. This was based upon his article published in the Canadian Medical Association Journal (CMAJ). We also had Dr. Tyler Black on that episode to provide his expertise as a suicidologist.  ED visits in the US for mental health conditions has increased by 44% from 2006 to 2014. Inadequately resourced provision for emergency mental health care is familiar to health care professionals in multiple jurisdictions and patients can spend days in the ED waiting for inpatient admission. We've talked about mental health issues in SGEM #252 in 2019. In that episode we concluded that clinician gestalt was likely to be as accurate and efficient in screening for suicidality as a specific tool (Convergent Functional Information for Suicidality screening tool). Also, in SGEM #313 we recognised that three or more ED attendances for alcohol-related issues was associated with a 1-year mortality risk of over 6%. Clinical Question: Does the implementation of a dedicated interdisciplinary unit for mental health patients presenting to an ED with suicidal ideation or a suicide attempt reduce inpatient admissions and ED boarding time? Reference: Kim et al. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. AEM February 2022. Population: Adults presenting to a single academic tertiary referral ED in Iowa with suicidal ideation or after a suicide attempt – determined using administrative data.. Excluded: Patients that were medically unstable, needed co-management of a medical condition, were incarcerated, actively violent or judged by the provider to be intoxicated. Also, patients with mental health conditions other than suicidal ideation or attempt. Intervention: Post-establishment of EmPATH unit Nov 2018 – May 2019. Comparison: Pre-establishment of EmPATH unit Nov 2017 – May 2018. Outcome: Primary Outcome: Proportion of patients admitted to inpatient psychiatric unit (direct from ED, via EmPATH Unit or by transfer). Secondary Outcomes: Any admission including psychiatry, intensive care, or medicine; complete vs incomplete psychiatric admission; hospital length of stay in those with a bed requested; ED length of stay; use of restraints in ED, scheduled follow-up, 30-day ED return; restraint use; code green Dr. Allie Kim This is an SGEMHOP episode which means we have the lead author on the show (Dr. Kim). And as a special treat we also have the senior author (Dr. Lee). Dr. Allie Kim graduated from emergency medicine residency at the University of Iowa last July and now works as an attending physician at Unity Point Health hospitals in Des Moines, Iowa. We also have senior author Dr.

Date: February 15th, 2022 Guest Skeptic: Dr. Tim Graham is a Clinical Professor of emergency medicine at the University of Alberta, and Associate Chief Medical Information Officer, Edmonton Zone, of Alberta Health Services from Edmonton, Alberta. Reference: Graham T. Physician heal thyself. CMAJ 2021 TRIGGER WARNING: As a warning to those listening to the podcast or reading this blog post, there may be some things discussed that could be upsetting. The SGEM is a free open access project trying to cut the knowledge translation down to less than one year. It is intended for clinicians providing care to emergency patients, so they get the best care, based on the best evidence. Some of the material we are going to be talking about on this episode could trigger some strong emotions. If you are feeling upset by the content, then please stop listening to the podcast or reading the blog. There will be resources listed at the end of the blog for those looking for assistance. Dr. Tim Graham This is an SGEM Xtra episode. Tim approached me about an article he wrote and published in the Canadian Medical Association Journal (CMAJ). The title of the article was "Physician, heal thyself" and was in the humanities section of the October 2021 issue. This article resonated with many people and was the 6th most read CMAJ article of 2021. Tim thanked his wife, Dr. Samina Ali, in the CMAJ article and on the podcast. Samina has been a guest skeptic on the SGEM. She is the one who suggested Tim share his story to reach an even wider audience. In this SGEM Xtra episode, Tim tells his experience with burnout. This is a topic we have discussed many times on the SGEM and I have shared my personal experience with burnout. SGEM Xtra: The Water is Wide SGEM#289: I Want a Dog to Relieve My Stress in the Emergency Department SGEM Xtra: CAEP Wellness Week 2019 SGEM Xtra: On the Edge of Burnout SGEM Xtra: Don’t Give Up – The Power of Kindness SGEM#178: Mindfulness – It’s not Better to Burnout than it is to Rust SGEM Xtra: Five Tips to Avoid Emergency Medicine Burnout A 2015 study by Shanafelt et al of US physicians showed that more 50% had at least one symptom of burnout. The highest prevalence of burnout was reported by emergency physicians. COVID19 has been hard on the health care system. Medscape just published a 2021 survey of 13,000 physician from 29 specialties and emergency physicians were still #1 reporting the highest level of burnout.  People have made a distinction between burnout and moral injury. Journalist Diane Silver describes moral Injury as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.” It is something that tears us apart at the fabric of what it is to be a physician. Tim discusses how he started getting suicidal ideations and what he did to try and address these thoughts. This included seeking professional help, medication, and lifestyle changes. Some interventions helped more than others. Tim reports he is now in the best place mentally and physically than he has been in many years. Tim also gives some advice to prevent others from going through a similar experience. This includes a wellness tool kit that starts with a healthy diet, regular exercise and good sleep. Two things he found really helpful were meditation and yoga. Suicidologist: Dr. Tyler Black When preparing this SGEM Xtra episode, I suggested to Tim we get an expert in mental health to give us some more information on the topic. I'm not an expert in this area and reached out to Dr. Tyler Black. Tyler is a suicidologist, emergency psychiatrist and pharmacologist from Vancouver. Dr. Tyler Black Tyler provided a definition for suicidologist. He discussed burnout and the association with suicidal ideation in physicians (Menon et al JAMA 2020. Tyler gave some potential reasons why physicians do not seek mental health care (stigma,...

Date: February 7th, 2022 Reference: Williams et al. Short- vs standard-course outpatient antibiotic therapy for community-acquired pneumonia in children: the scout-cap randomized clinical trial. JAMA Pediatrics 2022 Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. Case: A three-year-old boy presents to the emergency department (ED) with fever and cough. On exam, he is breathing a little fast and his oxygen saturation is 94% on room air but otherwise appears comfortable. You appreciate some decreased breath sounds and crackles on your lung exam. You make a clinical diagnosis of community-acquired pneumonia (CAP) and plan to send him home with a 10-day course of amoxicillin. His mother asks you, “Last time he took antibiotics for that long, he had terrible diarrhea. Do you think we can do fewer days of antibiotics and still treat the pneumonia?” Background: We have covered the topic of pediatric community-acquired pneumonia before on the SGEM #338 (Are Children with CAP Safe and Sound if Treated for 5 days rather than 10 days of antibiotics?) with Dr. Andrew Tagg on the Canadian SAFER Trial [1]. This trial suggested that a 5-day course of antibiotics was not non-inferior to the traditional 10-day course of antibiotics for children with CAP treated as outpatients. Things were much simpler when I started my pediatric training. I learned that a well-appearing child presenting to clinic with fever, slight tachypnea, and focal lung exam findings could be diagnosed with pneumonia by history and physical exam alone and go home with 10 days of amoxicillin BID. But now for some reason, this topic feels more complicated…maybe because there are so many different ways people go about diagnosing pneumonia and such variability in the reliability of physical exam findings [2,3]. Since we covered the SAFER trial, we have also had the CAP-IT [4] trial from the United Kingdom and Ireland which evaluated both high and low-dose amoxicillin for the treatment of CAP over three or seven days. They found that both a lower dose and a shorter duration of antibiotic therapy was non-inferior to higher dose, longer duration antibiotic therapy. They did find that cough persisted longer with the group that received a shorter duration of antibiotic therapy but overall adherence to medication was better in the group receiving a shorter duration of antibiotics. Why so many pneumonia studies? Ultimately, we want to find that balance of treating an infection but avoiding antibiotic-associated adverse effects and antibiotic resistance. So where is that sweet spot?  Clinical Question: Is a 5-day course of antibiotics superior to a 10-day course for the treatment of non-severe community-acquired pneumonia in children with respect to clinical outcomes, adverse effects, and antimicrobial resistance? Reference: Williams et al. Short- vs standard-course outpatient antibiotic therapy for community-acquired pneumonia in children: the scout-cap randomized clinical trial. JAMA Pediatrics 2022 Population: Children 6 to 71 months of age from 8 US cities diagnosed with uncomplicated CAP demonstrating early clinical improvement (no fever, tachypnea, severe cough) on day 3 to 6 of their initially prescribed oral beta-lactam therapy. Excluded: Severe pneumonia (Hospitalization, radiographic evidence of parapneumonic effusion, empyema, lung abscess, pneumatocele or Microbiologically confirmed Staph aureus or Strep pyogenes pneumonia. Parenteral or combination antibiotic therapy. Undergoing surgery or invasive airway procedures 7 days prior to diagnosis of CAP. Beta-lactam allergy. Concurrent bacterial infection necessitating >5 days of antibiotics. Aspiration pneumonia, bronchiolitis, bronchitis, acute asthma exacerbation. Chronic medical conditions. History of pneumonia within prior 6 months Intervention: Short 5 days course of previously prescri...

Date: January 25th, 2022 Reference: Beyde et al. Efficacy of empiric antibiotic management of septic olecranon bursitis without bursal aspiration in emergency department patients. AEM January 2022 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You’re working in your busy freestanding emergency department (ED) getting absolutely crushed handing out COVID19 tests like candy and are relieved to see a patient with something different. A 27-year-old male construction worker building a local house presents with a tender, warm, erythematous olecranon and you diagnose him with septic olecranon bursitis. You offer to drain the bursa and get him back to work ASAP, and the patient looks very anxious and asks if you really must. Background: We have covered skin and soft tissue infections multiple times on the SGEM. The most recent time was with guest skeptic and SAEM FOAMed Excellence in Education Award winner Dr. Lauren Westafer (SGEM#348). We reviewed Dr. David Talan and colleagues’ study that was the October 2021 SGEM Hot Off the Press. That study investigated if a single-dose long-acting intravenous antibiotic could reduce hospitalization in patients with skin infections. The SGEM bottom line from that episode was in hospital systems with access to IV dalbavancin and the ability to establish expedited telephone and in-person follow up, this clinical pathway is associated with a decrease in hospitalizations for patients with moderately severe cellulitis. A couple of other SGEM episodes have looked at the management of cellulitis including SGEM#131 and SGEM#209. The treatment of abscesses has been covered four times on the SGEM (SGEM#13, SGEM#156, SGEM#164 and SGEM#311). The latest episode looked at the loop technique to drain uncomplicated abscesses. One topic we have not looked at is infected bursa. It’s estimated that about half of olecranon bursitis cases are septic[1]. Often, diagnostic aspiration is performed, but complications include fistula formation, further infection, and need for bursectomy [2-6]. Often the workup of septic bursitis is based upon anecdotal evidence [7]. This is likely due to the lack of high-quality evidence to direct our care. One area with limited information is the efficacy of empiric antibiotics without bursal aspiration. Clinical Question: What is the efficacy and outcomes associated with empiric antibiotic therapy, without aspiration, for septic olecranon bursitis? Reference: Beyde et al. Efficacy of empiric antibiotic management of septic olecranon bursitis without bursal aspiration in emergency department patients. AEM January 2022 Population: Adults >18 years old with olecranon bursitis Excluded: Declined authorization, underlying fracture, or surgery on the joint within 3 months Exposures: Antibiotics, aspiration, surgery or admission to hospital Comparison: None Outcome: Primary Outcome: Complicated versus uncomplicated bursitis resolution (Uncomplicated was defined as bursitis resolution without the need for bursal aspiration, surgery, or hospitalization) Secondary Outcome: Descriptive statistics of the cohort Study Design: Retrospective observational cohort study Dr. Ronna Campbell This is an SGEMHOP episode which means we have the senior author on the show. Dr. Ronna Campbell is an emergency physician practicing since 2007 in Rochester, MN. She enjoys mentoring medical students, residents and others in research. Authors’ Conclusions: “Eighty-eight percent of ED patients with suspected septic olecranon bursitis treated with empiric antibiotics without aspiration had resolution without need for subsequent bursal aspiration, hospitalization, or surgery. Our findings suggest that empiric antibiotics without bursal aspiration may be a reasonable initial approach to ED management of select patients with suspected septic ...