
The Skeptics Guide to Emergency Medicine
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Latest episodes

Jan 9, 2021 • 23min
SGEM#314: OHCA – Should you Take ‘em on the Run Baby if you Don’t get ROSC?
Date: January 5th, 2021
Reference: Grunau et al. Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA 2020
Guest Skeptic: Mike Carter is a former paramedic and current PA practicing in pulmonary and critical care as well as an adjunct professor of emergency medical services at Tacoma Community College.
Case: During a busy emergency department (ED) shift the paramedic phone rings. On the other end of the line is one of your local crews who have responded to a 54-year-old male with a witnessed cardiac arrest. CPR is currently in progress with a single shock having been delivered. The crew is asking if they should transport the patient with resuscitation ongoing?
Background: Out-of-hospital cardiac arrest (OHCA) is something we have covered extensively on the SGEM over the years. This has included things like therapeutic hypothermia (SGEM#54, SGEM#82, SGEM#183 and SGEM#275), supraglottic devices (SGEM#247), crowd sourcing CPR (SGEM#143 and SGEM#306), and epinephrine (SGEM#238).
One aspect we have not looked at is the “load and go” vs. “stay and play” approach for OHCA. Different countries have different approaches to this problem. There is the European model that is physician led and provides more care in the field while the North American model tends to scoop and run. However, there is a fair bit of heterogeneity between EMS systems even in the US. In patients with OHCA, some EMS agencies transport almost all patients regardless of ROSC, while others rarely transport if ROSC is not achieved.
It is unclear from the existing literature which practice is superior to the other in providing patient-oriented benefit to among adult patients in refractory arrest who have suffered an OHCA.
Clinical Question: What is the association of intra-arrest transport compare to continued on-scene resuscitation in regards to survival to hospital discharge in adult patients with an OHCA?
Reference: Grunau et al. Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA 2020
Population: Adults 18 years and older with non-traumatic OHCA between 2011 and 2015treated by 192 EMS agencies in the USA. EMS. OHCA was defined as persons found apneic and without a pulse who underwent either external defibrillation (bystanders or EMS) or chest compressions.
Exclusions: Age less than 18 years, do-not-resuscitate (DNR) order being discovered, transport prior to cardiac arrest, missing data to classify as intra-arrest or to classify the primary outcome, missing variables required for propensity score analysis
Intervention: Intra-arrest transport prior to any episode of return of spontaneous circulation (ROSC) defined as palpable pulse for any duration
Comparison: Continued on-scene resuscitation
Outcome:
Primary Outcome: Survival to hospital discharge
Secondary Outcomes: Survival with favorable neurologic outcome defined as a modified Rankin scale (mRS) score of less than 3
mRS is categorized to 7 different levels, with 0 being no disability and 6 being death. A 3 is defined as moderate disability requiring some help, but able to walk without assistance
Authors’ Conclusions: “Among patients experiencing out-of-hospital cardiac arrest, intra-arrest transport to hospital compared with continued on-scene resuscitation was associated with lower probability of survival to hospital discharge. Study findings are limited by potential confounding due to observational design.”
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? Unsure

Jan 7, 2021 • 17min
SGEM Xtra: Happy New Year 2021
Date: January 7th, 2021
Happy New Years to all the SGEMers. I know 2020 has been a bit of a dumpster fire. We have all faced challenges During the COVID19 global pandemic. I tried not to contribute to the large volume of information coming out on Sars-Cov2.
There were only four episodes that directly addressed COVID19:
SGEM Xtra: Mask4All Debate
SGEM#229: Learning to Test for COVID19
SGEM Xtra: CAEP National Grand Rounds - COVID19 Treatments
SGEM#309: That’s All Joe Asks of You – Wear a Mask
There have been many other FOAMed resources (REBEL EM, First10EM, EM Cases, St. Emlyn's, and others) that have done a great job covering the pandemic.
This is an SGEM Xtra episode to announce a few exciting new things for 2021.
SGEM Continuing Medical Education Credits
The BIG news is that the SGEM will now be offering Continuing Medical Education (CME) credits for all SGEM episodes. Click on this LINK to find out more.
The Skeptics' Guide to Emergency Medicine (SGEM) is part of the Free Open Access to Meducation movement (FOAMed). The SGEM tries to cut the knowledge translation window down from over ten years to less than one year with the power of social media. The ultimate goal is for patients to get the best care, based on the best evidence.
The FOAMed philosophy is that the information should be available to anyone, anytime, anywhere at no cost. This is similar to the philosophy of emergency medicine. It is the light in the house of medicine that is always on for anyone, at anytime, for anything. The SGEM has been free since it started in 2012 and will always be free open access.
Many of you have asked about getting CME credits for listening to the SGEM podcast and reading the SGEM blog. We know physicians (MD and DO), Nurse Practitioners (NP) and Physician Assistants (PA) have to collect so many CME credit hours for their respective professional organizations. This can be more challenging with the cancelation of in-person conferences and meetings.
The SGEM Hot Off the Press (SGEMHOP) episodes which are published once a month do offer CME credits. However, you can only claim these credits if you are a member of the Society of Academic Emergency Medicine (SAEM). This new initiative will allow anyone to claim CME credits for all of the SGEM episodes.
Getting CME credits for the weekly SGEM episodes is something I have been wanting to do for years. The barriers to getting CME credits for the SGEM before now was that it takes a lot of time and costs a lot of money to get accreditation. The cancellation of in-person conferences due to COVID19 has been the push I needed to finally get this service added to the SGEM.
This project has been made possible through a partnership with a Legend of Emergency Medicine, Dr. Richard Bukata, and his Center for Medical Education (CCME) company. CCME has been providing providing medical education in the form of audio programs and conferences since 1977. They have the infrastructure to provide this type of service. They also have an arrangement to get the CME credits at a very reasonable price.
Sign up by January 31st, 2021:
There can be only one...
The SGEM CME program offers up to 26 credits (1 credit hour per SGEM episode) over 6 months for only $195. If you sign up before January 31st, 2021 we will also give you 26 credits for free. This will be the previous six months of SGEM content that has already been approved for CME credits. Basically it is a 50% off promotion to kick start the SGEM CME program.
Signing up for your education credits is easy. This is because "there can be only one" subscription option. You can earn up to 26 credit hours in six months. The price is $195 ($7.50/credit hour) for the six months. Again, those that sign up by January 31st, 2021 will receive a bonus 26 CME credits for free. That makes it only $3.75 for every credit hour of SGEM content!. It is as easy as 1-2-3 to start earning your CME credit tod...

Jan 4, 2021 • 1h 33min
SGEM Xtra: EBM Master Class – McGill University Grand Rounds 2020
Date: January 4th, 2021
This is an SGEM Xtra episode. I had the honour of presenting at the McGill University Emergency Medicine Academic Grand rounds. They titled the talk "Evidence-Based Medicine Master Class". The presentation is available to watch on YouTube, listen to on iTunes and all the slides can be downloaded (McGill 2020 Part 1 and McGill 2020 Part 2).
Five Objectives:
Look at the burden of proof and talk about what is science
Discuss EBM and give a five step process of critical appraisal
Talk about biases and logical fallacies
Do a check list for randomized control trials
Record a live episode of the SGEM
1) Who has the Burden of Proof and What is Science?
Those making the claim have the burden of proof. It is called a burden because it hard - not because it is easy. We start with the null hypothesis (no superiority). Evidence is presented to convince us to reject the null and accept there is superiority to their claim. If the evidence is convincing we should reject the null. If the evidence is not convincing we need to accept the null hypothesis.
It is a logical fallacy to shift the burden of proof onto those who say they do not accept the claim. They do not have to prove something wrong but rather not be convinced that the claim is valid/“true” and this is an important distinction in epistemology.
What is science? It is the most reliable method for exploring the natural world. There are a number of qualities of science: Iterative, falsifiable, self-correcting and proportional.
What science isn’t is “certain”. We can have confidence around a point estimate of an observed effect size and our confidence should be in part proportional to the strength of the evidence. Science also does not make “truth” claims. Scientists do make mistakes, are flawed and susceptible to cognitive biases.
Physicians took on the image of a scientist by co-opting the white coat. Traditionally, scientists wore beige and physicians wore black to signify the somber nature of their work (like the clergy). Then came along the germ theory of disease and other scientific knowledge.
It was the Flexner Report in 1910 that fundamentally changed medical education and improved standards. You could get a medical degree in only one year before the Flexner Report. The white coat was now a symbol of scientific rigour separating physicians from “snake oil salesman”.
Many medical schools still have white coat ceremonies. However, only 1 in 8 physicians still report wearing a white lab coat today (Globe and Mail).
Science is usually iterative. Sometimes science takes giants leaps forward, but usually it takes baby steps. You probably have heard the phrase "standing on the shoulders of giants"? In Greek mythology, the blind giant Orion carried his servant Cedalion on his shoulders to act as the giant's eyes.
The more familiar expression is attributed to Sir Isaac Newton, "If I have seen further it is by standing on the shoulders of Giants.” It has been suggested that Newton may have been throwing shade at Robert Hooke.
Hooke was the first head of the Royal Society in England. Hooke was described as being a small man and not very attractive. The rivalry between Newton and Hooke is well documented. The comments about seeing farther because of being on the shoulders of giants was thought to be a dig at Hooke's short stature. However, this seems to be gossip and has not been proven.
Science is also falsifiable. If it is not falsifiable it is outside the realm/dominion of science. This philosophy of science was put forth by Karl Popper in 1934. A great example of falsifiability was the claim that all swans are white. All it takes is one black swan to falsify the claim. There are some philosophers that refute Popper's claim about falsifiability.
Science is self-correcting. Because science is iterative and falsifiable it is also self correcting. Science gets updated.

Dec 26, 2020 • 32min
SGEM#313: Here Comes A Regular to the ED
Date: December 18th, 2020
Reference: Hulme et al. Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study. CMAJ 2020
Guest Skeptic: Dr. Hasan Sheikh is an emergency and addictions physician in Toronto and a lecturer at the University of Toronto. He holds a Masters in Public Administration from the Harvard Kennedy School of Government.
Hasan was on an SGEM Xtra last year discussing the Canadian Association of Emergency Physician's (CAEP) position statement on Dental care in Canada.
"The Canadian Association of Emergency Physicians believes that every Canadian should have affordable, timely, and equitable access to dental care."
CAEP has put out other position statements. The most recent is on sick notes for minor illness. For a list of other positions statements from CAEP click on this LINK.
Case: A 45-year-old male with no fixed address is found by a bystander with decreased level of consciousness (LOC) on the street. Emergency Medical Services (EMS) is called, and the patient is brought to the emergency department (ED). An empty bottle of vodka is found on the patient, and the decreased LOC is suspected to be due to alcohol intoxication. It is the patient’s fifth visit to the ED in the last two weeks with a similar presentation. The patient is observed over many hours, their LOC improves, and they are discharged after demonstrating that they can ambulate safely.
Background: A leading driver of morbidity and mortality worldwide is alcohol (1). Alcohol consumption is attributed to approximately 5% of all global deaths. This works out to an estimated 3 million deaths due to alcohol (2).
Alcohol was the single greatest risk factor for ill health worldwide among people aged 15–49 years according to the 2016 Global Burden of Disease Study (3). There are more hospital admissions in Canada for alcohol-attributable conditions than for myocardial infarction (4).
There is a cost associated with alcohol related harms. In Canada, that number is around $14.6 billion a year with $3.3 billion in health care costs (5). Alcohol related ED visits has also increased more than four times greater than the overall rate of ED visits (6).
This trend of increasing alcohol related ED visits is not unique to Canada. It has also been reported in England, Australia and the US (7-9).
Clinical Question: What is the one-year overall mortality rate for adults with frequent visits to the ED for alcohol related reasons?
Reference: Hulme et al. Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study. CMAJ 2020
Population: Adults aged 16-105 years of age who made frequent ED visits for alcohol related reasons (two or more ED visits in a year).
Excluded: Data inconsistencies, not Ontario residents, Age < 16 or > 105 or death at discharge
Exposure: Patients with ED visits for alcohol-related mental and behavioural disorders, using the ICD-10-CA code of F10. This includes simple intoxication and withdrawal
Comparison: Comparisons were made between groups of frequent ED users for alcohol-related reasons, including those that visited the ED twice in a year, 3-4 times in a year, and greater than four times in a year
Outcome:
Primary Outcome: One-year mortality, adjusted for age, sex, income, rural residence, and presence of co-morbidities
Secondary Outcomes: Mental and behavioural disorders, diseases of the circulatory system, diseases of the digestive system, and external causes of morbidity and mortality (e.g., accidents, including accidental poisoning, accidental injuries, injuries, intentional self-harm, assault) with frequency >5%. Cause of death using alcohol-attributable ICD-10-CA codes as well as ICD-10-CA codes for death by suicide.
Authors’ Conclusions: “We observed a high mortality rate among relatively young,

Dec 23, 2020 • 1h 1min
SGEM Xtra: Relax – Damm It!
Date: December 21st, 2020
Professor Tim Caulfield
This is a SGEM Xtra book review. I had the pleasure of interviewing Professor Timothy Caulfield. Tim is a Canadian professor of law at the University of Alberta, the Research Director of its Health Law Institute, and current Canada Research Chair in Health Law and Policy. His area of expertise is in legal, policy and ethical issues in medical research and its commercialization.
Tim came on the SGEM and discussed his new book called Relax, Dammit! A User's Guide to the Age of Anxiety. Listen to the podcast to hear us discuss his new book, skepticism, and science communication in general.
The SGEM has a global audience with close to 45,000 subscribers. Many of the SGEMers live in the US and Tim's book has a different title in America. It is called Your Day Your Way: The Facts and Fictions Behind Your Daily Decisions. Tim gives some insight on the podcast why there is a different title in Canada and the US.
Tim and I met in 2015 at the Canadian Associate of Emergency Physicians (CAEP) Annual Conference in Edmonton. He was a keynote speaker and discussed his previous book Is Gwyneth Paltrow Wrong about Everything? How the Famous Sell Us Elixirs of Health, Beauty & Happiness. Tim gave a fantastic presentation. I was in Edmonton talking nerdy as part of the CAEP TV initiative. We have been in contact via social media ever since trying to improve science communication.
Besides writing books, Tim has stared in his own Netflix series called: A User guide to Cheating Death. He has also collaborated Dr. Jennifer Gunter who wrote the book The Vagina Bible. Dr. Gunter visited BatDoc a few years ago for an SGEM Xtra extra episode.
A Few of Professor Caulfield's academic publications:
Commentary: the law, unproven CAM and the two‐hats fallacy. Focus on Alternative and Complementary Therapies, 17: 4-8.
Stem cell hype: Media portrayal of therapy translation. Science Translational Medicine.11 Mar 2015: Vol. 7, Issue 278, pp. 278ps4
Injecting doubt: responding to the naturopathic anti-vaccination rhetoric. Journal of Law and the Biosciences, Volume 4, Issue 2, August 2017, Pages 229–249
COVID-19 and ‘immune boosting’ on the internet: a content analysis of Google search. BMJ Open 2020;10:e040989.
Previous books reviewed on the SGEM:
Jeanne Lenzer The Danger Within Us: America's Untested, Unregulated Medical Device Industry and One Man's Battle to Survive It.
Dr. Steven Novella Skeptics Guide to the Universe: How to Know What's Really Real in a World Increasingly Full of Fake.
Dr. Brian Goldman The Power of Kindness: Why Empathy is Essential in Everyday Life
Tim's new book Relax Dammit! is organized into the day in the life of Tim Caulfield. It discusses the science behind our daily activities. On the podcast Tim provides five examples that he thinks might be interesting to the SGEM audience. This includes: Breakfast, coffee, commuting to work, napping and raw milk.
I hope you like this type of SGEM Xtra. Let me know what you think and I will consider doing more book reviews with authors if the feedback is positive.
The SGEM will be back episode with a structured critical review of a recent publication trying to cut the knowledge translation window down from over ten years to less than one year.
Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Dec 19, 2020 • 25min
SGEM#312: Oseltamivir is like Bad Medicine – for Influenza
Date: December 16th, 2020
Reference: Butler et al. Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial. The Lancet 2020
Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com. He has a great new blog post about how we are failing to protect our healthcare workers during COVID-19.
Case: A 45-year-old female presents to her primary care clinician complaining of fever, sore throat and muscle aches. She did not get a flu shot this year. You diagnose her with an influenza-like illness (ILI). She wants to know if taking an anti-viral like oseltamivir (Tamiflu) will help?
Background: We covered oseltamivir six years ago in SGEM#98. This is still the longest Cochrane review (300+ pages) I have ever read (Jefferson et al 2014a). The overall bottom line was when balancing potential risks and potential benefits, the evidence does not support routine use of neuraminidase inhibitors like oseltamivir for the treatment or prevention of influenza in any individual.
There has been some controversy around oseltamivir. It was approved by licensing agencies and promoted by the WHO based on unpublished trials. None of those agencies had actually looked at the unpublished data. In fact, the primary authors of key oseltamivir trials had never been given access to the data – Roche just told them what the data supposedly said. Other papers were ghost-written (Cohen 2009). The BMJ was involved in a legal battle with Roche for half a decade trying to get access to that information. When they finally got their hands on the data, the conclusions of the reviews suddenly changed. After countries had spent billions stockpiling the drug, it turned out that oseltamivir had no effect on influenza complications, was not effective in prophylaxis, and had significantly more harms than originally reported (Jefferson 2014a; Jefferson 2014b). You can read more details about this controversy in the BMJ.
The oseltamivir issue is a great example of the problems with conflicts of interest (COI) in medical research. This is something I have spoken about often. It is not an ad hominem attack on any of the authors. Our current system of medical research involves industry funding. COIs are just another data point that needs to be considered. This is because the evidence shows COIs can introduce bias into RCTs, SRMA and Clinical Practice Guidelines. When I use the term bias I am referring to something that systematically moves us away from the “truth”.
There is specific evidence of bias in the oseltamivir literature. Dunn and colleagues looked at 37 assessments done in 26 systematic reviews and then compared their conclusions to the financial conflicts of interest of the authors. Among eight assessments where the authors had conflicts, seven (88%) had favourable conclusions about neuraminidase inhibitors. However, among the 29 assessments that were made by authors without conflicts, only five (17%) were positive (Dunn et al 2014).
The current best evidence shows that oseltamivir (Jefferson et al 2014a):
Decreased time to first alleviation of symptoms by less than one day
Does not statistically change hospital admission rate (1.7% vs 1.8%)
Does increase nausea (NNH 28) and vomiting (NNH 22)
Does increase neuropsychiatric events (NNH 94)
Does increase headaches (NNH 32)
Clinical Question: Does oseltamivir improve time to recovery in patients presenting to their primary care clinician with an influenza-like illnesses?
Reference: Butler et al. Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial. The Lancet 2020.
Population: Patients from 15 European countries over three influenza seasons who were one year of age and older and who presented to their primary care clin...

Dec 12, 2020 • 33min
SGEM#311: Here We Go Loop De Loop to Treat Abscesses
Date: December 10th, 2020
Reference: Ladde et al. A Randomized Controlled Trial of Novel Loop Drainage Technique Versus Drainage and Packing in the Treatment of Skin Abscesses. AEM December 2020
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: A 52-year-old previously healthy woman presents to your emergency department (ED) with an abscess on her left forearm. She is systemically well and there is no sign of tracking, so you decide to perform incision and drainage in the ED. When you ask your nursing colleague to set up the equipment, he wants to know if you will be using standard packing or a vessel loop drainage technique.
Background: We have covered the issue of abscesses multiple times on the SGEM. Way back in 2012 we looked at packing after incision and drainage (I&D) on SGEM#13 and concluded routine packing might not be necessary.
Another topic covered was whether irrigating after I&D was superior to not irrigating (SGEM#156). The bottom line from that critical appraisal was that irrigation is probably not necessary.
Chip Lange (PA)
The use of antibiotics after I&D is another treatment modality that has been debated over the years. Chip Lange and I interviewed Dr. David Talan about his very good NEJM randomized control trial on SGEM#164. The bottom line was that the addition of TMP/SMX to the treatment of uncomplicated cutaneous abscesses represents an opportunity for shared decision-making.
One issue that has not been covered yet is the loop technique. This is when one or multiple vessel loops are put through the abscess cavity. This is done by making a couple of small incisions. An advantage to this technique over packing (which is not necessary) is that the Vessel loops do not need to be changed or replaced.
Clinical Question: In uncomplicated abscesses drained in the ED, does the LOOP technique reduce treatment failure?
Reference: Ladde et al. A Randomized Controlled Trial of Novel Loop Drainage Technique Versus Drainage and Packing in the Treatment of Skin Abscesses. AEM December 2020
Population: Patients of any age undergoing ED drainage of skin abscesses
Exclusions: Patient with abscess located on hand, foot, or face or if they required admission and/or operative intervention.
Intervention: LOOP technique where a vessel tie is left in situ
Comparison: Standard packing with sterile ribbon gauze
Outcome:
Primary Outcome: Treatment failure (need for a further procedure, IV antibiotics or operative intervention), assessed at 36 hours.
Secondary Outcomes: Ease of procedure, pain at the time of treatment, ease of care at 36 hours, pain at 36 hours.
Dr. Ladde
This is an SGEMHOP episode which means we have the lead author on the show. Dr. Ladde is in an active academic emergency physician working at Orlando Regional Medical Center serving as core faculty and Senior Associate Program Director. Jay also has the rank Professor of Emergency Medicine for University of Central Florida College of Medicine.
Authors’ Conclusions: “The LOOP and packing techniques had similar failure rates for treatment of subcutaneous abscesses in adults, but the LOOP technique had significantly fewer failures in children. Overall, pain and patient satisfaction were significantly better in patients treated using the LOOP technique.”
Quality Checklist for Randomized Clinical Trials:
The study population included or focused on those in the emergency department. Yes
The patients were adequately randomized. Yes
The randomization process was concealed. Yes

Dec 5, 2020 • 28min
SGEM#310: I Heard A Rumour – ER Docs are Not Great at the HINTS Exam
Date: November 30th, 2020
Reference: Ohle R et al. Can Emergency Physicians Accurately Rule Out a Central Cause of Vertigo Using the HINTS Examination? A Systematic Review and Meta-analysis. AEM 2020
Guest Skeptic: Dr. Mary McLean is an Assistant Program Director at St. John’s Riverside Hospital Emergency Medicine Residency in Yonkers, New York. She is the New York ACEP liaison for the Research and Education Committee and is a past ALL NYC EM Resident Education Fellow.
Case: A 50-year-old female presents to your community emergency department in the middle of the night with new-onset constant but mild vertigo and nausea. She has nystagmus but no other physical exam findings. You try meclizine, ondansetron, valium, and fluids, and nothing helps. Her head CT is negative (taken 3 hours after symptom onset). You’re about to call in your MRI tech from home, but then you remember reading that the HINTS exam is more sensitive than early MRI for diagnosis of posterior stroke. You wonder, “Why can’t I just rule out stroke with the HINTS exam? How hard can it be?” You perform the HINTS exam and the results are reassuring, but the patient’s symptoms persist…
Background: Up to 25% of patients presenting to the ED with acute vestibular syndrome (AVS) have a central cause of their vertigo - commonly posterior stroke. Posterior circulation strokes account for approximately up to 25% of all ischemic strokes [1]. MRI diffuse-weighted imagine (DWI) is only 77% sensitive for detecting posterior stroke when performed within 24h of symptom onset [2,3]. As an alternative diagnostic method, the HINTS exam was first established in 2009 to better differentiate central from peripheral causes of AVS [4].
But what is the HINTS exam? It’s a combination of three structured bedside assessments: the head impulse test of vestibulo-ocular reflex function, nystagmus characterization in various gaze positions, and the test of skew for ocular alignment. When used by neurologists and neuro-ophthalmologists with extensive training in these exam components, it has been found to be nearly 100% sensitive and over 90% specific for central causes of AVS [5-8].
Over the past decade, some emergency physicians have adopted this examination into their own bedside clinical assessment and documentation. We’ve used it to make decisions for our patients, particularly when MRI is not readily available. We’ve even used it to help decide whether or not to get a head CT.
But we’ve done this without the extensive training undergone by neurologists and neuro-ophthalmologists, and without any evidence that the HINTS exam is diagnostically accurate in the hands of emergency physicians.
Clinical Question: Can emergency physicians accurately rule out a central cause of vertigo using the HINTS examination?
Reference: Ohle R et al. Can Emergency Physicians Accurately Rule Out a Central Cause of Vertigo Using the HINTS Examination? A Systematic Review and Meta-analysis. AEM 2020
Population: Adult patients presenting to an ED with AVS
Exclusions: Non-peer-reviewed studies, unpublished data, retrospective studies, vertigo which stopped before or during workup, incomplete HINTS exam, or studies with data overlapping with another study used
Intervention: HINTS examination by emergency physician, neurologist, or neuro-ophthalmologist
Comparison: CT and/or MRI
Outcome: Diagnosis of HINTS examination for central cause for AVS (i.e., posterior stroke)
Authors’ Conclusions: “The HINTS examination, when used in isolation by emergency physicians, has not been shown to be sufficiently accurate to rule out a stroke in those presenting with AVS.”
Quality Checklist for Systematic Review Diagnostic Studies:
The diagnostic question is clinically relevant with an established criterion standard. Unsure
The search for studies was detailed and exhaustive. Yes
The methodological quality of primary studies were assessed for common form...

Nov 28, 2020 • 30min
SGEM#309: That’s All Joe Asks of You – Wear a Mask
Date: November 25th, 2020
Guest Skeptic: Dr. Joe Vipond has worked as an emergency physician for twenty years, currently at the Rockyview General Hospital. He is the President of the national charity Canadian Association of Physicians for the Environment (CAPE), as well as the co-founder and co-chair of the local non-profit the Calgary Climate Hub, and during COVID, the co-founder of Masks4Canada. Joe grew up in Calgary and continues to live there with his wife and two daughters.
Reference: Bundgaard et al. Effectiveness of Adding a Mask Recommendation to Other Public Health Measures to Prevent SARS-CoV-2 Infection in Danish Mask Wearers: A Randomized Controlled Trial. Annals of Internal Medicine 2020
Case: : Alberta is the last province in Canada that has yet to enact a mandatory mask policy. Should they do it?
Mask4All Debate
Background: During a respiratory pandemic, there still remains substantial questions about the utility and risk of facial masks for prevention of viral transmission. We debated universal mandatory masking back in the spring on an SGEM Xtra episode.
Some very well known evidence-based medicine experts like Dr. Trisha Greenhalgh were advocating in favour of stricter mask regulations based on the precautionary principle (Greenhalgh et al BMJ 2020). She was challenged on her position (Martin et al BMJ 2020) and responded with an article called: Laying straw men to rest (Greenhalgh JECP 2020).
A limitation of science is the available evidence. SARS-CoV-2 is a novel virus and we did not have much information specifically about the efficacy of masks. We needed to extrapolate from previous research on masks and other respiratory illnesses.
However, we do have a firm understanding of the germ theory of disease and masks have been used for over 100 years as an infectious disease strategy. It was surgeons in the late 1890’s that began wearing masks in the operating theaters. There was skepticism back then as to the efficacy of a “surgical costume” (bonnet and mouth covering) to prevent disease and illness during surgery (Strasser and Schlich Lancet 2020).
There was one recent cluster randomized control trial looking at surgical masks, cloth masks or a control group in healthcare workers (MacIntyre et al BMJ 2015). The main outcomes were clinical respiratory illness, influenza-like illness and laboratory-confirmed respiratory virus infection. All infectious outcomes were highest in the cloth mask group, lower in the control group and lowest in the medical mask group. As with all studies this one had limitations. One of the main ones is this looked at healthcare workers wearing a mask as protection not in the general public as a source control.
There has been a systematic review meta-analysis on physical distancing, face masks and eye protection to prevent SARS-Cov-2 (Chu et al Lancet 2020). With regards to masks, they found that face masks could result in a large reduction in risk of infection with a stronger association with N95 or similar respirators compared with disposable surgical masks or similar cloth masks.
SRMA also have limitations and one of the main ones is they are dependent on the quality of the included studies. This review in the Lancet included ten studies (n=2,647) with seven from China, eight looking at healthcare workers (not general public) and only one looking at COVID19. All 10 studies were observational designs and the authors correctly only claim associations. They also say their level of certainty about masks being associated with a decrease in disease is considered “low certainty” based on the GRADE category of evidence.
When considering an intervention, we cannot just consider the potential benefit, but we must also consider the potential harms. There is little or no evidence that wearing a face mask leads to potential harms. Yes, there are case reports of harm, children under 2 years of age should not wear face coverings (AAP News) and studie...

Nov 21, 2020 • 32min
SGEM#308: Taking Care of Patients Everyday with Physician Assistants and Nurse Practitioners
Date: November 19th, 2020
Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine.
Reference: Pines et al. The impact of advanced practice provider staffing on emergency department care: productivity, flow, safety, and experience. AEM November 2020.
Case: You are the medical director of a medium sized urban emergency department (ED). Volumes have increased over the past few years and you’re considering adding an extra shift or two. Your hospital has asked you to consider adding some advanced practice providers (APPs) instead of physician hours.
Background: Advanced practice providers (APPs) such as nurse practitioners (NPs) and Physician Assistants (PAs) are increasingly used to cover staffing needs in US emergency departments. This is in part driven by economics, as APPs are paid less per hour than physicians.
The calculation works if APP productivities are similar enough to physicians to offset differentials in billing rates. However, little data exists comparing productivity, safety, flow, or patient experiences in emergency medicine.
The American Academy of Emergency Medicine (AAEM) has a position statement on what they refer to as non-physician practitioners that was recently updated. The American College of Emergency Physicians (ACEP) has a number of documents discussing APPs in the ED.
There has been a concern about post-graduate training of NPs and PAs in the ED. A joint statement on the issue was published in September this year by AAEM/RSA, ACEP, ACOEP/RSO, CORD, EMRA, and SAEM/RAMS.
Clinical Question: How does the productivity of advanced practice providers compare to emergency physicians and what is its impact on emergency department operations?
Reference: Pines et al. The impact of advanced practice provider staffing on emergency department care: productivity, flow, safety, and experience. AEM November 2020.
Population: National emergency medicine group in the USA that included 94 EDs in 19 states
Exposure: Proportion of total clinician hours staffed by APPs in a 24-hour period at a given ED
Comparison: Emergency physician staffing
Outcome:
Primary Outcome: Productivity measures (patients per hour, RVUs/hour, RVUs/visit, RVUs per relative salary for an hour)
Safety Outcomes: Proportion of 72-hour returns and proportion of 72-hour returns resulting in admission
Other Outcomes: ED flow by length of stay (LOS), left without completion of treatment (LWOT)
Dr. Jesse Pines
This is an SGEMHOP episode which means we have the lead author on the show. Dr. Jesse Pines is the National Director for Clinical Innovation at US Acute Care Solutions and a 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 also leads the USACS opioid programs.
Authors’ Conclusions: “In this group, APPs treated less complex visits and half as many patients/hour compared to physicians. Higher APP coverage allowed physicians to treat higher-acuity cases. We found no economies of scale for APP coverage, suggesting that increasing APP staffing may not lower staffing costs. However, there were also no adverse observed effects of APP coverage on ED flow, clinical safety, or patient experience, suggesting little risk of increased APP coverage on clinical care delivery.
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? Unsure
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