The Skeptics Guide to Emergency Medicine

Date: February 19th, 2021 This is an SGEM Xtra episode. I had the honour of presenting at the Lehigh Valley Health Network Grand Rounds on February 4th, 2021. The title of the talk "Dogmalysis: Five Medical Myths in Emergency Medicine". The presentation is available to listen to on iTunes and GooglePlay and all the slides can be downloaded using this LINK.   Five Medical Myths in Emergency Medicine Myth #1: The use of non-selective NSAIDs will cause a nonunion in long bone fractures Myth #2: Topical anesthetics will cause blindness if used in simple corneal abrasions for less than 48 hours Myth #3: Mild paediatric gastroenteritis is best treated with expensive oral electrolyte solutions Myth #4: Tranexamic acid (TXA) has been proven to saves lives and results in good neurologic function in patients with isolated traumatic brain injuries (TBI) Myth #5: Epinephrine in adult out-of-hospital cardiac arrests (OHCA) results in better patient-oriented outcomes (POOs) Each of the five myths is presented with some background information and the PICO (population, intervention/exposure, comparison and outcome). Key results are provided with a number of the study limitations (dog leash) identified. There is an SGEM bottom line and a link to the original SGEM episode to provide more results and critical appraisal. There is also a link to the original article for people to read the primary literature for themselves. Myth #1: The use of non-selective NSAIDs will cause a nonunion in long bone fractures When bones break, they usually heal with either surgical or non-surgical management. Sometimes the healing process can take longer than usual (delayed union), does not heal (non-union) or in poor alignment (malunion). Non-union is defined as “a failure of the fracture-healing process” and occurs in up to 1 in 10 fractures. Several risk factors have been associated with increased risk of delayed or non-union: issues about the fracture (open/closed, displacement, location, etc) tobacco use, older age, severe anemia, alcohol intake, diabetes, low vitamin D levels, hypothyroidism, poor nutrition, infection, open fracture and certain medications (ex. steroids).  One class of medication that has been implicated in negatively impacting bone healing is NSAIDs. Non-selective NSAIDs and COX-2 inhibitors. There have been multiple studies investigating this issue with mixed results. The final cohort consisted of 339,864 patients identified in over 15 years. Less than 1% were diagnosed with a nonunion (2,996/339,864). The mean age was in the 50’s and around 60% were female. The most common fractures were radius, neck of the femur and humerus. Key Result: Patients who filled prescriptions for selective COX-2 inhibitors and opioids but not non-selective NSAIDs were associated with an increased risk of nonunion. SGEM Bottom Line: There is no high-quality evidence to support the claim that non-selective NSAIDS cause an increased risk of nonunion. SGEM#317: Dese bones gonna heal again, with or without a non-selective NSAID Reference: George et al. Risk of Nonunion with Nonselective NSAIDs, COX-2 Inhibitors, and Opioids. J Bone Joint Surg Am. 2020 Myth #2: Topical anesthetics will cause blindness if used in simple corneal abrasions for less than 48 hours Even small corneal abrasions can cause significant pain because the cornea is highly innervated. The first documented use of topical ophthalmologic anesthetics was in 1818. A cocaine derivative was employed to effectively block nerve conduction in the superficial cornea and conjunctiva (Rosenwasser). A number of proposed dangers have limited the use of topical anesthetic agents for the treatment of corneal abrasion associated pain. These dangers include delayed healing secondary to mitosis inhibition and decreased corneal sensation. The latter issue is of concern because of the potential for the abrasion to progress to an ulcer without the patient noticing. Additionally, these agents may have direct toxicity to corneal epithelium with prolonged use, leading to increased corneal thickness, opacification, stromal infiltration, and epithelial defects. The fear of these complications has led to the pervasive teaching that topical anesthetics should never be used for outpatient management of corneal abrasions. This is reflected in the condemnation of their use in major Emergency Medicine textbooks, including Rosen’s and Tintinalli’s. Some of the evidence used to support the claim of local anesthetics causing corneal harm comes from case reports, animal models or local anesthetic injected directly into the anterior chamber of the eye for cataract surgery. More information on the where the no topical anesthetic use on corneal abrasions come from can be found on a REBEL EM blog post. They enrolled 118 patients into the trial. The median age was in the mid 30’s and 60% were male. Baseline NRS for pain was 7 out of 10. Just over 10% had a metallic foreign body and more than ¼ had another foreign body. Key Result: Topical tetracaine was highly effective in reducing pain from simple corneal abrasions. SGEM Bottom Line: Topical tetracaine use for 24-48 hours provides effective pain control and seems to be safe when prescribed early after corneal abrasions and you are confident it is only a simple corneal abrasion.   SGEM#315: Comfortably Numb with Topical Tetracaine for Corneal Abrasions Reference: Shipman et al. Short-Term Topical Tetracaine Is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions: A Double-Blind, Randomized Clinical Trial. Annals of EM 2020 Myth #3: Mild paediatric gastroenteritis is best treated with expensive oral electrolyte solutions Gastroenteritis is a common illness in children and these children are at risk of dehydration from inadequate intake, excessive losses or both together. If children are unable to tolerate oral hydration we often have to use intravenous fluids and sometimes require admission to hospital for ongoing fluids. Goldman et al Pediatrics in 2008 published a helpful table describing the degree of dehydration in children ranging from mild, moderate to severe. Most cases of gastroenteritis are mild, self-limiting and can be treated effectively with oral rehydration. For more information on visit this site on Oral Rehydration Therapy. The Canadian Pediatric Society also has an algorithm for oral rehydration. Children with vomiting from gastroenteritis, and mild-moderate dehydration, should have a trial of oral rehydration therapy. Failing this, ondansetron should be administered. Failing that, intravenous fluid should be considered. 3,668 children presenting to the emergency department were assessed for eligibility. There were 647 children randomized into the study (n=323 for half-strength apple juice/preferred fluids and n=324 for electrolyte solution). The majority of exclusions were because no research personnel were present to enroll the child (1,297). It was about evenly split between boys and girls and the mean age was 28 months. There were not differences between groups at baseline. Key Result: Treatment failure was seen in 16.7% half-strength apple juice and preferred fluid group vs. 25.0% electrolyte solution group. SGEM Bottom Line: When advising parents with children with mild gastroenteritis and minimal dehydration, offering half-strength apple juice and preferred fluids compared to electrolyte solutions is a better choice. SGEM#158: Tempted by the Fruit of Another – Dilute Apple Juice for Pediatric Dehydration Reference: Freedman et al. Effect of dilute apple juice and preferred fluids vs. electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: A randomized clinical trial. JAMA. May 2016 Myth #4: Tranexamic acid (TXA) has been proven to saves lives and results in good neurologic function in patients with isolated traumatic brain injuries (TBI) TXA is a synthetic derivative of lysine that inhibits fibrinolysis and thus stabilizing clots that are formed. We have covered TXA as a treatment for bleeding a number of times on the SGEM. The evidence for TXA providing a patient-oriented outcome (POO) has been mixed. TXA seems to work for epistaxis, fails to cause a decrease in all-cause mortality in post-partum hemorrhage, does not demonstrate an improved neurologic outcome in hemorrhagic strokes but does have 1.5% absolute mortality reduction in adult trauma patients. Epistaxis – SGEM#53 and SGEM#210 Post-Partum Hemorrhage – SGEM#214 Stroke due to Intracranial Hemorrhage – SGEM#236 CRASH-2 Trial – SGEM#80 REBEL EM has also looked at TXA for those conditions plus a few others. It is unclear if it provides a benefit for gastrointestinal bleeds (GIB). Nebulized TXA shows promise for both post-tonsillectomy bleeding and hemoptysis. However, better studies are needed to confirm these observations. Zehtabchi et al published a SRMA of TXA for traumatic brain injuries (TBI). They found only two high-quality randomized control trials with 510 patients having TBI that met inclusion criteria. The results were no statistical difference in in-hospital mortality or unfavorable neurologic functional status. However, there was a statistical reduction in intracranial hematoma expansion size with TXA compared to placebo. The CRASH-3 investigators randomly allocated 12,737 patients with TBI to receive either TXA or placebo. There were 9,202 (72%) who were enrolled within 3 hours of injury. The mean age was 42 years, 80% were male, 80% had both pupils reactive and about 2/3 had a GCS less than 12. Key Result: No statistical difference in head-injury related mortality with TXA compared to placebo. SGEM Bottom Line: We cannot recommend the routine use of TXA for patients with isolated traumatic brain injuries at this time. SGEM#270: CRASH-3 TXA for Traumatic Head Bleeds?

Date: February 12th, 2021 Guest Skeptic: Dr. Dennis Ren is a paediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. Reference: Mintegi S et al. Clinical Prediction Rule for Distinguishing Bacterial from Aseptic Meningitis. Pediatrics 2020 Case: A 4-year-old immunized girl presents to the emergency department (ED) with a fever and rhinorrhea for the past four days. Her parents report that she has been complaining of a headache and seems more tired and sleepy in the past day. On exam, she is febrile to 38.5 ºC, appears tired, with meningismus on examination but answers questions appropriately. She does not have any petechiae or purpura on skin exam. You explain that you must obtain some blood for laboratory work and perform a lumbar puncture (LP) because you are concerned that she has meningitis. Her nervous parents agree to the LP. Her cerebrospinal fluid appears clear and preliminary cerebrospinal fluid (CSF) results show a pleocytosis with 16 white blood cells per µL without any red blood cells. Her parents ask you whether or not she will have to stay in the hospital or receive antibiotics. Background: Vaccines cause adults. Supporting this position is that since the introduction of conjugate vaccines the incidence of life-threatening bacterial meningitis has decreased. The first conjugate vaccine introduced was the haemophilus influenzae type b (Hib) vaccine. This vaccine has a reported efficacy of 98% (Makwana and Riordan 2007). The success of conjugate vaccines is that most cases of pediatric meningitis are now aseptic (viral cause). It is important to distinguish between bacterial vs aseptic meningitis. This is because bacterial meningitis is associated with serious morbidity and mortality and requires prompt antibiotic treatment; aseptic meningitis is self-limited and requires only supportive care. Patients with suspected bacterial meningitis require hospital admission with empiric antibiotics pending culture results (Sáez-Llorens and McCracken 2003). There is no single variable that can help discriminate between bacterial vs. aseptic meningitis.  Combinations of variables have been tried in the past as part of clinical scoring systems such as the Bacterial Meningitis Score (BMS) to identify children with CSF pleocytosis at low risk for bacterial meningitis (Nigrovic et al 2002). However, BMS did not take into account C-reactive protein and procalcitonin levels that have shown promise in risk stratifying febrile children at risk for bacterial infection (Van den Bruel et al 2011). Additionally, BMS has missed a few cases of bacterial meningitis. Specifically, 2 out of 1714 patients categorized as very low risk for bacterial meningitis had bacterial meningitis (sensitivity 98.3%, NPV 99.9%). Both patients missed were younger than 2 months old (Nigrovic et al 2007). The study we are reviewing today aimed to develop and validate a more accurate scoring system called the Meningitis Score for Emergencies (MSE) to distinguish between bacterial vs. aseptic meningitis in children 29 days to 14 years old with CSF pleocytosis based on four objective lab criteria. Clinical Question:  Can a clinical decision tool using laboratory data help distinguish between bacterial from aseptic meningitis in children 29 days to 14 years old with cerebrospinal fluid pleocytosis? Pleocytosis- CSF WBC ≥10 cells per µL. Corrected for presence of CSF RBCS (1:500 leukocytes to erythrocytes in peripheral blood) and CSF protein (every 1000-cell increase on CSF RBCs per mm3, CSF protein increased by 1.1 mg/dL) Bacterial meningitis defined as patient with either identification of bacterial pathogen in CSF culture and/or Neisseria meningitides or Streptococcus pneumoniae on polymerase chain reaction and either positive blood culture or blood PCR result for N meningitides or S pneumoniae Aseptic meningitis defined as CSF pleocytosis and negative CSF and blood bacterial cultures and negative Neisseria meningitidesor Streptococcus pneumoniae on polymerase chain reaction Reference: Mintegi S et al. Clinical Prediction Rule for Distinguishing Bacterial from Aseptic Meningitis. Pediatrics 2020 Population: Children between 29 days and 14 years old with a diagnosis of meningitis across 25 Spanish emergency departments. Exclusion: Children <29 days old, critically ill, with purpura, not previously healthy or treated with antibiotics within 72 hours before lumbar puncture. Intervention: Retrospective derivation and prospective validation of Meningitis Score for Emergencies (MSE) for distinguishing bacterial vs. aseptic meningitis using procalcitonin >1.2 ng/mL, CSF protein >80 mg/L, CSF absolute neutrophil count >1000 cells per mm3, and C-reactive protein >40 mg/L. The four laboratory components were given different points if present and zero points if absent. So, if the procalcitonin was elevated you got 3 points, 1 point for elevated CRP, 1 point for elevated ANC and 2 points for elevated CSF protein (max score 7). Comparison: Bacterial meningitis score (Pediatrics 2002), validated (JAMA 2007) The BMS had 5 components: four are laboratory and one is clinical (seizure at or before presentation). Each of these components were also given a different number of points if present and zero points if absent. The BMS is available on MDCalc. Outcome: Accuracy of clinical decision support tool in distinguishing bacterial vs aseptic meningitis in children with CSF pleocytosis. (sensitivity, specificity, negative predictive value, positive predictive value, and likelihood ratios). Authors’ Conclusions: “The meningitis score for emergencies (MSE) accurately distinguishes bacterial from aseptic meningitis in children with CSF pleocytosis.” Quality Checklist for Clinical Decision Tools: The study population included or focused on those in the ED. Yes The patients were representative of those with the problem. Unsure All important predictor variables and outcomes were explicitly specified. Yes This is a prospective, multicenter study including a broad spectrum of patients and clinicians (level II). No Clinicians interpret individual predictor variables and score the clinical decision rule reliably and accurately. Yes This is an impact analysis of a previously validated CDR (level I). No For Level I studies, impact on clinician behavior and patient-centric outcomes is reported.  N/A The follow-up was sufficiently long and complete. Unsure The effect was large enough and precise enough to be clinically significant. Unsure Key Results: The final study included 1,009 patients between 29 days and 14 years of age. There were 819 patients assigned to the derivation group while 190 were assigned to the validation group. Slightly over 1/3 were female with mean age of 2 years. The vast majority (91%) had aseptic meningitis and only 9% had bacterial meningitis. Of those with meningitis, 80% had either N meningitides (41.3%) or S pneumonia (38.5%). Other organisms included: Group B Strep 5.5%, Strep pyogenes 4.3%, Enterococcus faecalis, H influenzae (2.2% each) and E. coli, Listeria monocytogenese, Salmonella typhimurium, Strep bovis, Kingella kingae, Fusobacterium necrophorum (1.1% each). Validation Group MSE ≥1: Sensitivity 100%, specificity  77.4%, NPV 100%, PPV 46.3%, LR+ 4.4 and LR- 0 Derivation and Validation Group MSE ≥1: Sensitivity 100%, specificity 83.2%, NPV 100%, PPV 37.4%, LR+ 5.95 and LR- 0. No patients with bacterial meningitis were missed with the MSE. Two patients with bacterial meningitis were missed with the BMS. 1-month-old with Streptococcus agalactiae meningitis although BMS is used for patients >2 months 3-year-old with meningococcal meningitis 1) Procalcitonin Testing: Procalcitonin is the cool new kid on the block when it comes to detecting bacterial infections. Procalcitonin testing may not be available at all hospitals limiting applicability of this new scoring tool. 2) Age: Similar to the Bacterial Meningitis Score (BMS) study, this study did not include any patients <29 days old. Unlike the BMS study that included patients up to age 19, this study does not include any patients over the age of 14. It is difficult to determine whether the incidence of aseptic vs bacterial meningitis in the age group >14 to 19 years would have affected the accuracy of the MSE. 3) Derivation vs Validation Sets: Out of a total of 1,509 eligible patients, 500 were excluded: 414 from derivation group, 86 from validation group. Proportionately, 50 patients (12%) with bacterial meningitis were excluded from the derivation group while 28 patients (32%) with bacterial meningitis were excluded from the validation set. This may suggest that the groups were uneven in their relative distribution of bacterial vs aseptic meningitis. When comparing the characteristics between patients in the final derivation and validation groups, there was also a higher percentage of bacterial meningitis in the validation set compared to the derivation set (16.3% vs 7.4%). 4) CSF Gram-Stain: The authors made a decision to not include CSF Gram-stain in the score despite it being positive in 75% of cases of bacterial meningitis and positive CSF Gram-stain having specificity >97%. They state that this is due to limitations of availability of performing Gram-stain 24/7 in all EDs but recommend that a child with CSF pleocytosis and positive Gram stain should be put on antibiotics regardless of MSE score. 5) Geography: One of the limitations mentioned by the authors is that this study population is drawn purely from Spanish emergency departments. The prevalence of bacterial meningitis differs worldwide so this scoring tool would need external validation in different counties and in rural vs urban areas.

Date: January 20th, 2021 Guest Skeptics: Dr. Thorben Doll and Dr. Johannes Pott. They are both fourth year resident doctors in anesthesiology, intensive care and emergency care in St. Bernward Hospital in Hildesheim, Germany. Thorben and Johannes have a knowledge translation project called Pin-Up-Docs. It is a German emergency medicine and intensive care podcast. Their mission is to share  knowledge with paramedics, nurses, medical student and also young doctors as they take their first steps in the field of emergency medicine.  Each month they post new content and focus two main topics, the medical therapy of the month as well as tricks for dealing with complex emergencies. All of their shared information is based on the latest medical studies and data. Additionally, they host selected guests for special episodes, and publish blogs dedicated to more advanced medical questions or topics. Reference: Ruberto et al. Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Annals of EM 2020. Case: A 32-year-old male patient presents to your emergency department (ED) with severe nausea, vomiting and abdominal pain. He reports the symptoms have been continuous for 4 or 5 hours. Over-the-counter medications like acetaminophen (paracetamol) and ibuprofen have not helped. His flatmate (roommate) says he only gets relief by taking really long, hot showers. On examination, his vital signs are normal, and he is afebrile. The abdomen exam shows no peritoneal sign and normal bowel sounds are heard. Laboratory values are unremarkable. An ultrasound does not show any free fluids or any signs of an Ileus, appendicitis or gallbladder disease. His pain and nausea are difficult to control with standard medications. You admit him to hospital and the next day he undergoes gastroscopy which is unremarkable. In the afternoon the patient is seen by a nurse when he is smoking “weed” (cannabis) in the garden of the hospital. He admits to being a heavy cannabis user and his symptoms do seem to get worse when smoking weed. You suspect he has cannabis hyperemesis syndrome and discharge him home with the recommendation to stop smoking as much weed. Background: Chronic marijuana use was recognized by Allen el al in 2004 to cause cyclical vomiting in patients from South Australia. Roche and Foster quickly reported in 2005 that this was not an isolated problem to the Adelaide Hills of South Australia. The medical condition became known as cannabinoid hyperemesis syndrome. We covered this on SGEM#46: Don’t Pass the Dutchie   Cannabis stimulates two receptors: CB1 and CB2. CB1 is also expressed in the GI-system and reduces motility and relaxes the esophageal sphincter tonus. If you conduct chronical cannabis abuse, it seems that the anti-nausea effect of cannabis vanishes and there is a continuous hyperstimulation of CB1. That’s why you have abdominal pain and nausea with continuous vomiting. There are some criteria proposed for the diagnosis of cannabinoid hyperemesis. An essential feature is long term cannabis use (often daily). There are five major features for the diagnosis and five supportive features for the diagnosis. These are listed in the table.  Clinical Question: Can haloperidol effectively treat patients with cannabis hyperemesis syndrome? Reference: Ruberto et al. Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Annals of EM 2020. Population: Adult patients 18 years of age and older presenting to the ED with a working diagnosis of hyperemesis cause by cannabis who had at least two hours of ongoing, witnessed emesis or retching. Patients needed to report at least three episodes of emesis in a cyclic pattern separated by greater than one month during the preceding two years, and near-daily to daily use of cannabis by inhalation for at least six months. Exclusion: Daily opioid users, allergic to or intolerant of either study drug, deemed unreliable for follow-up, or unlikely to return for crossover, pregnant or received an antiemetic, anticholinergic or antipsychotic agent intravenously (other than up to 100mg of dimenhydrinate) in the previous 24 hours. Intervention: Haloperidol low-dose (0.05mg/kg) or high-dose (0.1 mg/kg) Comparison: Ondansetron 8mg IV Outcome: Primary Outcomes: Average reduction from baseline in abdominal pain and nausea scores measured on a 10-cm visual analog scale (VAS) at two hours after treatment Secondary Outcomes: Changes in either abdominal pain or nausea score over time, treatment success (ie, both abdominal pain and nausea <2 cm at !2 hours), being discharge ready at two hours, use of rescue antiemetics before discharge, time to discharge readiness, length of stay (LOS) greater than 12 hours, and unscheduled return visits within seven days. Any adverse events potentially related to the study drug and specifically any acute dystonia or moderate to severe akathisia. Authors’ Conclusions: “In this clinical trial, haloperidol was superior to ondansetron for the acute treatment of cannabis-associated hyperemesis. The efficacy of haloperidol over ondansetron provides insight into the pathophysiology of this now common diagnosis in many EDs”. 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 The patients were analyzed in the groups to which they were randomized. Unsure 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. Yes All groups were treated equally except for the intervention. Yes 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 Key Results: There were 313 unique individuals with nausea, vomiting and cannabis use mentioned. A total of 65 patients met inclusion criteria when the research team was notified and only 30 (46%) agreed to participate and were randomized. The mean age was 29 years with slightly more men than women. Haloperidol was superior compared to ondansetron for pain and nausea at two hours post treatment. Primary Outcome: Haloperidol vs ondansetron change from baseline Nausea: –5.0 vs –2.4, difference –2.5 (95% CI; –4.4 to –0.6) Pain: –4.3 vs –2.1, difference –2.2 (95% CI; –4.4 to 0) Secondary Outcomes:  Haloperidol was superior to ondansetron in all secondary outcomes. Three patients had prespecified adverse events (one moderate akathisia and two return visits for acute dystonia) all after the higher dose haloperidol (0.1 mg/kg). All three patients were treated without difficulty, discharged, and withdrawn from further study eligibility for crossover, given the compromised blind. There were four return visits (two for dystonia and two for ongoing nausea and vomiting) within the week after haloperidol compared with six return visits (all for ongoing nausea and vomiting) after ondansetron. This was a difficult study to successfully complete due to the inclusion and exclusion criteria, the cross-over design and the target population. The researchers should be congratulated for the data they were able to obtain. 1) Convenience Sample: These were not consecutive patients but rather a convenience sample. Participants were recruited only when on-site research personnel were available to facilitate enrollment. Out of the 313 unique patients presenting with nausea/vomiting and cannabis use, 201 people were excluded because the research team was not notified, or it was after hours. This could have introduced some selection bias. 2) Selection Bias: Speaking of selection bias, another possible source of this type of bias was that less than 50% of eligible patients agreed to participate (30/65). The authors said this was often due to patients being skeptical regarding the diagnosis as disclosed during the consent process. Also, if the patient was deemed unreliable for follow-up, or unlikely to return for crossover they were excluded. This is a subjective criterion that could have introduced selection bias into the process. The researchers did were not very successful considering only 9 of 30 patients (30%) returned the 24- and 48-hour VAS scores despite reminders by telephone, text, and e-mail. 3) Small Population: This was a relatively small study with only 30 patients. They discussed the difficulties they had in reaching their prespecified enrollment target. Part of the problem was the inclusion criteria of needing witnessed emesis, the exclusion due to IV ondansetron being given as a standing medical order for all-cause emesis before clinical assessment, lack of research personnel (Nerdy point#1) and a belief by some clinicians that their practice approach was superior to the study protocol. Despite the small numbers, they did see a large effect size that was statistically and clinically significant. Another small number we should consider was the low crossover rate of 25% (being treated more than once). This means they could only perform an ANOVA for the first period alone for the primary efficacy analysis. 4) Stopped Early: This trial was stopped early. We have talked about this issue before on the SGEM. Guyatt et al discussed the problem in a 2012 BMJ article. They said: “Guidance must include a high level of skepticism regarding the findings of trials stopped early for benefit, particularly when those trials are relatively small and replication is limited or absent.”  However,

Date: January 22nd, 2021 Guest Skeptic: Dr. Steve Joseph. Steve completed his Sport Medicine fellowship training with the Fowler Kennedy Sport Medicine Clinic in 2017.  He served with the Canadian Forces as a Medical Officer and Flight Surgeon. Steve is currently an Assistant Professor in the Department of Family Medicine at Western University (London, Ontario) working at the Fowler Clinic and the Roth McFarlane Hand and Upper Limb Centre. Reference: George et al. Risk of Nonunion with Nonselective NSAIDs, COX-2 Inhibitors, and Opioids. J Bone Joint Surg Am. 2020 Case: A healthy 55-year-old woman was out for a walk and had a FOOSH (fall on outstretched hand) of her dominant arm. The X-ray demonstrates a fracture of the distal radius that is in an acceptable position and does not require a reduction. You immobilize her in a below elbow splint which provides significant pain relief and refer her to the local orthopedic fracture clinic. Upon discharge she asks what she should take for pain because she read somewhere that anti-inflammatory drugs like ibuprofen can prevent bone healing. She currently takes thyroid replacement therapy and has no known drug allergies. Background: There are conflicting studies about fracture healing and the use of non-steroidal anti-inflammatories (NSAIDs) in humans. It remains a controversial topic in the orthopaedic specialty. When bones break, they usually heal with either surgical or non-surgical management. Sometimes the healing process can take longer than usual (delayed union), does not heal (non-union) or in poor alignment (malunion). Non-union is defined as "a failure of the fracture-healing process” and occurs in up to 1 in 10 fractures. Several risk factors have been associated with increased risk of delayed or non-union. These factors include: Use of tobacco products, older age, severe anemia, alcohol intake, diabetes, low vitamin D levels, hypothyroidism, poor nutrition, infection, open fracture and certain medications (ex. steroids). The top risk factors for non-union according to a study by Santolini et al were open method of fracture reduction, open fracture, presence of post-surgical fracture gap, smoking, infection, wedge or comminuted types of fracture, high degree of initial fracture displacement, lack of adequate mechanical stability provided by the implant used, fracture location in the poor zone of vascularity of the affected bone, and a fractured tibia [1]. One class of medication that has been implicated in negatively impacting bone healing is NSAIDs. Non-selective NSAIDs block cyclooxygenase (COX)-1 and 2 while selective NSAIDs only inhibit COX-2. There have been multiple studies investigating this issue with mixed results. Clinical Question: Is there increased risk for fracture non-union with certain classes of NSAIDs? Reference: George et al. Risk of Nonunion with Nonselective NSAIDs, COX-2 Inhibitors, and Opioids. J Bone Joint Surg Am. 2020 Population: Adults (18 years and older) inpatient or outpatients with a diagnosis of certain long bone fractures (neck of femur/tibia/fibula/tibia and fibula/radius/ulna/humerus/clavicle) based on ICD-9 codes. Excluded: Patients less than 18 years of age, multiple fractures, metastatic disease, history of malunion fracture in the year prior or within 90 days Exposure: Filled prescription for a non-selective NSAIDs, selective COX-2 inhibitor and/or opioid within 30 days of the fracture Comparison: Not filling a prescription for a non-selective NSAIDs, selective COX-2 inhibitor and/or opioid within 30 days of the fracture Outcomes: Primary Outcome: Diagnosis of non-union within the 91 to 365 days post fracture. This was based on two definitions. The primary definition used ICD-9 code for nonunion with a procedure to treat nonunion within 30 days of the nonunion diagnosis. The secondary definition was an inpatient or outpatient diagnosis of nonunion. Authors’ Conclusion: “COX-2 inhibitors, but not non-selective NSAIDs, were associated with a greater risk of non-union after fracture. Opioids were also associated with non-union risk, although patients filling prescriptions for opioids may have had more severe fractures.” 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? Unsure Was the exposure accurately measured to minimize bias? No Was the outcome accurately measured to minimize bias? Unsure Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Fairly precise Do you believe the results? Yes Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Key Results: The final cohort consisted of 339,864 patients identified in over 15 years. Less than 1% were diagnosed with a nonunion (2,996/339,864). The mean age was in the 50’s and around 60% were female. The most common fractures were radius, neck of the femur and humerus. Patients who filled prescriptions for selective COX-2 inhibitors and opioids but not non-selective NSAIDs were associated with an increased risk of nonunion. Primary Outcome: Nonunion COX-2- inhibitor prescriptions: Adjusted odds ratio (aOR) 1.84 (95% CI; 1.38 to 2.46) Opioid prescriptions: aOR 1.69 (95% CI; 1.53 to 1.86), Non-selective NSAID prescriptions: aOR 1.07 (95% CI; 0.93 to 1.23) 1) Question: They answered the question about an association between filling a prescription for various analgesics and the risk of nonunion. However, the question we want answered is whether or not any of these medications has a causal relationship with nonunion. Stronger evidence would be an RCT of these medications with the outcome of nonunion confirmed clinically and not using ICD-9 codes. It would be difficult to get ethics approval for a placebo-controlled trial. It could also be a challenge to maintain blinding due to the side effect profile of opioids. 2) Cohort Recruitment: We were unsure if the cohort was recruited in an acceptable way to minimize bias. They used ICD-9 codes to identify the individuals with a fracture. There was no reference to support that this is a validated method. 3) Exposure: The exposure was only if the patient filled a prescription, not if they took the prescription. Some prescriptions may have been filled and missed. They did not describe the process well. Filling a prescription does not confirm if they took the medication or even how much and for how long. Non-selective NSAIDS are widely available over the counter medications which also could confound the results. We will talk more about confounders in nerdy point #5. 4) Outcome: Their outcome was based on two non-union definitions. Both relied on ICD-9 codes. They did not provide a reference validating the first definition. The second definition did have a reference. It was a small, single centre study with a positive predictive value of only 89% [2]. The authors of the cited study for the definition acknowledge these weaknesses in their discussion of limitations. This included the issue of PPV being based on prevalence of disease. 5) Confounders: They identified many confounders in their analysis like diabetes, alcohol, steroid use, and others. However, there are other confounders (severe anemia, low vitamin D levels, hypothyroidism, poor nutrition, etc) which have associated with nonunion that were not identified. This could have impacted the magnitude of the point estimate and the 95% confidence interval (precision of the results). Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions but would have added a qualification that other unmeasured confounders could have impacted the results. SGEM Bottom Line: There is no high-quality evidence to support the claim that non-selective NSAIDS cause an increased risk of nonunion. Case Resolution: You suggest using acetaminophen or ibuprofen for pain. Dr. Steven Joseph Clinical Application: This will not change my practice. I will prescribe according to the patient’s preferences, my clinical judgment and available evidence. This will mean usually suggesting non-selective NSAIDs or acetaminophen. Sometimes I will prescribe a short course of opioids. I do not use COX-2 inhibitors because there is no high-quality evidence of better efficacy or safety profile and this study suggests an increased associated risk of nonunion. What Do I Tell My Patient? Broken bones can be very painful. Immobilization often provides a great deal of pain relief. You can also use acetaminophen or ibuprofen to help with the pain. The goal is not to get to zero pain but to minimize suffering. There is no high-quality evidence that anti-inflammatory drugs like ibuprofen will prevent bone healing.  If the pain is getting worse, you are getting numbness, loosing function, the hand is going cold/pale or you are otherwise worried, please come back to the emergency department for reassessment. Keener Kontest: Last weeks’ winner was Garrision Lin. He is a nursing student at Western University and is currently doing a placement at South Huron Hospital Association. He knew the first Nurse Practitioner program in the US was in 1965 by Loretta Ford and Dr. Henry K. Silver from the University of Colorado. Listen to the SGEM podcast to hear this weeks’ question. Send your answer to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.   Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. References: Santolini E, West R,

Date: January 20th, 2021 Guest Skeptic: Dr. Lauren Westafer 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  research methodology editor for Annals of Emergency Medicine and as an Associate Editor for the NEJM Journal Watch Emergency Medicine. Reference: Pines et al. Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain. AEM January 2021 Case: A 50-year-old male presents to the Emergency Department (ED) with left lower quadrant abdominal pain. The patient is seen by an advanced practice provider (APP). He wants to know if being seen by an APP alters his chance of diagnostic testing or hospital admission. Background: We covered the use of advanced practice providers (APPs) on the SGEM#308. That SGEMHOP episode asked how the productivity of APPs compare to emergency physicians and what is its impact on ED operations? The key result from that study of 13 million ED visits across 94 states was that physicians were more productive than PAs and NPs. The SGEM bottom line was that increasing APP coverage has minimal effect on ED flow and safety outcomes based on the data. Over the past two decades, the use of APPs has increased. APPs have a significantly truncated medical training (about 2 years of training) and practice experience compared with the traditional 4 years of medical school and 3-4 years of residency for emergency physicians. 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 2020 by AAEM/RSA, ACEP, ACOEP/RSO, CORD, EMRA, and SAEM/RAMS. 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) also has a number of documents discussing APPs in the ED. The difference in training between and emergency medicine physician and APPs is well recognized. A concern is that some APPs may compensate for this training gap by increased testing. Clinical Question: Is ED evaluation by an APP associated with higher test utilization and hospitalization compared with evaluation by a physician? Reference: Pines et al. Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain. AEM January 2021 Population: All ED patients with a chief complaint of chest pain or abdominal pain triaged as an Emergency Severity Index (ESI) 2,3, or 4 who were seen independently by either an APP or emergency physician Excluded: Patients who left without treatment or against medical advice, those who were dead on arrival or died in the ED. They also excluded those with a triage level ESI 1 or 5, as these are less common, as well as those with a final diagnosis of injury or poisoning – as in those cases the diagnosis would generally be apparent. Intervention: Evaluated by an APP Comparison: Evaluated a physicial Outcome: Primary Outcomes: Laboratory tests, ECGs, imaging studies as well as hospital admissions (including transfer to other hospitals and observation admissions) Secondary Outcomes: Testing based on evidence-based practice Dr. Jesse Pines This is an SGEMHOP episode which means we have the lead author on the show. Jesse Pines MD 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: “We demonstrate that the care delivered in the ED by advanced practice providers and emergency physicians for patients matched on complexity and acuity presenting with chest pain or abdominal pain chief complaints is largely similar with respect to diagnostic test utilization and admission decisions. Future research should continue to explore the optimal use of advanced practice providers in the ED and the best ways to deploy this expanding part of the U.S. ED workforce". 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? Unsure Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? No Was the follow up of subjects complete enough? Yes How precise are the results? Fairly precise Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Unsure Key Results: The data was collected over three years (2016-19) from around 90 facilities with over a thousand APPs and more than 1,500 emergency physicians. There were 663,599 patient visits for chest pain (12.8% seen by APPs and 87.2% seen by physicians). There were 946,042 patient visits for abdominal pain (21.3% seen by APPs and 78.7% seen by physicians). There was not much difference between APPs and physicians for laboratory, imaging studies or admissions with APPs being slightly lower for all outcomes. Physicians tended to see older patients, those with more comorbidities, and had a higher admission rate. In contrast, APPs tended to see younger patients, with less comorbidities and lower admission rates. However, once IPW-adjusted average treatment effects showed that being seen by an APP either reduced the probability or did not have a statistically significant impact the probability of having a laboratory test or imaging test ordered in comparison to physicians. This was consistent overall and among discharged ED visits, including models that contained past medical history. 1) Observational Study: One of the main limitations is this is an observational study. Although they stratified by age and did inverse propensity score weighting (IPW) there could have been confounding factors impacting the results. 2) Accuracy of Exposure Measurement:  Big datasets allow us to look at massive amounts of information. One problem, however, can be the granularity of the data. It’s not entirely clear in the manuscript how the exposure, which was whether an APP saw the patient or not, was determined. Was it that an APP was involved in any aspect of care? Was it that they saw the patient first? Last before disposition? In some EDs, while APPs may see patients primarily, physicians also see, evaluate, and help disposition the patient. In other EDs (or even the same ED but with different APP-attending physician combinations), the APP may truly independently see and manage the patient. These combinations make the exposure a little more opaque in this case. 3) Protocolized: Most of the patients (>90%) presenting with chest pain were adults. Often, they are being worked up for rule out ACS or rule out PE.  These tend to be very protocolized workups. There is also a zero-miss culture when it comes to MIs and PEs. It is not surprising that you did not find much variability in practice for patients presenting with chest pain. 4) Supervision: It says in the publication that all APPs had some degree of physician supervision and none were practicing independently. This is another reason why we would not expect to find much difference between APPs and physicians. 5) Patient-Oriented Outcome:  It could be argued that number of tests are not patient oriented outcomes depending on insurance status. A stronger case could be made about admission to hospital. Why not look at things like safety defined as mortality and morbidity? Martha Roberts We were correctly called out after SGEM#308 for not having an APP on the SGEM episode that reviewed a paper on APPs. Demonstrating that we listen to feedback and take action, Martha Roberts was invited to provide her comments on the paper. She is a critical and emergency care, triple-certified nurse practitioner currently living and working in Sacramento, California. She is the host of EM Bootcamp in Las Vegas, as well as a usual speaker and faculty member for The Center for Continuing Medical Education (CCME). She writes a blog called The Proceduralist and has started her own podcast with PA Mike Sharma called The 2-View podcast. Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors conclusions. SGEM Bottom Line: In patients presenting to the ED with chest pain and abdominal pain, physicians and APPs had similar practice patterns with test ordering and admissions rates. Case Resolution: The patient has a work-up for his abdominal pain, including labs and CT abdomen-pelvis, and is diagnosed with uncomplicated diverticulitis. He is discharged home with a prescription for appropriate antibiotics. Dr. Lauren Westafer Clinical Application: Unsure. We do not have high-quality data to inform us about the impact of APPs on the emergency department. This data comes from one large emergency department group and may lack external validity to other practice environments. What Do I Tell My Patient? It probably will not matter whether you see the APP or the physician. Both have similar practice styles, and the APP will be supervised by an attending physician. Keener Kontest: Last weeks’ winner was Kalmen Barkin an EMT from Somersworth, New Hampshire. They knew the term "blinding" came from an investigation into the practice of Dr. Franz Mesmer.

Date: January 5th, 2021 Reference: Shipman et al. Short-Term Topical Tetracaine Is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions: A Double-Blind, Randomized Clinical Trial. Annals of EM 2020 Dr. Glaucomflecken Guest Skeptic: Dr. Will Flanary is an ophthalmologist, writer, and comedian who moonlights in his free time as “Dr. Glaucomflecken” on Twitter and TikTok. Effortlessly blending humor with education, Dr. Glaucomflecken has spent the last five years informing audiences on a wide range of topics, like navigating the confusing world of over-the-counter eyedrops, the horrifying consequences of sleeping in contact lenses, and his recent experiences as a patient in the medical system. Case: A 32-year-old healthy man presents with left eye pain. He was giving his 9-month-old a hug and got poked in the eye with a sharp little fingernail.  His visual acuity is 20/20 bilaterally and he doesn’t wear corrective lenses or contact lenses. He tried some over-the-counter red eye drops that did not seem to work. In the emergency department (ED), tetracaine drops are applied prior to slit lamp examination and the pain is completely resolved. On examination, you see a vertical corneal abrasion with no evidence of ulceration and no foreign body. You prescribe antibiotic drop and prepare to discharge him home when he asks, “can I get some of those numbing drops to use at home”? Background: Even small corneal abrasions can cause significant pain because the cornea is highly innervated. The first documented use of topical ophthalmologic anesthetics was in 1818. A cocaine derivative was employed to effectively block nerve conduction in the superficial cornea and conjunctiva (Rosenwasser). A number of proposed dangers have limited the use of topical anesthetic agents for the treatment of corneal abrasion associated pain. These dangers include delayed healing secondary to mitosis inhibition and decreased corneal sensation. The latter issue is of concern because of the potential for the abrasion to progress to an ulcer without the patient noticing. Additionally, these agents may have direct toxicity to corneal epithelium with prolonged use, leading to increased corneal thickness, opacification, stromal infiltration, and epithelial defects. The fear of these complications has led to the pervasive teaching that topical anesthetics should never be used for outpatient management of corneal abrasions. This is reflected in the condemnation of their use in major Emergency Medicine textbooks, including Rosen’s and Tintinalli’s. Some of the evidence used to support the claim of local anesthetics causing corneal harm comes from case reports, animal models or local anesthetic injected directly into the anterior chamber of the eye for cataract surgery. More information on the where the no topical anesthetic use on corneal abrasions come from can be found on a REBEL EM blog post. We covered and randomized control trial by Waldman et al on topical tetracaine for simple corneal abrasions on SGEM#83. The bottom line from that episode was that tetracaine appears safe for uncomplicated corneal abrasions and provides more effective pain relief than saline eye drops. We also did a critical appraisal of a systematic review by Swaminathan et al looking at topical anesthetics for these types eye injuries on SGEM#145. The SGEM bottom line from that review was that the best evidence we currently have demonstrates that dilute topical anesthetic drops of either proparacaine or tetracaine are safe for use in ED patients with simple corneal abrasions to provide analgesia. The studies are small, but the data contained in them is far superior to the case series published 50 years ago which led to the dogma that using them is dangerous. Clinical Question: What is the efficacy of topical tetracaine in the treatment of simple corneal abrasions? Reference: Shipman et al. Short-Term Topical Tetracaine Is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions: A Double-Blind, Randomized Clinical Trial. Annals of EM 2020 Population: Adults 18 years to 80 years of age with suspected acute cornea abrasion Exclusions: Contact lens wearer, previous corneal surgery or transplant in the affected eye, injury greater than 36 hours old, had a grossly contaminated foreign body, or had coexisting ocular infection. Intervention: Tetracaine 0.5% one drop every 30 minutes as needed for pain for a maximum of 24 hours plus topical antibiotics (polymyxin B sulfate/ trimethoprim sulfate, two drops every four hours into the affected eye) and oral analgesic (hydrocodone/acetaminophen 7.5/325 mg, one or two tablets as needed every six hours) Comparison: Placebo (balanced artificial tear solution) one drop every 30 minutes as needed for pain for a maximum of 24 hours plus topical antibiotics (polymyxin B sulfate/ trimethoprim sulfate, two drops every four hours into the affected eye) and oral analgesic (hydrocodone/acetaminophen 7.5/325 mg, one or two tablets as needed every six hours) Outcome: Primary Outcome: Pain score using a numeric rating scale (NRS from 0-10) measured at the follow-up ED visit in 24-48 hours. Secondary Outcomes: Use of hydrocodone for breakthrough pain, and any adverse events. Authors’ Conclusions: “Short term tetracaine is effective for corneal abrasions.” 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 The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Yes The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. Unsure All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Unsure The treatment effect was large enough and precise enough to be clinically significant. Yes Key Results: They enrolled 118 patients into the trial. The median age was in the mid 30’s and 60% were male. Baseline NRS for pain was 7 out of 10. Just over 10% had a metallic foreign body and more than ¼ had another foreign body. Topical tetracaine was highly effective in reducing pain from simple corneal abrasions. Primary Outcome: Pain on NRS (0-10) at 24 to 48 hour follow-up Tetracaine 1 vs. placebo 8, difference 7 (95% CI 6 to 8) Secondary Outcomes:  Amount of hydrocodone tablets ingested (1 vs. 7) Adverse events (4% vs 11%) 1) Ophthalmologists vs. EM Physicians: There has been a divide between these two specialties. Ophthalmologists probably have some selection bias because you see the worst cases or those that have had complications. This bias can be quantified in this trial. Only about 1 in 5 patients referred to ophthalmology actually attended the consultation one week after injury. Ophthalmologists have a potential selection bias (only referred patients) and treat abrasions differently than EM doctors. We use bandage contact lenses and virtually never prescribe opioids. This will be helpful in framing the discussion of this paper and discussing the motivation for EM physicians to find alternative ways of treating abrasions (ie. tetracaine over opioids) 2) Simple Corneal Abrasions: This is very important. They had a good list of exclusion criteria in the manuscript such as length of time until evaluation in the ED, other ocular infection, grossly contaminated foreign bodies, or other injuries. There were even more listed in exclusion criteria listed in ClinicalTrials.gov that included: “pregnancy, retained foreign body, penetrating eye injury, immunosuppression, allergy to study medication, inability to attend follow up, inability to fluently read and speak English or Spanish, or any injury requiring urgent ophthalmologic evaluation (large or complicated abrasions with significant vision loss, corneal ulcers, corneal lacerations).” Previous studies have excluded corneal injuries with foreign bodies. I liked that they only excluded ones that were “grossly contaminated”. More than 1/3 of the cohort did have either a metallic or some other foreign body. This expands the external validity of the study. Establishing the diagnosis of “simple abrasion” is critical when considering prescribing tetracaine, but unfortunately, the diagnosis is not always straight forward. Severe dry eye and exposure keratopathy is another thing that is often misdiagnosed as an abrasion in the ED. 3) Blinding: The authors correctly acknowledge that the study could have been unblinded for a couple of reasons. Anyone who has used tetracaine knows it comes with a very strong burning sensation. The packaging of the tetracaine (bottle) and placebo (four ampules) were different. They never did confirm with the patients that blinding was maintained by asking which group they thought they had been allocated to. It’s hilarious to think you can adequately mask a study like this because 20 minutes out the door, and the patient will absolutely know if they have saline or tetracaine. I’m more interested in the people who received saline but kept using it. Wishful thinking, I guess. Should we be even using the term “blinding” in a trial involving eye injuries? The lack of blinding could certainly have introduced a placebo effect, but this is usually about 2-3 points on the NRS. The decrease in pain in this trial was 6 points in the treatment group and a 7-point difference compared to the placebo group. So,

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 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? Fairly precise  Do you believe the results? Yes [1,2] Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes [3,4] Key Results: The entire cohort consisted of 43,969 patients with a median age of 67 years, 1/3 were female and ½ were bystander or EMS witnessed. Of these OHCAs, 22% had an initial shockable rhythm and ¼ underwent intra-arrest transport. The probability of survival was greater with continuous on-scene resuscitation compared to intra-arrest transport in adults with OHCAs. 1) Association: The biggest limitation of study design is its observational nature. This means we can only conclude an association, not causation. Propensity score matching can help but is not able to eliminate unmeasured confounders that could bias the results. There were some details that should be explained about propensity matching. The initial cohort composed of greater than 57,000 patients with 13,756 were excluded due to a variety of reasons. In addition, only 18,812 underwent 1:1 propensity score matching (9,406 in each arm) with ~25,000 going unmatched.  Of these, 16,264 had no satisfactory match available. The end result is that it wasn’t 57,000 adult patients with OHCA whose propensity score were matched but rather less than 50% (9,406 intra-arrest transport and 18,299 on-scene resuscitation). These details are another reason why we need to be careful not to over-interpret the data that stay and play is superior to load and go.   2) Older Data: These results were based on older data from April 2011 to June 2015. This time frame was selected for a couple of reasons. Prior to April 2011, there were differences in data definition. Only including data from April 2011 forward minimizes this issue. The stop data of June 2015 was because the ROC registry was discontinued at that time. I do not think that older data would significantly impact the results of this study. We do not have been interventions that have demonstrated to have a patient-oriented outcome (POO) in patients with OHCA. There is the classic OPALS study by the Legend of EM Dr. Ian Steill on ACLS vs BLS (SGEM#64) showing no statistical difference in survival to hospital discharge (5.1% vs 5.0%).  We also mentioned things like pre-hospital therapeutic hypothermia, supraglottic devices, crowd sourcing CPR, epinephrine in the background section not resulting in a clinical benefit. The SGEM has also covered IV vs IO (SGEM#231) and amiodarone vs lidocaine (SGEM#162). Neither of these two studies were high-quality evidence demonstrating a superior strategy for a POO. It was ~2010 that the major emphasis towards high efficiency CPR started to get pushed in the prehospital arena.  ROC data has shown a gradual uptick in survival from OHCA, although this is in the realm of ~1% from 2011 - 2015 [5].  However, looking at CARES registry data there has been no change 3) Mechanical CPR: No data was presented on mechanical CPR utilization. There is some literature regarding better hemodynamics, chest compression fraction etc. with mechanical devices during transport. However, there is no evidence that mechanical CPR results in a POO. We covered this on SGEM#136 with REBEL EM and we even debated the issue at SMACC. That does not mean there could not be other benefits to mechanical CPR such as safety for EMS personnel. However, this claim would need to be demonstrated and is it any better than a special harness to secure paramedics while performing CPR in the back of the ambulance on transport. CPR has to be a bridge to somewhere. Adults patients with OHCA and non-shockable rhythms have a very poor prognosis. Prolonged CPR is associated with worse probability of survival with good neurologic outcome [6]. 4) Prognostication Bias: This is not a specific bias that we have discussed before in detail on the SGEM. However, we the discussed general idea of bias multiple times on the SGEM. I define bias as something that systematically moves us away from the “truth” (best point estimate of effect size). Prognostication bias is thought to have seven major domains for risk of bias in prognosis research. The seven major domains include: study participation, attrition, selection of candidate predictors, outcome definition, confounding factors, analysis, and interpretation of results [7]. The domain of prognostication bias recognized in this observational study by the authors was a potential for attrition bias. Those adult patients with OHCA and unfavorable phenotypes may (may not) have had resuscitation terminated early. This means they would not have the opportunity to achieve ROSC. They did document a difference in out-of-hospital termination of resuscitation. It was 0.2% of intra-arrest transport compared to 56.7% for the on-scene resuscitation for the full cohort. Similar results were observed in the propensity matched analysis. This could potentially have biased the results. 5) External Validity: We mentioned in the background material that different countries have either a physician led or non-physician led EMS system. There are even differences within countries whether or not policies exist to transport all patients depending on if ROSC is achieved.  This database was heterogenous because the medical care was carried out per local protocols, including decisions of hospital transport and termination of resuscitation. The local counties in my neck of the woods ascribe a significant degree of autonomy to our paramedics, with few protocols dictating a transport decision.  Most common are guidelines for ceasing efforts; such as PEA that remains refractory to all ALS procedures or persistent asystole.

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 today. Just click on the picture of the Highlander for all the details. SGEM Season#7 Book The SGEM continues to grow and has approximately 51,000 subscribers. It would not be so successful without the wonderful people like you who listen to the podcast and read the blog every week. I would also like to thank the SGEMHOP Team (Drs. Bond, Heitz and Morgenstern), PaperinaPic creator (Dr. Challen), all the guest skeptics and my best friend Chris Carpenter. The SGEM Season#7 book was put together with the help of my daughter Sage Milne. She came up with the steam punk theme and drew all the artwork for the book. The cover art was inspired by the 1982 movie TRON. She knows very well how much I like 1980's movies and music. Sage is currently doing doing a degree in Global Health Studies at Huron University College. Here are links to all six season of the SGEM as PDF books. You can download each season by clicking on the link: Season#1, Season#2, Season#3, Season #4, Season#5 and Season#6 If you are looking for the amazing theme music that helps with the KT for each SGEM episode, you can find them on Spotify. Most of the music comes from the 1980’s because it is clearly the best musical era. New SGEMHOP Faculty We are pleased to announce two new wonderful additions to the SGEM Hot Off the Press faculty: Dr. Kirsty Challen and Dr. Lauren Westafer. The SGEMHOP is done in collaboration with Society of Academic Emergency Medicine (SAEM). SAEM publishes the journal Academic Emergency Medicine (AEM). SGEMHOP Five Step Process: A paper that has been submitted, peer-reviewed, and ultimately accepted for publication in AEM is selected by the SGEMHOP faculty and made available free open access. We put our skeptical eye upon the manuscript using a standard critical appraisal tool to probe the paper for its validity and publish an SGEM blog of the paper. One of the authors of the paper is invited on the SGEM podcast, available on iTunes, Google Play and Spotify, as our guest to answer a number (5 or 10) nerdy questions to help us better understand the research. The SGEM audience gets a chance to interact with the author by posting comments and question on the SGEM blog. The best social media feedback will be published along with a summary of the SGEMHOP episode in a subsequent issue of AEM. Dr. Kirsty Challen Dr. Kirsty Challen (@KirstyChallen) is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). She completed her undergraduate and postgraduate training in North West England, acquiring a History of Medicine BSc, and has a PhD in Health Services Research. 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 regards her inner toddler as a great asset to medicine and finds #FOAMEd very helpful in answering “but WHY?” She is also the creator of the wonderful infographics called #PaperinaPic. When not at work she is happiest out running on a muddy mountain. Dr. Lauren Westafer Lauren Westafer, DO, MPH, MS (she/her) is an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School -  Baystate and Director of the Emergency Medicine Research Fellowship. Lauren is an implementation science researcher and FOAMed enthusiast. She is the author of the blog, The Short Coat, and cofounder of the emergency medicine podcast, FOAMcast.  She lectures internationally on social media in medical education, critical appraisal and journal club design, pulmonary embolism, and advancing the quality of healthcare for LGBTQI+ patients. In addition, she serves as the Social Media Editor and a research methodology editor for Annals of Emergency Medicine and an Associate Editor for the NEJM Journal Watch Emergency Medicine. We are very excited to have both of these talented physicians and educators as part of the SGEMHOP faculty. The SGEM will be back next episode doing a structured critical appraisal of a recent publication and will continue trying and to cut the knowledge translation window down from over ten years to less than one year using the power of social media. Ultimately we want patients to get the best care, based on the best evidence. One last thing. Could you please write a review of the SGEM podcast on iTunes, like the SGEM on Facebook and follow the SGEM on Twitter? Thank you for your ongoing support of the SGEM and all the best in 2021. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

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. We hopefully learn and get closer to the “truth” over time. Medical reversal is a thing and there is a great book and by Drs. Prasad and Cifu on this issue called Ending Medical Reversal: Improving Outcomes, Saving Lives. The evidence required to accept a claim should be in part proportional to the claim itself. The classic example was given by the famous scientist Carl Sagan (astronomer, astrophysicist and science communicator). Did the TV series Cosmos and wrote a number of popular science books (The Dragons of Eden). Sagan made the claim that there was a “fire-breathing dragon that lives in his garage”. The quality of evidence to convince you of something should be in part proportional to the claim being asserted. The summary is the famous quote by Carl Sagan that "extraordinary claims require extraordinary evidence". Science does not make claims about the truth. It gives an approximation of the the best point estimate of the observed effect. It’s the best known method for exploring the natural world. Science has no agency but rather it is a process. However, scientists are flawed individuals who make mistakes. As Blaise Pascal said: "There is not such thing as the truth, we can only deliver the best available evidence and calculate a probability". Real World Example: Marik et al made the claim in 2016 that vitamin C cocktail (hydrocortisone, thiamine and vitamin C) could cure sepsis. He published a before and after observational study with 94 patients. The result was a 32% absolute decrease in mortality (NNT 3). We covered this study on SGEM#174: Don’t Believe the Hype – Vitamin C Cocktail for Sepsis. Dr. Jeremy Faust (FOAMCast) and I had eleven other skeptics comment on Dr. Marik's study. Our bottom line was that vitamin C, hydrocortisone and thiamine was associated with lower mortality in severe septic and septic shock patients in this one small, single centre retrospective before-after study but causation has yet to be demonstrated. Higher-quality studies have since been published looking at they issue. Putzu et al had a SRMA of RCTs including critically ill patients (not just sepsis). They found no statistical difference in mortality. This was covered in SGEM#268: Vitamin C Not Ready for Graduation to Routine Use. There has been a RCT published by Fujii et al in JAMA 2020. It specifically looked at 216 patients with septic shock and found no statistical mortality benefit to vitamin C. Has the burden of proof been met that vitamin C is a cure for sepsis? I am not convinced by the available evidence. Note that this is different than claiming vitamin C does not work. That would shift the burden of proof. I am simple accepting the null hypothesis of no mortality superiority of vitamin C compared to placebo in septic patients. It is ok to say "I don't know" if vitamin C works. It reminds me of a quote from Dr. Richard Feynman. I have degrees of confidence or certainty about various positions. These positions are tentative and subject to change. I am not absolutely certain about anything. To be absolutely certain could be considered a logical fallacy (nirvana fallacy). Logical fallacies will be discussed later. 2) Evidence-Based Medicine and a Five Step Process to Critical Appraisal This was defined by Dr. David Sackett over 20 years ago (Sackett et al BMJ 1996). He defined EBM as “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”  I really like this definition, and the only tweak I would have added would be to include the word "shared".   The definition of EBM can be visually displayed as a Venn diagram. There are three components: The literature, our clinical judgement, and the patients values/preferences. Many people make the mistake of thinking that EBM is just about the scientific literature. This is not true. You need to know about the relevant scientific information. The literature should inform our care but not dictate our care. Clinical judgement is very important. Sometimes you will have lots of experience and other times you may have very limited experience. The third component of EBM is the patient. We need to ask them what they value and prefer. The easiest way to do this is to ask the patient. It should start with patients care and it ends with patient care. We all want patients to get the best care, based on the best evidence. Levels of Evidence: There is a hierarchy to the evidence and we want to use the best evidence to inform our patient care. The levels of evidence is usually described using a pyramid. The lowest level is expert opinion. the middle of the hierarchy is a randomized control trial and the top is considered a systematic review. The systematic review +/- a meta-analysis is put on the top of the EBM level of evidence pyramid. However, we need to watch out for garbage in, garbage out (GIGO). This means if you take a number of crappy little studies (CLS), mash them all up into a meat grinder and spit out a point estimate down to the 5th decimal place that results is some impressive p-value is an illusion of certainty when certainty does not exist. EBM Limitations: Harm and the parachutes argument - Smith and Pell BMJ 2003, Hayes et al CMAJ 2018, and Yeh et al BMJ 2018 Most published research findings are false - Ioannidis PLoS 2005 Guidelines are just cookbook medicine Good evidence is ignored Too busy for EBM Five Alternatives to EBM: This was adapted from a paper by Isaacs and Fitzgerald BMJ 1999. To paraphrase Sir Winston Churchill, EBM is the worst form of medicine except for all the others that have been tried. Eminence Based Medicine - The more senior the colleague, the less importance he or she placed on the need for anything as mundane as evidence. Experience, it seems, is worth any amount of evidence.

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, mostly urban, lower-income people with frequent emergency department visits for alcohol-related reasons. These visits are opportunities for intervention in a high-risk population to reduce a substantial mortality burden.” 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 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? Fairly precise Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Key Results: They identified 160,170 alcohol-related ED visits that had at least one more alcohol-related visit in the 1-year time frame. This represented a cohort of 25,813 patients. The median age was 45 years, two-thirds male, 88% urban, 59% arrived by ambulance and 13% were admitted to hospital on their index case. Increasing ED visits was associated with an increased all-cause mortality The all-cause one-year mortality rate was 5.4% overall, ranging from 4.7% among patients with 2 visits to 8.8% among those with 5 or more visits. Death due to external causes (e.g., suicide, accidents) was most common. The data could also be represented in years of potential life lost (YPLL). This showed the all-cause one-year mortality was 121 YPLL overall, ranging from 97 YPLL among patients with two visits to 231 YPLL among those with five or more visits. Listen to the podcast to hear Hasan answer my five nerdy questions. 1) Associations: The most obvious limitation to this study is the retrospective observational nature of the study. The multiple visits for alcohol use may be a surrogate marker for something else that is causing the increase observed in mortality. You did adjust for age, sex, income, rural residence, presence of comorbidities. However, there could be other unmeasured confounders responsible for the observed associated increase in all-cause mortality. 2) Validation: The use of ICD-10-CA code F10 to ascertain alcohol use disorders among patients presenting to the emergency department has not been validated. This does not mean it is not valid but should be interpreted with extra caution.  3) Interventions: It is mentioned in the conclusions that effective interventions have the potential to prevent premature mortality and reduce hospital use. In the introduction you state a systematic review suggests that screening and brief intervention for alcohol-related problems in the ED is a promising approach for reducing problematic alcohol consumption. This was a publication from 2002 (D’Onofrio and Degutis AEM). Is there high-quality evidence for effective interventions that prevent mortality in these high-risk individuals. 4) Rural Areas: More than 10% of the cohort was from rural areas. This will make access to Rapid Access Addiction Medicine clinics more difficult. Does identifying these high-risk individuals make a difference if they cannot obtain the services? 5) Comparison: This data set was not compared to other chronic conditions (diabetes, COPD, CHF, etc.) that present frequently do the ED. It would have been interesting to know if the mortality rate is higher, lower or the same for people who present multiple times to the ED in one-year due to alcohol related reasons. Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions. SGEM Bottom Line: Be aware that patients presenting frequently to the ED with alcohol related issues have an associated high risk of mortality in the next year. Case Resolution: You approach the patient with concerns over his multiple alcohol related ED visits and offer support in the department and at discharge. Offer referral/support to low-barrier addiction medicine services ex. RAAM clinic Offer anti-craving medications: naltrexone if no contraindications (especially no opiate use in the last 10 days) – start at 50 mg po daily x 1 week Consider additional anti-craving medications: gabapentin 300-600 mg po three-times a day x 1 week to help with cravings/reduce withdrawal symptoms Hope to engage people in care by taking this approach Dr. Hasan Sheikh Clinical Application: Have a high index of suspicion for this population. Ensure alcohol withdrawal is adequately treated in the ED. Get comfortable with anti-craving medications, including naltrexone and gabapentin. Familiarize yourself with the resources in your community, especially Rapid Access Addiction Medicine clinics. What Do I Tell My Patient? I see that you have had multiple visits over the last year. We are worried about you and want to get you the care you need and deserve. I can offer you some medications that could help. Would you also be interested in knowing more about our special Rapid Access Addiction Medicine clinics? Keener Kontest: Last weeks’ winner was Joshua McGough. Josh is a 3rd year medical student. He knew the word influenza comes from the Latin "Influentia" which translates to "Influence".  It refers to the idea that the disease was attributed to the influence of the stars! Listen to the SGEM podcast to hear this weeks’ question. Send your answer to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. Additional Resources: References: Rehm J, Mathers C, Popova S, et al.