The Skeptics Guide to Emergency Medicine

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

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

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

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

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

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

Date: October 29th, 2020 Guest Skeptic: Martha Roberts 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 Procedural Pause for Emergency Medicine News and is the lead content editor and director for the video series soon to be included in Roberts & Hedges' Clinical Procedures in Emergency Medicine. Reference: Vent et al. Buffered lidocaine 1%, epinephrine 1:100,000 with sodium bicarbonate (hydrogencarbonate) in a 3:1 ratio is less painful than a 9:1 ratio: A double-blind, randomized, placebo-controlled, crossover trial. JAAD (2020) Case: A 35-year-old female arrives to the emergency department with a 3 cm laceration to the palmar surface of her left forearm sustained by a clean kitchen knife while emptying the dishwasher. The patient reports a fear of needles and has concerns about locally anaesthetizing the area because, “I got stitches on my arm once before and that shot burned like crazy”! The patient asks the practitioner if there is any chance, she can get a shot that “burns less” than her last one. Background: We have covered wound care a number of times on the SGEM. This has included some myth busing way back in SGEM#9 called Who Let the Dogs Out. That episode busted five myths about simple wound care in the Emergency Department: Patients Priorities: Infection is not usually the #1 priority for patients. For non-facial wounds it is function and for facial wounds it is cosmetic. This is in contrast to the clinicians’ #1 priority that is usually infection. Dilution Solution: You do not need some fancy solution (sterile water, normal saline, etc) to clean a wound. Tap water is usually fine. Sterile Gloves: You do not need sterile gloves for simple wound treatment. Non-sterile gloves are fine. Save the sterile gloves for sterile procedures (ex. lumbar punctures). Epinephrine in Local Anesthetics: This will not make the tip of things fall off (nose, fingers, toes, etc). Epinephrine containing local anesthetics can be used without the fear of an appendage falling off. All Simple Lacerations Need Sutures: Simple hand lacerations less than 2cm don’t need sutures. Glue can be used in many other areas including criss-crossing hair for scalp lacerations. Other SGEM episodes on wound care include: SGEM#63: Goldfinger (More Dogma of Wound Care) This episode looked at how long do you have to close a wound. The bottom line was that there is no good evidence to show that there is an association between infection and time from injury to repair. SGEM#156: Working at the Abscess Wash The question from that episode was: does irrigation of a cutaneous abscess after incision and drainage reduce the need for further intervention? Answer: Irrigation of a cutaneous abscess after an initial incision and drainage is probably not necessary.  SGEM#164: Cuts Like a Knife – But you Might Also Need Antibiotics for Uncomplicated Skin Abscesses. SGEM Bottom Line: The addition of TMP/SMX to the treatment of uncomplicated cutaneous abscesses represents an opportunity for shared decision-making. The issue of buffering lidocaine was covered on SGEM #13. This episode briefly reviewed a Cochrane SRMA that looked at buffering 9ml of 1% or 2% lidocaine with 1ml of 8.4% sodium bicarbonate (Cepeda et al 2010). The SRMA of buffering lidocaine contained 23 studies with 8 of the 23 studies having moderate to high risk of bias. The SGEM bottom line was that patients might appreciate the extra effort of buffering the lidocaine. Interestingly, this Cochrane Review was withdrawn from publication in 2015. The reason provided was that the review was no longer compliant with the Cochrane Commercial Sponsorship Policy.

Date: October 21st, 2020 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician, creator of the excellent #FOAMed project called First10EM.com and a member of the #SGEMHOP team. Reference: Derkenne et al. Mobile Smartphone Technology Is Associated With Out-of-hospital Cardiac Arrest Survival Improvement: The First Year "Greater Paris Fire Brigade" Experience. AEM Oct 2020. Case: You are waiting in line for coffee, discussing the latest SGEM Hot Off the Press episode on twitter, when an alert pops up on your phone. It says that someone in the grocery store next door has suffered a cardiac arrest and needs your help. You remember installing this app at a conference last year, but this is the first time you have seen an alert. You abandon your coffee order and quickly head next-door, where you are able to start cardiopulmonary resuscitation (CPR) and direct a bystander to find the store’s automated external defibrillator (AED) while waiting for emergency medical services (EMS) to arrive. After the paramedics take over, you wonder about the evidence for this seemingly miraculous intervention. Background: Out of hospital cardiac arrest (OHCA) is something that we have covered many times on the SGEM. SGEM#64: Classic EM Papers (OPALS Study) SGEM#136: CPR – Man or Machine? SGEM#143: Call Me Maybe for Bystander CPR SGEM#152: Movin’ on Up – Higher Floors, Lower Survival for OHCA SGEM#162: Not Stayin’ Alive More Often with Amiodarone or Lidocaine in OHCA SGEM#189: Bring Me to Life in OHCA SGEM#231: You’re So Vein – IO vs. IV Access for OHCA SGEM#238: The Epi Don’t Work for OHCA SGEM#247: Supraglottic Airways Gonna Save You for an OHCA? SGEM#275: 10th Avenue Freeze Out – Therapeutic Hypothermia after Non-Shockable Cardiac Arrest The American Heart Association promotes the “Chain-of-Survival”. There are five steps in the Chain-of-Survival for OHCA: Step One – Recognition and activation of the emergency response system Step Two – Immediate high-quality cardiopulmonary resuscitation Step Three – Rapid defibrillation Step Four – Basic and advanced emergency medical services Step Five – Advanced life support and post arrest care Bystander CPR and early defibrillation are key components of the out of hospital cardiac arrest chain of survival. Unfortunately, most patients don’t receive these crucial interventions. Many people are trained in CPR but never use their skills, because it is unlikely that they will happen to be in exactly the right place at the right time. They may be willing and able to help, but if the patient in need is one block over, they may never know about it. The advent of the smart phone with GPS capability means that we should be better able to direct individuals trained in basic life support (BLS) to those in need around them. We should also be able to use smart phones to more easily identify the closest AEDs. Over the last decade, numerous apps have been developed to do exactly that, but the impact of those apps on clinical outcomes is still unclear. Clinical Question: Is the use of a smart phone app that can match trained responders to cardiac arrest victims and indicate the closest available AEDs associated with better clinical outcomes? Reference: Derkenne et al. Mobile Smartphone Technology Is Associated With Out-of-hospital Cardiac Arrest Survival Improvement: The First Year "Greater Paris Fire Brigade" Experience. AEM Oct 2020. Population: Cardiac arrests from a single emergency medical service (EMS) agency in Paris, France that were called through the central dispatch center and occurred while the chief dispatcher was available to participate, occurred in a public area, and in which there was not obvious environmental danger. Intervention: Alerts were sent through the Staying Alive app to volunteers trained in BLS who were within 500 meters of the reported cardiac arrest.

Date: October 21st, 2020 This is an SGEM Xtra episode. I had the honour of presenting at the Department of Family Medicine's Grand Rounds at the Schulich School of Medicine and Dentistry. The title of the talk was: How to think, not what to think. The presentation is available to watch on YouTube, listen to on iTunes and all the slides can be downloaded from this LINK. Five Objectives: Discuss what is science Talk about who has the burden of proof Discuss Evidence-based medicine (EBM), limitations and alternatives Provide a five step approach to critical appraisal Briefly talk about COVID19 and the importance of EBM 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 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.  Science and Proportionality: 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”. How much evidence would it take for you to accept the claim about the dragon? His word, pictures, videos, bones, other biological evidence, how about knowing any other dragons or dragons that breathe fire? Compare that to if I said we just got a new puppy and it’s in the garage. You would probably take my word for it. There is nothing extraordinary about the claim. Most of you should be familiar and have had experience with a puppy at some point in your life.

Date: October 14th, 2020 Guest Skeptic: Dr.Salim Rezaie is a community emergency physician at Greater San Antonio Emergency Physicians (GSEP), where he is the director of clinical education.  Salim is probably better known as the creator and founder of the wonderful knowledge translation project called REBEL EM. It is a free, critical appraisal blog and podcast that try to cut down knowledge translation gaps of research to bedside clinical practice. Reference: Rowell et al. Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury. JAMA 2020.  Case: A 42-year-old helmeted bicycle rider is involved in an accident where he hits his head on the ground.  At the time of emergency medical services (EMS) arrival, the patient is alert but seems a bit confused.  The accident was within one hour of injury and his Glasgow Coma Scale (GSC) score was 12. Vital signs show a slight tachycardia but otherwise normal. Pupils were both equal and reactive and he doesn’t appear to have any other traumatic injuries, or focal neurologic deficits. Other injuries appear minimal with some abrasions from the fall. Background: The CRASH-2 trial, published in 2010, showed a 1.5% mortality benefit (NNT 67) for patients with traumatic hemorrhage who received tranexamic acid (TXA) compared to placebo. Dr. Anand Swaminathan and I covered that classic paper on SGEM#80. TXA has become standard practice in many settings as a result of this data.  However, patients with significant head injury were excluded in this study and it was unclear of the effect of TXA in this group. CRASH-3 Fast forward to October 2019, when CRASH-3 was published. This large, very well-done randomized placebo-controlled trial examined the use of TXA in patients with traumatic brain injuries (TBIs) with GCS score of 12 or lower or any intracranial bleed on CT scan and no extracranial bleeding treated within 3 hours of injury. The authors reported no statistical superiority of TXA compared to placebo for the primary outcome of head injury-related deaths within 28 days. We reviewed that article published in the Lancet in SGEM#270. Subgroup analysis did demonstrate that certain patients (GCS 9 to 15 and ICH on baseline CT) showed a mortality benefit with TXA. While very interesting and potentially clinically significant, we need to be careful not to over-interpret this subgroup analysis. We did express concern over the possibility that this subgroup would be highlighted and “spun”. Unfortunately, that did happen with a subsequent media blitz and a misleading infographic. Further data is clearly needed to elucidate the role of TXA in patients with TBI. Clinical Question: Does pre-hospital administration of TXA to patients with moderate or severe traumatic brain injury improve neurologic outcomes at 6 months? Reference: Rowell et al. Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury. JAMA 2020. Population: Patients 15 years of age or older with moderate or severe blunt or penetrating TBI. Moderate to severe TBI was defined as a GCS 3 to 12, at least one reactive pupil, systolic blood pressure ≥90mmHg prior to randomization, able to receive intervention or placebo within two hours from injury, and destination to a participating trauma center. Exclusions: Prehospital GCS=3 with no reactive pupil, start of study drug bolus dose greater than two hours from injury, unknown time of injury, clinical suspicion by EMS of seizure activity, acute MI or stroke, or known history, of seizures, thromboembolic disorders or renal dialysis, CPR by EMS prior to randomization, burns > 20% total body surface area, suspected or known prisoners, suspected or known pregnancy), prehospital TXA or other pro-coagulant drug given prior to randomization or subjects who hav...