The Skeptics Guide to Emergency Medicine

Date: December 17th, 2019   Reference: Reeves and Reynolds. The NNT-WET and NNT-DRI: (Mostly) Satirical New Metrics to Emphasize the Inherent Inefficiency of Clinical Practice. AEM Dec 2019. Guest Skeptics: Dr. Mathew Reeves is a Professor and Interim Chair of the Department of Epidemiology and Biostatistics at the College of Human Medicine at MSU. Dr. Joshua Reynolds is an Associate Professor of Emergency Medicine at the College of Human Medicine at MSU. Outside of his academic duties, he works clinically in the adult ED at Spectrum Health in Grand Rapids, Michigan, the tertiary care center for Western Michigan. This is an SGEM Xtra and is a result of the December AEM publication suggesting new metrics to emphasize the inherent inefficiency of clinical practice. This (mostly) satirical article seems to be in the same theme of the annual BMJ holiday edition. The BMJ has published some great studies in their holiday edition. We have covered two of them on the SGEM: SGEM#6: Orthopedic Surgeons: Strong AND Smart! SGEM#23: A Bump Up Ahead (Diagnosis of Appendicitis) One of my other favourite BMJ holiday edition articles has been the classic parachute trial (Smith and Pell BMJ Dec 2003). Parachutes have been used for years to prevent orthopaedic, head and soft tissue injuries after a gravitational challenge (jumping out of planes). There was observational data that showed parachute use led to injury and there were case reports of people surviving falling/jumping out of a plane without a parachute or it opening properly. They could find no randomized controlled trials (RCT) to include in their systematic review and meta-analysis (SRMA). The authors suggested taking evidence-based medicine (EBM) advocates up in a plane and have them randomized in a double-blinded fashion to a parachute or a sham (backpack). It would be a cross over trial. Those participants who survived the first jump would be randomized into the opposite group. Only then would there be definitive evidence for the efficacy of parachutes. Since that SRMA published in 2003, there has been a randomized control trial conducted and published on the topic of parachutes. It was published last year in the 2018 BMJ holiday edition (Yeh et al BMJ Dec 2018). It will be covered as an SGEM Xtra in 2020. NNT: Number Needed to Treat Dr. Joshua Reynolds The NNT stands for the Number Needed to Treat. It estimates the average number of patients who need to be treated to positively impact one person with therapeutic benefit. It was originally described in 1988 by Andreas Laupacis, an internist and clinical epidemiologist who was at McMaster University in Ontario at the time. (Laupacis A et al NEJM 1988). How is the NNT Described Mathematically? The "number needed to do anything" is the inverse of the absolute change in risk. So in this case, the number needed to treat is the inverse of the absolute risk reduction (ARR): NNT=1/ARR An Example of Calculating the NNT Let’s say that there is a new drug to treat a bad disease and it reduces mortality from 25% to 15%. The absolute risk reduction is 10%, so NNT is the inverse of 0.1 and the NNT would be 10. Likewise, if that same drug reduces mortality from 25% to 20%, then the absolute reduction is 5% and the NNT would be 20, or 1 divided by 0.05. What is An Advantage To Using the NNT? One advantage is that using a single number, NNT describes the absolute impact or effectiveness of a particular therapy. Interventions with lower NNT are considered more efficacious, since one must theoretically treat fewer patients to observe an effect. Is the NNT Popular?  Yes, there is an entire Internet domain devoted to NNT (www.thennt.com) . This site extols the virtues of NNT to promote the most effective therapies while questioning those with insufficient benefit. NNH: Number Needed to Harm Dr.Mathew Reeves When quantifying the harms associated with treatment,

Date: December 13th, 2019 Reference: Belisle et al. Video discharge instructions for acute otitis media in children: a randomized controlled open-label trial. AEM December 2019 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: An 18-month-old, previously healthy female presents to the emergency department with 24 hours of fever. The past few days the parents note there has been some rhinorrhea and cough. She looks well, immunizations are up to date and her examination reveals right sided acute otitis media (AOM). When discussing discharge instructions for her AOM, you wonder whether having the parents watch a video will be more beneficial for the child’s symptoms, rather than giving the parents oral instructions with a paper handout. Dr. Chris Bond Background: AOM is the second most commonly diagnosed illness in children and the most common indication for antibiotic prescription [1-2]. There are significant costs associated with AOM and parents often bring their children to health care providers for evaluation of pain and fever [3-4]. More than one third of children experience pain, fever or both three to seven days following treatment, and nearly seventy-five percent of parents identify pain and disturbed sleep as the most important sources of AOM related burden [5-6]. There is significant parental uncertainty regarding treatment of AOM and less than 30% of US parents receive instructions on appropriate analgesia for their children [7-8]. Discharge instruction complexity and inadequate comprehension is associated with medication errors, suboptimal post-discharge care and unnecessary recidivism [9-12]. Medication errors can be reduced using standardized discharge instructions, and parents prefer these to verbal summaries [13-15]. Video discharge instructions have been shown to be preferred over paper instructions in many pediatric presentations, however no study has explored the effectiveness of video instructions for AOM [16-17]. Clinical Question: Are video discharge instructions superior to a paper handout with respect to the Acute Otitis Media – Symptom Severity Score (AOM-SOS)? Reference: Belisle et al. Video discharge instructions for acute otitis media in children: a randomized controlled open-label trial. AEM December 2019 Population: Parents of children age 6 months to 17 years with a chief complaint of otalgia in the setting of URTI and where the treating physician was at least 50% certain of a clinical diagnosis if AOM. Diagnostic certainty was on a 100mm visual analog scale based on the physicians’ rate of color photos of AOM. Excluded: Parents who were not the primary care provider, had poor English proficiency, lacked internet or telephone access, and whose children had: a pre-existing diagnosis of AOM (<72 hours old); other concomitant diagnoses (pneumonia, urinary tract infection, gastroenteritis, sinusitis, or any other condition requiring antibiotics and/or hospital admission); tympanostomy tubes; acute tympanic membrane perforation. Intervention: Video discharge instructions Comparison: Paper-based discharge instructions identical to the video discharge instructions Outcome: Primary Outcome: AOM Severity of Symptom (AOM-SOS) score on day three post-discharge. Secondary Outcomes: Knowledge questionnaire scores, parental satisfaction with the intervention, number of days of missed school or daycare (child) and work (parent), proportion of children with at least one return visit to a healthcare provider, and proportion of children who received analgesia. Dr. Naveen Poonai This is an SGEMHOP episode which means we have the lead author on the show.  Dr. Naveen Poonai is a Paediatric Emergency Medicine physician at the Children’s Hospital, London Health Sciences Centre,

Date: October 2nd, 2019   Reference: Ramgopal et al. Changes in the Management of Children With Brief Resolved Unexplained Events (BRUEs). Pediatrics 2019 Guest Skeptic: Dr. Katie Noorbakhsh is a pediatric emergency physician at the Children’s Hospital of Pittsburgh. This is an SGEM Xtra and it was inspired by the recent publication in Pediatrics on BRUEs. This will not be a traditional nerdy critical appraisal. We wanted to change things up a bit and just have a conversation about this topic. BRUE stand for a Brief Resolved Unexplained Event. It is a diagnosis of exclusion in an asymptomatic infant on presentation (no URI symptoms, no fever). The formal definition of a BRUE is: “A resolved event in an infant (less than one year) as described by an observer lasting less than one minute that includes one or more of the following: Color: Cyanosis or pallor Breathing: Absent, decreased or irregular Muscle Tone: Marked change (hyper or hypotonia) Level of Consciousness: Altered Here is another way to describe BRUEs. It is a diagnosis of exclusion that applies to infants under the age of 12 months. Most of the definition is in the name itself. It is Brief– it lasts less than 60 seconds It is Resolved– the infant is well appearing by the time we evaluate them It is Unexplained– If you think this episode can be explained as a seizure or a choking episode or gastroesophageal reflux, it is not a BRUE The Event includes one or more of the following four things: Change in Color– Specifically cyanosis or pallor Change in Breathing– Breathing is absent, decreased or irregular Change in Tone– Hyper or hypotonia or a Change in Level of Consciousness(LOC) It was previously called an ALTE (Apparent Life-Threatening Event) ALTE was defined in 1986 as “a frightening episode to the caregiver with apnea, choking, gagging, or changes in color, or muscle tone.” (McGovern and Smith). The diagnosis could have caused a great deal of anxiety in parents/caregivers. The name was not reassuring and the definition was vague. The Journal of Pediatrics published a systematic review of literature regarding the Management of ALTE in 2013 and one of the findings was that there was very little agreement in the literature on how to apply the definition. If even the folks who are really expert in the topic are not applying the definition consistently, then perhaps it’s time for a new definition. The change in name took place in 2016. The subcommittee on ALTEs in the AAP published a practice guideline renaming ALTEs to brief resolved unexplained events (BRUEs) in 2016. The New description broke things down into HIGH risk criteria and LOW risk criteria. High Risk Criteria: Prematurity (Gestational age less than 32 weeks and less than 45 weeks post conception) Age less than 60 days (two months) More than one event Low Risk Criteria:  Gestational age at least 32 weeks and post conception age at least 45 weeks Age greater than 60 days (two months) First BRUE Duration of event less than one minute No CPR by trained medical provider *No concerning historical features or physical findings There is an list of concerning historical features or physical findings at the end of this blog. Risk stratifying BRUE patients help direct management. High risk patients require a full evaluation and consideration for admission or observation should be considered. Low risk patients are broken up into four categories: Should do, should not do, may do and need not do. Should: Educate care givers about BRUE, shared decision making to guide management, recommend CPR training, and assess social risk factors to detect child abuse Should Not: CBC, blood cultures, CSF, electrolytes, VBGs or ABGs, ECHO, errors of metabolism, CXR, EEG, GERD study, neuroimaging, home monitoring, overnight sleep study, acid suppression or antiepileptic medication May Do: Pertussis testing,

Date: November 13th, 2019 Reference: van der Pol et al. Pregnancy-Adapted YEARS Algorithm forDiagnosis of Suspected Pulmonary Embolism. NEJM 2019 Guest Skeptic: Dr. Theresa Robertson-Chenier is currently an Emergency Physician practicing at the Peterborough Regional Health Centre. She is also an adjunct faculty member with Queen's University, Department of Family Medicine. Case: A 32-year-old female, G1P0, who is 22 weeks pregnant, presents to your local emergency department with the chief complaint of shortness of breath. She states that for the last one week she has had progressive shortness of breath on exertion. She denies any chest pain, fever, cough or leg swelling. She has no history of venous thromboembolic (VTE) disease like deep vein thrombosis (DVT) or pulmonary embolism (PE). But recently she drove seven hours from London, Ontario to Montreal, Quebec. She is worried about the possibility of a PE. She is otherwise healthy, takes only prenatal vitamins and has no allergies. She is terrified about any radiation exposure in pregnancy and has read on google that there is a blood test you can order to rule out PE. Background: We have covered VTE a number of times on the SGEM. This has even included a few of episodes with the PE guru and PERC rule creator Dr. Jeff Kline. However, we have never looked at the YEARS criteria study published by Van der Hulle T et al (The Lancet 2017). SGEM#51: Home (Discharging Patients with Acute Pulmonary Emboli Home from the Emergency Department) SGEM#126: Take me to the Rivaroxaban – Outpatient treatment of VTE SGEM#163: Shuffle off to Buffalo to Talk Thrombolysis for Acute Pulmonary Embolism SGEM#219:Shout, Shout, PERC Rule Them Out The YEARS algorithm starts with the clinician suspecting an acute PE. Then they order a D-dimer and apply the YEARS clinical decision instrument. It has three items with each getting one point: Clinical signs of DVT Hemoptysis PE most likely diagnosis If there are zero YEARS items and the d-dimer is <1,000ng/ml then a PE is excluded. If there are zero YEARS items but the d-dimer is equal to or greater than 1,000ng/ml then a CT pulmonary angiography (CTPA) scan is needed to rule out a PE. If there are one or more YEARS items and the d-dimer is <500ng/ml then a PE is excluded. If there are one or more YEARS items but the d-dimer is equal to or greater than 500ng/ml then a CTPA scan is needed to rule out a PE. While this publication was interesting, it was a prospective observational study from the Netherlands. There was a study by Kabrhel et al (AEM 2018) that was done in 17 hospitals in the USA. They compared usual care for possible PE vs. YEARS criteria. They enrolled 1,789 patients and 84 (4%) had a PE. Using standard d-dimer criteria, 53% would not have been imaged (2 misses). YEARS avoided imaging in 67%, but had 6 misses. Standard care had a sensitivity 97.6% vs, 92.9% for YEARS. It would be better if there was a randomized control trial comparing usual care to YEARS. In addition, the case you presented was of a pregnant woman. In the original YEARS study from 2017 it said pregnancy was an exclusion. Clinically, it can be difficult to diagnosis PE in pregnancy because of the overlap of symptoms due to the physiological changes in pregnancy (tachycardia, shortness of breath and leg swelling) with the signs and symptoms of PE. The incidence of PE is reported to be 1.72 cases per 1,000 deliveries, and it accounts for approximately one death in every 100,000 deliveries. In addition, the diagnostic tests used to diagnosis PE come with their own risks to mom and fetus. The radiation dose to the maternal breast can be potentially carcinogenic owing to the radiosensitive nature of the glandular breast during pregnancy. A CTPA study can increase the risk of breast cancer by 1.5% in a 25-year-old woman (see reference on last page). Clinical Question: Can the YEARS algorithm,

Date: November 21st, 2019 Reference: Daley et al. Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs. AEM November 2019 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You are caring for a 45-year-old male patient in the emergency department with pleuritic chest pain. You suspect he has a pulmonary embolism (PE), and the CT scanner is currently being used up by a multi-patient multiple-trauma pan-scan which promises to take hours. Your patient has a heart rate of 105 bpm and a systolic blood pressure of 95 mmHg. You pull the department’s ultrasound machine to the bedside and prepare to do a focused cardiac ultrasound to decide if you want to treat for a PE while waiting for the scanner to free up. Background: We have covered the issue of PE many times on the SGEM. This has included outpatient management (SGEM#51 and SGEM#126), catheter directed thrombolysis (SGEM#163) and even discussed the PERC rule with its creator, Dr. Jeff Kline (SGEM#219). We may have covered it so often because PE is commonly suspected in patients presenting the ED with chest pain, shortness of breath, or other symptoms. The current gold standard test is a CT angiogram of the pulmonary arteries (CTA), but this test cannot be performed immediately in some patients due to renal function, availability of the equipment, or contrast allergies. There are concerns about doing CTAs in pregnant patients due to the radiation exposure to both the mother and fetus. We have a show coming up soon looking at a pregnancy adapted YEARS criteria to help minimize the number of CTAs ordered in this patient population. In addition, patients with hemodynamic instability may not be appropriate to take out of the resuscitation bay. Focused cardiac ultrasound (FOCUS) can show findings of right ventricular strain caused by a PE, but in all patients suspected of PE, it is relatively insensitive. However, it has been suggested that in patients with hemodynamic instability, the sensitivity may be higher. Clinical Question: In patients presenting to the ED with suspected PE, who have abnormal vital signs, what is the sensitivity of FOCUS for PE? Reference: Daley et al. Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs. AEM November 2019 Population: Adult patients (>17 years old) undergoing evaluation for PE who are tachycardic (HR >100bpm) and/or hypotensive (systolic BP <90mmHg) Excluded: Prisoners, wards of the state, non–English-speaking patients, and those where investigators could not obtain any ECHO data due to technical challenges. Intervention: Focused cardiac ultrasound (FOCUS) Comparison: CT angiography of the pulmonary arteries Outcome: Primary Outcomes: Sensitivity of FOCUS for PE patient with a HR ≥ 100 beats/min or sBP < 90 mm Hg (n = 136) and those with a HR ≥ 110 beats/min (n = 98). Secondary Outcomes: Specificity and likelihood ratios of FOCUS for PE in each population. Dr. James Daley This is an SGEMHOP episode which means we have the lead author on the show. Dr. James Daley is an emergency physician at Yale New Haven Hospital where he's currently finishing up a fellowship in emergency ultrasound and research. His work centers around the use of point of care echocardiography in the diagnosis of pulmonary embolism and he hopes to branch out to other topics in resuscitation research in the future. Authors’ Conclusions: “A negative FOCUS exam may significantly lower the likelihood of the diagnosis of PE in most patients who are suspected of PE and have abnormal vital signs. This was especially true in those patients with a HR ≥ 110 BPM. Our results suggest that FOCUS can be an important tool in the initial evaluation of ED patients ...

Date: November 6th, 2019 Reference: Lascarrou et al. Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. NEJM Oct 2019 Guest Skeptic: Dr. Laura Melville (@lmelville535) is an emergency physician in Brooklyn, New York, is a part of the New York ACEP Research Committee, ALL NYC EM, and is the NYP-Brooklyn Methodist Resident Research Director. Case: A 59-year-old woman comes is brought into your emergency department (ED) by EMS in cardiac arrest. She had a witnessed arrest, and CPR was initiated by bystanders. Her initial rhythm in the field was reported as pulseless electrical activity (PEA) by EMS.  The patient achieved return of spontaneous circulation (ROSC) on arrival to the ED.  You call your hyperthermia team to initiate targeted temperature management (TTM), which in your hospital means 33C for 24 hours followed by slow rewarming for 24 hours. Your senior resident asks you “should we really be cooling our patient to 33C, doesn’t the data suggest 36C is just as good? And if she was not in a shockable rhythm at arrest, will she be likely to benefit from this treatment?”  The patient’s family has separately mentioned they heard she might have a better chance of being “normal” if she gets cooled down.  What do you say?  Do you continue with the ICE Code? What do you tell the patient’s family? Background: We have covered therapeutic hypothermia many times on the SGEM. This has been or out-of-hospital cardiac arrests (OHCA). Therapeutic hypothermia has not been demonstrated to have benefit in the pre-hospital setting (SGEM#54 and SGEM#183). But two earlier randomized controlled trials (Hypothermia after Cardiac Arrest Study Group 2002 and Bernard et al 2002) showed benefit for good neurologic outcome when TTM was initiated in the hospital after ROSC was achieved.  In those studies, the temperature goal was 32C-34C and 33C respectively. The SGEM covered the targeted temperature management (TTM) trial published in the NEJM. It showed cooling patients to 33C was not superior to 36C for the primary outcome (SGEM#82). The most recent time we have looked at therapeutic hypothermia was SGEM#199. This was a trial looking to see if there was a neuroprotective effect of hypothermia in patients with status epilepticus. Unfortunately, that study failed to demonstrate a benefit of therapeutic hypothermia for adult patients admitted to the ICU with convulsive status epilepticus. It seems like TTM is a good example of an intervention that “makes sense” but doesn’t always work. There are many examples like this in the literature where something makes sense from a pathophysiologic standpoint but is not demonstrated to work when properly tested. Clinical Question: Does therapeutic hypothermia improve survival with good neurologic outcome in patients who achieve ROSC after non-shockable cardiac arrest? Reference: Lascarrou et al. Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. NEJM Oct 2019 Population: Adults (18 years and older) with OHCA or IHCA of any cause, with non-shockable rhythm and a Glasgow Coma Scale (GCS) score of 8 or lower. Exclusion: No flow time of more than 10 minutes (collapse to starting CPR), low-flow time of more than 60 minutes, major hemodynamic instability (continuous vasopressor infusion), time from cardiac arrest to screening >300 minutes, moribund condition, severe hepatic dysfunction, pregnant or breast-feeding, prisoner, lack of health insurance and decide not to participate (by next of kin). Intervention: Targeted temperature management to 33C (+/- 0.5C) was started post arrest and then maintained for 24hrs. Cooling protocol was determined by each of the 25 participating sites. Slow rewarming of 0.25-0.5C/hr to target of 36.5-37.5C, which was maintained for 24hrs. Cooling: Active internal cooling with a specific device, active external cooling with a specific device,

Date: November 2nd, 2019 Reference: Lee and Yun. Diagnostic Performance of Emergency Physician-Performed Point-of-Care Ultrasonography for Acute Appendicitis: A Meta-Analysis. AJEM 2019. Guest Skeptic: Chip Lange is an Emergency Medicine Physician Assistant (PA) working primarily in rural Missouri in community hospitals. He also hosts a great #FOAMed blog and podcast called TOTAL EM. Chip is the CEO of an ultrasound education company called Practical POCUS which is based in the United States but is expanding into an international market. Case: A 6-year-old boy comes into your emergency department at around midnight with his parents complaining of abdominal pain.  His mother reports that the symptoms began a couple of days ago and he did not eat today.  Now, the patient has been vomiting for the last couple of hours.  Initially, he would point to the periumbilical area, but his father says that now he points to the right lower portion of the abdomen as his area of pain.  You do not have an ultrasound tech available at night and you are thinking of using your point of care ultrasound (POCUS) skills to look for a possible appendicitis, but you are unsure how accurate this test would be especially compared to other modalities such as radiology performed ultrasound. Background: We have reviewed papers on POCUS many times over the years on the SGEM. This has included performing lumbar punctures, diagnosing acute abdominal aneurysms, acute heart failure, pediatric fractures, retinal detachments and endotracheal tube placement. SGEM#41: Ultra Spinal Tap (Ultrasound Guided Lumbar Puncture) SGEM#94: You Better Think Ultrasound for Acute Abdominal Aneurysm SGEM#97: Hippy Hippy Shake – Ultrasound Vs. CT Scan for Diagnosing Renal Colic SGEM#119: B-Lines (Diagnosing Acute Heart Failure with Ultrasound) SGEM#124: Ultrasound for Skull Fractures – Little Bones SGEM#153: Simulation for Ultrasound Education SGEM#177: POCUS –A New Sensation for Diagnosing Pediatric Fractures SGEM#245: Flash-errrs (POCUS for Retinal Detachments) SGEM#249: Ace in the Hole –Confirming Endotracheal Tube Placement with POCUS Ultrasound, especially in the pediatric population, has been a common form of imaging for the diagnosis of appendicitis.  It avoids the concerns for radiation and contrast that is seen with CT.  MRI is not practical in many situations, especially in rural or remote environments. However, ultrasound does have its limitations especially in obese patients or those unable to comply with the exam for reasons such as pain. Clinical Question: What are the diagnostic performance of point of care ultrasonography (EP-POCUS) for diagnosing acute appendicitis? Reference: Lee and Yun. Diagnostic Performance of Emergency Physician-Performed Point-of-Care Ultrasonography for Acute Appendicitis: A Meta-Analysis. AJEM 2019. Population: Patients in original research articles with right-lower quadrant (RLQ) abdominal pain with EP-POCUS being performed as the index test and the use of surgical or pathological findings as the reference standard for acute appendicitis. There had to be sufficient information to reconstruct a 2x2 contingency table regarding sensitivity and specificity. Excluded: Case reports, case series, review articles, guidelines, consensus statements letters, editorials, clinical trial, and conference abstracts. Additionally, studies that did not pertain to the field of interest, insufficient data to create the 2x2 tables, POCUS was not performed by emergency physicians (EPs), and studies that only used the radiologists’ final report. Intervention: EP-POCUS for diagnosing acute appendicitis. Comparison:Radiologist-performed ultrasonography (RADUS) Outcome: Primary Outcome: Diagnostic parameters of EP-POCUS for acute appendicitis (sensitivity, specificity and likelihood ratios). Secondary Outcomes: Subgroup analysis of pediatric patients comparing EP-POCUS ...

Date: October 29th, 2019 Reference: Pellatt et al. Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial. Annals of EM 2019 Bootcamp Buddies Guest Skeptic: Martha Roberts is a critical and emergency care, triple certified nurse practitioner, currently living and working in western Massachusetts. 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 videos series soon to be included in Roberts & Hedges Clinical Procedures in Emergency Medicine. Martha also serves as an adjunct professor for both Georgetown University and Marymount University in the Washington D.C. area. We thought about using Simon and Garfunkel’s song “The Boxer” but  later decided to use “My Buddy” song by Anne Murray. “The Boxer” was one of the most highly produced songs by Simon and Garfunkel. The song is the single of and is featured on the album Bridge over Troubled Water released in May,1969. It was written by Paul Simon as he laments about being criticized by the public.  The song also features a bass harmonica and a Moog synthesizer. The song made it to the Rolling Stones list of top 500 songs of all time as #106. Case: A 26-year-old right-handed male presents to the emergency department on Friday night with a swollen right hand after punching a wall.The x-ray confirms an uncomplicated boxer’s fracture. You explain to him the traditional management which includes adequate pain control, immobilization with a cast and referral to a hand surgeon. He does not want any opioids because a friend was addicted to oxycocet. He is fine with going to see a hand surgeon in clinic, but asks if he really needs a cast. He is concerned that it will interfere with going to work on Monday morning. Background: Boxer’s fractures are common hand injuries. They are usually due to punching a solid object with a closed fist. For clarity, in this SGEM episode: when we say boxer’s fracture, we are referring to a fracture of the neck of the fifth metacarpal. There has been some controversy on the best way to manage an uncomplicated boxer’s fracture. This is typically defined as a minimally displaced closed fracture with angulation up to 70 degrees. Poolman et al (Cochrane 2005) did a SRMA and pooled together five studies with a total of only 252 patients. Most of the studies were of poor quality and functional outcome was not used in any of the studies. Because of the lack of good evidence, no treatment modality could be recommended over another. Another systematic review meta-analysis was done by Dunn et al (Orthopedics 2016). They found that cast immobilization is not superior to soft wrap without reduction in most cases. No study had investigated whether or not buddy taping would be superior to casting for functional outcomes in patients with boxer’s fractures. Clinical Question: Is buddy taping an uncomplicated boxer's fracture just as effective as a plaster cast? Reference: Pellatt et al. Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial. Annals of EM 2019 Population: Adults (18-70 years of age) with uncomplicated fractures of the fifth metacarpal neck (boxer’s fracture). Uncomplicated Fractures: These were defined as fractures confirmed by radiograph with at least two views showing a closed fracture (NOT comminuted, NOT intra-articular) with fracture angulation less than 70 degrees, less than one week old, did not have tendon involvement and with no polytrauma or other significant injury. Excluded: Patients less than 18 years of age or older than 70 years. Fractures that were open,

Date: October 22nd, 2019 Reference: Iyengar R et al. The Effect of Financial Incentives on Patient Decisions to Undergo Low-value Head Computed Tomography Scans. AEM October 2019. Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com Case: A 21-year-old comes into the emergency department after being knocked unconscious while playing rugby. The patient is now feeling great, or as they say in New Zealand “sweet as”. He had no pain, nausea, or neurologic symptoms. His exam is normal. You aren’t worried, but his dad is the coach of the American national rugby team and says that his players always get a CT when this happens. You wonder what factors might influence a patient’s preference for imaging? CT Scanner Background: The CT scan is arguably one of the most important pieces of diagnostic technology that we use in emergency medicine. It allows for incredibly rapid identification of a myriad of life-threatening conditions. However, likely because it is such a valuable tool, there seems to be little doubt that we overuse it. For example, one study that looked retrospectively at all head CTs ordered for trauma concluded that more than 1/3 were unnecessary based on the Canadian CT head rule [1]. Not only does unnecessary testing reduce efficiency and add costs, it also directly harms patients with unnecessary radiation [2]. Many imaging decisions are obvious – the patient either clearly requires or clearly does not require imaging. One way to decrease CT scans of the head is to use a clinical decision instrument like the Canadian CT Head Rule (CCHR). The SGEM covered the classic paper on the CCHR by the Legend of Emergency Medicine Dr. Ian Stiell on SGEM#106. We also recently reviewed a paper that looked at increasing the CCHR age criteria from 65 years of age to 75 years of age (SGEM#266). The bottom line was that this paper opens the door for further research to try to narrow the criteria in the CCHR to further reduce unnecessary head CT imaging in the emergency department. However, further, high quality prospective studies are required prior to clinical application. There is a great deal of uncertainty in emergency medicine, which leaves a sizeable number of patients in a grey zone – where harms and benefits are closely matched, qualitatively different, or just unknown. For these patients, shared decision making is probably the best route forward. Even when it seems clear to the physician that imaging isn’t required, we can be met with resistance from our patients. In addition, if we are working in a zero-miss culture, we may be more likely to order CT scans that are not medically necessary. Thus, it is important to know what factors influence patients’ decision to undergo CT. This study by Iyengar and colleagues examines the impacts of financial incentives, as well as varying levels of risk and benefit, on patient preference for CT imaging in the setting of low risk head injury [3]. Clinical Question: Do financial incentives, together with potential risk and potential benefit information, influence patient preference for diagnostic testing? Reference: Iyengar R et al. The Effect of Financial Incentives on Patient Decisions to Undergo Low-value Head Computed Tomography Scans. AEM October 2019. Population: A convenience sample of adult patients presenting to the University of Michigan emergency department. Exclusions: Patients with chest pain or head trauma (because those were the conditions in the hypothetical cases presented). They also excluded patients with altered mental status, with contact precautions, or in resuscitation bays. Intervention and Comparison: Patients were all presented with a hypothetical low risk head trauma scenario. The scenario was designed such that the Canadian Head CT rule suggests against imaging. Three aspects of the scenario were randomized:

Date: October 17th, 2019 Reference: Driver et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation. A Randomized Clinical Trial. JAMA May 2018 Guest Skeptic: Missy Carter, former City of Bremerton Firefighter/Paramedic, currently a physician assistant practicing in emergency medicine in the Seattle area and an adjunct faculty member with the Tacoma Community College paramedic program. Case: You are preparing for a rapid sequence intubation in a patient suffering from respiratory distress. While doing your airway assessment you notice some difficult airway characteristics (obese patient with a small mouth opening). In the past you’ve had failed first pasts attempts on a similar patient and used a bougie as your back up device. You wonder if this time you would be more successful using the bougie for your first attempt. Background: We have covered airway a number of times on the SGEM. This has included supraglottic airways for OHCA (SGEM#247), POCUS for confirming endotracheal tube placement (SGEM#249) and non-invasive positive pressure ventilation for OCHA (SGEM#96) just to name a few. However, we have never covered the issue of using a bougie for intubation.  For many years the bougie has been considered a back up or “rescue” airway tool and only pulled out after one or even several failed intubation attempts. Many studies have shown that multiple intubation attempts can increase mortality and morbidity, so we are always striving to increase our first pass intubation success rates to improve patient care. Clinical Question: Does using a bougie increase first pass intubation success? Reference: Driver et al. The Bougie and First-Pass Success in the Emergency Department. Annals of Emergency Medicine 2017 Population: Adult patients (age > 17 years) who underwent intubation in the emergency department Excluded: Patients with missing videos that recorded the intubation, cases in which a bougie was used with a hyper angulated video laryngoscope blade (GlideScope) or were intubated before arrival to the emergency department Intervention: Bougie with Macintosh or CMAC laryngoscope Comparison: Intubation with endotracheal tube and stylet Outcome: Primary Outcome: First-pass success rates Secondary: Duration of attempts, hypoxia and esophageal intubations Authors’ Conclusions: “Bougie was associated with increased first-pass intubation success. Bougie use may be helpful in ED intubation.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes How precise are the results? Fairly precise given the small sample size 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: There were 543 patients included in this cohort. The median age was in the late 40’s and more than two-thirds were male. The vast majority (~95%) of the intubations were performed by a senior resident. First-pass success was greater with than without bougie Primary Outcome: First-pass success 95% with bougie vs. 86% without bougie Absolute difference 9% (95% CI; 2% to 16%) Secondary Outcomes:  Median first-attempt duration was higher with than without bougie (40 seconds vs. 27 seconds) with a difference of 13 seconds (95% CI; 11 to 16). Hypoxia 17% with and 13% without bougie