The Skeptics Guide to Emergency Medicine

Date: May 21st, 2019 Guest Skeptic: Dr. Andrew Worster is full professor at McMaster University and the creator of Best Evidence in Emergency Medicine (BEEM). BEEM is an international, non-profit, emergency medicine, knowledge translation project created by emergency physicians for emergency physicians. The BEEM faculty is heading to the Canadian Association of Emergency Physicians (CAEP) annual conference in Halifax, Nova Scotia May 26-29, 2019.  The faculty includes the following: Dr. Andrew Worster Dr. Andrew Worster is a staff Emergency Physician and Professor of Emergency Medicine and Health Research Methods, Evidence, and Impact at McMaster University. He is the current Director and Editor-in-Chief of the not-for-profit, international knowledge translation project, Best Evidence in Emergency Medicine (BEEM). He is an investigator for multiple clinical studies funded by the Canadian Institutes of Health Research.   Dr. Katrina Hurley Dr. Katrina Hurley is the Interim Chief of the IWK Emergency Department in Halifax, Nova Scotia. She has a Master’s degree in Health Informatics and is a self-professed “data geek” with more ideas than time. She enjoys supervising learners and mentoring junior faculty in their research. In her spare time, she embarks on outdoor adventures with her family. Dr. Gauri Ghate   Dr. Gauri Ghate is an Emergency Physician in London, Ontario. She has an interest in the Sexual Assault & Domestic Violence Program. She enjoys public speaking and coordinates Grand Rounds for the Division of Emergency Medicine at the University of Western Ontario. Having grown up in Northern New Brunswick, she’ll always be an East Coaster at heart. Dr. Tracy Meyer Dr. Tracy Meyer is an Emergency Physician in Saint John. She has an interest in marginalized populations and addiction medicine with a mixed practice of Emergency Medicine and a clinic for Opioid Use Disorder. She works with the psychiatry department for improved collaboration with the Emergency Department and is an advocate for harm reduction in New Brunswick.   Dr. Justin Yan Dr. Justin Yan is an Emergency Physician, Assistant Professor, and clinician researcher at Western University in London, Ontario. His research interests include diabetic emergencies, procedural sedation, and cardiac care. Outside of work, Justin enjoys traveling, international cuisine, physical fitness, and playing with his two dogs, Robbie and Marlee.   The BEEM will be presenting Catch of the Day on Monday, May 27th. They will be highlighting a collection of clinical trials, systematic reviews and clinical practice guidelines identified by BEEM raters around the world as the most clinically relevant and recent publications. The nine studies to be presented include: Prasad et al. Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline. BMJ Dec 2018 Feld et al. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics Dec 2018  Frey et al. Effect of Intranasal Ketamine vs Fentanyl on Pain Reduction for Extremity Injuries in Children: The PRIME Randomized Clinical Trial. JAMA Pediatrics Feb 2019 (SGEM#242) Akhlaghi et al. Premedication With Midazolam or Haloperidol to Prevent Recovery Agitation in Adults Undergoing Procedural Sedation With Ketamine: A Randomized Double-Blind Clinical Trial. AEM May 2019 Detsky et al. Will This Patient Be Difficult to Intubate?: The Rational Clinical Examination Systematic Review. JAMA Feb 2019 Siddiqui et al. Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks: A Randomized Clinical Trial. Anesthesiology Dec 2018 Murata et al. Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode. Pediatrics Nov 2018 (SGEM#239) Shen et al.

Date: May 15th, 2019 Reference: Terp et al. Civil Monetary Penalties Resulting from Violations of the Emergency Medical Treatment and Labor Act (EMTALA) Involving Psychiatric Emergencies, 2002 to 2018. AEM May 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 working in your emergency department at a hospital that has an on-site psychiatric unit. You are holding several patients in the department who have been placed on involuntary holds for suicidal ideation while a bed search occurs at facilities elsewhere in the region. Your charge nurse tells you that she has learned the psychiatric unit has open beds that currently aren’t being used. Background: The Emergency Medical Treatment and Labor Act (EMTALA) was passed in 1986 to combat and prevent delayed, denied, or inadequate treatment of uninsured ED patients. This federal US law mandates that patients who present to an emergency department must have a medical screening evaluation, stabilization of their emergent needs and arrange transfer to higher level of care if necessary. There is also an obligation on the receiving hospital. They must accept these patients in transfer if they have a specialist on-call with the ability to manage the patient. The Center for Medicare and Medicaid Services (CMS) has clarified that EMTALA applies to psychiatric emergencies. CMS has terminated Medicare provider agreements to 12 hospitals, four of which were related to psychiatric emergencies. Civil monetary penalties may also be levied for EMTALA violations. Clinical Question: What are the characteristics of civil monetary penalties related to EMTALA violations involving psychiatric emergencies compared to non-psychiatric emergencies? Reference: Terp et al. Civil Monetary Penalties Resulting from Violations of the Emergency Medical Treatment and Labor Act (EMTALA) Involving Psychiatric Emergencies, 2002 to 2018. AEM May 2019 Population: All civil monetary penalty settlements between 2002 and December 11, 2018 Exposure: EMTALA violations related to psychiatric emergencies. Comparison: EMTALA violations not involving psychiatric emergencies. Outcome: Civil monetary penalties levied by the Office of the Inspector General (OIG). Dr. Sophie Terp This is an SGEMHOP episode which means we have the lead author on the show. Dr. Sophie Terp is an is an assistant professor of clinical emergency medicine in the Department of Emergency Medicine at the Keck School of Medicine of USC. Her research focuses primarily on access to emergency care for vulnerable populations and specifically on enforcement of the Emergency Medical Treatment and Labor Act (EMTALA). Authors’ Conclusions: “Nearly one in five civil monetary penalties related to Emergency Medical Treatment and Labor Act violations involved psychiatric emergencies. Settlements related to psychiatric conditions concentrate in two of the 10 Centers for Medicare & Medicaid Services regions, with half of all settlements occurring in three states (Florida, North Carolina, and Missouri). Average financial penalties related to psychiatric emergencies were over twice as high as penalties for nonpsychiatric complaints. Recent large penalties related to violations of the Emergency Medical Treatment and Labor Act law underscore the importance of improving access to and quality of care for patients with psychiatric emergencies.” Quality Checklist forObservational 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? Unsure Was the follow up of subjects complete enough? Unsure

Date: May 6th, 2019 Reference: Sceats et al. Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients. JAMA Surgery 2018 Guest Skeptic: Dr. Robert Leeper is an assistant professor of surgery at Western University and the London Health Sciences Centre. His practice is in trauma, emergency general surgery, and critical care with an academic interest in ultrasound and medical simulation. Case: An 18-year-old woman presents with a Grade 1 appendicitis (Tominaga et al J Trauma Acute Care Surg 2016).  Background: The first documented appendectomy was done by Claudius Amyand in 1735. The standard treatment for acute appendicitis has been appendectomy ever since Charles McBurney described it in 1889. Omar et al (2008) showed just how safe laparoscopic appendectomies have become. They found in a study of over 230,000 UK patients under the age of 49 there were no deaths. Being that there are doctors out there without scalpels, and that diverticulitis has often been treated successfully with antibiotics.  Some clinicians have hypothesized that perhaps acute appendicitis could also be treated successfully with antibiotics. Two meta-analyses have been done and they looked at nearly the same studies on “uncomplicated” acute appendicitis and came up with two opposite conclusions. This is an example of why things in evidence-based medicine can be “complicated” (SGEM#115 and SGEM#180 Clinical Question: Operative treatment or non-operative treatment of acute Grade 1 (uncomplicated) appendicitis? Reference: Sceats et al. Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients. JAMA Surgery 2018 Population: Adult patients admitted to hospital with a diagnosis of acute uncomplicated (Grade I) appendicitis. Exclusion: Patients with co-occurring diagnosis or procedure codes consistent with complicated appendicitis and patients lacking appendectomy codes. Exposure: Non-operative management of appendicitis Comparison: Operative management of appendicitis Outcome: Primary Outcomes: Short Term (<30 days) Complications: ED visits, all-cause readmissions, appendicitis-associated readmissions, rate of abdominal abscess and C. difficile. Long Term (>30 days) Complications: Readmission for small-bowel obstruction, diagnosis of incisional hernia, and diagnosis of appendiceal cancer. Secondary Outcomes: “Length of stay during index hospitalization, cost of index hospitalization, number of follow-up visits required in the following year, and the total cost of appendicitis-associated care in the year after diagnosis. Total cost of appendicitis-associated care was determined by summing the total cost for every in-patient and outpatient encounter associated with appendicitis for the following year, including the index hospitalization.” Post Hoc Analysis: Rates of non-operative management failure (<30 days) and rates of appendicitis recurrence (>29d days) as well as timing of the failure or recurrence. Authors’ Conclusions: “According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.” 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? Unsure Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results?

Date: April 29th, 2019 Reference: Kuppermann et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. NEJM June 2018 Guest Skeptic: Dr. Nikki Abela is a final year trainee in Emergency Medicine and Paediatric Emergency Medicine in Liverpool, UK from sunny Malta. She is a blog editor for RCEM Learning . She is a mum of one who wants to run. Case: 6-year-old Caroline is brought to the emergency department by her parents. She is known to have diabetes and has had diarrhea and vomiting for the last 24 hours. In spite of using her sick day regime of insulin, she still has “high” blood glucose readings and can not tolerate oral fluids. On her blood gas her pH is 7.1 and her glucose is 35 mmol/l (630mg/dl). You confirm her bedside ketones to be 6 and have secured a cannula (intravenous) ready to reverse her dehydration – but what fluids should you use and at what rate? Background: The study we are going to talk about today comes from PECARN (Pediatric Emergency Care Applied Research Network). They are a fantastic group that conducts high-quality, clinically relevant research in the management and prevention of acute injuries and illnesses in children. We’ve mentioned PECARN before when discussing pediatric traumatic brain injury (TBI) on SGEM#112. There is a similar group in the UK and Ireland. It is called PERUKI (Paediatric Emergency Research in UK and Ireland). Canada has something similar to PECARN called Pediatric Emergency Research Canada (PERC). They are “dedicated to improving care in pediatric emergency medicine through multi-centre research”.  Each country has their own pediatric research groups. These different groups often come up with a different clinical decision instruments, for example, to decide when to get neuroimaging in pediatric head trauma. There is the PECARN from the USA, CATCH Tool from Canada and the CHALLICE Tool from the UK. A study by Easter et al (Ann Emerg Med 2014) concluded that PECARN seemed to be the best of the three tools. But we are not talking about TBIs today we are talking about diabetic ketoacidosis (DKA). Almost 1% of children presenting with an episode of DKA exhibit clinically apparent brain injuries. These injuries are associated with morbidity and mortality (1-3).  It has been historically thought that the cerebral edema from rapid rehydration with IV fluids could be causing these injury (4-5).  As such, protocols recommend slow administration of IV fluids in children with DKA. Clinical Question: Does rate or sodium chloride content of intravenous fluids contribute to brain injuries in children with DKA? Reference: Kuppermann et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. NEJM June 2018 Population: Children 0-18 years of age with a diagnosis of DKA (blood glucose > 16.7 mmol/l or > 300 mg/dl, and either pH < 7.25 or a serum bicarbonate level of < 15 mmol/l) Key Exclusions: “Underlying disorders that could affect mental status testing or neurocognitive evaluation; concurrent alcohol or narcotics use, head trauma or other conditions that could affect neurologic function; diabetic ketoacidosis for which the patient had already received substantial treatment; known pregnancy; or factors for which treating physicians determined that a specific fluid and electrolyte therapy was necessary. Children who presented with a Glasgow Coma Scale score of 11 or lower (on a scale ranging from 3 to 15, with lower scores indicating worse mental status) were excluded after year 2 because many participating clinicians believed that fluid regimens for such children should not be deter- mined on the basis of randomization.” Intervention: Fast rehydration (20ml/kg bolus) with either 0.45% or 0.9% NaCl (assumed 10% deficit with half being replaced in first 12 hours with the rest in the next 24hrs plus maintenance fluid). Insulin 0.1u/kg/hr IV Comparison: Slow rehydration (10ml/kg bolus) with 0.

Date: April 16th, 2019 Reference: Schnadower et al. Lactobacillus rhamnosus GG versus placebo for acute gastroenteritis in children. NEJM 2018 Guest Skeptic: Dr. Anthony G. Crocco is a Pediatric Emergency Physician and is the Medical Director & Division Head of the Division of Pediatric Emergency at McMaster’s Children’s Hospital. He is an Associate Professor at McMaster University. Anthony is known for his online RANThonys and website SketchyEBM. Case: A two-year-old girl presents with two days of non-bloody watery stools and one episode of vomiting.  She is otherwise well appearing and has normal vitals and examines normally.  After you explain the diagnosis of gastroenteritis to the parents, and the importance of hand washing at home, they ask you whether they should give probiotics to help shorten the course of her illness. Background: We have covered many pediatric topics with you on the SGEM. One of them included a RANThony on getting x-rays for constipation. This time we are talking about stuff coming out too much rather than not enough.  Viral gastroenteritis is rivalled by bronchiolitis for one of the most common Pediatric presentations to the emergency department.  The discomfort this illness imbues, the time away from daycare required, and the time away from parental work necessitated can be quite disruptive.  Even small changes to the course of this illness, due to its prevalence, could have huge comfort and economic benefit. We looked at a trial by Freedman et al using half-strength apple juice or fluids of choice to treat mild gastroenteritis in children who were minimally dehydrated (SGEM#158). The bottom line from that episode was that this strategy was a better choice compared to electrolyte solutions. We have also reviewed a couple of papers that looked at using ondansetron in pediatric gastroenteritis (SGEM#12 and SGEM#122). There are some guidelines on managing gastroenteritis: TREKK- Gastroenteritis AAP- Managing Acute Gastroenteritis Among Children NICE- Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management AAFP– Gastroenteritis in Children Sick Kids– Acute Gastroenteritis In this episode we are going to be looking at using probiotics to treat pediatric gastroenteritis. The theory of using probiotics to replenish the normal gut flora to minimize disease is neither new nor unstudied.  Previous work in this area has been described as being “underpowered or had methodology problems related to the trial design and choice of appropriate end points.” Clinical Question: Does prescribing probiotics to children with gastroenteritis, specifically giving L. rhamnosus, improve the course of the illness? Reference: Schnadower et al.  Lactobacillus rhamnosus GG versus placebo for acute gastroenteritis in children. NEJM 2018 Population: Children three months to four years of age presenting to the emergency department with a diagnosis of acute gastroenteritis. This was defined as “three or more episodes of watery stools per day, with or without vomiting, for fewer than 7 days.” Exclusions: There were 18 exclusion criteria and these can be found at ClinicalTrials NCT 01773967. Intervention: L. rhamnosus GG twice a day for five days Comparison: Placebo twice a day for five days Outcome: Primary Outcome: Moderate-to-severe gastroenteritis. This was defined as an illness episode with a modified Vesikari scale greater than 8 during the 14-day follow-up period. The modified Vesikari Scale helps establish severity of gastro symptoms using a 7-item scale that ranges from 0-20 overall points.  Although I have never used this scale clinically, its utility is in being able to quantify symptom improvement in research. Secondary Outcomes: Frequency and duration of diarrhea and vomiting, the incidence of unscheduled health care visits for symptoms of gastroenteritis within two weeks after the index vi...

Date: April 17th, 2019 Reference: Little et al. Major trauma: Does weekend attendance increase 30-day mortality? Injury 2019 Guest Skeptic: Alison Armstrong is a Certified Emergency Nurse, Trauma Program Coordinator and TNCC Course Director. This was a special episode of the SGEM done live at the Talk Trauma 2019 Conference help in London, Ontario. Talk Trauma is a two-day conference for nurses, allied health and EMS professionals involved in providing care for the adult and paediatric trauma patient. Our philosophy for Talk Trauma is to have fun while learning so we put on a conference packed with useful tips for all trauma care providers but in a really fun way! It attracts participants from all over Ontario and even the US. To get the crowd warmed up for our nerdy structured critical appraisal we reviewed a paper by Dr. Esther Choo et al. The article was called "A lexicon for gender bias in academia and medicine: Mansplaining is the tip of the iceberg". It was published in the December 2018 edition of the BMJ.  Theme music is an important part of the SGEM. Alison picked the song "It's A Man's World"  by James Brown for this paper on gender bias in academia and medicine. Mansplaining is defined as explaining something in a condescending or patronizing way, typically to a woman. Alison picked out five of her favourite terms from the BMJ publication and presented them to the audience. This included: misteria, himpediment, hystereotyping, mutehism, and bromoteher. As a rural physician, I added one more term to the medical lexicon called "urbansplaining" You can down load a copy of the slides, watch the presentation on the SGEM Facebook page and get a PDF copy of Dr. Choo's article.  Case: A 52-year-old man presents to the emergency department via EMS after a motor vehicle collision while driving home from the city. It is 2am Saturday morning and the night shift has been busy. You suspect he has been drinking. He has a Glasgow Coma Scale (GCS) score of 13 and an Injury Severity Score (ISS) of 19. There is small frontal head laceration. He is complaining of some right sided chest wall pain and shortness of breath.  There is an obvious knee injury. While he is waiting to get imaging and laboratory tests done, he asks if he will be more likely to die because it’s a weekend? Background: We have busted many myths on the SGEM over the years. This have included the following medical myths: Myth: Epinephrine saves lives with good neurologic outcome in OHCA (SGEM#64 and SGEM#238) Myth: All buckle and greenstick fractures should be casted (SGEM#19) Myth: A vitamin C cocktail can cure sepsis based on an observational study (SGEM#173) Myth: Ketorolac 30mg IV is better than 10mg or 15mg IV for pain control (SGEM#174) Myth: OHCA patients need an endotracheal airway (SGEM#247) There are many other myths in medicine like that of the full moon effect (lunar effect). One large area of controversy is that of the “weekend effect”. This urban legend is that mortality rates go up when patients are admitted on the weekend vs. the weekdays. Clinical Question: Does the “weekend effect” exist (increased mortality) in a UK trauma centre? Reference: Little et al. Major trauma: Does weekend attendance increase 30-day mortality? Injury 2019 Population: Trauma patients presenting to the emergency department defined as Injury Severity Score greater than eight admitted between 2013 – 2015. Intervention: None Comparison: Weekday (Monday 00:00 to Friday 23:59) vs. weekend (Saturday 00:00 - Sunday 23:59). Outcome: Primary Outcome: Mortality by 30 days Secondary Outcomes: Age, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), mortality by days of the week, and mortality by 30 days on Friday 00:00 to Saturday 23:59 vs. Sunday 00:00 to Thursday 23:59. Authors’ Conclusions: “There is no significant difference in 30-day mortality when directly comparing weekday to weekend attend...

Date: April 11th, 2019 Reference: Brucker et al. Assessing Risk of Future Suicidality in Emergency Department Patients. AEM April 2019 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com WARNING: This SGEM episode discusses suicide. This is a warning to those listening to the podcast or reading the blog post. The SGEM is free and open access initiative trying to cut the knowledge translation down from over ten years to less than one year. It is intended for clinicians providing care to emergency patients, so they get the best care, based on the best evidence. If you are feeling upset by the content, then please stop listening or reading. There will be resources listed at the end of the blog for those looking for assistance. Case: A 32-year-old woman presents to the emergency department after spraining her ankle playing basketball. Although she has no other health problems, and no other complaints, you are aware of data that indicates there is a high level of psychiatric illness and suicidal ideation among emergency department patients and wonder what is the best way to approach this problem? Background: Suicidal ideation is common; it accounts for about 1% of emergency department visits, or about 1.4 million visits a year in the United States [1]. Although there are numerous validated screening tools, such as the PHQ9, the ED-Safe Patient Safety Screener, and the Suicide Behaviors Questionnaire–Revised (SBQ-R), none have been tested against physician gestalt, and none are widely used in clinical practice [2,3,4]. The Convergent Functional Information for Suicidality (CFI-S) is a validated screening tool for suicidal ideation, but it has not been tested in an emergency department (ED) setting [5,6]. The current trial aimed at assessing the accuracy of the CFI-S in the ED, while comparing it to a screening tool already in use and physician gestalt [7].  Clinical Question: Can the CFI-S improve on clinician gestalt for screening of all adults to an emergency department for suicidal ideation? Reference: Brucker et al. Assessing Risk of Future Suicidality in Emergency Department Patients. AEM April 2019 Population: Adult patients presenting to the emergency department, without regard to the chief complaint. Exclusions: Severe trauma or illness requiring emergent intervention or acute intoxication. Intervention: The Convergent Functional Information for Suicidality (CFI-S) screening tool Comparison: Physician gestalt Outcomes: Any suicidality spectrum event in the six months after the ED visit. This was defined as a repeat ED visit or admission for suicidal ideation, preparatory acts, suicide attempts, aborted or interrupted attempts, or completed suicide. Dr. Krista Brucker This is an SGEMHOP episode which means we have the lead author on the show. Dr. Krista Brucker is an emergency physician in South Bend, IN. With the help of a dedicated team of medical students and some very patient mentors, Dr. Brucker completed this work while she was an assistant professor of emergency medicine at Indiana University school of Medicine. Authors’ Conclusions: “Using CFI-S, or some of its items, in busy EDs may help improve the detection of patients at high risk for future suicidality.” Quality Checklist for a Prognostic Study:  The study population included or focused on those in the emergency department? Yes The patients were representative of those with the problem? Unsure The patients were sufficiently homogenous with respect to prognostic risk? Unsure Objective and unbiased outcome criteria were used? No The follow-up was sufficiently long and complete? No The effect was large enough and precise enough to be clinically significant? No Key Results: A total of 367 patients were approach and 338 agreed to participate in the study.

Date: April 10th, 2019 Guest Skeptic: Dr. Scott Weingart. He is an ED intensivist from New York City and runs the popular EMCrit blog and podcast. Scott is attempting to bring upstairs care, downstairs one podcast at a time. This is an SGEM Xtra that came about due to SGEM#249. That episode was with Chip Lange from TOTAL EM and looked at using point of care ultrasound (POCUS) for endotracheal tube (ETT)  confirmation. It sparked a bit of a twitter conversation and lead to a key tweet by Scott. Before we got into the the point of contention, Scott discussed a couple of key concepts (Blow to Know and No Trace-Wrong Place). We also acknowledge a few parts of the SGEM podcast that we agreed upon: Waveform capnography should be used to confirm tube placement SGEM Bottom Line: "Transtracheal sonography represents a potential fast and accurate way to help confirm endotracheal tube placement in conjunction with other methods." Case Resolution: “While you directly visualize the passage of the endotracheal tube through the vocal cords, she is able to see the appropriate findings consistent with successful placement. Waveform capnography is used in addition and further supports the appropriate placement.”  The Clinical Application:“[POCUS] represents another potential tool that can be used in combination with existing methods to verify correct tube placement. As these bedside devices become pocket size and more affordable, it will be interesting to see how clinicians continue to include POCUS in their practice.” Scott then had five questions. Listen to the podcast to hear our discussion. 1) Who has the burden of proof? The person making the positive/new claim has the burden of proof. This is known as onus probandi in Latin. It can be a logical fallacy to shift the burden of proof onto the person who is not making the new claim. When two individuals are discussing an issue the person who makes the new claim is responsible to justify or provide evidence to support their position. The evidence can then be reviewed and decided upon whether or not it is adequate. Carl Sagan Standard: “Extraordinary claims require extraordinary evidence" Hitchens’s Razor: “What can be asserted without evidence can be dismissed without evidence” In the SGEM#249, we made a general claim in the background material. This was after providing the ACEP policy statement about physical exam, direct visualization, pulse oximetry, CXR, esophageal detector devices and EtCO2 detection. There is evidence indicating that commonly used endpoints for rapid confirmation can be inaccurate.  It was the specific claim about the accuracy of EtCO2 presented in our background material that really got Scott's attention. Quantitative waveform capnography, thought to be one of the best methods, correctly confirms tube placement only two-thirds of the time in cardiac arrest (Takeda et al, Tanigawa et al andTanigawa et al). To support this claim we provided three citations. Scott and I discussed the multiple limitations to the three studies. One of the consistent results from these three studies was if you saw a clear wave form the tube was in the right place (endotracheal). Tanigawa et al 2000 Tanigawa et al 2001 Takeda et al 2002 Scott made two claims in his tweet: AFAIK (as far as I know) and in the face of all evidence i have seen, with compressions (and a blood volume to circulate)—there will ALWAYS be a wave form with a properly placed ETT. After 6-8 breaths, there will NEVER be a wave form with an esoph(ageal) ETT These statements puts the burden of proof on Scott to support his ALWAYS and NEVER claims. Listen to the SGEM podcast to hear us discuss the strengths and weaknesses of this evidence. Silvestri et al 2004 Grmec 2002 2) When does standard of care translate into evidence? To quote my EBM mentor, Dr. Andrew Worster, "it all depends". The standard of care can mean that is what most people ...

Date: April 5th, 2019 Reference: Connolly et al. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. NEJM 2019 Guest Skeptic: Dr. Ryan Radecki is an Emergency Physician at Kaiser Permanente NW, co-host of the Annals of Emergency Medicine podcast and Journal Club section editor. Case: You are caring for a 72-year-old man who comes in after having slipped on the ice.  A routine evaluation finds only minor bumps and bruises, including a rather nasty one on his occiput where he struck a step.  He reports he has been taking apixaban to prevent stroke in the context of atrial fibrillation, which you easily recognize as one of the modern oral anti-Factor Xa inhibitors.  You order a non-contrast CT to rule out hemorrhage. It demonstrates a 7mm subdural hematoma with 3mm of midline shift.  As you are reassessing your patient and treatment plan, the question presents itself – how should we reverse his anticoagulation? Background: More and more patients are being treated with direct oral anticoagulants (DOACs). This number will probably increase since the AHA/ACC/HRS 2019 updated guidelines for atrial fibrillation guidelines. It now contains the following recommendation: NOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are recommended over warfarin in NOAC-eligible patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve). Level A One of the concerns clinicians had with DOACs was there was no way to reverse these new anti-coagulants when they were introduced. In contrast, protamine could be used for heparin and LMWH reversal and vitamin K, fresh frozen plasma and prothrombinase complex concentrate could be used to reverse coumadin (Hunt and Levi BMJ 2018). This changed in 2015 when the Food and Drug Administration (FDA) approved idarucizumab for the reversal of dabigatran. Dabigatran is a direct thrombin inhibitor. We covered the interim analysis of 90 patients included in a prospective cohort study by Pollack et al NEJM 2015 on SGEM#139. Our bottom line for that episode was that idarucizumab is here (USA) and probably works but its patient-oriented efficacy and safety are still pending. The full study cohort of 503 patients has since been published (Pollack et al NEJM 2017) and we are in the same place we were in 2015. Idarucizumab clearly and effectively removes dabigatran from circulation and this ought to be occasionally clinically useful. I would certainly exhaust all potential supportive and expectant management options first, as well as try to definitively confirm dabigatran as the culprit for abnormal hemostasis (EM Lit of Note). The FDA granted accelerated approval for andexanet alfa (Andexxa) in May of 2018. Andexxa is an antidote for factor Xa inhibitor like rivaroxaban, apixaban and edoxaban. It acts as a decoy and binds to the factor Xa inhibitors. The American College of Cardiology has published a fact sheet to provide some guidance for the use of anticoagulation reversal agents. Clinical Question: Should andexanet alfa be used to treat serious bleeding events in patients taking Factor Xa inhibitors? Reference: Connolly et al. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. NEJM 2019 Population: Adult patients presenting with an acute major bleed, and had received a DOAC (apixaban, rivaroxaban, or edoxaban) at any dose or enoxaparin at a dose of at least 1 mg per kilogram of body weight per day within the previous 18 hours. Acute Major Bleed: Bleeding having one or more of the following features: potentially life-threatening bleeding with signs or symptoms of hemodynamic; bleeding associated with a decrease in the hemoglobin level of at least 2 g per deciliter or bleeding in a critical area or organ. Exclusions: There were a number of exclusions listed in supplemental material but the key ones were as follows: Planned surgery within 12hrs; ICH in a patient wit...

Date: March 20th, 2019 Guest Skeptic: Dr.Katie Walker is an emergency physician in Melbourne, Australia. She is a clinical researcher at Cabrini Hospital and an Adjunct Clinical Associate Professor at Monash University. Case: The emergency department is backing up. You have ambulances ramping and patients queuing at triage. Your medical team is great, but you notice that the busier you all become, the more you see your docs at their computers, rather than at patient bedsides. You are frustrated that whilst you frantically fill in data in the Electronic Medical Record (EMR) from your last consultation, your neighbor is in your waiting room with a dislocated shoulder and you haven’t been able to get to her yet. Is there a better way of working than this way? Background: One in ten health high-income country consultations are now in Emergency Medicine. Most emergency physicians use some form of electronic medical records (EMRs) when seeing patients. The EMR tasks we undertake are expanding rapidly, far beyond simply documenting history and physical examination and every implementation slows us down. Research by Hill et al (1) demonstrated that an ED shift can have 4,000 clicks. Physicians are spending more time on EMRs (40%) than any other activity including direct patient care (30%). SGEM#159 looked at the implementation of an EMR in a tertiary care ED. Median wait times, length of stay, left without being seen, and length of stay for admitted patients all got worse with adding computerized physician order entry (CPOE) as part of their EMR (2). The implementation of the EMR into clinical practice represents a very large, global, medical productivity loss. It could also have a negative impact on patient care. There are studies showing that EMRs are one of the biggest causes, if not the number one cause of physician burnout (3). Physicians suffering from burnout provide a lower quality and safety of care (4). This means there is an association between EMRs and worse patient care. If we have to use EMRs, how can we improve our productivity? There haven’t been any large, independent, multi-centre, randomised evaluations of scribe effectiveness and safety, until now. Scribes are individuals who help physicians by doing the clerical tasks. There is a long list of things that they do including documentation of the clinical encounter, information retrieval, and discharge preparation. Most physicians (85%) prefer working with scribes (5) and most patients tolerate scribes being involved in the clinical encounter (6). They have been used in US departments for years, but are only now beginning to be used in Canada and Australia. Clinical Question: What is the impact of scribes on emergency medicine physicians’ productivity and patient throughput.  Reference: Impact of scribes on emergency medicine doctors’ productivity and patient throughput: multicentre randomised trial, BMJ January 2019 Population: Five emergency departments in Australia Intervention: Scribes rostered to a physician for a shift Comparison: Same physicians working shifts without scribes Outcomes: Primary: Total patients/physician/hour (including medical triage and handovers, where another doctor undertakes the primary/main consultation) Secondary: Primary patients/physician/hour, door-to-doctor time, door-to-discharge time, regions of emergency department patients/physician/hour, patient safety events (scribe group only, no comparator) and retrospective cost-benefit analysis Authors’ Conclusions: “Scribes improved emergency physicians’ productivity, particularly during primary consultations, and decreased patients’ length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia’s.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes