The Skeptics Guide to Emergency Medicine

Date: September 25th, 2019 Reference: Bath PM et al. Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomized, sham-controlled, blinded, phase 3 trial. The Lancet March 2019. Guest Skeptic: Clay Odell is a Paramedic/RN for New London Hospital EMS in New Hampshire, USA which provides 9-1-1 coverage and Mobile Integrated Healthcare for seven rural communities. He’s been involved in EMS for over 30 years in a variety of roles and is a strong advocate for evidence-based EMS protocols. Case: Your ambulance responds to a 9-1-1 call for a 75-year-old male experiencing abrupt onset of left sided weakness. You arrive to find the patient awake and alert, with a facial droop, slurred speech and left-sided arm drift (FAST-ED score = 3). He has a history of hypertension. His vital signs are heart rate 90 beats per minute, blood pressure 162/96 mmHg, respiratory rate 14 breaths per minute, SpO2 96% on room air, capillary blood glucose 120 mg/dl (6.7 mmol/L). His 12-lead ECG shows a normal sinus rhythm without ST abnormality or ectopy. While preparing for transport you contemplate administering nitroglycerin due to the likelihood of stroke. Background: We have covered stroke many times on the SGEM (SGEM#29: Stroke Me, Stroke Me; SGEM#70: The Secret of NINDS; SGEM Xtra:Thrombolysis for Acute Stroke; SGEM Xtra: No Retreat, No Surrender; and SGEM Xtra: The Walk of Life). This episode will not debate the use of tPA for acute ischemic stroke. Rather we will be discussing whether lowering the blood pressure of a patient suspected of having a stroke in the pre-hospital setting will have a net beneficial patient-oriented outcome (POO). Hypertension is common in acute stroke and is a predictor of poor outcome [1]. There is still some controversy on whether or not it is beneficial to lower the blood pressure in these cases [2]. Previous studies suggested that Nitric Oxide (NO) donors, such as transdermal glyceryl trinitrate (GTN – also known as nitroglycerin), reduced blood pressure, improved cerebral blood flow and reduced stroke lesion size if administered early [3 and 4]. There have been five randomized trials looking at nitroglycerin with four not showing superiority for functional outcome. One phase 2 trial done in the pre-hospital setting (RIGHT: Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial) did suggest a benefit to nitroglycerine [5]. The RIGHT study was a subgroup analysis of the ENOS (Efficacy of Nitric Oxide in Stroke) that looked at nitroglycerin within 6 hours of stroke. It too failed to demonstrate a statistical benefit [6]. However, a SRMA of individual patient data in these five trials suggested that earlier administration of nitroglycerin was associated with better outcomes in both ischemic and intracerebral hemorrhage stroke. It also was associated with lower mortality, disability, cognitive impairment, mood disturbance and poor quality of life (QOL) [7]. The conclusion to the RIGHT study was that a larger trial is needed to determine if nitroglycerin improves survival with good neurologic outcome. Clinical Question: Does early administration of glyceryl trinitrate (nitroglycerin) by paramedics in the pre-hospital setting improve neurologic outcome in patients with presumed acute stroke? Reference: Bath PM et al. Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomized, sham-controlled, blinded, phase 3 trial. The Lancet March 2019. Population: Adult patients who called emergency services for presumed stroke within 4 hours of onset of symptoms and a FAST score of 2 or 3, systolic blood pressure of equal or greater than 120 mmHg Exclusions: Nursing home patients, Glasgow Coma Scale <8, hypoglycemia or witnessed seizure, life expectancy < 6 months, known to have taken PDE5 inhibitor in the previous days and sens...

Date: September 11th, 2019 Reference: Putzu et al. The Effect of Vitamin C on Clinical Outcome in Critically Ill Patients: A Systematic Review with Meta-Analysis of Randomized Controlled Trials. Critical Care Medicine. June 2019. Guest Skeptics: Dr. Erin Willard is a PGY-3 Emergency Medicine Resident, Department of Emergency Medicine, University of Arkansas for Medical Sciences. Dr. Carly Eastin is an Associate Professor, Division of Research and Evidence Based Medicine, Department of Emergency Medicine, University of Arkansas for Medical Sciences. Case: A 45-year-old female in the emergency department is being admitted to the intensive care unit (ICU) for septic shock secondary to urinary tract infection (UTI). She has been given fluids, antibiotics, and is currently maintaining adequate mean arterial pressure (MAP) on low-dose vasopressors. You are ready to call the ICU and get her admitted. But you remember seeing in the news there was a study claiming vitamin C could cure sepsis. You wonder if giving vitamin C will affect her outcome? Background: There was a huge buzz in the media a few years ago about a vitamin C cocktail (vitamin C, hydrocortisone and thiamine) as a possible cure for sepsis. This was because of a well-known critical care physician Dr. Paul Marik. Dr. Paul Marik Dr. Marik published a retrospective before and after study that included a vitamin C cocktail reporting an impressive number needed to treat of 3 to prevent one death due to sepsis. For the scientific rationale why vitamin C therapy may help septic patients check out Dr. Josh Farkas’ post on PulmCrit. We reviewed Dr. Marik’s observational study on SGEM#174. A dozen skeptics commented about the validity of the study including my EBM mentor Dr. Andrew Worster who started BEEM and Legend of Emergency Medicine Dr. Jerome Hoffman. The SGEM Bottom Line was that Vitamin C, hydrocortisone and thiamine was associated with lower mortality in severe septic and septic shock patients in this one small, single centred retrospective before-after study but causation has yet to be demonstrated. A number of clinical trials are currently underway in an attempt to replicated Dr. Marik’s findings. The existing evidence to support vitamin C use in patients with septic shock is weak and has been summarized in a systematic review meta-analysis.  Clinical Question: Does the administration of vitamin C to an adult critically ill ICU patient or cardiac surgery patients decrease mortality? Reference: Putzu et al. The Effect of Vitamin C on Clinical Outcome in Critically Ill Patients: A Systematic Review with Meta-Analysis of Randomized Controlled Trials. Critical Care Medicine. June 2019. Population: Randomized trials examining critically ill adult ICU or cardiac surgery patients Exclusions: Inappropriate setting (cardiac or ICU) or study design (RCT), pediatrics, non-critically ill Intervention: Any type of vitamin C formulation or regimen Comparison: Placebo or no therapy Outcome: Primary outcome: Mortality at the longest follow-up available Secondary outcomes: Acute kidney injury, supraventricular tachycardia, ventricular arrhythmia, stroke, ICU and hospital length of stay. Authors’ Conclusions:“In a mixed population of ICU patients, vitamin C administration is associated with no significant effect on survival, length of ICU or hospital stay. In cardiac surgery, beneficial effects on postoperative atrial fibrillation, ICU or hospital length of stay remain unclear. However, the quality and quantity of evidence is still insufficient to draw firm conclusions, not supporting neither discouraging the systematic administration of vitamin C in these populations. Vitamin C remains an attractive intervention for future investigations aimed to improve clinical outcome.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes

Date: September 18th, 2019 Reference: Scheuermeyer et al. A Multicenter Randomized Trial to Evaluate a Chemical-first Cardioversion Strategy for Patients with Uncomplicated Acute Atrial Fibrillation. AEM Sept 2019 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and clinical lecturer in Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: A 55-year-old male presents to the emergency department with sudden onset of palpitations and pre-syncope starting one hour ago. He has no chest pain or shortness of breath and aside from a heart rate of 140 beats per minute, the rest of his vital signs appear within normal limits. His past medical history is significant for hypertension for which he takes perindopril. His ECG shows atrial fibrillation with a rapid ventricular response. Background: Atrial fibrillation is the most commonly encountered significant dysrhythmia in the emergency department (1). We have covered this topic a number of times on the SGEM. SGEM#88: Shock Through the Heart (Ottawa Aggressive Atrial Fibrillation Protocol) SGEM#133: Just Beat It (Atrial Fibrillation) with Diltiazem or Metoprolol? SGEM#222: Rhythm is Gonna Get You – Into an Atrial Fibrillation Pathway SGEM#260: Quit Playing Games with My Heart – Early or Delayed Cardioversion for Recent Onset Atrial Fibrillation? The most recent episode looked at whether late cardioversion is non-inferior to early cardioversion (SGEM#260) in acute atrial fibrillation. The SGEM bottom line from that episode was that the late approach was non-inferior to early approach and that both strategies achieve high rates of sinus rhythm at the 4-week follow up (>90%). In uncomplicated patients with symptoms less than 48 hours and no stroke or TIA in the past six months, the 2018 Canadian Cardiovascular Society (CCS) guidelines permit rate or rhythm control (2). There is significant variability in the management of patients with acute atrial fibrillation, with the proportion undergoing rhythm control ranging from 42-85% in Canadian academic centres (3). The rhythm control strategies typically employed are chemical cardioversion with procainamide infusion or electrical cardioversion with electrical countershock (3-6). Both of these strategies appear safe from prior studies, but comparative effectiveness data is lacking. Thus, Canadian management varies, with 56% of patients receiving a chemical-first approach and 44% an electrical-first approach (3). Clinical Question: In emergency department patients with atrial fibrillation, is sinus rhythm achieved more rapidly with electrical-first rhythm control when compared with chemical-first rhythm control? Reference: Scheuermeyer et al. A Multicenter Randomized Trial to Evaluate a Chemical-first Cardioversion Strategy for Patients with Uncomplicated Acute Atrial Fibrillation. AEM Sept 2019 Population: Adults between 18 and 75 years of age with atrial fibrillation less than 48 hours duration and a CHADS2 score less than two. Excluded: Hemodynamic instability, atrial flutter, CHADS2 score greater than or equal to two, patients with an acute underlying medical illness, recent cardiac procedure, acute intoxication or withdrawal from alcohol or illicit substances. They also excluded those who attended the emergency department for other reasons (eg. trauma, gout) who were incidentally found to be in atrial fibrillation. Intervention: Chemical cardioversion with procainamide (a dose of 17mg/kg up to a maximum of 1500mg infused over one hour was recommended). This was followed by electrical cardioversion if chemical cardioversion was unsuccessful. Comparison: Electrical cardioversion using a synchronized biphasic waveform sequence of 100J to 150J to 200J to a maximum of three shocks were allowed. Patients were sedated at the physicians’ discretion. The study recommended an initial propofol bolus of 0.

Date: September 18th, 2019 I had the honour of presenting at FIX19 conference in New York City. Thank you to Dr. Dara Kass and the organizing committee for giving me the opportunity to present at this amazing conference. FIX stands for FeminEM Idea Exchange and is part of FeminEM. While attending FIX19, I had the opportunity to interview a couple of fantastic women. One of them was Dara Kass. She is an Assistant Professor, Emergency Medicine, Columbia University Medical Center. Dara has been on the SGEM before (FIX You Up and FeminEM-Stronger Together). Barb Lubell, Jen Gunter and Ken Milne I also interview Dr. Jennifer Gunter who is a super hero of science wielding the lasso of truth. When she was back in London, Ontario for Western's Homecoming she too made an appearance on the SGEM (Super Hero of Science). Dr. Gunter has written a new book called The Vagina Bible that has been on the New York Times bestseller list. She also has her own TV show on CBC called Jensplaining. You can listen to the brief conversation with Drs. Kass and Gunter on iTunes. From Evidence-Based Medicine to Feminist-Based Medicine. My talk at FIX19 was called from Evidence-Based Medicine to Feminist-Based Medicine. Over the last few years Dara and others have opened my eyes to some of the other limitations to EBM. You can get copies of my slides at this LINK. Evidence-based medicine was originally defined by Dr. David Sackett over 20 years ago. He defined EBM as: “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”   I would add the word SHARED to this definition.  The modified version would be “The conscientious, explicit and judicious use of current best evidence in making SHARED decisions about the care of individual patients.”  There is a Venn diagram used to represents the EBM definition. Many people think that EBM is just about the scientific literature. This is not true. The evidence informs and guides our care but it should not dictate our care. EBM also needs your clinical judgement based on your experience. We also need to engage with patients and ask them about their preferences and values. These three components make up EBM: The literature, our clinical judgement and the patient's values. If you do that, you will be giving patients the best care, based on the best evidence and engaging in a shared decision making model, or so I thought. My eyes have been opened to the inequities in medicine by Dara Kass and other. I cannot look away any longer or stay silent These are the inequities I see in EBM. The Medical Literature: Who gets most of the grant money in medicine? Men Who rises to the top academic positions at universities? Men Who rises to the top academic positions in medicine? Men Who rises to the top academic positions in Emergency Medicine? Men Who is most likely the first author on a medical publication? Men Who is most likely the first author on a emergency medicine publication? Men Who is most likely to be the first author on a Pediatric Emergency Medicine (PEM) Paper? Men 62% of PEM  are women but only 42% are lead authors in the four high impact pediatric journals. Who are often excluded from being subjects in medical research? Women The Clinicians: Who historically has been the clinician in the room? Men Who is most likely to rises to top leadership positions within the hospital structure? Men. Only 3% of healthcare CEOs are women, 6% are Department Chairs, 9% are Division Chiefs, and 3% are serving as Chief Medical Officers. This is despite women comprising 80% of the healthcare workforce. Who gets paid more in medicine? Men ($20,000/year) Who gets paid more in academic medicine? Men ($17,000/year) Who gets paid more in academic Emergency medicine? Men ($12,000/year) Who is more likely to be introduced with their professional title at grand rounds...

Date: September 10th, 2019 Reference: Fournier et al. Adapting the Canadian CT head rule age criteria for mild traumatic brain injury. Emergency Medicine Journal 2019. Guest Skeptics: Dr. Sarah Berg is a PGY-3 resident in Emergency Medicine at Washington University School of Medicine in St. Louis. She is interested in social determinants of health in the emergency department and health policy. Dr. Ian Holley is also a PGY-3 resident in Emergency Medicine at Washington University School of Medicine in St. Louis.  He is interested in ultrasound and international emergency medicine. Case: It’s a busy night in the emergency department, your next patient is a well appearing 70-year-old man, presenting after a mechanical fall from standing with loss of consciousness.  He is neurologically intact with a Glasgow Coma Scale (GCS) of 15 one hour after the fall.  There are no other external signs of trauma on your exam. He is not on anticoagulation and there is no history of seizures. Background:  Head trauma is an exceedingly common presenting complaint in the emergency department, with approximately 2.5 million emergency department visits in the US in 2014 [1], with the most significant proportion of visits occurring in the elderly ≥75 (1,682/100,000) [1]. Head trauma can result in a spectrum of brain Injuries varying from mild to severe.  In cases of severe injury, the decision to obtain head CT imaging is straight forward.  In mild traumatic brain injury (mTBI), this decision is can be more difficult, as there may be no or minimal evidence of injury on exam.  Traditionally CT imaging was obtained for fear of missing intracranial pathology. In an attempt to improve resource utilization, emergency department length of stay, limit cost and improve outcomes, there have been multiple Clinical Decision Rules (CDRs) created to help guide clinicians in their decision-making process.  Two of the most commonly used rules include the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC); other rules include NEXUS-II, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies, the National Institute of Clinical Excellence guidelines, and the Scandinavian Neurotrauma Committee guideline. We have covered the CCHR on the SGEM with the EM Swami and Dr. Emily Junck back on SGEM#106. It was a classic EM paper published in the Lancet back in 2001 by the Legend of Emergency Medicine, Dr. Ian Stiell. We also discussed three studies that compared CCHR to the NOC. The bottom line was while both rules are highly sensitive for positive CT findings and clinically important brain injuries, the CCHR had higher specificity and may be more clinically applicable given it is designed to predict clinically important brain injuries. The Canadian CT Head Rule [2] is a clinical decision instrument to help you decide if a patient with a mild head injury requires a CT head. Minor head injury was defined as blunt head trauma, resulting in amnesia, loss of consciousness or an altered mental state (confusion or disorientation) with a GCS score ≥13. The CCHR only applies to those patients with minor head injury and is not applicable to non-traumatic cases, GCS less than 13, age less than 16 years, coumadin or bleeding disorder or obvious open skull fractures. The CCHR is the most researched CDR in mTBI [3] and has shown sensitivities and specificities from 99-100% and 48-77% [3].  The use of CDRs such as CCHR, have the ability to reduce the amount of unnecessary head CT imaging obtained in the emergency department [4]. Unfortunately, the CCHR uses age ≥ 65 as a high-risk criterion for obtaining head CT imaging in mTBI.  This is based on the initial validation study which demonstrated an odds ratio (OR) of 4.1 for risk of clinically important brain injury (CIBI) [2].  CIBI is defined, per the CCHR, as “any acute brain finding revealed on CT and which would normally require admission to hospital and neurologi...

Date: September 5th, 2019 Reference: Dalziel et al. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. The Lancet May 2019 Guest Skeptic: Dr. Tessa Davis is a Paediatrician specializing in Paediatric Emergency Medicine and currently practicing at the Royal London Hospitals. She is also the co-founder of Don’t Forget the Bubbles and on the FeminEM Speaker Bureau. Case: Julia is a 4-year-old girl with a history of seizures and developmental delay. She presents the emergency department with another seizure for more than five minutes and has not been aborted with two doses of midazolam intramuscularly.You know the guidelines recommend phenytoin as a second line agent, but the junior doctor asks you if levetiracetam would work faster with less side effects. Background: Convulsive status epilepticus can be defined as a single seizure lasting greater than 20 to 30 minutes, or recurrent shorter seizures without recovery of consciousness between seizures. Status epilepticus is a common paediatric emergency with significant consequences for the patients. Our focus on management of status is to stop the seizures quickly to avoid any complications. Guidelines recommend benzodiazepines as the first line treatment, and we have plenty of evidence to back this up. Most guidelines recommend phenytoin or fosphenytoin as a second-line treatment, but the evidence base for its use is much weaker. CPS - Emergency management of the paediatric patient with generalized convulsive status epilepticus APLS - Advanced Life Support Group. Advanced paediatric life support: a practical approach to emergencies, 6th edn. Hoboken: Wiley-Blackwell, 2016. NICE - Epilepsies: diagnosis and management. London: National Institute for Health and Care Excellence, 2012. AES - Glauser T, Shinnar S, Gloss D, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr 2016 Phenytoin is linked to many adverse events including liver damage, Steven-Johnson syndrome, extravastion, pancytopenia, hypotension, arrhythmias, and death due to dosing errors. Levetiracetam is an alternative to phenytoin for second line treatment of convulsive status epilepticus. It can be given more quickly, is more compatible with intravenous fluids, has less drug interactions, and has a lower risk of adverse events. Although small studies suggest that levetiracetam is effective, there have been no comparison studies until now. Clinical Question: Is levetiracetam superior to phenytoin as a second-line treatment for convulsive status epilepticus in children? Reference: Dalziel et al. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. The Lancet May 2019 Population: Children aged three months to 16 years of age presenting to 13 emergency departments in Australia and New Zealand in status epilepticus. Convulsive status epilepticus was defined as having a seizure for more than five minutes or two or more recurrent seizures without recovery of consciousness between seizures. Or three or more seizures within the preceding hour and a current seizure. They also had to have received two doses of benzodiazepines. Exclusions: Being on regular phenytoin or levetiracetam; having already had a second-line treatment; known to be refractory to the medication; allergy; seizures secondary to a head injury; or seizure due to eclampsia in late pregnancy. Intervention: Levetiracetam 40mg/kg (max 3g) IV or IO over five minutes. Five minutes after the infusion finished, patients were assessed to see if the seizures had stopped. If the patient was still convulsing, then the other drug was given.

Date: May 14th, 2019 Dr. Michael Brown Guest Skeptic: Dr. Michael Brown is founding chair of the Department of Emergency Medicine at the Michigan State University College of Human Medicine. He is affiliated with multiple hospitals, including Spectrum Health Gerber Memorial and Spectrum Health United Hospital. Dr. Brown received his medical degree from Michigan State University College of Human Medicine and has been in practice for more than 20 years. He has a Masters degree in Epidemiology and currently serves as President for the Association of Academic Chairs of Emergency Medicine. This is an SGEM Xtra that was recorded at the Society of Academic Emergency Medicine 2019 (SAEM) annual meeting in Las Vegas, Nevada. It was SAEMs largest meeting every with over 3,000 attendees. DISCLAIMER: THE VIEWS AND OPINIONS EXPRESSED BY DR. MICHAEL BROWN ON THIS SGEM EPISODE ARE HIS OWN AND DO NOT REPRESENT THE VIEWS OR OPINIONS OF THE COCHRANE COLLABORATION OR ANY OTHER ORGANIZATION. Dr. Archie Cochrane I took this opportunity of being together in Las Vegas for the SAEM meeting to discuss with Mike the following issues: What is the Cochrane Collaboration? Who was Archie Cochrane? What is the Cochrane Mission Statement? How has Cochrane reorganized itself? What was the recent Cochrane controversy? Here is a video from Dr. Damian Rowland from the wonderful DFTB17 Conference. The presentation is called "When we get the wrong answer from the right research". In this talk Damian discusses Cochrane. The SGEM will be back next episode for the start of Season#8. Our goal continues to be to try and cut the knowledge translation window down from over ten years to less than one year using the power of social media (FOAMed). REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

Date: August 9th, 2019 Reference: Daoust et al. Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain. AEM August 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 taking care of a 56-year-old woman who presented to the emergency department with a Jones fracture. During your discharge discussion, you offer her a prescription for oxycodone/acetaminophen and she gets a worried look on her face and says: “I try to stay away from those medications…what if I get hooked?” You realize you are unsure what to tell her about the chances of continued opiate use after an initial prescription. Background: Opioid use and misuse have increased greatly in the past 15 years, but opioids remain a mainstay of treatment for acute pain. Some have identified the 2001 Joint Commission making pain the fifth vital sign in an attempt to address the oligoanalgesia issue as part of the opioid misuse problem. ED physicians are among the most frequent prescribers of opioids. (Volkow et al. JAMA 2011). Attempting to decrease a patient’s pain to zero is certainly well-intentioned but you have to ask yourself how many patients are being harmed by such a goal? Another question you need to ask is: Do patients want their pain to be eliminated at the expense of their level of awareness and understanding why they are in pain? We have all had patients who express concern about opioid use like the case presented.  The literature has shown that more educated patients would rather receive less opioids and live with some pain compared to less educated patients. (Platts-Mills TF, et al. Pain 2012). Several studies have looked at opioid use after an initial prescription, but many of them included a large number of patients with prior substance abuse or used prescribing databases to extrapolate recurrent use as a surrogate for misuse. ACEP has a clinical policy regarding prescribing of opioids for adult ED patients that was published in 2012 (Cantrill et al). They suggest that opioid use be carefully individualized and time-limited; that opioids are best left for patients with severe or refractory acute pain; and that exacerbations of chronic pain not be treated with opioids. Clinical Question: What is the incidence of opioid use three months after an initial prescription, and what are the reasons for consumption? Reference: Daoust et al. Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain. AEM August 2019 This episode has a PECO not a PICO. The “I” for intervention is replaced by “E” for exposure because this is a prospective observational study looking at the relationship between an exposure (opioid prescription) and an outcome not a trial of an intervention. You can learn more about study design by going to the Center for Evidence Based Medicine website (CEBM Study Designs). Population: Patients 18 years or older with a painful condition less than two weeks without recent (less than two weeks) opioid use Excluded: Patients who did not speak French or English, were using opioid medication in the past two weeks prior to the ED visit, stayed in the ED for more than 48 hours before discharge home, and patients with cancer pain or who were being treated for chronic pain. Exposure: Discharged from the ED with an opioid prescription Comparison: None Outcome: Opioid use/misuse at three months This is an SGEMHOP episode which means we have the lead author on the show. Dr. Raoul Daoust is a Professor, Université de Montréal Emergency physician Hôpital Sacré-Cœur de Montréal Dr. Raoul Daoust Authors’ Conclusions: “Opioid use at the 3-month follow-up in ED patients discharged with an opioid prescription for an acute pain condition is not necessarily associated with opioid misuse; 91% of those patients consumed opioids to treat pain.

Date: August 6th, 2019 Guest Skeptic: Dr. Alyssa Stroud (@TheBlondeMD) is a PGY2 surgery resident who is trying to survive the hardships of residency and dating, one glass of wine at a time. This is an SGEM Xtra episode that was recorded in Algonquin Park where I am volunteering to be the camp doctor at the Taylor Statten Camps. You may hear sounds in the background of nature or campers when listening to the podcast. Dr. Stroud was invited on the SGEM to discuss a recent twitter thread she posted. There was an initial tweet that inspired the thread. Then someone named Bill Ferguson (@billferg1941) sent Dr. Stroud a direct message (DM). Here are the 11 tweets in the twitter thread and a copy of the DM. You can listen to us discuss each one of these tweets on iTunes. We then went on to discuss the good, the bad and the ugly responses to the twitter thread. There was one person named Becky (@BeckylNelson) that really got under Dr. Stroud's skin. The vast majority of the tweets were in support of Dr. Stroud. I asked her why she thought some people seem to get so angry? Some of these negative tweets led Dr. Stroud to step away from twitter for 12 hours. When she logged back onto twitter she found a number of people supporting her by changing their twitter name to include the word "Barbie". Many #FOAMed friends joined included Dr. Esther Choo who has been on the SGEM and Dr. Kirsty Challen who creates the #PaperinaPic infographics for the SGEM. I too changed my twitter name to EBM/Rural EM Barbie and assured Dr. Stroud that she was good enough just the way she was. I learned that from Mr. Rogers on his children's TV show called Mr. Roger’s Neighbourhood. He said: “Love isn’t a state of perfect caring. It is an active noun like struggle. To love someone is to strive to accept that person exactly the way he or she is, here and now”. To be more inclusive in 2019 I would tweak the quote to be gender neutral…but the world needs more love. Dr. Stroud then discusses her twitter name "OR Barbie" and what it means to her. She also explains why being known as a "Barbie" is not degrading to women, it’s not upholding the patriarchy, it’s not negative. It’s about taking back our power and deciding what kind of woman she wants to be. Dr. Alyssa Stroud I hope you enjoyed this SGEM Xtra and finding out more about the amazing person Dr. Alyssa Stroud. The SGEM will be back next episode with a structured critical review of a recent publication. Cutting the knowledge translation window down from over ten years to less than one year with power of social media. The ultimate goal of the SGEM continues to be that patients get best care on best evidence. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Date: July 22nd, 2019 Reference: Yadav et al. A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings. AEM July 2019 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and clinical lecturer in Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: A 25-year-old female presents to the urgent care with two days of cough, purulent sputum, fever and myalgias. Vitals signs are within normal limits and her exam is unremarkable. She asks for a prescription for antibiotics to help treat her infection.  Background: Inappropriate antibiotic use exposes patients to opportunistic infections, accelerates the development of antibiotic resistant bacteria and leads to adverse drug events [1]. Acute respiratory infections (ARIs) are a major cause of unnecessary antibiotic use. Emergency departments (EDs) in the United States write 10 million antibiotic prescriptions each year, approximately half of which are inappropriate [2, 3, 4]. Given these risks, strategies to reduce inappropriate antibiotic use in the ED and urgent care centers (UCCs) are needed. Despite recognizing the need for antibiotic stewardship by EDs and emergency providers, this has not led to practice change [5, 6]. Providers in the ED and UCC setting are faced with numerous challenges that may limit change, including: Frequent interruptions, boarding and overcrowding, frequent patient handoffs, and the need to see high volumes of patients [7, 8, 9]. There is evidence in both the medical literature and economic theory to support using a package of feedback, nudges and peer comparisons to improve prescribing outcomes. This has been shown to reduce unnecessary antibiotic prescribing in primary care, and in one study of peer comparisons in outpatient clinics and doctor’s offices, these improvements were sustained for at least 12 months after the interventions were completed [10, 11, 12]. Richard Thaler and Cass Sunstein wrote a book on the nudge theory. The book is called Nudge: Improving Decisions about Health, Wealth, and Happiness. The authors discuss psychologic and behavioral economics research to support active engineering of choice architecture. It’s a great book to put on your reading list. Clinical Question: Is an enhanced intervention using audit and feedback, peer comparisons, and nudges more effective than a standard intervention in reducing inappropriate antibiotic prescribing for acute respiratory infections by clinicians in an ED/UCC setting? Reference: Yadav et al. A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings. AEM July 2019 Population: Clinicians (general ED physicians, pediatric ED physicians, advanced care practitioners, internists and pediatricians) at five EDs and four UCCs in three academic health systems who prescribed antibiotics for ARIs. Excluded: Resident physicians Intervention: Enhanced intervention: This used all the elements of the adapted intervention, but also included peer comparison feedback via email, comparison to top performing peers, and additional locally tailored public posters demonstrating commitment to judicious antibiotic use. Comparison: Adapted intervention: This incorporated strategies from the Centre for Disease Control and Prevention’s Core Elements for Outpatient Antibiotic Stewardship, including provider and patient education, a physician champion and departmental feedback. This used adapted brochures and other campaign messages for acute care providers. Outcome: Primary Outcome: Rate of inappropriate outpatient antibiotic prescribing for acute respiratory infections diagnosis that were deemed antibiotic-nonresponsive. Secondary Outcome: Difference between the enhanced and adapted intervention g...