The Skeptics Guide to Emergency Medicine

Reference:  St Peter, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomized noni-inferiority trial. The Lancet. Jan 2025 Date: March 19, 2025 Dr. Camille Wu Guest Skeptic: Dr. Camille Wu is a paediatric surgeon based at Sydney Children’s Hospital where she is the Head of Department. She is also on the Training Committee of Paediatric Surgery for Australia and New Zealand. Case: A 10-year-old boy presents to the emergency department (ED) with his parents. He started having abdominal pain yesterday and did not want to eat. Today, his abdominal pain worsened, and he developed a fever. On examination, he looks uncomfortable and is tender to palpation in the right lower quadrant. You tell the parents that his examination is concerning for appendicitis. You order an ultrasound that demonstrates a dilated and non-compressible appendix. You consult the surgery team and both of you come to speak with the family. His parents tell you, “His sister was diagnosed with appendicitis during the Covid pandemic. At that time, she was admitted to the hospital but just treated with antibiotics. She was able to go home and has done well since that time. Do you think he needs surgery, or can he be treated with antibiotics as well?” Background: Acute appendicitis is one of the most common pediatric surgical complaints that we encounter in the ED. Traditionally, appendicectomy has been the gold standard for treatment, based on its effectiveness in preventing complications such as perforation, abscess formation, and peritonitis​. This is typically done laparoscopically through a few small incisions. The concept of non-operative treatment of appendicitis (NOTA) with antibiotics has gained interest over the past decade. This has been supported by growing evidence suggesting that some cases of uncomplicated appendicitis may resolve without surgery​. We have covered NOTA before on the SGEM that included some meta-analyses, randomized controlled trials, and observational studies. SGEM #115: Complicated-Non-operative Treatment of Appendicitis (NOTA) SGEM #180: The First Cut is the Deepest- N.O.T. for Paediatric Appendicitis SGEM #256: Doctor Doctor Give Me the News, I Gotta Bad Case of RLQ Pain- Should I have an Appendectomy? SGEM #345: Checking In, Checking Out for Non-Operative Treatment of Appendicitis (APPAC II RCT) SGEM #384: Take Me Out Tonight, I Don’t Want to Perforate My Appendix Alright The results have been mixed. Some of these studies have suggested that antibiotic therapy is non-inferior to surgical management while other studies have suggested antibiotic therapy did not meet criteria for non-inferiority compared to appendectomy. Most of these studies were conducted in the adult population with fewer studies conducted in children. The question remains: To cut or not to cut? Clinical Question: In children with acute uncomplicated appendicitis, is treatment with antibiotics non-inferior to appendicectomy? Reference:  St Peter, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomized noni-inferiority trial. The Lancet. Jan 2025 Population: Children aged 5-16 years with suspected non-perforated appendicitis based on clinical diagnosis +/- imaging Excluded: suspicion of perforated appendicitis, appendix mass/phlegmon, previous antibiotic treatment, positive pregnancy test, current treatment for malignancy, comorbid condition altering length of stay Intervention: Antibiotic therapy, initially with IV antibiotics followed by oral antibiotics after clinical improvement Comparison: Laparoscopic appendectomy Outcome: Primary Outcome: Treatment failure within 1 year. Secondary: Complications (adverse events that required interventions without general anesthesia), length of hospital stay, patient-reported outcomes (quality of life and pain scores) and healthcare utilization. Trial: Pragmatic, multicentre, parallel-group, unmasked, randomized, non-inferiority trial Authors’ Conclusions: Based on cumulative failure rates and a 20% non-inferiority margin, antibiotic management of non-perforated appendicitis was inferior to appendicectomy. Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Unsure  The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. Yes. All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No. All groups were treated equally except for the intervention. Unsure Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Unsure Financial conflicts of interest. None Results: They recruited 936 patients from 11 children’s hospitals in Canada, the US, Finland, Sweden, and Singapore. 459 were assigned to the appendicectomy group and 477 were assigned to the antibiotic group. Key Result: Antibiotic therapy was inferior to appendicectomy for management of non-perforated appendicitis. Primary Outcome: 34% of the patients in the antibiotic group had treatment failure compared to 7% of the appendicectomy group. That was a difference of 26.7% (90%CI 22.4-30.9). Most treatment failure in the appendicectomy group was due to negative pathology. In the antibiotic group, 72 (47%) met definition of treatment failure during the first admission. Secondary Outcomes:  Neither of the groups had deaths or serious adverse events. The relative risk of having an adverse event related to the antibiotic treatment compared to the appendicectomy was 4.3 (95% CI 2.1-8.7). Most of these adverse events were classified as Gastrointestinal Distress. Median length of stay was 1.0 day (IQR 0.76-1.68) for the appendicectomy group compared to 1.25 days (IQR 0.92-2.09) for the antibiotic group. The patients from the antibiotic group spent more time in the hospital during the 12 month follow up period 1.6 days (IQR 1.0-2.6) compared to 1.0 days (IQR 0.75-1.7). The antibiotic group was able to return to normal activity and school faster than the appendicectomy group. They also did not require pain medications compared to the appendectomy Approximately three-quarters (73%) of the families surveyed from both groups reported being satisfied with their treatment. Diagnosis of Appendicitis In previous studies, the way a diagnosis of appendicitis is made has varied. Some studies have included imaging findings on CT scan or ultrasound. Some studies have included lab tests. This study included patients with a diagnosis of simple, non-perforated appendicitis. They excluded those with suspicion of perforated appendicitis. How was this diagnosis made? We went back to the trial protocol on ClinicalTrials.gov to find some more details. It appears that all children with suspected acute non-perforated appendicitis were assessed by the on-call surgeon. The diagnosis could be made based on clinical suspicion with or without ultrasound imaging. What is the gold standard for diagnosing appendicitis? We would imagine that surgical pathology consistent with the diagnosis is best but also recognize that is does not make any sense to remove the appendix of every child in the study. Camille does not rely on imaging. However, often by the time she's called to see the patient in ED, they’ve already had an ultrasound. Sometimes it’s helpful, sometimes it’s unnecessary, and sometimes it’s distracting. One of the common annoying scenarios is the finding of a mildly thickened 7mm appendix in a child who does have right inferior quadrant tenderness with no other signs of appendicitis, and parents are expecting an operation as the ultrasound says “appendicitis’ and the referring hospital has told them that’s why they were getting transferred. Many of these kids have a viral illness, causing lymphoid tissue in the wall of the appendix to hypertrophy, thereby enlarging the appendix. Treat the patient, not the test or image finding. Tests are an adjunct to clinical evaluation. They help us to confirm our diagnosis. How sure does a surgeon need to be to take a patient to theatre? How sure does an ED doctor need to be to call their surgeon to review? Seems like the threshold is different for different specialties, different hospitals, different practitioners, and different countries! Selection Bias Of the patients screened for eligibility in the study, 90% were excluded. Of those excluded, ~40% were excluded due to perforated appendicitis or suspected perforation, and the other 60% were excluded because they either declined to participate or “other reasons.” Suspected perforation seems fairly subjective. I asked Camille to comment on how she clinically distinguishes between perforated or non-perforated appendicitis and the accuracy of making that determination based solely on physical exam. Duration of symptoms: the authors also included duration ≥ or < 48 hours in their randomisation. Surgical teaching is that perforation occurs around Day 3, so be more suspicious of this group. Beware the kids under 5, they tend to perforate earlier at Day 2. Also be suspicious of pain on day 3 that’s suddenly better, but the patient is sicker. Young and atypical presentation: presents like gastroenteritis, rather than the classic “central pain migrating to right inferior quadrant.

Dr. Matt Schmitz, an orthopedic surgeon specializing in adolescent sports medicine at Rady Children’s Hospital, shares invaluable insights into scaphoid fracture management. He discusses the dilemmas of diagnosing these complex injuries, advocating for evidence-based approaches. Innovative research reveals that short-term bandaging may work as effectively as traditional casting. Schmitz also emphasizes the need to understand biases in clinical trials and offers alternative strategies for monitoring patients with suspected fractures, ultimately aiming for improved care outcomes.

Date: May 6, 2025 Guest Skeptic: Actor, producer and director Noah Wyle. Many of us know him as Dr. John Carter from ER, the show that arguably influenced an entire generation of EM physicians. Since that groundbreaking show, he has been busy with multiple movie roles (Pirates of Silicon Valley, Donnie Darko, White Oleander, Shot, and At the Gate) and TV series (The Librarian, Falling Skies, The Red Line and Leverage: Redemption). Noah is back in scrubs again, playing Dr. Robinavitch in The Pitt, a new medical drama that captures one chaotic, fifteen-hour emergency department shift. There will be no spoilers for the one or two SGEM listeners who haven’t streamed The Pitt. A  big shout-out to Dr. Mel Herbert, creator of EMRap, for setting up this interview. Mel has been on the SGEM talking about the extraordinary power of being average. Mel is also a medical consultant for The Pitt. Let’s set the scene of how The Pitt starts: Noah is shown walking to work for a day shift, hoodie on, earbuds in, scruffy beard, backpack, Yeti and cargo pants. He nailed the look of a seasoned EM doctor. The hoodie was from a brewery called Beers of the Burgh, and they are selling the hoodie Noah wears for the entire season. Noah's portrayal as Dr. Robby is so believable that I was instantly willing to suspend disbelief and accept him as a legit EM attending.  As an EM physician who has been practicing for nearly 30 years, I felt seen. We’ve done previous SGEM Xtra episodes on how pop culture helps us reflect on our practice of EM—Star Trek, Top Gun, Batman, and even Ted Lasso. But ER was perhaps the most formative show for this EM doctor. I started residency in 1995, and identify with the character, Dr. Robby, in The Pitt. This is especially true in today’s healthcare environment. FIVE NERDY QUESTIONS for Noah Wyle Listen to the SGEM Podcast to hear Noah answer the five nerdy questions. 1. Three Decades: It’s been 30 years since ER first aired in 1994. What’s changed in emergency medicine besides the disappearance of white lab coats and ties and the introduction of designer scrubs (Figs) or, in your case, a hoodie from a beer company? 2. Being A Doctor Again: What was the easiest and hardest part about returning to a role as an emergency physician? For me, it’s the incorporation of ultrasound and a drug names that keeps getting harder to pronounce. What was the easiest and hardest part for you stepping into the role of an EM attending decades later? Teamwork is essential in EM. We talk a lot about being on “Team Patient.” The cast, crew, set designers, writers, directors, and producers of The Pitt captured that flow state we strive for on shift. How did you and your team get into the flow? 3. Feedback: The show has resonated widely; dare I say cultural phenomenon. How has the response been from different groups from your perspective: healthcare workers (doctors, nurses, residents, etc), administrators, and patients? I’m watching it with my wife (Barb) while encouraging my friends and colleagues to do the same. It’s the most accurate window into my life as an attending EM physician that I’ve ever seen. 4. Evidence-Based Medicine: I teach EBM, which combines the best available evidence with clinical judgment while asking patient about their values and preferences. This means not following GUIDElines as if they were GODlines. The show reflects EBM beautifully. I hear you had an EM bootcamp to get the cast up to speed on terminology, procedures and other things. What was that like? I also hear you shadowed some real EM docs on shift. Any specific memories from that experience that informed your acting and the show? 5. Tough Topics: The show doesn’t shy away from tough topics like abortion, healthcare worker violence, vaccine hesitancy, miscarriage, organ donation, burnout, mass shootings, substance use among staff, moral injury, and so much more. Why was it important to tackle these head-on? Was there a deliberate choice to “show the hard stuff” and lean into the controversial aspects of EM? Season#2 of The Pitt has been given the green light, with production starting in June. It will be set during a July 4th holiday weekend shift.  The American College of Emergency Physicians (ACEP) has also announced that Noah will be their special guest at the Scientific Assembly in September in Salt Lake City. The SGEM will return next episode with a structured critical appraisal of a recent publication. We're using the power of social media to cut the Knowledge Translation window from over ten years to less than one. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Reference: Umana E, et al. Performance of clinical decision aids for the care of young febrile infants: A multicenter prospective cohort study. eClinicalMedicine Lancet December 2024 Date: March 6, 2025 Dr. Demetris Athanasiou Guest Skeptic: Dr. Demetris Athanasiou is a paediatric registrar based in London and enrolled in the PEM MSc program through Queen Mary University in London. Case: A 6-week-old boy is brought by his parents to your emergency department (ED) for fever. His older sister has been sick with upper respiratory symptoms for the past week but seems to be recovering. Today, while his father was feeding him a bottle, he noticed that the baby was feeling warm and took his temperature, which was 38.2°C (100.7 °F). The boy has otherwise been feeding and acting normally. You examine the baby with an astute medical trainee. As you discuss the next steps in management, she asks you, “I know there’s a bunch of guidelines or decision tools to help risk stratify which babies are low risk for bacterial infections, but I can never keep them straight. Is there one you prefer?” Background: Back in the day, we were performing lumbar punctures (LP) on febrile infants up to 3 months of age because there was concern for bacterial infections. We used to lump urinary tract infections, bacteremia, and meningitis under one umbrella term, “serious bacterial infection” or SBI. Recently, we’ve been told to stop using that term and be more specific about what we are referring to. Bacteremia and meningitis have been termed invasive bacterial infections (IBI) and, fortunately, are rare, occurring in 1-4%. There have been several guidelines and clinical decision tools, such as those developed by the National Institute for Health and Care Excellence (NICE), the American Academy of Pediatrics (AAP), and others that offer strategies to identify low-risk infants who might avoid invasive procedures like a lumbar puncture. These clinical decision tools have been developed to stratify febrile infants into high- and low-risk categories to balance the risk of under-treatment and over-treatment. Several of these tools have been reviewed on the SGEM. SGEM #341: AAP Guidelines SGEM #296: PECARN SGEM #171: Step By Step The hot new test is procalcitonin. Unfortunately, it’s expensive, and not all EDs have access to it or can receive the results promptly to help with decision making. Some are still using other inflammatory markers like C-reactive protein (CRP). With ongoing research and evolving guidelines, the clinical utility of these decision tools continues to be refined. Understanding their strengths, limitations, and applicability in various healthcare systems remains a crucial aspect of evidence-based emergency medicine. Clinical Question: How well do various clinical decision aids perform in identifying febrile infants at low risk for invasive bacterial infection? Reference: Umana E, et al. Performance of clinical decision aids for the care of young febrile infants: A multicenter prospective cohort study. eClinicalMedicine Lancet December 2024 Population: Infants from birth to 90 days of age from across 35 paediatric EDs and paediatric assessment units across the UK and Ireland with fever ≥38°C Excluded: Guardians who declined or withdrew consent Intervention: Application of clinical decision aids (CDA) [American Academy of Pediatrics (AAP), British Society Antimicrobial Chemotherapy (BSAC), National Institute for Health and Care Excellence (NICE) NG143, Aronson] Comparison: Against each other and “treat all” approach Outcome: Primary Outcome: Diagnostic accuracy of CDAs Secondary Outcomes: Etiology of IBI, clinical predictors of IBI, and mean cost per patient Trial: Prospective multicenter cohort study Guest Author : Dr. Etimbuk Umana (Timbs) is a consultant in emergency medicine and lead author of the FIDO study. Authors’ Conclusions: “The AAP and BSAC CDAs are highly sensitive at excluding IBI, with a cost saving to hospital services when compared to a treat all approach. The substitution of CRP for PCT made no difference to the performance of the AAP CDA in this cohort and was more costly.” 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? Unsure  Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Pretty precise Do you believe the results? Yes Can the results be applied to the local population? Yes, to the UK and Ireland pediatric populations Do the results of this study fit with other available evidence? Yes Funding of the Study: No financial conflicts of interest Results: There were 1,821 infants included with a median age of 46 days, 61% male, 14% had comorbidities present, and 58% appeared unwell. There were 67 (3.7%) infants who were diagnosed with IBI. 62 had bacteremia 9 had bacterial meningitis 4 infants had both bacteremia and meningitis Key Results: BSAC and AAP CDAs had the highest sensitivities, while NICE NG143 and Aronson CDAs had the highest specificities. The AAP and BSAC CDAs each misclassified one infant as low risk who was diagnosed with IBI. Both were in the 29-to-60-day age range and presented very early after fever onset. Tune into the podcast to hear Dr. Umana answer our questions. Public and Patient Involvement We love that there was involvement from the public continuously throughout this study right from the start. Were there any changes that you made based on their insights and experiences? Included/Excluded Patients The FIDO study included many different existing CDAs. Among the patients included in the study, close to 60% were categorized as “unwell appearing.” At least some of these existing guidelines, like the AAP guidelines, are meant to be applied to “well-appearing” febrile infants. CDAs are not meant to supersede clinician judgement so if we encounter an infant with a fever who looks sick, they have already fallen off any existing algorithm, and we are likely performing the full workup [1]. Can you comment on the decision to include the unwell-appearing febrile infants? Some of the infants were excluded due to missing data. How do you think that could have biased the results? Clinical Risk Factors The study identified four independent clinical risk factors for IBI. Among them was the clinical opinion of IBI likely (p < 0.001). Previous studies on clinical observations such as the Yale Observation Scale Score demonstrate poor reliability in identifying infants with IBI [2]. Why do you think that the clinical opinion of IBI in this study was significant? Do you think it has anything to do with the inclusion of unwell-appearing infants? Missed Cases It’s mentioned that because the standard of care was followed, not all infants underwent blood testing, and it was assumed that the data would have been in the normal range. There was a group of participants who did not have cultures or PCR testing done. It was assumed that these infants did not have IBI if they were not found to have been diagnosed with it within seven days of discharge on checking hospital records. Is it possible this method may have missed some children who did not re-present to the hospital or presented a center that was not among the 35 included in the study? Role of Viral Testing Some of the infants were tested for respiratory syncytial virus, influenza, and SARS-CoV-2 [3]. Around three-quarters (76.6%) of infants had respiratory viral testing. Of those tested, close to a quarter (24.5%) were positive for one of the viruses we mentioned. Of the infants who had a positive viral test, 1.5% had IBI compared to 3.8% who had a negative viral test. When you looked at infants 29 days or older, the rate of IBI was 0.7% for infants with a positive viral test compared to 3.2% with a negative viral test. Both differences were statistically significant. We talk about the difference between statistical significance and clinical significance on the SGEM quite a bit. Do you think this difference of 0.6% overall or 2.5% in the older than 29 days group is clinically significant? Bonus Question: It looks like there was a portion of the patients who did not have urine testing (19%) and/or blood testing (11%). We also noticed that your study included ages up to 90 days. The AAP guidelines go up to 60 days.  There is a lot of variation in workup for infants greater than 2 months (specifically in the 2 to 6 month range) [4]. Can you comment on why you included up to 90 days. Did the infants who did not receive blood or urine testing tend to be >60 days? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion. SGEM Bottom Line: There are many CDAs to help risk stratify the care of febrile infants. Of the ones included in this study, AAP and BSAC are the most sensitive. Use these CDAs in conjunction with your clinical judgment. Case Resolution: You tell your trainee that there are many CDAs out there to help us risk stratify febrile infants. This is because it is often difficult to rely solely on our clinical exam to be accurate. We do not want to miss infections such as UTIs, bacteremia, and meningitis. Currently, many CDAs recommend testing blood and urine. Inflammatory markers such as C-reactive protein and procalcitonin can be used to guide decision making about whether a lumbar puncture should be performed in slightly older infants. Unfortunately,

Dr. Howie Mell, a board-certified emergency physician and EMS expert, dives into the heated debate over using Midazolam versus Ketamine for acute agitation in pre-hospital settings. He unpackages clinical decision-making, examining the urgency of sedation strategies and their safety implications. Listeners will gain insights into observational study challenges and the importance of local factors in applying research findings. With a focus on real-world scenarios, Mell highlights key considerations for managing agitated patients effectively among varied emergency environments.

In this discussion, emergency physician researcher Hashem Kareemi delves into the integration of AI in emergency medical care, exploring its potential to improve clinical decisions under pressure. Dr. Kirsty Challen, a seasoned emergency medicine consultant, shares insights on the evolution of clinical decision support systems and the pressing need for ethical AI implementation. They tackle challenges in the current AI landscape, reflect on healthcare inequities, and emphasize the necessity of clinician involvement to ensure technology enhances patient care rather than complicates it.

Dr. Brandon Ho, a pediatric emergency medicine fellow at Children’s National Hospital, discusses the significant challenges in accurately triaging pediatric patients. He reveals concerning trends of misclassifying seriously ill children and the implications for patient care. The conversation covers the limitations of the Emergency Severity Index (ESI), biases in triage assessments, and the importance of effective communication. Ho also explores innovative solutions like AI and machine learning to enhance triage accuracy and improve health outcomes for young patients.

The discussion dives into the myth that non-urgent patients are the primary cause of emergency department crowding. Misconceptions surrounding this issue are debunked, illustrating the risks of diverting patients who might have serious conditions. The conversation critiques traditional approaches, labeling them as ineffective solutions and calling for evidence-based strategies. It emphasizes the need for comprehensive solutions that address deeper healthcare system flaws, rather than just treating the symptoms of overcrowding.

Dive into the latest findings in emergency medicine as key research papers are dissected. Discover innovative pre-oxygenation techniques and the reliability of trials that can reshape clinical practices. Explore pivotal insights into pediatric injuries and the nuances of decision-making in critical situations. The discussion highlights biases in research and safe sedation methods for agitated patients, while also questioning the safety of anticoagulant reversal trials. A must-listen for anyone in the medical field!

Nicholas Peoples, a standout medical student from Baylor College of Medicine with a rich background in global health, dives into the pressing issue of citation errors in biomedical literature. He reveals that up to 40% of citations may reference non-existent studies, undermining clinical practice. The conversation highlights the role of AI in enhancing citation accuracy and the urgent need for accountability among researchers. They also discuss the cultural shift necessary in academia to ensure integrity and trust in scientific research.