Date: November 22, 2023 Reference: Stopyra et al. Delayed First Medical Contact to Reperfusion Time Increases Mortality in Rural EMS Patients with STEMI. AEM November 2023. Guest Skeptic: Dr. Lauren Westafer an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for Annals of Emergency Medicine. Case: A 72-year-old man with a history of high blood pressure and diabetes calls emergency medical services (EMS) for chest pressure and dyspnea that started 1 hour ago. Upon EMS arrival, they find the patient is sweaty with normal vital signs. A 12-lead electrocardiogram (ECG) demonstrates ST elevations in leads II, III, and aVF with ST depressions in leads I and aVL and the team begins transport to the nearest percutaneous coronary intervention (PCI) capable hospital. Background: We have covered the issue of heart attacks several times on the SGEM. These include looking at the HEART score, troponin testing and cardiovascular disease in women. One aspect we have not addressed is rural. SGEM#151: Groove is in the HEART Pathway SGEM#160: Oh Baby, You’re Too Sensitive – High Sensitivity Troponin SGEM#280: This Old Heart of Mine and Troponin Testing SGEM#370: Listen to your HEART (Score) SGEM#400: A Little Bit of Heart and Sport and Sports Related Sudden Cardiac Arrest in Women SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease Current guidelines target a time between first medical contact (FMC) like EMS on-scene and stent or balloon deployment (PCI) of 90 minutes or less. If time from FMC to PCI is anticipated to be greater than 120 minutes, the guidelines recommend systemic thrombolysis rather than PCI [1]. I’ve published on this issue with a project we called “barn door-to-needle time” [2]. We looked at 101 STEMI patients from two rural EDs. The median door-to-ECG time was 6 minutes, door-to-physician time was 8 minutes and DTN time was 27 minutes; 58% of patients received thrombolytics within 30 minutes. Regional systems of care have been designed to rapidly recognize patients with STEMI and direct STEMI patients to timely reperfusion. Many hospitals do not provide PCI, prolonging transportation times, which disproportionately affects rural patients. There are several distinct time intervals in the care of patients with STEMI and it is unclear which steps in pre-PCI care of patients contribute to avoidable delays. Clinical Question: Is there an association between in-hospital mortality and time between first medical contact and primary percutaneous coronary intervention in rural patients who present with a STEMI? Reference: Stopyra et al. Delayed First Medical Contact to Reperfusion Time Increases Mortality in Rural EMS Patients with STEMI. AEM November 2023. Population: Patients ≥ 18 years of age who were transported to one of three tertiary care hospitals by a rural EMS agency and received primary percutaneous coronary intervention (PCI) for STEMI. Rural agency was defined by US census codes (2014) Excluded: Patients <18, those who had prehospital cardiac arrest, and those who were transferred between hospitals Exposure: 90-minute first medical contact to PCI goal (defined as time between the time recorded as EMS personnel arrival on scene and the time the angioplasty or stent was deployed Comparison: Greater than 90 minute first medical contact to PCI Outcome: Primary Outcome: All-cause in-hospital mortality during the index hospitalization Secondary Outcomes: Prehospital time intervals stratified by index hospitalization mortality. Type of Study: A retrospective cohort study from eight rural North Carolina EMS agencies between January 2016 to March 2020. Dr. Michael Supples

Dr. Matt Schmitz, an Orthopaedic Surgeon transitioning from a 20-year Air Force career to Clinical Professor at UC San Diego, tackles the tricky world of scaphoid fractures. He sheds light on the flaws of X-rays in diagnosis, discussions about the significance of clinical exams, and the implications of misdiagnosis. The conversation extends to surgical techniques, patient communication, and even a quirky contest. Packed with insights, this episode explores how to improve outcomes while navigating the complexities of wrist injuries.

Dr. Damian Roland, a Consultant in Paediatric Emergency Medicine at the University of Leicester NHS Trust, shares his expertise in managing pediatric sepsis. He discusses the critical need for early detection and effective interventions. The conversation dives into the complexities of diagnosing sepsis, questioning the effectiveness of current screening methods and lab tests. Roland critiques the misuse of 'sepsis screening' terminology, arguing it's more about clinical judgment and timing than standard tests. He highlights the challenges of pediatric fever assessments in emergency settings.

Dr. Sergey Motov, an Emergency Physician and leading pain management researcher, shares insights on back pain management. He discusses a recent clinical case of severe back pain and the complexities of patient treatment choices. The conversation highlights the limited efficacy of opioids compared to placebo, emphasizing non-opioid alternatives for safer management. Dr. Motov critiques treatment guidelines versus real-world prescribing, shedding light on the importance of evidence-based approaches in emergency medicine.

Dr. Kirsty Challen, an Emergency Medicine Consultant at Lancaster Teaching Hospitals, and Dr. Angela Cai, a Clinical Assistant Professor at the University of Pennsylvania, delve into the nuances of diagnosing spinal epidural abscesses. They discuss staggering misdiagnosis rates and the crucial role of clinical management tools in improving detection. The conversation highlights how these tools can streamline diagnostic processes while navigating the complexities of emergency practices. Their insights reveal the challenges of achieving substantial patient outcome improvements despite implementing evidence-based approaches.

Dr. Vicki Currie, a pediatric emergency medicine registrar and editor for Don’t Forget the Bubbles, shares vital insights on pediatric vital signs and their evolving reference ranges. The discussion starts with a poignant case of a boy suspected of having sepsis, emphasizing the critical need for understanding these signs. Dr. Currie critiques recent research, revealing potential discrepancies in heart rates compared to established guidelines. She advocates for individual assessments in pediatric care, arguing that patient outcomes should take precedence over strict numerical values.

Date: September 28, 2023 Reference: Jarman et al. Sex Differences in Guideline-Consistent Diagnostic Testing for Acute Pulmonary Embolism Among Adult Emergency Department Patients Aged 18-49. AEM September 2023 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: During a shift in the emergency department (ED), you see two patients with pleuritic chest pain, one female and one male. Pulmonary embolism (PE) is a diagnosis you are considering for both. After d-dimer testing your female patient, you order a CT scan of the chest for the male patient. One of the nurses on shift asks you why you didn’t order a d-dimer for the male, like you did the female patient. Background: PE is commonly considered during ED workups for chest pain and shortness of breath (1). We have covered the topic of PE more than ten times on the SGEM: SGEM#51: Home (Discharging Patients with Acute Pulmonary Emboli Home from the Emergency Department) SGEM#118: I Hope you Had a Negative D-dimer (ADJUST PE Study) SGEM#126: Take me to the Rivaroxaban – Outpatient treatment of VTE SGEM#163: Shuffle off to Buffalo to Talk Thrombolysis for Acute Pulmonary Embolism SGEM#184: We Weren’t Born to Follow-Up – The PEITHO Long-Term Follow-up Study SGEM#219: Shout, Shout, PERC Rule Them Out SGEM#276: FOCUS on PE in Patients with Abnormal Vital Signs SGEM#277: In the Pregnant YEARS – Diagnosing Pulmonary Embolism SGEM#282: It’s All ‘bout that Bayes, ‘Bout that Bayes- No Trouble – In Diagnosing Pulmonary Embolism SGEM#295: Teacher, Teacher – Tell Me How to Do It (Diagnose a PE) SGEM#323: Mama I’m Comin’ Home – For Outpatient Treatment of a Pulmonary Embolism Many patients may be able to have PE ruled out without imaging, after risk stratification with one of several decision tools (2). A very common clinical decision instrument is the Well’s Criteria. It has seven items with each item having a weighting from 1 to 3. The score is added up and then can be applied in a three-tiered model (low, moderate, or high risk) two-tiered model (PE is unlikely or likely). Another common tool is the revised Geneva Score (rGS). It is an eight-item clinical decision instrument for risk stratification. Each item in this tool also has different weight assigned to the items. Patients are considered low, intermediate, or high-risk depending on their total score. Neither of these two scores considers the sex of the patient for risk stratification. However, sex differences exist in the workup of PE, with females receiving more diagnostic testing, but with a lower diagnostic yield. Female patients are also more likely to undergo diagnostic imaging, and females who undergo imaging are less likely to be diagnosed with PE (3-5). Clinical Question: Are male and female patients equally likely to receive care consistent with guidelines for suspected PE? Reference: Jarman et al. Sex Differences in Guideline-Consistent Diagnostic Testing for Acute Pulmonary Embolism Among Adult Emergency Department Patients Aged 18-49. AEM September 2023 Population: Patients 18-49 years of age presenting with chest pain, shortness of breath, hemoptysis, or syncope alone or in combination Excluded: Pregnancy or incomplete ED visits Exposure: Objective testing for PE Comparison: Sex (male or female) Outcome: Primary Outcome: Receipt of guideline-consistent care based on revised Geneva Score (rGS) Secondary Outcomes: Rates of d-dimer testing, d-dimer positivity, rates of CT-pulmonary artery scanning (CTPA), overall yield of testing. Type of Study: A retrospective cohort study conducted at two U.S. academic tertiary care hospitals Dr. Angela Jarman This is an SGEMHOP episode which means we have the lead author on the show.  Dr. Angela Jarman is an Assistant Professor and the Director of Sex & Gender in Emergency Medici...

Reference: Snelling et al. Ultrasonography or radiography for suspected pediatric distal forearm fractures. New England Journal of Medicine June 2023 Date: July 19, 2023 Guest Skeptic: Dr. Casey Parker is a Rural Generalist that includes in his practice emergency medicine, anesthesia, and critical care. He is also a fully-fledged ultrasonographer. Casey currently splits his time between Broome, a small rural hospital in the remote Kimberley region of Western Australia, and a large tertiary ED in sunny Perth. He has been a guest skeptic on the SGEM multiple times. He is also the creator of the amazing #FOAMed website, Broome Docs. Dr. Casey Parker Case: It is a steady Saturday afternoon in your rural emergency department (ED). The triage nurse calls you to have a look at a child who has arrived with his parents in ED after falling from a bouncy castle at a birthday party.  He is six years old and appears to be in pain with his left wrist swaddled in an ice pack.  He tells you that he was attempting “a double backflip like Spiderman” when he landed heavily on the outstretched hand - this happened about an hour ago. Clinically there is some swelling and tenderness over the distal radius but no deformity.  He has good perfusion and no neurological symptoms in the hand. Because it is a small, rural ED there is no radiographer on site but they can be called in if we would like to get an X-ray…. or there is a portable bedside ultrasound machine in the next room ready to go. The child’s mother tells you that the X-ray tech was also at the party having a great time with her children. So, the question is: should we call in our x-ray tech in and disrupt her party fun or just use the ultrasound machine to diagnose this possible fracture? Background: We have covered pediatric wrist fractures a few times on the SGEM. This includes SGEM#19 way back in 2013 reporting a bandage wrap is a safe alternative to traditional casting for children with greenstick fractures. More recently, the amazing Dr. Tessa Davis covered the FORCE trial on SGEM #372 which looked at buckle fractures and compared immobilization in a cast or splint vs. a soft bandage and they found no difference in pain scores or functional outcomes. The use of bedside ultrasound to diagnose uncomplicated wrist injuries in children has been studied in several diagnostic prospective, observational trials to compare its accuracy to traditional plain film X-rays [1-5].  Most of these trials have shown diagnostic sensitivity and specificity above 90% when compared to X-ray as a gold standard.  This same research team from Queensland in Australia have also published a paper describing the learning curve for novices in detection of forearm fractures in kids [6].  In 2022 Mobasseri et al published a review of 9 such diagnostic studies and concluded that from an orthopedic perspective that the accuracy was not acceptable, the lack of a randomized controlled trial meant that there was not enough data to support the use of ultrasound over X-ray as an initial diagnostic test [7]. There have been no randomized trials that have compared the patient-centered, functional outcomes after a wrist injury based upon the choice of initial diagnostic test modality. Clinical Question: In children with non-deformed distal forearm injuries, does the use of ultrasound as an initial diagnostic test result in inferior functional outcomes? Reference: Snelling et al. Ultrasonography or radiography for suspected pediatric distal forearm fractures. New England Journal of Medicine June 2023 Population: Children between 5 and 15 years of age who presented to the ED with an isolated, acute, clinically non-deformed, distal forearm injury for which imaging for a suspected fracture was indicated Excluded: obvious angulation/deformity (soft tissue swelling allowed), injury >48hr prior, external X-rays obtained, known bone disease, concern for non-accidental trauma,

Date: August 30, 2023 Reference: Griffey et al. The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics. AEM August 2023 Dr. Suchismita Datta Guest Skeptic: Dr. Suchismita Datta. She is an Assistant Professor and Director of Research in the Department of Emergency Medicine at the NYU Grossman Long Island Hospital Campus. This is the last show for Season#11. It has been a great year with the addition of PedEM SuperHero Dr. Dennis Ren. We have some exciting news to cap off the end of this amazing year. Suchi will be joining the SGEM faculty as part of the Hot Off the Press team. Case: A 28-year-old male with a history of type-1 diabetes mellitus presents to the emergency department (ED) with increase in thirst and light headedness. He is otherwise healthy. Blood glucose in triage is 489 mg/dl (27.2 mmol/L). Venous blood gas (VBG) shows an acidosis with a pH of 7.21. Electrolytes show a gap of 21. The patient’s symptoms begin to improve after initial intravenous (IV) fluid administration of one litre of 0.9% saline. The patient states he has had multiple “diabetic emergencies” in the past and usually ends up in the intensive care unit (ICU) on a drip. He is wondering, “Hey doc, do I have to go back to the ICU strapped to an IV pole?” The flow nurse has similar questions for you and wants to know if she should clear out a bed in the critical care bay so that the patient can have appropriate nursing requirements for an insulin infusion. Your resident is eager to go ahead and sign off on the diabetic ketoacidosis (DKA) insulin order set and the ICU attending’s “Spidey senses” are going off. They are on the phone asking you if you already have another admission for them on this busy day. However, the ICU is full and the patient will likely be boarding in your ED for a bit before coming upstairs. Just as all this is happening, you notice how the waiting room is filling up and you can hear the sirens of approaching ambulances becoming louder. You take a deep breath, and you think to yourself…let the squid games begin. Background: DKA is a common yet potentially fatal condition seen in patients with type 1 diabetes. It accounted for roughly 8.9 ED visits /1000 adults with diabetes [1]. DKA results in over 500,000 annual hospital days with estimated annual hospital costs of over $5 billion [2]. Dr. Nathan Kuppermann Despite how common and expensive the management of DKA can be, we have only looked at it once on the SGEM. That was an episode covering the practice changing randomized control trial published in NEJM by Dr. Nathan Kuppermann from the PECARN Team for pediatric DKA [3]. They reported that the type of intravenous fluids (0.45% NaCl or 0.9% NaCl) or speed of infusion did not appear to make a clinically important difference (SGEM#255). Because of the complexity of care around managing DKA, the typical approach is an insulin drip with ICU level of care for all degrees of severity. Increased resource utilization around this can prolong ED length of stay, especially in the context of a busy hospital or a global pandemic. However, over the past 20 years, there is burgeoning evidence that fast-acting subcutaneous insulin analogs could be a potential treatment option for mild to moderate severity DKA including a 2016 Cochrane SRMA [4]. If proven to be a safe and effective management strategy, this would eliminate the need for an insulin drip and opens new options for management and disposition of DKA patients from the ED. Using fast-acting subcutaneous insulin could streamline care in the ED and decrease the length of stay (LOS) in the department. This reduction in LOS is desirable for many reasons including overcrowding, prolonged wait times, and the availability of ICU beds for other critical patients. Clinical Question: Can a patient with mild to moderate severity DKA be safely managed with subcutaneous fast acting insulin analogs on a non-ICU floor wit...

Date: August 20th, 2023 Reference: Milne WK, Challen K, Young T. Skeptics' Guide to Emergency Medicine Season #10 Book Dr. Kirsty Challen Guest Host: Dr. Kirsty Challen is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). She completed undergrad and postgrad training in North West England, acquiring a History of Medicine BSc, a PhD in Health Services Research, an anesthesiologist husband and four children along the way. She is Chair of the Royal College of Emergency Medicine Women in Emergency Medicine group, and involved with the RCEM Public Health and Informatics groups. Kirsty also produces all those wonderful Paper in a Pic Infographics summarizing each SGEM episode. Dr. Tayler Young Guest Skeptic: Dr. Tayler Young is a second year Family Medicine resident at Queen’s University in Kingston, Ontario, Canada. Her interests are quality improvement, Free Open Access Medical Education (FOAMEd) and point of care ultrasound (POCUS). This is an SGEM Xtra to announce that SGEM Season #10 is now available as a FREE pdf book. The SGEM provided the content and Tayler designed the book. She has designed infographics for the Emergency Medicine Ottawa Blog and has summarized SGEM Season #8 and Season #9 with the Avengers and Batman themes. Tayler chose a Harry Potter theme for Season #10 as she is a huge fan of the films and the books. Her favorite character is Norbert the dragon who was secretly hatched by Hagrid in Book 1. Kirsty's favourite character from the Harry Potter series (being a woman in academic EM, still a male-dominated world – see SGEM #352 on the gender pay gap and our Xtra from October 2021 with the wonderful Dr. Suchi Datta about gender inequity) is Hermione Granger. She is the competent skilled witch who faces pushback for knowing the answers and ostracism for not fitting in. She also confesses to having a soft spot for Neville Longbottom, who is quietly ignored and disregarded until trouble really happens and he comes through with the sword of Gryffindor. SEASON #10 Foreword by Dr. Kirsty Challen Harry Potter arrived in our consciousness in 1997 as an unsupported orphan venturing into the magical world for the first time, facing the ever-present but initially under-appreciated threat of Voldemort with Ron and Hermione. The Skeptics Guide to Emergency Medicine was a few years behind, emerging into the #FOAMEd-o-sphere in 2012, but as Harry and his world developed through the books, so has the SGEM. This 10th Edition arrives as advocates of Evidence-Based Medicine continue to tackle the forces of misinformation and pseudoscience. Like Voldemort rising slowly back to power, many in the Ministry of Magic office of academic medicine failed to spot or believe the level of influence social media would have in the world of 2023. Ken Milne was an early adopter of using social media to narrow the knowledge translation gap and reduce the time it takes for quality research to percolate into clinical practice. This isn’t always easy; as Dumbledore says in the Goblet of Fire “there will be a time when we must choose between what is easy and what is right”. As clinicians it might sometimes seem easier to adopt the line of least resistance; blindly and unthinkingly to follow the “rules” of specialty guidelines or the preferences of consultants. But things are not always what they seem; many initially promising treatments fail to translate to benefit in the longer term and it can be tricky to know which is the Scabbers (apparently benign and well received, eventually found to be treacherous and deadly) and which is the Snape (initially unpleasant but at his core hugely valuable). Dr. Dennis Ren As Harry’s group of friends and allies grew wider through the books, so Ken has grown the SGEM faculty; the rotating cast of the SGEM-HOP has been joined by Dennis Ren leading SGEM-PEDS and an ever-increasing numb...