The Skeptics Guide to 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,

Suchismita Datta, an Assistant Professor at NYU, and Richard Griffey, a Professor at Washington University, dive into innovations in managing diabetic ketoacidosis (DKA). They discuss the SQuID protocol, which uses fast-acting subcutaneous insulin, potentially improving treatment efficiency and reducing emergency department stays. The conversation also critiques study methodologies and the impact of patient demographics on outcomes, emphasizing the need for diverse representation in research. It's a thrilling look at how new protocols can reshape emergency medicine!

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...

Date: August 14, 2023 Reference: Ma et. al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet 2023 Guest Skeptic: Dr. Mike Pallaci is a Professor of Emergency Medicine (EM) for the Northeast Ohio Medical University, and an Adjunct Clinical Professor of EM for the Ohio University Heritage College of Osteopathic Medicine. He has been program director for two EM residency programs, and is currently a core faculty member for the EM residency at Summa Health System in Akron, OH, where he also serves as the Medical Director of the Virtual Care Simulation Lab. This episode originated because of a thread Mike posted on the social media site formerly known as Twitter.  The tweet said: “I am sick and tired of some non-EM docs/specialists slamming EM when we don’t aggressively lower BP in ICH.” It certainly got a lot of attention. It got a lot of attention both on the positive side (mostly from EM docs who share the frustration) and on the negative side from some neurologists who didn’t seem to particularly care for the premise of the tweet or for the generally positive response. It started out with venting on Twitter about an unpleasant interaction with one of Mike's partners and turned into a week-long discussion that culminated in an invitation to be the guest skeptic on the SGEM to critically appraise INTERACT-3. Mike backed up his position on blood pressure (BP) lowering using evidence. Specifically, he pointed out that the evidence behind the guidelines re BP management in intracranial hemorrhage (ICH) is relatively weak. This received a mixed response on Twitter. Most EM physicians shared the frustration and made positive comments. Some neurologists disagreed with the premise of the tweet and challenged it. I responded by posting the 2013 SGEM episode on INTERACT-2 (SGEM#73) which showed no statistical difference between intensive (<140 mmHg) and guideline directed (<180 mmHg).  In 2017, the SGEM reviewed the ATACH-2 trial (SGEM#172) which showed similar results. A meme was also posted of Charlton Heston from the classic movie the Ten Commandments. It emphasized that GUIDElines are not GODlines. The literature should inform and guide our care, but it should not dictate our care. This is a core principle of evidence-based medicine (EBM). Often the available evidence on a specific medical question is weak. We still need to apply our clinical judgement and ask the patient about their values and preferences. Case: A 67-year-old male presents to the emergency department obtunded with left hemiplegia.  Symptoms began just prior to presentation.  His blood pressure (BP) is 194/110 mmHg.  CT reveals a hemorrhage in the right internal capsule, suggestive of acute hypertensive hemorrhagic stroke.  Should the blood pressure be treated?  If yes, what should the target blood pressure be? How quickly do we want to get there? And are there any other physiologic variables we want to be aggressive about controlling in the early treatment window? Background: We have covered the common issue of elevated BP after ICH on SGEM#73 and SGEM#172. The 2022 AHA/ASA guidelines give several recommendations on this topic. The class (strength) of their recommendation is 2a/2b based upon Level B and Level C quality of evidence.   It is really important to pay attention to the specific language used in the guidelines. First of all, as we’ve already covered, a guideline is something developed by humans giving their best interpretation of the evidence to serve as a guide, not something given to Moses on Mount Sinai. But that point aside, the basis of this discussion was that the strength of the evidence behind these guidelines and the strength of the recommendations in the guidelines themselves are frequently misunderstood and/or misrepresented by our consultants.

Reference: Easter JS et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Annals of Emergency Medicine 2014. Date: July 10, 2023 Guest Skeptic: Dr. Joe Mullally is a paediatric trainee in the Welsh paediatric training program and interested in Paediatric Emergency Medicine. He is a student in the Paediatric Emergency Medicine Masters Program through Queen Mary University in London in collaboration with the Don’t Forget the Bubbles team. Dr. Joe Mullally Background: Children have big heads proportionally to their body compared to adults which makes them more at risk of traumatic brain injury (TBI). Computerized tomography (CT) is commonly used in the emergency department in the diagnosis of TBI. But we’re always trying to balance the potential harms and potential benefits in medicine. A CT scan does mean radiation to the pediatric brain which can increase the risk of leukemia or brain cancer later [1]. Thankfully, clinically important intracranial injuries are rare in children [2]. So, should we CT scan children with minor head injury? The SGEM covered pediatric concussions and head imaging in SGEM #112 and the NEXUS II Pediatric Head CT Decision Instrument in SGEM #225. Today we’re talking about three other popular clinical decision rules (PECARN, CATCH, and CHALICE). But we also want to know, how do those rules compare to physician judgement? Clinical Question: What is the diagnostic accuracy of clinical decision rules and physician judgment in identifying clinically important traumatic brain injuries (TBI) in children with minor head injury? Reference: Easter JS et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Annals of Emergency Medicine 2014. Population: Children less than 18 years of age presenting with head injury to a level 2 pediatric trauma center in the United States between 2012-2013. These children have to have 1) history of signs of blunt injury to the head 2) GCS scores ≥13, 3) injury within the previous 24 hours prior to presentation, 4) physician concern for potential TBI Excluded: Heightened TBI risk (GCS<13, brain tumors, ventricular shunts, on anticoagulants, or had bleeding disorders), or if they presented >24 hours after injury Intervention: CT vs no CT Comparison: Comparison of PECARN, CHALICE, CATCH, physician judgement, and physician practice Outcomes: Primary Outcome: “Clinically important TBI” defined as death from TBI, need for neurosurgery, need for intubation >24hrs for TBI, or hospital admission >2 nights for TBI. Secondary Outcomes: TBI on scan TBI requiring neurosurgery (craniotomy, elevation of skull fracture, monitoring of intracranial pressure, or intubation for elevated intracranial pressure) Type of Study: Single center prospective cohort study Authors’ Conclusions: “Of the 5 modalities described (PECARN, CATCH, CHALICE, physician judgment and physician practice), only physician practice and PECARN identified all clinically important TBIs, with PECARN being slightly more specific. CHALICE was incompletely sensitive but the most specific of all rules. CATCH was incompletely sensitive and had the poorest specificity of all modalities.” 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? Unsure  Was the outcome accurately measured to minimize bias? Unsure  Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes How precise are the results? Fairly precise Do you believe the results? Yes Can the results be applied to the local population? Unsure

Join emergency medicine physician Dr. Chris Bond and paramedic Neil MacDonald as they dissect the evolving practices in spinal motion restriction following a workplace injury case. They discuss the shift away from traditional cervical immobilization techniques and the impact of paramedic perceptions on patient care. Delve into the intricacies of statistical methodologies in spinal care research and the debate over cervical collar effectiveness, all while advocating for more personalized and evidence-based approaches in emergency medical protocols.

In this discussion, Dr. Jeff Jarvis, Chief Medical Officer at MedStar and seasoned emergency medicine expert, weighs in on the evolving techniques for intubation, focusing on the debate between video and direct laryngoscopy. He highlights the vital role of first-pass success in emergency settings and shares insights from recent research. The conversation also touches on ethical dilemmas in clinical trials and the challenges of informed consent, particularly in pre-hospital environments. Jarvis's engaging take combines humor with crucial medical insights.