The Skeptics Guide to Emergency Medicine

Date: June 12, 2026 Guest Skeptic: Mr. Ross Fisher. Ross is a paediatric surgeon, presentation guru (P-Cubed), and long-time friend of the SGEM.  Reference: Talan et al. Nonoperative Treatment of Appendicitis and Implications for Emergency Department Management: A Narrative Review. Ann Emerg Med. June 2026 Case: A 29-year-old healthy man presents to the emergency department (ED) with 18 hours of abdominal pain that began around the umbilicus and migrated to the right lower quadrant. He has anorexia, nausea, a temperature of 38.1°C, and focal right lower quadrant (RLQ) tenderness without diffuse peritonitis. The white blood cell (WBC) count is 13,500/µL. CT abdomen/pelvis shows an 8-mm inflamed appendix with periappendiceal fat stranding but no abscess, phlegmon, perforation, mass, or appendicolith. He is hemodynamically stable, not immunocompromised, has no history of inflammatory bowel disease (IBD), can return to the ED if worse, and asks whether he really needs surgery tonight. Background: Appendicitis is one of those diagnoses we don’t want to miss. It’s common, it can be sneaky, and the classic textbook presentation only shows up around half the time. That means labs and scores can help, but they often can’t rule out appendicitis. In 2026, imaging (especially CT scans) is still doing much of the heavy lifting. For more than a century, appendicitis was taught as a surgical emergency: diagnose it, call surgery, and remove the appendix before it ruptures. This new narrative review challenges that mental model. It argues that modern imaging can identify uncomplicated appendicitis, that perforated and nonperforated appendicitis may be biologically different entities, and that short delays to surgery in uncomplicated disease do not appear to increase perforation risk. This new narrative review notes that the American College of Surgeons (ACS) has endorsed antibiotics as a safe alternative for selected patients while continuing to endorse appendectomy. The SGEM has followed this topic for years, and our interpretation of the literature has evolved as the evidence has changed (see list of other SGEM episodes at the end of this blog post). In 2015, the SGEM emphasized diagnostic uncertainty and concern that failed antibiotics could increase morbidity; in 2017, the pediatric conclusion was that NOTA was “not ready for prime time.” By 2019, we were more open to antibiotics in selected patients, using shared decision-making and acknowledging that nonoperative care may be better than we thought, though it may (or may not) come with a small absolute increase in complications. So, the question is no longer whether to cut or not to cut. The ED question is: who is safe for an antibiotic-first pathway, who needs the surgeon now, and who can reliably come back if things go sideways? This is a classic preference-sensitive decision: surgery is highly definitive, while antibiotics may reduce pain, disability, and time away from school or work, but with a meaningful recurrence/appendectomy risk. This review by Talan et al explicitly places emergency physicians in the shared decision-making role for selected uncomplicated appendicitis patients. Clinical Question: In ED patients with imaging-confirmed acute uncomplicated appendicitis, can initial nonoperative management with antibiotics and observation, with appendectomy reserved for worsening, nonresponse, or recurrence, be considered a safe and effective alternative to urgent appendectomy? This matters because appendicitis sits right at the intersection of emergency medicine, surgery, radiology, antibiotics, patient values, and system capacity. Some patients want the most definitive treatment. Others want to avoid surgery if it's safe to do so. Our job is not to sell one option. Our job in the emergency department is to explain the trade-offs. Reference: Talan et al. Nonoperative Treatment of Appendicitis and Implications for Emergency Department Management: A Narrative Review. Ann Emerg Med. June 2026 Population: Adults and children with clinically suspected, localized, imaging-confirmed acute, uncomplicated appendicitis. The included trials enrolled children as young as 5 years and adults older than 80 years. Exclusions: The major exclusions were diffuse peritonitis, severe systemic illness/sepsis, pregnancy, immunocompromise, renal failure, inflammatory bowel disease (IBD), prior antibiotic-treated appendicitis, and imaging evidence of major abscess, phlegmon, perforation, mass, or tumour. Some trials also excluded appendicolith, abnormal WBC thresholds, prolonged pain duration, or older age. Intervention: Nonoperative treatment: initial antibiotics plus observation, with appendectomy if the patient worsened, failed to improve, or later recurred. Antibiotic regimens varied but generally used parenteral antibiotics followed by oral antibiotics to complete a total therapy of 7–10 days. Comparison: Urgent appendectomy with perioperative antibiotics, usually laparoscopic in the more recent trials. Outcome Primary Outcome: There was no single primary outcome in the review. Across the major trials, the most important outcomes were 1-year appendectomy/treatment failure rates for antibiotic-first care, and in CODA, 30-day EQ-5D health-status noninferiority. Secondary Outcomes: Complications/serious adverse events, pain resolution or pain medication use, disability days, recurrence, ED return visits, feasibility of ED discharge/outpatient treatment, cancer detection, cost-effectiveness, and appendicolith subgroup outcomes Type of Study: Narrative review of the major comparative trials, not a true systematic review or meta-analysis. Authors’ Conclusions: “Nonoperative treatment of uncomplicated appendicitis will be increasingly considered as experience and confidence grows among physicians and as awareness grows among patients in this new treatment option. Emergency physicians are being asked about nonoperative treatment of uncomplicated appendicitis and have an important role now to inform patients of their treatment options and expected associated outcomes, and an emerging role in expanding access to safe and cost-effective care for patients with appendicitis, including those who can be managed by nonoperative treatment of uncomplicated appendicitis as outpatients.” Quality Checklist for Systematic Reviews: (Yes/No/Unsure) Was the clinical question sensible and answerable? Yes Was the search for studies detailed and exhaustive? No Were the primary studies of high methodological quality? Unsure Were the assessments of studies reproducible? No Were the outcomes clinically relevant? Yes Was there low statistical heterogeneity for the primary outcomes? N/A Was the treatment effect large enough and precise enough to be clinically significant? Unsure Who funded the review? The authors stated that no funding was received for this work. Did the authors declare any conflicts of interest? The authors reported no conflicts of interest. Results: The review focused on four major comparative trials: APPAC, CODA, MPSC, and APPY. Together, they included more than 2,000 adults and more than 2,000 children. The review did not provide a pooled table of sex, race, baseline pain duration, comorbidities, or socioeconomic demographics. Key Result: In selected patients with uncomplicated appendicitis, antibiotics initially worked in about 90% and reduced pain/disability, but roughly one-third underwent appendectomy within 1 year, with higher appendectomy rates among patients with appendicolith. Primary Outcome: APPAC reported a 1-year appendectomy rate of about 27% in adults treated with antibiotics. CODA found antibiotics noninferior to appendectomy for 30-day EQ-5D health status, but the 1-year appendectomy rate was 36% without appendicolith and 52% with appendicolith. MPSC reported a 1-year appendectomy rate of about 33% in children APPY reported about 34% treatment failure/appendectomy in the antibiotic group. The table on page 3 of the review summarizes these trial-specific results. Secondary Outcomes: These generally favoured antibiotics for short-term recovery, but not always for adverse events. APPAC reported fewer 1-year complications with antibiotics than surgery, 2.8% vs 20.5%, with faster pain resolution and fewer disability days. CODA reported similar serious adverse event rates, 3% vs 3%, and fewer disability days with antibiotics. MPSC reported similar complicated appendicitis rates, 3.6% vs 3.3%, and fewer disability days with antibiotics. APPY reported no serious adverse events in either group, but more mild-to-moderate adverse events with antibiotics, largely GI distress; antibiotics reduced post-discharge pain medication use and disability days. The ED discharge data came mainly from CODA. In a CODA sub-analysis, 335 of 726 antibiotic-treated adults, 46%, were discharged from the ED after longer-acting parenteral antibiotics, observation, oral tolerance, stable status, and pain control. Serious adverse events over 7 days were uncommon: 0.9 per 100 outpatients vs 1.3 per 100 inpatients. ED discharge was associated with fewer appendectomies and about one day less disability, without a significant increase in first-week ED return visits. Summary of the Four RCTs: 1. Narrative Review: This was not a systematic review, and that matters. No PRISMA diagram, no duplicate screening, no formal risk-of-bias assessment, and no pooled estimate. That does not make it useless, and we should not judge it against a formal SRMA. It just means we should treat it for what it is, an expert narrative synthesis, not the final word. Open Label 2. Open-Label: The included RCTs were not masked and vulnerable to performance, detection, and preference bias. You really can’t blind antibiotics vs surgery....

Date: April 21, 2026 Lauren Openshaw Guest Skeptic: Lauren Openshaw is a medical student at the George Washington University School of Medicine & Health Sciences, Class of 2027, where she is a part of the Disaster Medicine Scholarly Concentration. Her clinical interests include pediatrics, disaster medicine, critical care, and emergency preparedness, particularly as they relate to protecting vulnerable children during natural disasters and public health crises. Background:  Floods, fires, hurricanes, blizzards, cyberattacks, hospital surges, the list goes on. Disasters are no longer just movie events or rare abstractions. These are real-world events that disrupt and change how we care for patients and families. We spend a lot of time in training learning how to manage sepsis, trauma, asthma, etc. But disaster medicine? For many learners and clinicians, that part of the curriculum is thin, fragmented, or missing entirely.  Not every medical school has a disaster medicine concentration. There is typically very minimal formal teaching around disasters, if any, in the medical school curriculum. Today, we’d like to introduce our audience to a new Free Open Access to Medical Education (FOAMed) resource, the Disaster Medicine Handbook, which we like to call the front door to disaster medicine. Tune in to the podcast to hear Lauren's perspective on this resource and how she's used and contributed to it. The Gap Let’s start with the basic question: why create something like this at all? Many trainees, nurses, Emergency Medical Services (EMS) clinicians, and even attending physicians may have heard of terms like surge capacity, incident command, crisis standards of care, evacuation, decontamination, and major incident triage. We know these things matter, and they affect children, families, hospitals, and communities.  However, there's often no good starting point in disaster medicine for students, residents, or other learners. That’s the space the Disaster Medicine Handbook is trying to fill. It was built for the person who is curious, motivated, maybe a little intimidated, and looking for a place to begin. It depicts key topics in disaster medicine in a friendly, digestible format that also incorporates a pediatric lens.  That idea of an entry point is really important. This is not trying to replace formal disaster training, advanced courses, or deeper reference material. It’s trying to do something else: help someone say, “Okay, now I finally understand the basics in words that make sense.”  Plain Language One of the things we like most about many existing FOAMed resources and what we’ve adopted for the Handbook is that it starts from a very simple premise: explain disaster medicine in normal words.  Disaster medicine is full of technical language, acronyms, frameworks, and systems terminology. That can be useful once you’re in the field, but it can also become a barrier for people who are just trying to understand the fundamentals. We love this quote attributed to Einstein, “Everything should be made as simple as possible, but not simpler.” That’s the balance we try to strike. We recognize that disaster medicine, with its various frameworks and systems, is complex. Our goal is to make it more understandable and accessible.  We want it to pique interest and give people that “aha” moment that unlocks a complicated concept, leaving them curious to learn more. Which is why we have references and resources to further material.  Bite-Size, Choose-Your-Own-Adventure  These are bite-sized chapters. Short, focused, digestible pieces that you can read in one sitting.  After a busy clinical day, it’s hard to sit down and read a giant textbook chapter or digest a dense academic article. We often try to learn between other tasks or during parts of our day, before a conference, on our commute, or during a quiet moment in the department. Maybe even in the ten minutes after seeing something pop up in the news, you realize, I should probably understand this better. It’s built like a choose-your-own-adventure. You don’t have to start at page one and go in order. You start with your question. If you want to understand triage, start there. If you’re interested in surge, start there. If you want to know how to prepare children and families, start there. That kind of navigation matters because curiosity is not linear. Lauren has used and shared this resource a few times. Tune in to hear how she's used it.  Peer-Reviewed and Living The next piece is quality and evolution. FOAMed sometimes gets a bad rap because some people believe it’s not high-quality, even though it hasn’t undergone the traditional peer-review process. (There are potential issues around peer review which have been written about elsewhere.) The Handbook is peer-reviewed by subject matter experts. In fact, the content and chapters are reviewed by many experts who provide comments and feedback before publication. It is a living resource. It is not static. Our goal is for it to grow, change, and improve over time. Balancing the evolution and quality of the resource is important to us. On the one hand, it stays dynamic. On the other hand, it still has rigour. Community Maybe the most distinctive part is that this resource is built around community. There’s a forum where learners and contributors can suggest revisions, flag areas that need clarification, propose new topics, and even contribute to writing future chapters. This was inspired by the community around Don’t Forget the Bubbles. It changes the relationship between the audience and the resource. You’re not just passively consuming content. You can help shape what comes next. Some of the early visible contributors are medical students and trainees. That sends a strong message that we value the learner perspective and that this field is open to you. For our audience: Go check out the Disaster Medicine Handbook. Don’t worry about reading everything. Just pick one chapter that catches your eye. Read it. See if it helps something click. And then join the forum. Ask a question. Suggest a revision. Propose a topic. If you’re a learner and you’ve ever thought, "I wish someone would explain this better," this is a chance not only to learn but to help build the resource you wish you had. Remember, the goal here is not to turn everyone into a disaster medicine expert overnight. It’s to create a clear and welcoming first step. A front door. The SGEM will be back next episode, doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over 10 years to less than 1 year using the power of social media. So, patients get the best care, based on the best evidence. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. Resources: GW DM Scholar Concentration Resources page https://ospe.smhs.gwu.edu/disaster-medicine-resources

Date: May 20, 2026 Guest Skeptic: Dr. Matt McArthur is an ED Physician working primarily in Guelph and Kitchener with occasional rural locums in the small town of Walkerton, where he grew up. His clinical interests include POCUS, emergency cardiology, QI, knowledge translation, motivational interviewing, and vertigo. He is very active in medical education, including as a clinical skills and POCUS instructor, a Contributing Editor with the EMCases Podcast, and Regional Education Lead for Undergraduate Family Medicine at the Waterloo Regional Campus of McMaster University. Reference: Qiang et al. Safety and Effectiveness of Subcutaneous Insulin for Management of Mild to Moderate Diabetic Ketoacidosis in Non-Pregnant Patients: A retrospective cohort study at a tertiary care centre. Canadian Journal of Diabetes. Oct 2025 Case: A 56-year-old woman with insulin-treated type 2 diabetes presents to the emergency department (ED) with 24 hours of nausea, vomiting, polyuria, and weakness after missing insulin doses during a viral illness. She is alert, mildly tachycardic, normotensive, breathing slightly fast, and appears dry but not toxic. Her labs show glucose 23 mmol/L, pH 7.26, bicarbonate 14 mmol/L, an anion gap of 22, and positive serum ketones. You diagnose her with diabetic ketoacidosis (DKA). After initial IV fluids, she has clinically improved and does not require any vasopressors or airway support. The practical question is whether she really needs an intravenous (IV) insulin drip and intensive care unit (ICU)-level care, or whether a structured subcutaneous (SC) insulin pathway would be safe and effective. Background: DKA is one of the classic endocrine emergencies that lands squarely in the wheelhouse of emergency medicine. It is a state of insulin deficiency that leads to progressive dehydration, electrolyte deficits, and acidemia, which together can be fatal if untreated. Clinically, these patients show up with some combination of polyuria, polydipsia, nausea, vomiting, abdominal pain, tachypnea or Kussmaul respirations, dehydration, and sometimes altered mental status. Since the discovery of insulin by Fredrick Banting in Toronto in 1921, the treatment of DKA has changed dramatically in the last 100 years. Prior to insulin, the mortality from DKA was thought to exceed 95%. In modern times, the mortality is less than 1%. As a reminder, Sir Frederick Banting, Charles Best and James Collip, sold the patent for insulin to the University of Toronto for just $1 in January 1923. Banting famously stated, “Insulin does not belong to me, it belongs to the world”. DKA treatment involves protocol-based care, including IV rehydration to address hypovolemia; insulin therapy to stop ketoacidosis and restore normal metabolism; electrolyte and dextrose replacement to correct deficits, with regular monitoring of glucose and electrolytes (especially potassium) during treatment. Most hospitals have labour-intensive DKA protocols involving IV insulin infusion, which often require patients to be admitted to the ICU due to high nursing demands. However, with the introduction of rapid-acting subcutaneous (SC) insulin analogues in the late 1990s, such as insulin lispro and aspart, some clinicians have evaluated the use of rapid-acting SC insulin boluses as an alternative to IV infusion. SGEM has already dipped a toe into these waters in SGEM#414, which covered the SQuID protocol. That episode asked whether adults with mild-to-moderate DKA could be treated with fast-acting subcutaneous insulin on a non-ICU floor, resulting in shorter ED length of stay. That study by Griffey et al in AEM highlighted the operational appeal of avoiding an insulin drip and an ICU bed for every uncomplicated DKA patient. Between 2004 and 2016, six small randomized controlled trials found no difference in safety between SC insulin boluses and IV infusions in adults. Given the safety evidence and out of a desire to provide more efficient DKA care and avoid unnecessary ICU admissions, some hospitals have designed and implemented SC insulin-based treatment protocols as a first-line option for uncomplicated DKA patients and have published their outcomes in the medical literature. In the last five years, several observational studies have been published reporting patient and operational outcomes after implementation of a hospital-wide SC DKA protocol. That includes SQuID I by Griffey et al (SGEM#414), as well as SQuID II, which provided a further report on outcomes in the same hospital in St Louis. Additionally, we have seen Rao's 2022 report on their protocol introduced at Kaiser Permanente San Jose, Stuhr et al. in 2023 from Utah, and Ibarra et al. in Fresno in 2026. There were also Diabetes Consensus Guidelines published in 2024 that endorse the use of SC insulin in DKA. Clinical Question: In nonpregnant adults with mild to moderate DKA, is SC insulin a safe and effective alternative to IV insulin for DKA management? Reference: Qiang et al. Safety and Effectiveness of Subcutaneous Insulin for Management of Mild to Moderate Diabetic Ketoacidosis in Non-Pregnant Patients: A retrospective cohort study at a tertiary care centre. Canadian Journal of Diabetes. Oct 2025 Population: Nonpregnant adults aged 18 years or older admitted with mild or moderate DKA defined as an elevated urinary or serum ketones plus at least two of: pH 12 mmol/L, or glucose >14 mmol/L; euglycemic DKA could have relatively normal glucose.  Excluded: Severe DKA or unknown DKA severity, insufficient data, incomplete treatment, patients treated with both IV and SC insulin, insulin pump cases, pregnancy, reduced consciousness (GCS 160 kg. Patients not eligible for the SC protocol also included those with these higher-acuity features.  Intervention/Exposure: SC insulin protocol: glargine 0.3 U/kg (or home dose) plus aspart 0.2 U/kg every 4 hours unless glucose fell below 14 mmol/L, with glucose checks every 2–4 hours and electrolytes/blood gas every 4 hours; fluids and replacement per treating physician.  Comparison: Standard IV insulin treatment.  Outcome: Primary Outcome: Co-primary outcomes were time to anion-gap closure and hospital length of stay (LOS). Secondary Outcomes: Hypoglycemia, hypokalemia, and anion-gap acidosis requiring intervention within 24 hours.  Type of Study: Retrospective cohort study. Authors’ Conclusions: “These results suggest SC insulin is safe. Although it may take 8.4 hours longer to close the AG with SC insulin, there is less hypoglycemia and hypokalemia and no difference in LOS in hospital.”  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? No Was the follow-up of subjects complete enough? Yes How precise are the results? Unsure Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Funding of the Study? It was supported by a Quality Improvement Grant from Banting and Best Diabetes Centre Innovative Diabetes. Did the authors declare any conflicts of interest? None were declared. Results: The final cohort included 153 unique admissions: 92 treated with IV insulin and 61 with SC insulin. The mean age was about 57 years in both groups. Women made up 53% of the IV group and 54% of the SC group. Type 2 diabetes predominated (65% IV, 69% SC), with type 1 diabetes making up about one-third (33% IV, 31% SC). Euglycemic DKA was present in 24% of IV-treated patients and 16% of SC-treated patients. The IV group appeared sicker at baseline, with more moderate DKA (37% vs 11%), more renal dysfunction (33% vs 13%), and more neurologic dysfunction (17% vs 3%). About 30% of the cohort was taking an SGLT2 inhibitor.  Key Result: IV insulin closed the anion gap more quickly, but SC insulin caused less hypoglycemia and hypokalemia, with no meaningful difference in hospital length of stay or in anion-gap reopening requiring intervention. Primary Outcomes: IV insulin was faster to close the anion gap: adjusted median 15.6 hours versus 24.0 hours for SC, with an adjusted hazard ratio of 0.65 (95% CI 0.45 to 0.92; p=0.02) There was no statistically significant difference in hospital LOS: adjusted relative risk 0.83 (95% CI 0.61 to 1.13; p=0.24).  Secondary Outcomes: 1a. Confounding by Indication: Treatment was not randomized; the treating physician chose IV or SC insulin. In a cohort study, the exposed and comparison groups should have the same prognosis if we want a minimally biased estimate of the effect. Here, the IV group was clearly sicker at baseline, with more moderate DKA, more renal dysfunction, and more neurologic dysfunction. Multivariable adjustment helps, but no regression model can fully remove bias from unmeasured or poorly measured prognostic differences in a retrospective cohort study. 1b. Critical Appraisal of a Hospital Implementation/Quality Improvement (QI) Study: This is an observational study in which the authors retrospectively report on outcomes in their hospital after they introduced a new treatment protocol. So, we must appraise it for what it is, and not read it like an RCT. Observational studies, particularly QI/implementation studies like this one, generally aim to determine whether a given intervention in a specific healthcare setting was feasible and effective. QI studies are highly specific to the site where they took place. ...

Reference:  Perry DC, et al. Non-surgical casting versus surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study): a multicentre, randomised, controlled non-inferiority trial and economic evaluation. Lancet April 2026. Date: May 8, 2026 Dr. Andrew Tagg Guest Skeptic:  Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder and website lead of Don’t Forget the Bubbles. Case: A healthy 7-year-old boy presents to the emergency department (ED) with obvious deformity of the wrist after a fall from playground equipment. X-rays show a severely displaced distal radius fracture, with an associated ulnar fracture. The child is neurovascularly intact. But the wrist looks dramatic. It’s quite bent. The child gazes at his arm, a mix of fear and intrigue. You consult the friendly orthopedics specialist who greets the family and recommends reduction under sedation because “it looks too crooked to leave alone.” You recall that in younger children, some fractures can remodel quite well on their own. The child’s father asks you whether you think the boy really needs a procedure to re-align the bones, or if he can just be placed in a cast.  Background: Distal radius fractures are among the most common fractures in childhood, and severely displaced injuries create one of those classic tensions between what looks bad on an X-ray and what matters to patients over time. Traditional teaching has favored reduction, often under sedation or general anesthesia, to restore anatomy and avoid concerns about deformity, loss of motion, or unhappy families. But pediatric bone is not adult bone. Younger children have substantial remodeling potential, especially near active growth plates, and prior observational studies suggested that even very displaced distal radial fractures can straighten out over time with good function. Many clinicians still feel uneasy leaving these fractures unreduced. The visual deformity can be alarming. Families may equate straight bones with proper healing. Procedural reduction also comes with costs and potential harms: anesthesia, sedation, procedural pain, wound complications, etc. Clinical Question: In children aged 4 to 10 years with severely displaced distal radial fractures, is non-surgical casting non-inferior to surgical reduction for functional recovery? Reference:  Perry DC, et al. Non-surgical casting versus surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study): a multicentre, randomised, controlled non-inferiority trial and economic evaluation. Lancet April 2026. Population: Children aged 4 to 10 years from 49 UK hospitals with severely displaced distal radial fractures, either metaphyseal or Salter-Harris II, with or without an associated ulnar fracture. Exclusion: Injury >7 days, complex wrist fractures that were open or extending into the joint, additional fractured bones elsewhere, inability to adhere to trial procedures or follow up. Intervention: Non-surgical casting without purposeful manipulation, without sedation or general anesthesia. Comparison: Surgical reduction under general anesthesia or conscious sedation, with fixation permitted at the surgeon's discretion. Outcome: Primary Outcome: Patient Report Outcomes Measurement System (PROMIS) Upper Extremity Score for Children at 3 months. Secondary Outcomes: Pain, health-related quality of life, cosmesis, complications, refracture, unplanned surgery, school absence, parental satisfaction, and cost-effectiveness. Trial: Pragmatic, multicenter, randomized, controlled non-inferiority trial with economic evaluation Authors’ Conclusions: “The CRAFFT trial did not demonstrate non-inferiority of non-surgical casting at 3 months against a conservative margin; however, the observed difference in favour of surgical reduction was small, below thresholds that families considered meaningful, and did not persist beyond early recovery. Surgical reduction was associated with higher costs, early procedural complications, and only a modest improvement in cosmetic appearance, supporting consideration of a cast-first strategy for most children.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes 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. Yes, Who funded the study? Funded by the National Institute for Health and Care Research Health Technology Assessment programme and supported by the NIHR Oxford Biomedical Research Centre. Financial conflicts of interest. One author declared paid lectures for Smith & Nephew and Arthrex; all other authors declared no competing interests. Results: The trial enrolled 750 children, with 375 randomized to non-surgical casting and 375 to surgical reduction. The median age was 7.9 (IQR 6.5-9.5) years, with 456 (61%) being male. 44% had completely off-ended or displaced fractures. Key Results: In children aged 4 to 10 with severely displaced distal radius fractures, surgery provided a small early functional advantage, but the difference was not clinically meaningful and disappeared in later months. Non-surgical casting was less expensive and had fewer early complications. Primary Outcome: PROMIS Upper Extremity score was: 44.9 in the non-surgical group vs 46.6 in the surgical group Adjusted mean difference was minus 1.64 points [95% CI -2.84 to -0.44], favouring surgery. This confidence interval crossed the prespecified conservative non-inferiority margin of 2.5. Non-surgical casting did not meet formal non-inferiority for the full cohort. Secondary Outcomes: There are several secondary outcomes from this study (check out the paper for more detail). Secondary outcomes mostly told a small early advantage, little long-term difference story. First, in the pre-specified subgroup with completely off-ended fractures, non-surgical casting was non-inferiority. Keep in mind this threshold was a bit wider with a margin of minus 5 points. When they looked at PROMIS scores over time, there was really no functional difference between groups by 6 and 12 months. Surgical patients had more early complications, including pressure injury, wound infection, scarring, and nerve irritation. Cosmesis slightly favored surgery early on, but the gap narrowed over time Non-surgical casting saved about £1665 per patient and had a 100% probability of being cost-effective at standard UK willingness-to-pay thresholds. Statistical vs Clinical Significance This was a non-inferiority trial, but whether something is ‘non-inferior’ depends entirely on where you draw the line. The margin was –2.5 PROMIS points, and the result was minus 1.64 with the 95% confidence interval barely crossing the prespecified margin at -2.84. So technically, it failed non-inferiority. It’s important to keep in mind that, because they had incorporated patient and public involvement across many aspects of the trial, they knew that families said a 5-point difference mattered. They chose a bit more conservative margin of -2.5. This is one of those trials where the statistics say, ‘maybe not’… but the patients say, ‘we don’t care.’ And we care about the POOs, those patient-oriented outcomes, more. Lack of Masking (and why it matters here) One thing worth pausing on is the lack of masking. In this trial, neither clinicians nor families were masked to the treatment, and the primary outcome was a parent-reported function measure using PROMIS. That combination matters because it opens the door to expectation bias, which is a form of observer bias. If your child has gone to theatre, had an anaesthetic, and the bone has been “put back in place,” it’s very natural to feel that something definitive has been done. It feels like proper treatment. On the other hand, if the arm has been put in a cast and left looking a bit bent, that can feel like something has been left unfinished even if it’s entirely appropriate. When we see a small early functional advantage for surgery, it’s worth asking how much of that is true benefit, and how much might be shaped by perception. Because if you’ve just watched your child go through a procedure, you might understandably feel like they’re doing better, regardless of what’s happening at the level of bone healing. There’s a lot of additional information in the supplemental section, but one part includes parental satisfaction scores, and there were really no big differences between the two groups. Selection Bias / Equipoise Problem Another interesting aspect is who made it into the trial. Of the 1,227 children who were eligible, only 750 were randomized. Many families declined to participate, and a notable proportion of clinicians felt there wasn’t enough equipoise to even offer enrollment. Some of these exclusions based on clinician equipoise seem warranted like concern for neurovascular compromise. When it came to the families who declined consent, most of them declined because they had a preferred treatment…which more preferring surgical reduction. ...

Date: April 23, 2026  Guest Skeptic: Dr. Manrique Umaña McDermott is an attending physician specializing in Emergency Medicine based in San José, Costa Rica. He has a passion for medical education, is a renowned international speaker and serves as a faculty member in undergraduate Internal Medicine at UCIMED and postgraduate training programs in Emergency Medicine and Family and Community Medicine at the University of Costa Rica (UCR). You can follow him on X and Instagram at @umanamd.  Reference: Zhang et al. Coffee and Tea Intake, Dementia Risk, and Cognitive Function. JAMA 2026 March Case: A 47-year-old emergency physician presents to their primary care physician for a rare act of preventive care between a run of night shifts. She drinks 3 large coffees most workdays, switches to tea on post-nights when her hands are vibrating fast enough to start an IV at 20 paces and asks whether her caffeine habit is frying her brain or secretly protecting it. She has heard that coffee is either a miracle, a menace, or both, depending on which headline got posted in the group chat that week. Background: Coffee’s origin story reads like a case report from the annals of caffeinated discovery. Legend traces it back to Ethiopia, where a goat herder observed his animals behaving like over-caffeinated residents after nibbling on certain berries. From there, coffee spread through the Arabian Peninsula, where it was first cultivated and consumed in Yemen, eventually fueling the rise of coffeehouses. By the 17th century, coffee had reached Europe, where it was alternately praised as a miracle tonic and condemned as a suspicious stimulant. Over time, coffee became embedded in global culture, transitioning from a mystical brew to an industrial-scale commodity, and ultimately, a critical adjunct in emergency medicine workflow optimization. Costa Rica takes coffee seriously, arguably more seriously than most emergency departments (EDs) take shift coffee orders. Introduced in the late 18th century, coffee quickly became a cornerstone of the country’s economy and identity. The government actively promoted coffee cultivation, even offering farmers free land to grow it, resulting in a thriving industry based on small family farms rather than large plantations. Costa Rican coffee is renowned for its high quality, thanks to ideal growing conditions: volcanic soil, high altitude, and just enough rain to keep things interesting. The country even banned the production of low-quality coffee. Today, Costa Rica is a leader in sustainable coffee production. So, the next time you’re powering through a night shift, there’s a good chance your cognitive performance is being supported by carefully cultivated beans from a hillside in Central America. Emergency physicians do not need a pathophysiology lecture on caffeine; they need a fresh cup. Coffee is practically a staffing model, while tea is the civilized cousin, and both have long been part of the informal pharmacopeia of night shift survival. The real question is whether our specialty’s favourite legal liquid stimulant does anything beyond keeping our differential diagnoses alive until sunrise. Biologically, the hypothesis is plausible. Coffee and tea contain caffeine and other bioactive compounds, including polyphenols, that may influence oxidative stress, neuroinflammation, vascular function, and insulin sensitivity. These are all pathways that could plausibly matter for cognitive decline and dementia. But human studies have been inconsistent, and many older studies did not clearly distinguish between caffeinated and decaffeinated coffee.  Clinical Question: Is long-term intake of caffeinated coffee, decaffeinated coffee, or tea associated with incident dementia and cognitive outcomes? Reference: Zhang et al. Coffee and Tea Intake, Dementia Risk, and Cognitive Function. JAMA 2026 March Population: Adults from the Nurses’ Health Study (NHS) and Health Professionals Follow-up Study (HPFS). Excluded: People with cancer, Parkinson’s disease, or dementia at baseline; those with implausible total energy intake; and those missing caffeinated beverage intake data.  Exposure: Long-term intake of caffeinated coffee, decaffeinated coffee, and tea, assessed every 2 to 4 years with validated food frequency questionnaires (FFQs).  Comparison: Lower intake categories, especially the lowest quartile or tertile of consumption, depending on the beverage.  Outcomes: Primary Outcome: Incident dementia, identified via death records and physician diagnoses.  Secondary outcomes: Subjective cognitive decline and objective cognitive function; objective testing was assessed only in the NHS cohort, including a telephone interview for cognitive status (TICS) and composite cognitive measures.  Type of Study: Prospective observational cohort study. Authors’ Conclusions: “Greater consumption of caffeinated coffee and tea was associated with lower risk of dementia and modestly better cognitive function.”  Quality Checklist for Observational Studies: 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? Reasonably for the primary outcome. Do you believe the results? Yes Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Who funded the study? Multiple National Institutes of Health grants. Did the authors declare any conflicts of interest? Yes. Dr. Hu reported receiving research support from the Analysis Group; no other disclosures were reported. Result: The study included 131,821 middle-aged US health professionals from 2 cohorts: female nurses in the NHS and male health professionals in the HPFS. The mean age at baseline was 46.2 years in NHS and 53.8 years in HPFS, and 66% of the pooled sample was female. Follow-up was extraordinarily long, up to 43 years, with a median of 37 years. Higher coffee consumers tended to be younger, drink more alcohol, smoke more, and consume more total energy.  Key Result:  Higher caffeinated coffee intake was associated with lower dementia risk. Primary Outcome: Incidence of dementia HR 0.82 (95% CI 0.76 to 0.89) Secondary Outcomes? Higher caffeinated coffee intake was associated with lower prevalence of cognitive decline, 7.8% versus 9.5% in the highest versus the lowest quartile, prevalence ratio 0.85. In the NHS objective testing subgroup, higher caffeinated coffee intake was associated with a small increase in the telephone interview for cognitive status (TICS) score (mean difference 0.11), whereas the global cognition result (mean difference 0.02) did not reach conventional statistical significance. Tea showed similar patterns; decaf did not.  1. Residual Confounders: This is the biggest threat. Observational cohort studies are appropriate for exposure questions but inherently vulnerable to bias from prognostic differences between the exposed and the unexposed groups. Even after multivariable adjustment, coffee and tea drinkers may differ from lower-intake participants in ways that matter for cognition. These include sleep habits, education, work patterns, health-seeking behaviour, medication use, diet quality, and unmeasured social factors. The authors acknowledge residual confounding, including neuroactive drugs that were not fully captured across follow-up.  2. Reverse Causation: Even in a prospective cohort, early cognitive decline could influence beverage habits or the reliability of dietary self-report before formal dementia diagnosis. Someone drifting into cognitive decline may reduce coffee intake due to sleep disturbance, jitters, gastrointestinal symptoms, or a caregiver’s influence, making coffee appear protective when declining cognition changes the exposure. The authors conducted sensitivity analyses but still acknowledge that reverse causation cannot be fully excluded.  3. Imperfect Exposure Measurement: Repeated validated food frequency questionnaires (FFQs) are better than a single baseline diet snapshot, yet they cannot fully capture brew strength, cup size, preparation method, shifts between caffeinated and decaf products, or additives like sugar and cream. Mismeasurement of exposure can distort observed associations, and nutrition studies are especially vulnerable because the dose is harder to standardize than a prescription drug.  4. Outcome Ascertainment: The primary outcome relied on death records and self-reported physician diagnoses, with medical-record confirmation when available. That is pragmatic and probably better in health professionals than in the general population, but it still leaves room for missed cases and misclassification. The authors also could not isolate Alzheimer's disease specifically, which matters because all-cause dementia may lump together biologically distinct conditions with different relationships to caffeine.  5. Time-Varying Confounding & Imperfect Capture of Exposure Over Time: This combines nerdy point #1 and #3. Although the authors used repeated FFQs, beverage consumption is likely to change meaningfully over a 30- to 40-year follow-up. Participants may switch between caffeinated and decaffeinated coffee, change dose, or modify intake due to early (subclinical) cognitive decline, sleep issues, comorbidities, or physician advice. Even with cumulative averaging, this introduces time-varying confounding and exposure misclassification, which represents a major threat in longitudinal observational studies....

Reference: Burstein B, et al. Prediction of Bacteremia and Bacterial Meningitis Among Febrile Infants Aged 28 Days or Younger. JAMA. Published online December 08, 2025. Date: April 3, 2026 Dr. Margarita Ramos Guest Skeptic: Dr. Margarita Ramos is a pediatric hospitalist at Children’s National Hospital in Washington, D.C., and Assistant Professor of Pediatrics at the George Washington University School of Medicine and Health Sciences where completed the Master Teacher Leadership Development Program in 2024. Her scholarly interests include equity in medical education and health services research. Case: A 12-day-old boy is brought to the emergency department (ED) by his parents for fever. At home, he felt a little warm, so they took his temperature and found it was 38.3°C. The family called the boy’s pediatrician, who told them to bring him to the ED immediately. The baby has been feeding well. He has had a normal number of wet diapers and stools. He has no other medical history and was born full-term. On your exam, the baby looks good. There is no obvious source for his fever. His parents say to you: “Our pediatrician told us that fevers at this age are worrisome, and our baby may need a lot of testing, including something called a lumbar puncture. We looked it up, and it sounds really scary. Do we have to do all that?” Background: We’re back on the topic of well-appearing febrile infants, and things have changed! Specifically, the “limbo” bar of age for which of the infants requiring a lumbar puncture (LP) has dropped quite a bit. Some may recall practicing at a time when any febrile babies ≤3-months-old were getting an LP. Later, that bar had dropped down to febrile babies ≤28 days getting an LP. Along the way, we’ve had various tools to help guide us in identifying babies at low risk for what was once termed a serious bacterial infection (SBI), including urinary tract infection, bacteremia, and bacterial meningitis. These included tools like the Philadelphia, Rochester, and Boston criteria that risk-stratified based on pre-determined thresholds for temperature, lab tests, urine studies and more. In 2019, the Pediatric Emergency Care Applied Research Network (PECARN) derived and validated a clinical decision rule for identifying low-risk febrile infants based on urine, absolute neutrophil count (ANC) and procalcitonin. We covered this study in SGEM#296. The rounded PECARN Rule is: Negative urinalysis Absolute Neutrophil Count (ANC) ≤4,000/µL Serum procalcitonin ≤0.5 ng/ml In 2021, we saw the limbo bar drop again with new guidance from the American Academy of Pediatrics (AAP) covered on SGEM#341. The age for LP moved down to 22 days. Based on this guideline, the decision to perform LP on infants from 22 to 28 days could be guided by inflammatory markers. There was also another shift. Instead of focusing on SBIs, which included UTIs, one of the most common sources of infection, researchers started to focus on bacteremia and bacterial meningitis, termed invasive bacterial infections (IBIs), which have very bad consequences if missed. Right now, the bar sits around 21–22 days because that’s where the data feels comfortable. And to be fair, newborns are different from older infants. Their immune systems are immature, their symptoms are subtle, and the consequences of missing meningitis are enormous. So naturally, we are cautious. Clinical Question: How accurately can the PECARN rule identify febrile infants 28 days or younger at low risk for invasive bacterial infections? Dr. Brett Burstein Reference: Burstein B, et al. Prediction of Bacteremia and Bacterial Meningitis Among Febrile Infants Aged 28 Days or Younger. JAMA. Published online December 08, 2025. Population: well-appearing febrile infants ≤ 28 days, temperature ≥38°C, from four prospective cohort studies across six countries within the global Pediatric Emergency Research Network (PERN) who underwent testing with PECARN rule components (procalcitonin, ANC, UA/urine dipstick). Excluded: Criteria differed across the included studies. Some exclusion criteria included prematurity, pre-existing medical conditions, and being critically ill. Other studies excluded infants with viral signs. Intervention: PECARN clinical decision rule Comparison: None Outcome: Diagnostic accuracy of the PECARN rule to identify infants with IBI (bacteremia or bacterial meningitis) Type of Study: A pooled analysis of 5 published prospective cohort studies that was analyzed using meta-analytic methods to assess diagnostic accuracy Guest Authors: Dr. Nathan Kuppermann Dr. Brett Burstein is a paediatric emergency medicine physician at Montreal Children’s Hospital and Associate Professor in the Department of Pediatrics at McGill University. His research focuses on the care of febrile young infants, emphasizing parental preferences, shared decision-making, and family-centered outcomes.  Dr. Nathan Kuppermann is executive vice president, chief academic officer of Children’s National Hospital and director of the Children’s National Research Institute. He also serves as chair of the Department of Pediatrics and associate dean of Pediatric Academic Affairs at the George Washington University School of Medicine and Health Sciences. Dr. Kuppermann is a pediatric emergency medicine physician, clinical epidemiologist and leader in emergency medical services for children.   Authors’ Conclusions: “The updated PECARN rule had higher sensitivity but lower specificity for identifying febrile infants 28 days or younger with invasive bacterial infections, with no missed cases of bacterial meningitis. These results may support shared decision-making regarding selective vs routine use of lumbar puncture among infants classified as low risk.” Quality Checklist for Systematic Review Diagnostic Studies The diagnostic question is clinically relevant with an established criterion standard. Yes The search for studies was detailed and exhaustive. No The methodological quality of primary studies were assessed for common forms of diagnostic research bias. Yes and No. The assessment of studies was reproducible. Yes There was low heterogeneity for estimates of sensitivity or specificity. No  The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. Yes Funding of the Study: No industry funding was reported Conflicts of Interest: No major conflicts of interest were reported Results: They included 1537 infants in the primary analysis, of whom 69 (4.5%) had IBI. The majority were male (~59%) and presented within 12 hours of fever onset. Not surprisingly, most (86.15%) were hospitalized. Approximately 41% of infants met PECARN low-risk criteria. Of those infants who had invasive bacterial infections: 58 with bacteremia 11 with bacterial meningitis (0.7%) The prevalence of IBI ranged from 2.5% to 7.3% between studies. Key Results: The PECARN clinical prediction rule for identifying febrile infants ≤28 days at low risk for invasive bacterial infection has good sensitivity but low specificity. It did not miss any infants with bacterial meningitis. The rule had a sensitivity of 94.2%, specificity of 41.6%, negative predictive value of 99.4%, and negative likelihood ratio of 0.14. They also conducted a secondary analysis across all six cohorts (n=2531) that included the PECARN cohorts. The accuracy was quite similar. All six cohorts together had 96 (3.8%) cases of IBI with 22 (0.9%) cases of bacterial meningitis. The PECARN rule did misclassify 5 infants as low risk. Three infants had bacteremia with S. aureus, H. influenzae, and E. coli. The other two infants had positive urine cultures with E. coli, one of whom had concurrent E. coli bacteremia while the other had S. aureus bacteremia. Tune into the podcast to hear Brett and Nate answer our questions! Measurement of Temperature: Here in the United States, we are more accustomed to measuring core temperature, especially in this very young population, rectally. It is mentioned that rectal temperature is used in three of the included cohort studies. But one study included temperatures measured by any method. There is differing evidence regarding the accuracy of temperature measurement by different methods. How do you think the inclusion of that patient population may have affected your results? Biases: Some of the exclusion criteria may introduce selection bias. For example, in two of these study cohorts, patients were excluded because they had “viral signs present.” The AAP febrile infant guideline excludes infants with clinical bronchiolitis but states that infants with respiratory symptoms or positive viral test results may still be included. What do you think about excluding babies with viral symptoms from the workup? How does the exclusion of those babies with viral signs in the two cohorts mentioned affect your results? Here are some other examples of potential biases: Not all infants in the pooled cohorts underwent a complete reference standard evaluation, particularly lumbar puncture for meningitis. This is appropriate given we try to limit invasive testing like LPs if possible. However, when only a subset of patients receives the gold-standard test, the accuracy of the diagnostic rule can be distorted. This is known as partial verification bias, where patients with higher clinical suspicion are more likely to undergo confirmatory testing. If infants classified as low risk were less likely to receive an LP, it is possible that some cases of meningitis could have been missed, artificially inflating the rule's sensitivity (true positive) estimates. The authors followed the STARD guidelines for diagnostic accuracy studies, but there was not a formal methodological quality assessment such as the

Date: April 2, 2026   Reference: Lee et al. GRADE-Based Clinical Practice Guidelines for Emergency Department Delirium Risk Stratification, Screening, and Brain Imaging in Older Patients With Suspected Delirium. AEM Feb 2026 Guest Skeptic: Dr. Christina Shenvi is a board-certified emergency physician, educator, keynote speaker, coach, and academic leader. She is widely recognized for her work in geriatric emergency medicine, faculty development, and professional identity formation in EM. She brings deep clinical expertise along with thoughtful perspectives on systems-level change and guideline development. Case: An 82-year-old woman with hearing impairment and mild baseline dementia is brought to the emergency department (ED) by her daughter because she became “not herself” over 24 hours. She is more sleepy, intermittently agitated, keeps losing the thread of conversation, and cannot say the months backward. She arrived by ambulance from home after nearly falling twice. Vitals show fever and mild tachycardia. The daughter reports foul-smelling urine and poor oral intake for two days. On examination, there is no head trauma and no focal neurologic deficit. The question in the ED is not simply “Is she confused?” but “Does she have delirium, how do we confirm it efficiently, and does she need a head CT as part of the workup?” Background: Delirium is an acute brain dysfunction: a disturbance in attention and awareness that develops over hours to days, fluctuates, and is accompanied by additional cognitive disturbances such as memory, language, orientation, or perceptual changes. In older adults, it is common, dangerous, and often goes unnoticed. The latest GED Delirium Guidelines indicate that delirium occurs in about 6% to 38% of older ED patients, increases mortality, contributes to functional decline, and imposes a significant burden on health systems. ED-based geriatric screening tools also highlight that delirium is frequently under-recognized by emergency clinicians and that hypoactive delirium is most common, making bedside detection even more challenging.  For emergency physicians, delirium matters because it is rarely the final diagnosis. Delirium is usually a clue that something else serious is also wrong. The practical ED task is to identify the syndrome, search for precipitants, and avoid worsening the situation. But one reason the new guideline is so useful is that it is honest about the evidence gap. Prior reviews found no consistent ED-based strategy to prevent incident delirium or to treat prevalent delirium, so this guideline appropriately focuses on the parts of care for which there is sufficient evidence to guide bedside decisions now. It addresses risk stratification, diagnosis, and brain imaging.  This delirium guideline is also notable because it was built using the newer GED 2.0 model for subspecialty guideline development [1].  The Geriatric Emergency Department initiative moved beyond the older consensus-based 2014 framework and adopted a transparent GRADE process: multidisciplinary working groups, explicit PICO questions, systematic reviews and meta-analyses, Evidence-to-Decision frameworks, attention to feasibility, equity, and stakeholder values, plus external stakeholder review. This SGEM episode highlights the first EM subspecialty guideline effort to fully adopt GRADE, and this delirium guideline shows that process in action.  Clinical Questions: Which older ED adults are at the highest risk on walking in, and who should then be further assessed for delirium? (or CLS addition, should have special prevention measures or expedited treatment or bed placement). Which tools should be used to identify ED delirium? Should acutely confused older ED patients undergo head CT as part of the delirium evaluation? Reference: Lee et al. GRADE-Based Clinical Practice Guidelines for Emergency Department Delirium Risk Stratification, Screening, and Brain Imaging in Older Patients With Suspected Delirium. AEM Feb 2026 Authors’ Conclusions: “Rigorous ED-based research is needed to strengthen evidence and guide delirium care for older adults in geriatric emergency medicine.” Quality Checklist for a Guideline: The study population included or focused on those in the emergency department? Yes  An explicit and sensible process was used to identify, select and combine evidence? Yes The quality of the evidence was explicitly assessed using a validated instrument? Yes An explicit and sensible process was used to value the relative importance of different outcomes? Yes The guideline thoughtfully balances desirable and undesirable effects? Yes The guideline accounts for important recent developments? Yes Has the guideline been peer-reviewed and tested? Yes/No Practical, actionable and clinically important recommendations are made? Yes The guideline authors’ conflicts of interest are fully reported, transparent and unlikely to sway the recommendations? Unsure Key Recommendations: They came up with six recommendations that are conditional and all rest on very low certainty of evidence. Risk Stratification A Delirium Risk Score may be used to identify low-risk older adults. Conditional FOR; very low certainty. The delirium risk score gives you a baseline risk of delirium before the patient comes into the ED. It’s based on work by Jin Han and friends from 2009. In a cross-sectional convenience sample of about 300 patients, they identified three factors were independently associated with presenting with delirium in the ED: dementia, Katz ADL<=4, and hearing impairment. They then developed a score based on those three factors and found that higher scores were associated with more delirium If you have none of those factors, then you have <1% prevalence of delirium on arrival (prevalent vs incident delirium). If you have all three factors, then the rate is close to 50%. So, you could conceivably only screen patients who have at least 1 of those factors, now known as the delirium risk score, to avoid screening every single patient. For adults >65 admitted to ED observation, Zucchelli’s tool with threshold ≥4 may be used to identify low- or high-risk patients [2]. Conditional FOR; very low certainty. Zucchelli’s age >= 75, dementia, hearing impairment, and psychotropic drugs. High risk is >= 4. This could be used to identify patients at high risk. For adults >75 presenting to the ED, REDEEM threshold ≥11 may identify low- or high-risk patients, and a cutoff =11 would mean about 1/5th or 20% of the ED older adult population, so then if you only screened those patients for delirium, then it may reduce the work. But that means you’re screening everyone with REDEEM and then 20% of them with a delirium diagnostic tool. And the redeem questions are more complex (see paper). REDEEM stands for Recognizing Delirium in geriatric Emergency Medicine and is based on a paper from 2021. It was an observational study of patients age >=75 coming to the ED who were screened for delirium, and then regression analysis was used to create a model with 10 variables – 7 from triage info and 3 obtained during early history. Some caveats here. Also scores from -3 to +66. This, to me seems more complex than just screening everyone for delirium with a DTS and bCAM or the 4AT Diagnostic Tools 4AT, bCAM, CAM-ICU, mCAM, AMT-4, or RASSmay be used to rule delirium in or out. Conditional FOR; very low certainty. Delirium Triage Screen (DTS) may be used to rule out, but not rule in, delirium [4]. Conditional FOR; very low certainty. The DTS and bCAM are frequently used in concert. Start with the DTS (2 components: RASS=/0 or ALOC and attention – spell LUNCH backwards). If normal, NOT delirious. If not normal, do the bCAM: Acute change or fluctuating course – from family or pt Inattention eg months of the year backwards Altered level of consciousness or Disorganized thinking eg will a stone float on water If you have 1, 2, and 3 or 4, then you are delirious. 4AT is often used internationally for 4 items and a single step. Alertness, normal/mild sleepiness/clearly abnormal AMT4 (abbreviated mental test for orientation) Age Date of birth Location Year Attention - months of the year backwards Acute change or fluctuating course Score 0 - normal, 1 to 3 possible cognitive impairment, >=4 possible delirium or severe cog impairment Brain Imaging In the undifferentiated older ED patient with delirium or altered mental status (AMS), there are insufficient data to recommend for or against a head CT. Conditional EITHER; very low certainty. 1. Certainty: The biggest limitation is the certainty of the underlying evidence. The guideline authors are admirably transparent about the fact that every recommendation is conditional and based on very low-certainty evidence. In GRADE terms, this means the true effect may be substantially different from the estimate, especially when evidence is downgraded for risk of bias, indirectness, inconsistency, and imprecision. That matters because even a methodologically rigorous guideline can only be as trustworthy as the body of evidence beneath it.  2. External Validity: A second threat is that much of the evidence base consists of single-center diagnostic or prognostic studies with limited external validation. The delirium paper explicitly notes that the risk-stratification tools were supported by single-center evidence and, in most cases, lacked separate validation research. From an evidence-based diagnosis perspective, this raises real concerns about spectrum effects and transportability: a tool that appears to work in one ED case mix may perform differently in another.  3....

Date: March 23, 2026 Dr. Christina Shenvi Guest Skeptic: Dr. Christina Shenvi is a board-certified emergency physician, educator, keynote speaker, coach, and academic leader. She is widely recognized for her work in geriatric emergency medicine, faculty development, and professional identity formation in emergency medicine (EM). She brings deep clinical expertise along with thoughtful perspectives on systems-level change and guideline development. This is another SGEM Xtra episode. Today’s show focuses on how to build high-quality subspecialty clinical practice guidelines, using the Geriatric Emergency Department Guidelines 2.0 (GED 2.0) as a model. We’ve talked about Geriatric EM a lot on the SGEM over the years. And if we’re serious about evidence-based emergency medicine, we must be serious about geriatric EM. Here are some previous SGEM episodes:  SGEM#89: Preventing Falling to Pieces SGEM Xtra: Don’t Bring Me Down – Preventing Older Adult Falls from the ED SGEM#261: Cristal Ball to Assess Older Patients in the ED SGEM#280: This Old Heart of Mine and Troponin Testing SGEM#424: Ooh Ooh I Can’t Wait to Be Admitted to Hospital The original 2014 GED Guidelines were consensus-based and helped establish standards for geriatric emergency departments, including staffing, education, transitions of care, quality improvement, equipment, and protocols. Since then: The evidence base in geriatric EM has expanded. Expectations for clinical practice guideline development have evolved. The GRADE framework has become the international standard for rating the quality of evidence and the strength of recommendations. GED Guidelines 2.0 represent the first EM subspecialty effort to fully adopt the GRADE methodology and provide a transparent, reproducible model for future EM guideline development.  This work involved a multidisciplinary collaboration, including experts affiliated with organizations such as the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM), as well as geriatricians, methodologists, and patient representatives. Started with an open call to the Geriatric Emergency Medicine community via SAEM, ACEP, AGS, EUSEM, and ENA. With funding via JAHF. The GED Guideline 2.0 group is planning 14 Systematic Reviews/Meta-analyses, with 6 or 7 Clinical Practice Guidelines. They will all be available on the GEAR 2.0 website Five Questions for Dr. Shenvi I have five key questions to frame our discussion about the GED 2.0 Model for Subspecialty Clinical Practice Guidelines. As a reminder, they are called GUIDElines, not GODlines. This means they are meant to guide our care, not dictate care. 1) Why Update the Original GED Guidelines? The original 2014 GED Guidelines were enormously important because they gave the field its first shared framework for what high-quality emergency care for older adults should look like. But they were developed as consensus-based guidelines at a time when the evidence base in geriatric emergency medicine was much less mature than it is now. Since then, there has been major growth in research, especially through work from GEAR and GEAR 2.0, in areas like delirium, dementia, falls, medication safety, transitions of care, and elder abuse. The update was needed to ensure the guidelines reflected the newer evidence and remained clinically relevant. A second reason is that expectations for guideline development have changed. The paper makes clear that the original guidelines did not include a formal assessment of the quality, quantity, reproducibility, or applicability of the evidence. In today’s environment, clinicians and health systems expect more transparency about how recommendations are made, how strong the evidence is, and how benefits, harms, feasibility, and equity are weighed. GED Guidelines 2.0 was designed to meet those newer standards. A third issue was implementation. The original guidelines had a clear impact, especially through ACEP accreditation, but the paper notes that accredited GEDs still represent a minority of EDs, and many sites have struggled with barriers such as limited resources, competing priorities, and a lack of local champions. So, this update was not just about refreshing content. It was also about making the guidance more usable, transparent, and implementable in both accredited and non-accredited settings. Bottom line, hospitals won’t do things unless there are clear clinical reasons, or financial reasons, or mandates, like CMS measures, which are financial. 2) Why Adopt the GRADE Framework? GRADE stands for: Grades of Recommendation, Assessment, Development, and Evaluation. They provide a systematic, transparent framework for rating the quality of evidence and grading the strength of recommendations in healthcare.  The group adopted GRADE because they wanted the updated guidelines to be more rigorous, more transparent, and more trustworthy. According to the paper, GED Guidelines 2.0 is the first emergency medicine subspecialty guideline effort to fully adopt GRADE. The attraction of GRADE is that it provides a structured framework for framing questions, assessing evidence, evaluating bias, and connecting the certainty of the evidence to the strength of the recommendations. That makes it easier for clinicians to understand not only what is being recommended but also why.  GRADE also helps move the field beyond expert opinion alone. The new process is grounded in systematic reviews and meta-analyses, and it explicitly incorporates patient values and preferences, health equity, feasibility, and the balance of benefits and harms. That is especially important in geriatric emergency care, where decisions are often preference-sensitive and where the “right” intervention may depend on function, cognition, caregiver context, and resource availability. What were the biggest challenges in implementing GRADE in a largely volunteer-driven initiative? The biggest challenge was GRADE's resource intensity. The paper explicitly states that it requires trained methodologists, research librarian support, and the completion of systematic reviews and meta-analyses. On top of that, the working group was largely volunteer-driven, and there was variability in members’ familiarity with systematic-review methods and GRADE processes. So, the group had to invest in ongoing training, recalibration, and role adaptation over time. 3) What are the Seven Priority Domains? The seven priority domains were delirium, dementia, falls, frailty, medication management, palliative care, and elder abuse.  How were these selected, and were there important areas left out? They were the result of 6 to 9 months of meetings, starting in 2019. They were selected through a gap analysis of the original guidelines, plus a review of where the evidence base had become strong enough to support a formal guideline. The paper also makes clear that not everything was revised. Some foundational operational elements were intentionally left unchanged because they remained current. So, the omission of some areas was not because they were unimportant, but because the group prioritized where new evidence-based guidance would add the most value. How did patient and caregiver input shape the priorities? Each guideline has involved a patient or a patient's care partner. Evidence for decision rule meetings when they vote on the level of evidence. The patient or advocate takes part in that meeting and process. For each of the 6 or 7 Clinical Practice Guidelines (CPGs). 4) What is Different about GED Guidelines 2.0?  Dr. Chris Carpenter Core leaders Dr. Chris Carpenter (expert in methodology and content), Dr. Shan Liu, and seven subgroups with leaders. Greater than 60 people from seven countries, not just physicians, nurses, allied health, methodologists, and patient representatives. What is most different is that this was intentionally built as a broad, multidisciplinary, international, and methodologically rigorous process. The paper describes a collaboration involving more than 60 members from 23 US states and seven countries, including not only emergency physicians but also geriatricians, nurses, allied health professionals, methodologists, and patient caregivers. That is a broader coalition than many traditional emergency medicine guideline efforts, which are often more specialty-contained. The second major difference is the method. Rather than relying primarily on expert consensus, this model uses formal GRADE methods, systematic reviews, meta-analyses, and structured PICO questions. The paper presents this as a transparent, replicable framework intended not only to generate better geriatric emergency guidelines but also to serve as a blueprint for future emergency medicine subspecialty guideline development. A third difference is the emphasis on implementation from the beginning. The model was designed not just to write guidelines, but also to anticipate dissemination, adoption, feasibility, equity, and usability across different ED environments. In that sense, it is not just a content update. It is also a delivery model for creating and spreading subspecialty guidelines in a way more likely to reach frontline practice. How does this process serve as a blueprint for other EM subspecialties? It shows that an emergency medicine subspecialty can develop guidelines using the same formal architecture as other major guideline organizations: broad stakeholder engagement, PICO-based question framing, systematic review, evidence grading, and explicit attention to feasibility and equity. The authors explicitly present this as a replicable framework for other EM subspecialty groups. What lessons can be generalized to areas like toxicology, critical care, or ultrasound? The generalizable lessons are: start with a broad coalition,...

Date: March 26, 2026 Dr. Rob Leeper Guest Skeptic: Dr. Robert Leeper is a trauma surgeon at the London Health Sciences Centre and an ATLS instructor who has helped train generations of physicians in trauma care. He has previously joined SGEM for: SGEM #200 – Bloodletting and Alexander Hamilton SGEM #256 – RLQ Pain and Appendectomy SGEM #345 – Non-operative Management of Appendicitis It’s SGEM Xtra time, where we go beyond a single paper and dive into broader topics that impact our daily practice. Now, some of you may remember that back in 2018, we did a Top 10 list for ATLS 10th Edition. Yes, we cranked it up to 10. ATLS 10th Edition: Top 10 Changes But today… We’re not stopping at 10. Because this SGEM episode goes to 11. If you don’t get that reference, go watch This Is Spinal Tap. It’s a mockumentary about a fictional rock band whose amplifiers go to 11 instead of 10. And when asked why they didn’t just make 10 louder, the guitarist replies: “These go to 11.” And that brings us to ATLS, now officially in its 11th edition. For those who don’t know the history of ATLS, here is the brief back story. ATLS was born out of tragedy. In 1976, orthopedic surgeon Dr. James Styner crashed his small plane in rural Nebraska. His wife died at the scene. He and his children survived but were severely injured. When they arrived at a small hospital, the trauma care they received was, by his account, disorganized and inadequate. Styner later said: “When I can provide better care in the field with limited resources than my children and I received at the primary care facility, there is something wrong with the system.” That moment led to the development of a structured approach to trauma, one that could be taught, replicated, and standardized. The first ATLS course was introduced by the American College of Surgeons (ACS) in 1980. It emphasized something radical at the time: a systematic, prioritized assessment of trauma patients, beginning with Airway, Breathing, Circulation, Disability, Exposure (ABCDE). In EM, our alphabet is A-B-CT, send them to the donut of truth. But back to the 1980s, the systematic ABCDE approach wasn’t about memorizing injuries. It was about preventing death from the first thing that kills. Over the decades, ATLS became one of the most widely adopted trauma education programs in the world. It has trained hundreds of thousands of clinicians in over 80 countries. And like any long-running franchise (Star Wars, Mission Impossible, Star Trek and Batman), each new edition tries to improve on the original. So today, instead of a Top 10 list as we did for ATLS 10, we’re going with: The 5 important changes in ATLS 11. Because sometimes less is more. Even if the amplifier goes to 11. Five Changes to the ATLS 11th Edition 1. xABCDE – Hemorrhage Now Comes Before Airway: The most noticeable clinical change in ATLS 11 is the addition of the “x” to ABCDE, making it xABCDE, with the “x” standing for exsanguinating hemorrhage. Massive external bleeding is now formally prioritized before airway management in select patients. While many trauma teams have already internalized the “bleeding kills first” principle, especially after a decade of military-to-civilian trauma translation, ATLS has now codified it. In practical terms, this reinforces early tourniquet use, direct pressure, and hemostatic adjuncts as first-line priorities when appropriate. It’s less of a revolution and more of an official acknowledgment that the trauma world has already turned the volume up on hemorrhage control. But formalizing it in the primary survey does matter, because what gets taught gets practiced. 2. Hemodynamic Optimization Before Intubation: Another subtle but important evolution in the 11th edition is the greater emphasis on resuscitating shock before proceeding with rapid sequence intubation (RSI). ATLS 11 highlights the risk of peri-intubation hypotension and arrest in unstable trauma patients, encouraging clinicians to correct hemodynamics before pushing paralytics. This aligns with growing emergency medicine literature around the dangers of precipitous airway management in the shocked patient. It’s a welcome shift toward physiologic thinking rather than purely procedural thinking. In other words, it reminds us that the airway isn’t just anatomy, it’s physiology. 3. Major Structural Reorganization and Systems Focus: The changes to ATLS 11 aren’t just clinical. This edition reorganizes the manual into three major sections: resuscitation, trauma systems/context, and specific injury patterns. More notably, it introduces full chapters on Trauma Systems, Injury Prevention, Trauma-Informed Care, and Communicating Serious News. This reflects a broader view of trauma care that extends beyond the primary survey. ATLS is no longer just about what happens in the first 15 minutes. It is also about the system in which those 15 minutes occur. For instructors, this may feel like an expansion into public health. Whether that’s evolution or mission creep may depend on your worldview. But it’s clear ATLS is trying to move from protocol to platform. 4. Dedicated Penetrating Trauma Chapter: Penetrating trauma now has its own standalone chapter in the 11th edition. This shows recognition that penetrating injury has unique management considerations compared to blunt trauma. The new edition emphasizes mechanism-driven evaluation, selective non-operative management, and updated surgical decision-making paradigms. For the USA trauma systems, this is particularly relevant given the epidemiology of violence-related injury (acute lead poisoning…Gun Shot Wounds [GSWs]). GSWs are the leading cause of death in the US for children aged 1 to 17 years. The key question, from an SGEM lens, is whether the content fully reflects contemporary evidence, especially regarding selective non-operative approaches. But structurally, this is a meaningful shift that gives penetrating trauma its own intellectual real estate. Dr. Andrew Worster 5. “Standardized Flexibility” – A Global Adaptation Philosophy: Perhaps the most philosophically important change in ATLS 11 is the formal adoption of “standardized flexibility.” The manual explicitly acknowledges global variability in trauma resources. Some places have CT availability, blood products, and access to specialist care, while others do not. ATLS now encourages adapting principles to the setting, rather than assuming Level I trauma center capabilities everywhere. This is a recognition that trauma education must be globally applicable. It moves ATLS from a rigid protocol toward a framework. It reminds me of the Evidence-Based Medicine (EBM) answer I learned from my mentor, Dr. Andrew Worster, “It all depends”. Traumas occur in a context (urban/rural/remote, academic/community, low-resource/high-resource, etc.). How ATLS is applied in your clinical situation will depend on many factors and requires flexibility. Other changes we wanted to mention: Head and spine combined into “disability.” Expanded section on geriatric trauma (now “Trauma in the Older Adult”) Enhanced team communication emphasis Hybrid learning and required pre-course videos Updated transfer mnemonic: S-xABCDE-BAR S: Situation (Who/Where/Why): Your name & role, location, patient demographics, mechanism of injury and reason for transfer.  xABCDE: Primary Survey Summary x – Exsanguinating Hemorrhage: Tourniquet? Pelvic binder? Massive Transfusion Protocol activated?Ongoing bleeding? A – Airway: Patent? Intubated? Endotracheal tube size? C-spine protected? B – Breathing O₂ saturation? Chest tube? Vent settings? Tension pneumothorax addressed? C – Circulation: Blood Pressure/Heart Rate? Intravenous/Intraosseous access? Blood products given?TXA given? D – Disability: Glasgow Coma Scale? Pupils? Lateralizing deficits? E – Exposure: Other injuries? Temperature? Hypothermia prevention? BAR: (B) Background: Past Medical History. Medications (Anticoagulants?). Allergies. Baseline function. (A) Assessment: Confirmed injuries. Working diagnosis. Clinical concerns. (R) Recommendations: Immediate needs? Operating Room? Intensive Care Unit? Imaging? Surgical team activation? SGEM Bottom Line: ATLS 11th Edition doesn’t radically reinvent trauma care. However, it formalizes hemorrhage-first thinking, expands systems-based trauma care, modernizes structure and teaching and recognizes global variation. The SGEM will be back next episode with a structured critical appraisal of a recent publication. Our goal is to shorten the knowledge translation (KT) window from over 10 years to less than 1 year by leveraging the power of social media. So, patients get the best care, based on the best evidence.  Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Reference: Wong KH, et al. Improving Use of Oral Antihistamines in a Children’s Hospital. Pediatrics. Feb 2026; Date: March 15, 2026 Dr. Stephanie Kubala Guest Skeptic: Dr. Stephanie Kubala is an attending physician in the Division of Allergy and Immunology at Children’s Hospital of Philadelphia. She is double board-certified in both pediatrics and allergy and immunology. Case: A 5-year-old girl is brought in by her parents for an itchy rash. Her symptoms started last night. The parent reports an itchy, raised red rash on her trunk and extremities. She has not had any fever. She does not have any difficulty breathing, wheezing, vomiting, or diarrhea. On your exam, you note hives on her body but no lip or tongue swelling. Her lungs are clear to auscultation. She intermittently scratches at the rash. Her parents tell you, “We gave her a dose of diphenhydramine last night, and it may have helped a little, but it seems to have worn off. Can you help?” Background: In a lot of emergency departments, “hives = diphenhydramine” is practically muscle memory. It’s familiar, it’s been around forever, and families often expect it because it’s what they already have at home. As with many medical interventions, we must weigh potential harms against potential benefits. The problem is that diphenhydramine and other first-generation antihistamines like hydroxyzine come with a bunch of potential side effects, such as sedation, anticholinergic side effects, and unpredictable behavior changes in some kids. It doesn’t always last very long, which can lead to repeat dosing and frustrated families when symptoms come back a few hours later. On the other hand, second-generation antihistamines like cetirizine target the same H1 receptor for itch and urticaria but tend to be longer-acting and better tolerated, which is why many guidelines and expert groups prefer them for routine allergic symptoms. And there’s a bigger safety angle here, too: first-generation agents show up in dosing errors and misuse/overdose cases. The real issue isn’t whether second-generation antihistamines like cetirizine work. They do. We need to start asking why our systems still nudge clinicians toward the older first-generation antihistamines as a default. The issue is well-suited to a quality improvement (QI) study. Before we dive into the details of the study itself, let’s talk about some basics around QI. QI helps close the gap between best practice and day-to-day care. It starts with a clear, measurable aim (what you want to improve, by how much, by when). This is followed by a simple measurement plan: an outcome measure (the main result you’re trying to change), process measures (the steps that should drive that result), and balancing measures (what might worsen unintentionally). Teams then map the current workflow, identify barriers, and build a key driver diagram that links the aim to the handful of system levers most likely to move the needle. The work is tested and refined using Plan–Do–Study–Act (PDSA) cycles. [2] These are iterative rather than a single big rollout. Data is tracked over time with run/control charts to show whether changes are real and sustained. Clinical Question: Can a bundled QI approach meaningfully reduce first generation antihistamine use and increase cetirizine use among pediatric patients receiving oral antihistamines in the ED and inpatient settings? Reference: Wong KH, et al. Improving Use of Oral Antihistamines in a Children’s Hospital. Pediatrics. Feb 2026; Population: Patients 6 months to 21 years in the pediatric ED and inpatient units at a tertiary academic children’s hospital Excluded: Patients in NICU, PICU, or hematology-oncology units Intervention: There were 3 main drivers: education/awareness, cetirizine availability, and standardization through clinical pathways. Comparison: Pre-intervention baseline prescribing practices Outcome: Primary Outcomes: There are two primary outcomes: The proportion receiving oral FGA and the proportion receiving cetirizine Secondary Outcomes: PED revisits within 48 hours, median LOS, clinicians’ knowledge, frequency of clinical pathway use and monthly antihistamine cost. Type of Study: Quality improvement initiative Authors’ Conclusions: “Using the Model for Improvement, we reduced FGA use and increased cetirizine use in the PED and inpatient setting.” Quality Checklist for Ql Study (adapted from QI-MQCS): Do they clearly state the problem and why it mattered? Yes Do they explain why the intervention should improve the outcome? Yes Are the specific changes described in enough detail that another site could reproduce them? Unsure  Do they describe the setting the intervention took place (type of hospital/clinic, size, population)? Yes  Do they describe the approach to designing and introducing the program? Yes Is the evaluation approach explicit? Yes Do they describe what they are comparing against? Yes Are data sources clear and is the primary outcome operationally defined? Yes Is the timeline clear? Yes Do they measure whether the intervention was actually delivered/used as intended? Yes  Do they include patient health outcomes? No  Do they describe organizational barriers/facilitators that affect readiness? Yes Do they report who/what was eligible vs who/what actually participated? Yes Do they describe the maintenance and sustainability of their interventions over time? Yes Do they address whether the intervention could be replicated elsewhere? Yes Do they discuss limitations? Yes Funding of the Study. No funding for this study. No declared conflicts of interest. Results: The study included 1235 pediatric ED patients and 737 inpatients. They undertook a total of 5 PDSA cycles, including the ED and inpatient units. Key Results: FGA use decreased and cetirizine use increased after implementation of QI initiatives. The use of FGA decreased from 74% to 28% in the pediatric ED and 54% to 36% in the inpatient units. The use of cetirizine went from 31% to 75% in the pediatric ED and 54% to 74% un the inpatient units. The changes were sustained for 8.5 months in the pediatric ED and 9 months in the inpatient units. Secondary Outcomes Knowledge assessment improved (among 31 surveyed participants): Median 50% to 100%. Clinical pathway usage increased: Median 36 to 44 clinicians/month. Balancing measures: ED revisit within 48 hours and median inpatient LOS remained stable. Cost: Monthly median antihistamine costs increased (PED $53 to $177; inpatient $57 to $104), with discussion of unit cost drivers for cetirizine formulation. A crucial part of any QI process is the identification of key stakeholders. This study included representation from the pediatric ED, a pediatric resident (a great inclusion given that residents rotate through so many units in the hospital), allergy and immunology, and pharmacy. These stakeholders helped the group identify the key drivers that included education and awareness, availability of cetirizine, and standardization of preferred medication. Individuals from each group of stakeholders also acted as champions to help push the QI initiative. Uncontrolled Before-After Design QI studies do not necessarily need to include control groups. However, without a concurrent control group/unit, improvements can reflect background practice drift, staffing changes, guideline diffusion, seasonal case-mix shifts, or other QI initiatives rather than the intervention itself. are a classic threat in time-based comparisons. In addition, when clinicians are aware a practice is being measured (or receive peer-to-peer feedback), behavior can shift independent of the intrinsic effectiveness of the intervention. This is well described as the Hawthorne effect and the related sentinel effect [3]. Intervention Bundle Because they implemented multiple components (education, stocking, reminders, pathway updates, audit/feedback), the observed effect can’t be confidently attributed to any single change. This is a common challenge with complex interventions, where fidelity and mechanism can vary across units and time.  Education and Awareness Reliance on purely educational interventions for QI will likely only have a limited effect. For this study, the authors did a 30-minute lecture during a staff meeting and emailed the lecture materials to absent staff. They also put up flyers in work areas. This intervention in the first PDSA cycle did not result in a consistent reduction in first-generation antihistamine use. Based on feedback from a PDSA flyer, they also shortened the educational sessions for the inpatient implementation phase, recognizing that attention wanes after 15-20 minutes. Cetirizine Availability The group worked with the pharmacy in the hospital to ensure the cetirizine solution and tablets were available in the medication dispensing machines. They emailed the pediatric ED staff to let them know. It is important to recognize that some children may either be too young or unable to swallow tablets or pills. This seems like a basic step, but if we want people to start using something new or different, we should try to make it accessible to them. Standardizing Preferred Antihistamines Now that the alternative second-generation antihistamine is available, there’s another step this group took to help with adopting the change. They looked at the existing clinical pathways for anaphylaxis and penicillin allergy delabeling and changed the primary antihistamine recommendation from diphenhydramine to cetirizine. This is a nice way of making it easy for people to adopt the change. For those already accustomed to using the clinical pathway and order set, this does not really change workflow at all. Indications for Antihistamines ...

Date: March 11, 2026 Reference: RENOVATE Investigators and the BRICNet Authors; High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients With Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial. JAMA March 2025 Guest Skeptic: Dr. Rory Spiegel is an emergency medicine and critical care physician known for his work in evidence-based medicine and critical care. He is widely recognized for translating emerging research into practical bedside insights through lectures, writing, and digital medical education. His work focuses on resuscitation science, airway management, and the critical appraisal of medical literature. I’m in Maui at the Centre for Continuing Medical Education Year in Review Course. CCME has been doing courses for almost 40 years. The courses take place at amazing locations in the US, including Maui, Hilton Head, Key West, and NYC. CCME recruits four outstanding educators to review ~260 articles from the past year. It’s a unique course because there are no PowerPoint slides to get in the way of the attendees and the speakers. Two faculty members summarize a few articles on a topic in ½ hour with direct interaction with the speakers. You come to this course…you are up to date on the latest EM literature.   Case: A 64-year-old woman with a history of COPD (GOLD stage III) and hypertension presents to the emergency department (ED) with worsening shortness of breath over the past 24 hours. She reports increased sputum production and wheezing. On arrival, she is tachypneic and speaking in short phrases. Her vital signs are heart rate 104 beats per minute, blood pressure 148/86 mm Hg, respiratory rate 30 breaths per minute, and SpO₂ 88% on 4 L nasal cannula. She is using accessory muscles and has diffuse expiratory wheezes on auscultation. An arterial blood gas reveals pH 7.29, PaCO₂ 58 mm Hg, and PaO₂ 62 mm Hg. Chest X-ray shows hyperinflation without focal consolidation. Background: Acute respiratory failure (ARF) is one of the most common serious respiratory problems managed in emergency medicine and critical care. For decades, noninvasive ventilation (NIV) has been a central part of therapy for selected patients. This is particularly true for those with COPD exacerbations and acute cardiogenic pulmonary edema. By delivering positive pressure, NIV reduces the work of breathing, improves oxygenation and ventilation. This intervention has been shown to reduce intubation rates and mortality in specific populations. However, NIV can be poorly tolerated, requires a tight mask seal and monitoring, and is resource-intensive [1-3]. These downsides can become more problematic in disease states that are not readily reversible over the first few hours. High-flow nasal oxygen (HFNO) has emerged over the past decade as an attractive potential alternative. By delivering heated, humidified oxygen at high flow rates, HFNO improves oxygenation, improves ventilator efficiency by reducing dead space, and is often better tolerated than mask-based ventilation. Its physiologic appeal and ease of use have led to widespread adoption, particularly during the COVID-19 pandemic. Yet enthusiasm has at times outpaced evidence, and important clinical questions remain:  Is HFNO equivalent/non-inferior to NIV in preventing intubation or death? How does it perform across different types of respiratory failure? And when should clinicians choose one over the other? Clinical Question: Is HFNO noninferior to NIV regarding the rates of endotracheal intubation or death at 7 days across five distinct patient groups with ARF? Reference: RENOVATE Investigators and the BRICNet Authors; High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients With Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial. JAMA March 2025 Population: Hospitalized adults with ARF (hypoxemia plus respiratory effort or tachypnea) classified into 5 groups: Nonimmunocompromised with hypoxemia Immunocompromised with hypoxemia COPD exacerbation with respiratory acidosis Acute cardiogenic pulmonary edema (ACPE) Hypoxemic COVID-19 Exclusions: The main exclusion criteria were if there was an urgent need for endotracheal intubation, hemodynamic instability or contraindications to NIV. Intervention: High-flow nasal oxygen (HFNO) delivered continuously, titrated toward 60 L/min. Comparison: Noninvasive ventilation (NIV) delivered through a face mask. Outcome: Primary Outcome: Endotracheal intubation or death within 7 days. Secondary Outcomes: 28-day and 90-day mortality, mechanical ventilation-free days, and ICU-free days. Type of Study: Multicenter, adaptive, noninferiority randomized clinical trial using a Bayesian hierarchical model with dynamic borrowing across patient groups. Authors’ Conclusions: “Compared with NIV, HFNO met prespecified criteria for noninferiority for the primary outcome of endotracheal intubation or death within 7 days in 4 of the 5 patient groups with ARF. However, the small sample sizes in some patient groups and the sensitivity of the findings to the choice of analysis model suggests the need for further study in patients with COPD, immunocompromised patients, and patients with ACPE.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes 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). Yes The patients in both groups were similar with respect to prognostic factors. Unsure 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  Funding: Supported by a grant from the Brazilian Ministry of Health. Fisher & Paykel Healthcare provided the high-flow nasal oxygen equipment and associated disposables. The trial coordinating center and sponsor were the Hcor Research Institute. “The funders/sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.” Financial conflicts of interest. Multiple authors reported multiple COIs, with one author receiving personal fees from Fisher & Paykel Healthcare. Results: RENOVATE randomized 1,800 hospitalized adults with ARF across 33 hospitals in Brazil, with 1,766 completing the trial. The mean age was 64 years, and 40% of participants were women. The population was primarily older adults with moderate to severe respiratory failure. The largest of the five pre-defined subgroups (almost half) consisted of patients with hypoxemic COVID-19. Key Result: HFNO was noninferior to NIV for the composite outcome of endotracheal intubation or death within 7 days in four out of five subgroups. Primary Outcome: Endotracheal intubation or death Overall, 39% HFNO vs 38% NIV Noninferiority: Met in four of the pre-specified groups (Nonimmunocompromised, COPD, ACPE, and COVID-19). Immunocompromised Group: Stopped for futility (57.1% HFNO vs 36.4% NIV). Secondary Outcomes: There were no statistically or clinically meaningful differences in 28-day mortality, 90-day mortality, mechanical ventilation-free days, or ICU-free days overall. However, subgroup-specific secondary outcome estimates were imprecise and should be interpreted cautiously. 1. Diverse Etiology: The authors enrolled all adult patients presenting with hypoxic respiratory failure to non-invasive support with either HFNO or NIV. Using such a broad enrollment criterion led them to enroll a wide variety of clinical etiologies in this trial. The advantages of such broad inclusion criteria mean that the results can be applied broadly to patients presenting with hypoxic respiratory failure. In this case, it is likely accurate to say that neither NIV nor HFNO is superior when treating an undifferentiating population of patients with hypoxic respiratory failure. A disadvantage is that the 5 subtypes of respiratory failure represent very different physiological causes of ARF, which may respond differently to different forms of respiratory support. There may, in fact, exist potential benefits for either NIV or HFNO in one or more of these specific subgroups that are obscured when looking at this greater population. The authors address this by performing subgroup analyses for each of the 5 predefined subgroups. Unfortunately, due to the small sample sizes in each subgroup, there were too few patients to confidently demonstrate that one form of non-invasive support is preferred over the other. Therefore, the broad inclusion criteria used by these authors make it very difficult to identify a potential benefit of NIV or HFNO in any one subtype of hypoxic respiratory failure. For example, among immunocompromised patients with hypoxemia, the primary outcome (endotracheal intubation and death within 7 days) occurred in 57.1% of patients in the HFNO group vs 36.4% of patients in the NIV group. Due to the small sample sizes (28 and 22 patients in the two groups, respectively), the 20.7% difference met criteria for futility, as the confidence intervals were too wide to demonstrate non-inferiority or superiority. Open Label 2. Lack of Masking: This was an open-label trial where both clinicians and patients knew which treatment was assigned. This design can lead to performance bias if clinicians adjust co-intervent

Date: March 5, 2026 Today, we’re not in the studio. We’re not in Canada. We’re not even in North America. We are in Oxford. And not just Oxford, we are recording this SGEM Xtra in a pub. This will be the second-ever SGEM PUBcast. We need to travel back in time to 2012 for the first PUBcast. That happened when I came to Oxford for a mini-fellowship at the Centre for Evidence-Based Medicine (CEBM) on how to teach evidence-based medicine (SGEM#6). I had no idea that experience would change my professional career and open so many doors for me around the world. In that early SGEM episode, we did a structured critical appraisal of a 2011 BMJ article by Subramanian et al. called: Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study. That trial examined the dominant grip strength of male orthopedic surgeons compared with male anesthesiologists. No surprise, they found orthopedic surgeons had significantly greater grip strength. However, they also compared the two specialties using an intelligence score and found that orthopedists scored significantly higher than anesthetists. The SGEM bottom line was that the stereotypical image of male orthopedic surgeons as strong but stupid is unjustified in comparison with their male anesthetist counterparts. Well, the SGEM has grown over the last 14 years, with greater than 85,000 subscribers, has been translated into four other languages, and has more than 600 episodes. Tonight, we are back in Oxford at the historic St. Aldate’s Tavern. We are surrounded by centuries of scholarship, skepticism, and possibly a few pints of beer. Joining me to co-host this SGEM Xtra PUBcast is the wonderful Melanie Golob. She is a DPhil candidate in Evidence-Based Health Care here at Oxford. Melanie is also the HTA Program & FFS Operations Manager in the US. Melanie Golob has been a shining star of the DPhil Program for Evidence-Based Health Care and a real ambassador of Evidence-Based Medicine (EBM). Some of us who are older might say you are the Julie McKoy of the DPhil program. She makes everyone feel welcome and appreciated. Questions for Melanie Golob Listen to the SGEM Xtra podcast on iTunes or Spotify to hear Melanie's responses. Question#1: Why Oxford? What drew you here for your DPhil? Was it the Centre for Evidence-Based Medicine (CEBM) specifically? Is there something “statistically significant” about Oxford’s approach to EBM? Does being in a place with this much academic history change how you think? Responds Question#2: What is Your Research About? What problem are you trying to solve with a Living Evidence Synthesis (LES)? Why does “living” evidence matter? Are we ready for AI-assisted living evidence? Question#3: Advice for Future Oxford Students What advice would you give someone interested in doing a DPhil in Evidence-Based Health Care? What makes someone a good candidate? What’s the hardest and most rewarding part? Questions for DPhil Candidates Layal and Taylor Who are you (name and where are you from), and what brought you to Oxford? What is your area of research? What is the most challenging thing about being at Oxford, and the best thing? That concludes the second SGEM PUBcast. We will be back next episode, trying to cut the knowledge translation window from over 10 years to less than 1 year with the power of social media. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. Note: Other people mentioned on the PUBcast Ross Drain- 4th Year Medical Student at Keble College, University of Oxford Juliana Louw - 5th Year Medicine Student at University of Oxford and President of Oxford Lifestyle Medicine Society Carl Heneghen - Professor of Evidence-Based Medicine, University of Oxford Liam Barrett - Emergency Medicine Trainee pursuing a DPhil in Medical Sciences at the University of Oxford Nicholas De Vito - Postdoctoral researcher at the Bennett Institute for Applied Data Science Layal Bou Harfouch- Drug Policy Analyst at the Reason Foundation, DPhil Candidate at the University of Oxford and Founder of Omniwomyn Taylor Hirschberg - CEO Scientist, AI Healthcare Researcher, Pulitzer and GLAAD nominated, Documentary Film Maker and DPhil candidate at the University of Oxford.

Date: February 26, 2026 Guest Skeptic: Terry O’Reilly is the host of the long-running and popular podcast Under the Influence. He is also an acclaimed storyteller and book writer. However, Terry is not just some radio host talking about marketing; he was an adman on the front lines, working in the trenches for 35 years in the advertising industry. I’ve been a listener of Under the Influence for a long time, and it’s helped me think about how we communicate with emergency clinicians and how we make ideas memorable without overselling them. I see many similarities with Terry. I’m not just some podcaster talking about emergency medicine. I’ve been working in the emergency department (ED), on the front line, for 31 years. I’m not an academic sitting in an Ivory tower opining on how to practice emergency medicine based on the literature. I worked 17 ED shifts in February. I’m walking the walk while I talk the talk. I think that brings a perspective and credibility to the SGEM, similar to the credibility of what Terry does on Under the Influence. Terry and I met in person with my wife, Barb, and 11-year old son, Ethan, around 2009. Terry was promoting his book The Age of Persuasion: How Marketing Ate Our Culture. We pulled Ethan out of school to go to Sarnia for a day and watch him give a talk. Terry even signed a copy of his book for Ethan. Our son was so inspired by the event and went on to pursue an academic career in Marketing. Ethan will be defending his PhD in Marketing from the Ivey School of Business this spring. Today, we are going to talk about Terry's latest book: Against the Grain: Defiant Giants Who Changed the World. It is a collection of stories about people who challenged the status quo and changed what the rest of us thought was possible. It reminded me of Apple's famous commercial, "Think Different." I made a parody video about rural physicians titled “Here’s to the Crazy Ones”. People may be wondering why this matters to emergency physicians. I think the “against the grain” ethos is common in emergency medicine. We have healthy skepticism and often challenge dogma, based on the evidence, when discussing management with other specialties. We also must be good at persuading patients, families, learners, consultants, and administrators that what we are doing is the right thing. Five Questions for Terry O'Reilly 1) What inspired you to write Against the Grain? Was there a single person/story that sparked the project? What’s your definition of defiant? Did you notice a pattern in how these defiant giants resisted the herd/groupthink? 2) What was one of the most surprising stories you uncovered while researching the book? What surprised you: the person’s personality, the risk they took, or how others reacted? Was there a moment in your researching a story where you thought, “No way this is true”, and then it was? 3) There are four medical stories in the book (Chapter 4). Most SGEMers probably know about Ignaz Philipp Semmelweis. Can you briefly tell us the story of Dr. Katalin Karikó  Katalin Karikó and Drew Weissman 2023 Nobel Prize in Medicine for their discoveries concerning nucleoside base modifications that enabled the development of effective mRNA vaccines against COVID-19. Do you think healthcare messaging has unique challenges compared with marketing products? In your view, what’s the difference between educating vs persuading in healthcare? We do need to be careful in science and medicine not to commit the Galileo Fallacy. This is when someone assert a is true or should be given more credibility because the person making the claim has been prosecuted or otherwise mocked. This fallacy originates from Galileo Galilei's famous persecution by the Roman Catholic Church for his defence of heliocentrism, when the commonly accepted belief at the time was an earth-centred universe. The truth is independent of whether the person is being mocked/persecuted, as with Semmelweis. What matters is the objective, verifiable evidence and logical arguments.  4) What has the feedback been like on the book tour so far? Which types of readers are connecting most with it? Have any audience questions surprised you? Has anyone pushed back on the idea of celebrating “defiance”? 5) What do you hope the audience learns after reading the book? If you had to boil it down, what should we be more skeptical of? How do we encourage against-the-grain thinking without sliding into cynicism? The SGEM will be back next episode with a structured critical appraisal of a recent publication. Our goal is to reduce the knowledge translation (KT) window from over 10 years to less than 1 year using the power of social media. So, patients get the best care, based on the best evidence. Remember to be skeptical of anything you learn, even if you heard it on The Skeptics’ Guide to Emergency Medicine. Previous SGEM Xtra Book Interviews SGEM Xtra – Brian Goldman: The Power of Kindness SGEM Xtra – Tim Caulfield: Illusion- What you Don't Know and Why It Matters SGEM Xtra – Steven Novella: The Skeptics Guide to the Universe  SGEM Xtra - Tim Caulfield: Relax – Damm It! SGEM Xtra - Mel Herbert: The Extraordinary Power of Being Average SGEM Xtra - Brian Goldman: Casino Shift - Stories from an ER on the Edge (coming soon) SGEM Xtra - Darren McKee: Uncontrollable - The Threat of Artificial Superintelligence and the Race to Save the World

Reference: . Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. Lancet Child & Adolescent Health. July 2025 Dr. Kammeron Brissett Guest Skeptic: Dr. Kammeron Brissett is a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. She completed her pediatrics residency and a chief year at Rainbow Babies and Children’s Hospital in Cleveland, Ohio. Her interests include injury prevention, social determinants of health, and advocacy. Case: A 7-year-old boy with a peanut allergy presents to the emergency department (ED) after eating a cookie at a birthday party. Shortly afterwards, he developed hives and wheezing. His parents gave him an epinephrine auto-injector to improve his symptoms. In the ED, he feels much better. His vital signs are normal, and his lungs are clear. He has no other gastrointestinal or cardiovascular symptoms. The parents tell you, “Unfortunately, we’ve been through this before. It’s not the first time he has accidentally eaten something that may have had some peanuts in it. Last time, we sat in the ED for a few hours before going home. It’s been a long day. Can we just go home now?” Background:  Anaphylaxis is a serious, potentially life-threatening systemic allergic reaction with a fast onset. It is a clinical diagnosis that should be considered when: Acute illness with skin/mucosal involvement and either respiratory compromise or reduced blood pressure/end-organ symptoms; or Two or more of the following occurring rapidly after exposure: skin/mucosal involvement, respiratory compromise, reduced blood pressure, or persistent gastrointestinal symptoms; or Reduced blood pressure after exposure to a known allergen for the patient. Early recognition and treatment with intramuscular epinephrine is crucial. Sometimes, even after initial symptom improvement with IM epinephrine, anaphylaxis symptoms can recur even without exposure to the known trigger. This is called a biphasic reaction and can happen up to 72 hours later. The SGEM discussed anaphylaxis and biphasic reactions 13 years ago on SGEM#57. The bottom line was that prolonged observation is likely unnecessary in patients whose symptoms resolve with therapy in the ED. Biphasic reactions are rare and can occur anywhere from 10 minutes up to 6 days. We already have problems with boarding and overcrowding. We can’t keep all patients with anaphylaxis for 6 days. So, when can we send them home? Traditionally, ED observation after anaphylaxis has been around 4 to 6 hours to monitor for biphasic reactions. The Resuscitation Council UK recommends a risk-stratified approach: A patient can be discharged after 2 hours when there’s a good response to a single dose of epinephrine, the symptoms have resolved, the child and family has another epinephrine autoinjector and knows how to use it, and has adequate supervision after discharge. They recommend at least 6 hours of observation if two IM doses of epinephrine were needed or there was a prior biphasic reaction. Finally, they recommend at least 12 hours observation if there was severe respiratory compromise, >2 doses of epinephrine, ongoing allergen absorption, late-night presentation/limited access to care, or difficult access to emergency services. The National Institute for Care and Health Excellence (NICE) is even a bit more conservative, recommending any child under age of 16 with suspected anaphylaxis be admitted. What about in the US? In the United States, the 2023 AAAAI/ACAAI Joint Task Force Practice Parameter (JTFPP) emphasizes individualized, risk-based observation and shared decision-making, noting that risk for biphasic reactions is higher with more severe initial reactions and when >1 dose of epinephrine is required. It also highlights that patients with a prompt, complete, and durable response to epinephrine may not always require activation of EMS or prolonged monitoring, underscoring tailored disposition planning.  Clinical Question: Among children treated with epinephrine for anaphylaxis, what is the timing and incidence of repeat epinephrine that could inform safe observation periods? Reference: . Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. Lancet Child & Adolescent Health. July 2025 Population: Children 6 months to 17 years presenting to 31 EDs (30 US, 1 Canada) with an acute allergic reaction treated with epinephrine from 2016 to 2019. Excluded: Transfers from outside facilities, ED medication-induced reactions, missing pre-ED symptom documentation; comorbidities requiring tailored management Intervention: ED observation following the first epinephrine dose and need for additional epinephrine Comparison: Comparisons were made across severity strata (no respiratory/cardiovascular involvement vs respiratory involvement only vs cardiovascular involvement). Outcome: Primary Outcome: Time from first to last epinephrine dose (repeat epinephrine as a proxy for clinically significant ongoing/recurrent reaction). Secondary Outcomes: Biphasic anaphylaxis and non-anaphylaxis, persistent anaphylaxis and non-anaphylaxis, refractory anaphylaxis, other return-care outcomes Trial: Multicenter retrospective cohort Authors’ Conclusions: “A 2-h observation period is probably safe for most children who present to an emergency department with an acute allergic reaction requiring epinephrine. A 4-h observation period might be enough for patients with cardiovascular involvement who appear well.”  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? Unsure Was the follow-up of subjects complete enough? Unsure How precise are the results? Unsure Do you believe the results? Yes Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Funding of the Study: National Center for Advancing Translational Sciences and The National Institute of Allergy and Infectious Diseases of the National Institutes of Health. The funders had no role in study design, data collection, data analysis, interpretation, or writing of paper. Two of the authors report receiving consultant fees. One is on the advisory board and gets stock options from biotech companies and royalty fees from the publisher. Results: They included 5,641 eligible children with a median age of 7.9 years, with slightly more males (56%). 4956 (88%) fulfilled the National Institute of Allergy and Infectious Diseases and Food Allergy and Anaphylaxis Network criteria for anaphylaxis. In that group, 1.5% met criteria for biphasic anaphylaxis and 10.7% had persistent anaphylaxis. 4.7% received repeat epi after 2 hours from initial dose. 1.9% received repeat epi dose after 4 hours. Patients with cardiovascular involvement had higher rates of biphasic anaphylaxis. Key Results: Around 95% of children can be safely discharged after 2 hours of observation without the need for additional epinephrine. Among all patients, 5% received a repeat dose of epinephrine after 115 minutes. There were differences in patients with or without respiratory or cardiovascular involvement. Primary Outcome: In the entire cohort, 4.7% received epi 2 hours after the initial dose, 1.9% received epi after 4 hours, 1.1% received epi after 6 hours, and 0.8% received epi after 8 hours.  Secondary Outcomes:  86 (1.5%) had biphasic anaphylaxis 236 (4.2%) had biphasic non-anaphylactic allergic reactions 605 (10.7%) had persistent anaphylaxis 1400 (24.8%) had persistent non-anaphylactic allergic reactions 118 (2.1%) had refractory anaphylaxis Diagnosis of Anaphylaxis  We mentioned that anaphylaxis is a clinical diagnosis, but it’s not always clear-cut. In this retrospective review, the authors used ICD-10 codes and chart reviews to determine whether patients experienced anaphylaxis. They included patients who were treated with intramuscular, subcutaneous, or intravenous epinephrine. Potential biases include selection bias, information bias, and misclassification bias. Not all the patients included in this study actually met criteria for anaphylaxis, which is acknowledged by the authors. Anaphylaxis Practice Guideline update in 2023 states, “treatment with epinephrine or clinical response to epinephrine should also not be used as a surrogate marker to establish a diagnosis of anaphylaxis because there are many cases in which patients receive epinephrine for milder reactions.” Some of these patients were included because authors reported that “the administration of epinephrine might have mitigated reaction progression.” Appendix Table 3, which examines interrater reliability for agreement on anaphylaxis identification, reports kappa values ranging from 0.68 to 0.76, indicating substantial agreement but not perfect agreement. Repeat Epinephrine  The primary outcome for this study was the time from first to last administration of epinephrine. We must be careful and state that this is not the equivalent of a biphasic reaction. The decision to administer a repeat dose of epinephrine is also not always clear-cut. It is pragmatic. The clinician may have decided to administer another dose of epinephrine despite the patient not meeting the exact definition of anaphylaxis or a biphasic reaction. Epinephrine may have been administered because the child exhibited concerning signs or symptoms. For example,...

Date: February 13, 2026 Reference: Lang et al. Factors associated with emergency department length of stay in Alberta: a study of patient-, visit-, and facility-level factors using administrative health data. CJEM. 2026 Jan 29. Guest Skeptic: Dr. Paul Parks is an emergency physician from Medicine Hat, Alberta. He has been the President of the Alberta Medical Association (AMA) Section of Emergency Medicine for many years, the AMA Board of Directors for 9 years, and the Previous President of the Alberta Medical Association.  Paul has won the Canadian Association of Emergency Physicians (CAEP) National Teacher of the Year Award and the CAEP Alan Drummond National Advocacy Award. Case: A 78-year-old man with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) arrives at the emergency department (ED) by ground emergency medical services (EMS) at 15:30 with dyspnea and hypoxia. He’s triaged Canadian Triage and Acuity Scale (CTAS) 2, needs non-invasive ventilation (NIV), diuresis, labs, chest x-ray, and likely admission. The department is packed; multiple admitted patients are boarded in hallway spaces because inpatient beds are unavailable, and nursing assignments are stretched. The patient is placed in the “EMS-PARK” area, which is an extension of the waiting room, and part of a mandatory EMS offload policy. Workup is done while the patient is still technically in the waiting room. The workup and disposition decision happen within a few hours, but transfer to an inpatient bed doesn’t occur until 2-3 days later. Background: ED length of stay (LOS) can be considered a vital sign of ED operations and the broader acute-care system. When LOS rises, it often signals that the ED is no longer functioning as a short-stay diagnostic and stabilization unit but is serving as a buffer for upstream demand and downstream capacity issues. The consequences are not just operational (hallway beds, delayed assessments, delayed analgesia, delayed imaging), but also human. We covered a study that showed for older patients, one overnight stay in the ED waiting for an inpatient bed was associated with a 4% absolute increase in mortality (SGEM#424). In addition, increasing LOS can lead to clinician burnout and moral injury. LOS is also tricky because ED crowding is rarely a single-point failure within the ED. Modern crowding frameworks (often summarized as input–throughput–output) remind us that while ED processes matter, some of the most powerful determinants are output constraints. This is especially true when there is access block and inpatient bed scarcity. In other words, you can run an efficient front-end, but if admitted patients cannot be moved to inpatient beds, the system backs up, and ED LOS climbs. As one concrete example of the output challenges many provinces struggle with, in Alberta, 1/3 of our acute hospital capacity, or about 30%, can be occupied by Alternate Level of Care patients. These alternative level of care (ALC) patients have had their acute care needs met, but they cannot be safely discharged from the hospital without specific continuing care resources – home care, assisted living, or long-term care. We’ve talked about ED crowding on an SGEM Xtra. It covered some of the Zombie Ideas that have been circulating around for decades. The classic one is to blame non-urgent patients for using the ED. They are not responsible for ED crowding. Diverting non-urgent patients away can be dangerous and won’t solve the underlying problem. CAEP published a position statement on emergency department overcrowding in 2013. CAEP argued for nationally standardized performance benchmarks. The statement also called for system-level solutions to improve flow while recognizing that ED optimization alone cannot solve crowding without hospital-wide and community-wide action. While CAEP’s advocacy has influenced awareness, policy discussion, and accountability framing, significant problems continue into 2026. Clinical Question: Across Alberta ED visits, what patient-, visit-, and facility-level factors are associated with longer ED length of stay? Reference: Lang et al. Factors associated with emergency department length of stay in Alberta: a study of patient-, visit-, and facility-level factors using administrative health data. CJEM. 2026 Jan 29. Population: ED visits drawn from linked Alberta Health Services administrative data for 14 ED facilities in Alberta, covering May 2022 to March 2023. Exposures: Factors such as age, deprivation measures, EMS arrival, triage acuity (CTAS), primary care continuity, time/day patterns, and facility-level constraints, including emergency inpatient pressure and hospital occupancy; staffing signals (hours worked per nurse) were also examined. Comparison:Between levels of each exposure, typically relative to a reference category or per-unit change (hospital occupancy, EMS vs non-EMS arrival, different facility types, weekday vs weekend, etc.). Outcomes Primary Outcome:ED total length of stay (LOS). Secondary Outcomes: There were no clearly prespecified secondary outcomes; however, the analysis was stratified by disposition (admitted vs discharged vs other = LWBS, Left AMA, transferred, or died), which functions like a planned subgroup/stratified analysis rather than a distinct secondary endpoint. Type of Study: This is an observational cross-sectional study using population-based administrative data. Authors’ Conclusions: “ED length of stay is associated with modifiable factors, including hospital capacity constraints, hours worked per nurse, and healthcare access inequities. Addressing hospital occupancy, optimizing staffing, and improving care coordination across the patient trajectory—such as between the ED, inpatient units, and post-discharge services—may enhance ED efficiency and reduce prolonged stays. Our findings align with established frameworks describing ED overcrowding and support targeted, system-level interventions to improve the efficiency of emergency care.” Quality Checklist for Observational Studies (Yes/No/Unsure) Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Unsure Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Unsure Have the authors identified all-important confounding factors? No Was the follow-up of subjects complete enough? N/A How precise are the results? Very precise due to a large sample size, resulting in narrow confidence intervals for several of the point estimates. Do you believe the results? Yes  Can the results be applied to the local population? Unsure Do the results fit with other available evidence? Yes Who funded the trial? The authors acknowledge support under the Alberta Atlas of Healthcare Variation initiative. Did the authors declare any conflicts of interest? Brian R. Holroyd was the Senior Medical Director of the Emergency Strategic Clinical Network of Alberta Health Services at the start of this work. Matthew Pietrosanu was employed by Alberta Health Services for statistical consulting, technical writing, and general advising in the Alberta Atlas of Healthcare Variation initiative, which was expanded to include the preparation of this manuscript. Results: The dataset included 587,419 ED visits. The median age was 38 years, and 52% were female.  Most patients were discharged (68%), with 18% being admitted and 14% left without being seen, left AMA, transferred, or died. The median ED LOS was 3.1 hours overall, and LOS differed substantially by disposition (admitted patients had a much longer median LOS than discharged patients). Key Result: Facility- and system-level constraints were strongly associated with ED LOS, especially among admitted patients. The more emergency inpatient hours and higher hospital occupancy were associated with longer stays. Primary Outcome: Across all disposition categories, several patient-level factors were consistently associated with longer ED LOS, including older age, higher material or social deprivation, and arrival by EMS (ground or air). At the visit level, higher triage acuity and certain temporal factors (weekend admissions) were also associated with prolonged LOS, particularly among admitted patients. However, the largest and most clinically meaningful associations were at the facility level. Measures of hospital capacity strain dominated the results. Higher hospital inpatient occupancy and a greater number of emergency inpatients boarding in the ED were strongly associated with longer LOS, especially for admitted patients. For admitted patients, a one–standard deviation increase in hospital occupancy (approximately 0.11) was associated with a 17% increase in ED LOS, an effect size that dwarfed most patient- and visit-level predictors. This finding strongly supports the concept of access block (outflow from the ED) as the primary driver of prolonged ED stays. Higher hours worked per nurse were associated with shorter ED LOS in initial models, suggesting a potential staffing effect. However, this association disappeared after accounting for facility-level clustering, indicating that staffing effects may reflect broader organizational or structural differences between hospitals rather than a simple linear relationship with nursing hours. 1) Cross-Sectional Design & Temporality: The biggest design constraint is that this is a cross-sectional observational analysis. Exposures and outcomes are assessed within the same time frame. This means the direction of association can be unclear and may be difficult to determine. 2) Selection Bias: Although the dataset is large, it is not all Alberta EDs.  The authors explicitly acknowledge that excluding facilities without staffing/occu

Date: January 3, 2026  Reference: Shroyer et al. Accuracy of cath lab activation decisions for STEMI-equivalent and mimic ECGs: Physicians vs. AI (Queen of Hearts by PMcardio). Am J Emerg Med. 2025 Nov. Guest Skeptic: Dr. Amal Mattu has been on the faculty at the University of Maryland since 1996. He has developed an academic niche in emergency cardiology and electrocardiography, and he also enjoys teaching and writing on other topics, including emergency geriatrics, faculty development, and risk management. Amal is currently a tenured professor and Vice Chair of Emergency Medicine at the University of Maryland School of Medicine, and a Distinguished Professor of the University of Maryland-Baltimore. Case: A 58-year-old man with diabetes and hypertension arrives at the emergency department (ED) 30 minutes after the sudden onset of substernal chest pressure radiating to the left arm, now improved to 3/10. His vital signs are BP 146/88, HR 92, RR 18, O2 sat 98% on room air. The initial 12-lead ECG shows RBBB with left anterior fascicular block and subtle anterior ST‑depression with proportionally tall, broad T waves in V2 to V4. This is an appearance that can be seen with Hyper-Acute T Wave Occlusive Myocardial Infarction (HATW‑OMI) or an ST-Elevated Myocardial Infarction (STEMI)‑mimic in conduction disease. A debate ensues between emergency medicine and cardiology on whether to activate the cath lab now or get troponins plus serial ECGs? Background: Emergency physicians need to be experts at interpreting ECGs. For decades, we’ve been taught STEMI criteria, only to learn repeatedly that important exceptions exist (posterior OMI, de Winter, hyperacute T waves, modified Sgarbossa in LBBB, etc.). Those exceptions have evolved into two distinct categories. There are the STEMI‑equivalents (OMI without classic ST‑elevation) and STEMI‑mimics (ST‑elevation without OMI). That expanding exception list increases diagnostic complexity and uncertainty. This is the area where artificial intelligence (AI), utilizing computer vision and machine learning, could provide a benefit. ECG-specific AI models now aim squarely at this problem. The study we are reviewing today evaluated the Queen of Hearts (QoH) AI. It is a deep neural network trained to detect occlusive myocardial infarction (OMI) on 12-lead ECGs. The model is described as “91% accurate” in prior work and is undergoing FDA review as of March 24, 2025, but whether it outperforms practicing clinicians on the hardest cases (STEMI‑equivalents and mimics) remained unclear. ECG diagnostic accuracy is important in emergency medicine because misclassification cuts both ways. Missed OMI delays reperfusion, while overcalls send patients and teams to the cath lab unnecessarily, putting patients at risk and using up valuable resources. A diagnostic aid that catches true positive OMIs while reducing false activations could improve outcomes and team throughput. Clinical Question: Among EM physicians and cardiologists interpreting STEMI‑equivalent and STEMI‑mimic ECGs, how accurate are they compared with a machine‑learning ECG algorithm? Reference: Shroyer et al. Accuracy of cath lab activation decisions for STEMI-equivalent and mimic ECGs: Physicians vs. AI (Queen of Hearts by PMcardio). Am J Emerg Med. 2025 Nov. Population: 53 emergency physicians and 42 cardiologists from a community system. Intervention: Human interpretation and QoH AI algorithm classifying each ECG as OMI requiring immediate CLA vs not Comparison (Reference Standard): OMI Present: Angiographic culprit with ≤TIMI II flow and elevated troponin, or culprit with TIMI III flow and significantly elevated troponin. OMI Absent: No culprit ≥50% stenosis on angiography or, when no angiography, negative serial troponins, no new echo wall‑motion abnormality, and negative clinical follow-up Outcome: Diagnostic accuracy of ECG-based CLA decisions. CLA‑positive was defined a priori for STEMI/STEMI‑equivalents and for “reperfused OMI” (Wellens, transient STEMI). Type of Study: A cross-sectional diagnostic accuracy study using a fixed case‑set, with comparisons to a reference standard. Authors’ Conclusions: “Physicians frequently misinterpret STEMI-equivalent and STEMI-mimic ECGs, potentially impacting CLA decisions. QoH AI demonstrated superior accuracy, suggesting a potential to reduce missed OMIs and unnecessary catheterization laboratory activations. Prospective studies are needed to validate these findings in clinical practice.”  Quality Checklist for a Diagnostic Study: The clinical problem is well-defined. Yes The study population represents the target population that would normally be tested for the condition (ie no spectrum bias). No The study population included or focused on those in the ED. No The study participants were recruited consecutively (i.e. no selection bias). No The diagnostic evaluation was sufficiently comprehensive and applied equally to all patients (i.e. no evidence of verification bias). No All diagnostic criteria were explicit, valid and reproducible (i.e. no incorporation bias). Unsure The reference standard was appropriate (i.e. no imperfect gold-standard bias). Yes/No  All undiagnosed patients underwent sufficiently long and comprehensive follow-up (i.e. no double gold-standard bias). No The likelihood ratio(s) of the test(s) in question are presented or can be calculated from the information provided. Yes The precision of the measure of diagnostic performance is satisfactory. Reasonable Funding and Conflicts of Interest. No external funding. Several authors report stock ownership/consulting with Powerful Medical (QoH developer), and other authors reported no conflicts. Results: They recruited 95 physicians to interpret the ECGs. There were 53 EM physicians and 42 cardiologists (23 general, 15 interventional, 4 EP electrophysiology). Experience: EPs 7 years (IQR 3 to 15) vs cardiologists 15 years (IQR 9.2 to 21). Key Result: QoH AI had significantly higher accuracy than humans, and there was no significant difference between EM and cardiologists. Primary Outcome: EM Physicians 65.6% (95% CI ~51 to 78) Cardiologists 65.5% (95% CI ~51 to 77) QoH AI 88.9% (95% CI 82 to 93) The most frequently misclassified by humans were LBBB (±OMI), transient STEMI, HATW‑OMI, and de Winter. QoH AI missed LBBB‑OMI and LV aneurysm. RBBB + fascicular block and HATW‑OMI produced the largest EP-cardiologist disagreement. 1) Spectrum Bias: The investigators intentionally selected “ambiguous” STEMI‑equivalent and STEMI‑mimic ECGs and fixed the OMI prevalence at 50% for the reader study. That design improves efficiency in comparing readers and the AI, but it does not reflect the spectrum or prevalence we see in day-to-day ED practice and therefore threatens external validity. In diagnostic accuracy research, spectrum bias occurs when the distribution of disease/non-disease, disease severity, or look-alikes in the sample differs from that in the clinical population in which the test will be used. It can change sensitivity and specificity in either direction. Selecting borderline cases may deflate both compared with routine practice, and it will certainly distort PPV/NPV because predictive values are prevalence‑dependent. The authors acknowledge this by noting the 50% OMI prevalence and the deliberate use of ambiguous ECGs “may not accurately reflect predictive values observed in real-world settings.” 2) Differential Verification & Imperfect Gold Standard: Not every patient had the same reference standard. While most OMI determinations used angiography, some mimic cases without angiography were adjudicated by serial troponins, echocardiography, and clinical follow-up. Using different reference standards in different subgroups constitutes differential verification (double gold‑standard) bias and can bias sensitivity and specificity up or down, depending on whether the disease can resolve or only become detectable over time. In addition, any composite or clinical adjudication process is an imperfect gold standard, which can either inflate or deflate the index test’s performance depending on how errors correlate across tests. The authors explicitly note these issues in their discussion. 3) Incorporation/Review Bias: The paper reports that cardiologists performing angiography were not masked to the ECG. When the result of (or information from) the index test helps determine the reference diagnosis, that is incorporation (review) bias. This typically inflates both sensitivity and specificity of the index test because the gold standard classification is partially “contaminated” by the test under study. In this context, seeing a concerning ECG may tilt the invasive assessment and adjudication toward “culprit” lesion labelling or influence borderline calls, making ECG-based classification look better than it truly is. 4) Unit‑of‑analysis & Precision Limitations: This was a reader study with 95 clinicians classifying the same small set of 18 ECGs. Even with appropriate statistics, the small number of cases means performance estimates can be fragile, and the 95% confidence intervals reflect that imprecision. To their credit, the authors modelled accuracy with multi-level robust variance to account for clustering (multiple readers rating the same cases), but the design still limits precision and generalizability across the full morphology spectrum of each category. The authors themselves state that “one representative ECG per type…cannot represent all ST‑T variants”, and that asking physicians to read far more than 18 tracings was impractical. This imprecision concerns should raise our skeptical radar, and we should factor this into our study interpretation. 5) External Validity: The study is single-center and uses an online survey without the interruptions, time pressure, serial ECGs,...

Date: January 6, 2026  Guest Skeptic: Darren McKee is an author and speaker. He has served as a senior policy advisor and policy analyst for over 17 years. Darren hosts the international award-winning podcast, The Reality Check. He is also the author of an excellent, thought-provoking book called Uncontrollable: The Threat of Artificial Superintelligence and the Race to Save the World (2023). The book lays out what AI is, why advanced systems could pose real risks, and what individuals and institutions can do to increase AI safety.  We have discussed AI on the SGEM a few times: SGEM Xtra: Rock, Robot Rock – AI for Clinical Research SGEM#459: Domo Arigato Misuta Roboto – Using AI to Assess the Quality of the Medical Literature SGEM#460: Why Do I Feel Like, Somebody’s Watching Me – CHARTWatch to Predict Clinical Deterioration SGEM#472: Together In Electric Dreams – Or Is It Reality? AI already touches the emergency medicine world through triage, documentation (AI scribes), imaging, and patient communications. You argue in the book that we’re in exponential times, AI capabilities may accelerate, and that simple rules won’t reliably constrain advanced systems. All of which has implications for safety, bias, reliability, and public trust in healthcare.  The book is divided into three sections. I expanded on that so I could ask Daren questions about five different areas. Listen to the SGEM Xtra podcast to hear his responses: Five Questions for Darren Origin Story & Stakes: The book's introduction contrasts the confident historical skepticism about nuclear power with the speed with which reality overtook it. Give us a brief history of nuclear power. Then the book pivots to today’s AI and uses an analogy of humanity’s "smoke detector " moment. Explain what that is and why you decided now was the time to write this book. Part I: What is Happening? In the first part of the book, you build a narrative from AI to AGI to ASuperI. Can you provide some definitions of those terms and explain why they matter? Can you walk us through how current systems (large language models and image models) work at a high level? Why did emergent capabilities surprise even their builders, and why don’t we fully understand what’s happening under the hood of these machines? Part II: What are the Problems? You outline six core challenges: exponential progress, uncertain timelines (and expert disagreement), the alignment problem, why simple rules (à la “Three Laws”) fail, how control erodes as tech integrates into our lives, and how all this aggregates into societal risk. We are not going to go through all six, but could you explain the alignment problem? The other topic I wanted to expand on was the Three Laws. Part III: What Can We Do? The last two chapters get practical and discuss what institutions can do for safe AI innovation and what individuals can do to increase AI safety. Give us your top 2 or 3 institutional moves (transparency, evaluation, guardrails). How about your top 2 to 3 personal moves that listeners can do?  AI in the Emergency Department: Bring it home for us in the emergency department if you can. When an AI-enabled tool is proposed for triage, documentation, or image support, what are the three questions every emergency clinician or leader should ask before adoption?  The SGEM will be back next episode with a structured critical appraisal of a recent publication. Our goal is to reduce the knowledge translation (KT) window from over 10 years to less than 1 year using the power of social media. So, patients get the best care, based on the best evidence.   Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Reference: Aronson PL, et al. Prediction Rule to Identify Febrile Infants 61–90 Days at Low Risk for Invasive Bacterial Infections. Pediatrics. September 2025 Date: January 6, 2026 Dr. Jillian Nickerson Guest Skeptic: Dr. Jillian Nickerson is a pediatric emergency medicine attending at Children’s National Hospital and Assistant Professor of Pediatrics and Emergency Medicine at The George Washington University School of Medicine and Health Sciences in Washington, DC. Prior to completing her PEM fellowship, she completed an emergency medicine residency at Mount Sinai in New York. Now she is also the associate program director for the pediatric emergency medicine fellowship program at Children’s National Hospital. Background: Fever is a common complaint that we encounter in the emergency department. In general, we want to be careful in our counseling and our practice not to perpetuate many of the myths and misconceptions that contribute to fever phobia. But there are certain populations where fever does get us a bit worried. When infants present with fever, we have to think about evaluating for other sources of infection such as bacteremia or meningitis, termed invasive bacterial infections (IBI). Fortunately, the prevalence of IBI tends to be low, but missing one could lead to significant morbidity or mortality. How do we determine whom to test and what tests to perform? We’ve covered multiple clinical decision rules for risk-stratifying febrile infants before on the SGEM: SGEM #171: Step-by-Step Approach to the Febrile Infant SGEM#296: She’s Got the Fever but Does She Need an LP, Antibiotics or an Admission? SGEM#341: Are the AAP Guidelines for the Evaluation and Management of the Well-Appearing Febrile Infant SGEM#387: Lumbar Punctures in Febrile Infants with Positive Urinalysis SGEM #474: Help! Which Clinical Decision Aid Should I Use to Risk Stratify Febrile Infants? Some of these clinical decision rules like Step by Step can be applied to infants up to 90 days. Others like the 2021 American Academy of Pediatrics (AAP) clinical practice guideline and the Pediatric Emergency Care Applied Research Network (PECARN) clinical decision rule, only include infants up to 60 days. Clinical Question: Is there an accurate prediction rule to identify well-appearing febrile infants 61–90 days old who are at low risk for invasive bacterial infection (IBI)? Reference: Aronson PL, et al. Prediction Rule to Identify Febrile Infants 61–90 Days at Low Risk for Invasive Bacterial Infections. Pediatrics. September 2025 Population: Non-ill-appearing febrile infants 61–90 days who had evaluation with both urinalysis/urine dipstick and blood culture Excluded: infants who were critically ill (ESI level 1, intubated, received vasoactive medication), death in the ED, prematurity ≤32 weeks, substantial pre-existing medical or surgical conditions, skin or soft tissue infections, home antibiotic use before ED visit Intervention: Derivation of a clinical prediction rule using urinalysis, temperature, ANC, ± procalcitonin. Comparison: none Outcome: Primary Outcome: Accuracy of the prediction rule to identify infants at low risk for IBI, defined as bacteremia or bacterial meningitis. Secondary Outcomes: none Trial: Retrospective cohort study Dr. Nathan Kuppermann Dr. Paul Aronson Authors: Dr. Paul Aronson is a pediatric emergency medicine attending and Professor of Pediatrics and Emergency Medicine at Yale School of Medicine. He is the Deputy Director of the Pediatric Residency Program and leads the Research Track. Dr. Nathan Kuppermann is executive vice president, chief academic officer of Children's National Hospital and director of the Children's National Research Institute. He also serves as chair of the Department of Pediatrics and associate dean of Pediatric Academic Affairs at the George Washington University School of Medicine and Health Sciences. Dr. Kuppermann is a pediatric emergency medicine physician, clinical epidemiologist and leader in emergency medical services for children. Authors’ Conclusions: We derived two accurate clinical prediction rules to identify febrile infants 61–90 days at low risk for invasive bacterial infections when urine and blood testing are obtained. Prospective validation is needed. Quality Checklist for Clinical Decision Rules: The study population included or focused on those in the ED. Yes Where was the study conducted (external validity). Conducted across 17 EDs in the PECARN Registry over 10 health systems (with many pediatric EDs). The patients were representative of those with the problem. Unsure. All important predictor variables and outcomes were explicitly specified. Yes This is a prospective, multicenter study including a broad spectrum of patients and clinicians (level II). No Clinicians interpret individual predictor variables and score the clinical decision rule reliably and accurately. Yes Is this an impact analysis of a previously validated CDR (level I study)? No For Level I studies, impact on clinician behavior and patient-centric outcomes is reported. N/A The follow-up was sufficiently long and complete. Yes The effect was large enough and precise enough to be clinically significant. Unsure. Funding of the Study: Eunice Kennedy Shriver National Institute of Child Health and Human Development. No financial conflicts of interest. Did the authors declare any conflicts of interest? The authors reported no conflicts of interest to disclose. Results: They included 4,952 infants. The median age was 72 days, and 54% male. Median maximum qualifying temperature was 38.7°C. Urinalysis was positive in 18%, LP/CSF testing was performed in 10%, antibiotics were given in 26%, and 34% were hospitalized. Approximately 100 (2%) tested positive for IBI with 95 cases of bacteremia and 5 cases of bacterial meningitis. A little bit over half (57%) with bacteremia also had UTI. Of those infants 1207 (24%) had procalcitonin and absolute neutrophil count (ANC) measured. That group had 27 with IBIs with 2 being bacterial meningitis.  Low risk predictors: Procalcitonin <0.24 ng/mL ANC < 10,710 cells/mm3 Key Results: This clinical prediction rule for risk-stratifying febrile infants 61-90 days based on urine and temperature >38.9°C had a sensitivity of 86%, specificity of 58.9%, NPV of 99.5%, and -LR of 0.24, but still needs external validation. This decision rule missed 14 infants with IBIs (13 with bacteremia and one with Group B Strep meningitis). There was a second decision rule that included procalcitonin ≤0.24 ng/mL and ANC  ≤10,710 cells/mm3. The derivation sensitivity was 100% but dropped to 85.2% on cross-validation. The specificity was around 65-68%. NPV ranged from 99.5-100%, Negative likelihood ratio was 0.22. Tune in to the podcast to hear Drs. Aronson and Kuppermann answer our nerdy questions. Selection Bias This secondary analysis included only febrile infants aged 61-90 days who underwent both urine and blood testing. A total of 20,211 infants in that age range had fevers, but only 30% of them had urine and blood cultures obtained. It’s also mentioned that the included infants had higher maximum qualifying temperatures, more assigned ESI triage level 2, and received parenteral antibiotics or were hospitalized. It’s possible that these infants may have been deemed sicker than those who did not undergo testing. The study was unable to capture the clinical decision-making that determined which infants underwent testing and which did not. How do you think this selection bias could impact your results? Overfitting the Data  The PCT and ANC rule showed perfect sensitivity in derivation but lower sensitivity on cross-validation (4 false negatives). This is a pattern that may represent model instability especially when dealing with uncommon outcomes. Increasing model complexity can improve apparent performance in the derivation set but worsen performance in validation because of overfitting. What steps did you take to try to limit overfitting and what changes if any do you anticipate in making to this CDR for external validation? The “Original” PECARN  Although this new clinical decision rule has a high NPV, we must also recognize the limitation that the prevalence of IBI is low. As disease prevalence decreases, NPV increases. The study team did look at this with the “original” PECARN rule’s rounded cutoffs of procalcitonin ≤0.5 and ANC ≤4000 without urinalysis. The sensitivity was 100% (95% CI 87.2-100) and specificity was 49.7% (95% CI 46.8-52.6). This was in the supplemental section. While we’re waiting for external validation of this new clinical decision rule, why not use the tried-and-true existing clinical decision rule? One less thing with new cutoffs for inflammatory markers to remember right? 90 Days and Beyond!  The clinical decision rule in this study, if and when externally validated, would apply to infants up to 90 days. What about beyond that? There’s quite a bit of variation in practice when it comes to workup for infants 2-6 months presenting with fever to the emergency department. How do you approach the workup of infants over 90 days?  Prematurity Many of the existing clinical decision rules exclude infants born prematurely. In reality, we also encounter these patients in the ED. How do you approach the workup of a febrile premature infant?  Bonus Question: Respiratory Virus Testing You report that you were unable to assess the results of respiratory viral testing as a predictor because of missing data, but we do know that febrile infants with viral infections do seem to have lower prevalence of IBI compared to those without. In your clinical practice, how do you manage infants with viral symptoms?...

Date: January 17, 2026 Reference:  Casey et al. RSI Investigators and the Pragmatic Critical Care Research Group. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. NEJM. 2025 Dec Guest Skeptic: Dr. Scott Weingart is an ED Intensivist from New York. He did fellowships in Trauma, Surgical Critical Care, and ECMO. Scott is best known for talking to himself about Resuscitation and Critical Care on the podcast EMCrit, which has been downloaded more than 50 million times. Scott and I will both be presenting at Incrementum 2026 in Spain.  Case:  You’re working an evening shift in a busy tertiary-care emergency department (ED). Emergency Medical Services (EMS) rolls in a 62-year-old woman with a history of hypertension and type 2 diabetes. She’s febrile at 39.2°C, tachycardic at 125 beats/min, hypotensive at 86/52 mm Hg despite 2 L of crystalloid and breathing 32/min on a non-rebreather with oxygen saturation of 88%. Chest X-ray shows a right‑lower‑lobe infiltrate; lactate is 5.6 mmol/L. She’s now on a norepinephrine infusion at 0.15 µg/kg/min and still looks exhausted and altered. You decide she needs emergent rapid sequence intubation (RSI) for worsening work of breathing and impending respiratory failure. The respiratory therapist is at the bedside, the pharmacist has arrived with the RSI box, and your resident says: “For induction, should we go with ketamine because she’s septic and hypotensive, or etomidate because we’re worried about pushing her over the edge?” Background: Intubating critically ill patients can be one of those high-stakes, high-adrenaline things we do often in emergency medicine (EM), but the physiology is stacked against us. These patients are often hypoxic, hypotensive, acidotic and catecholamine-depleted before we even reach for the laryngoscope. Emergency airway registries and multicentre cohorts consistently report serious peri-intubation complications (profound hypotension, hypoxemia, cardiac arrest, failed or difficult intubation) in roughly 10% to 20% of critically ill adult intubations in the ED and ICU [1].  Even a single episode of severe hypotension or hypoxemia during intubation is associated with increased mortality and organ failure in the ICU population [2].  So, the choice of induction agent seems to matter. Etomidate became the darling of emergency RSI because it has a rapid onset, short duration, and relatively preserved hemodynamics compared with agents like thiopental or high‑dose propofol [3].  The flip side is adrenal suppression: a single dose transiently inhibits 11‑β hydroxylase and measurably blunts cortisol production for 24–72 hours. Observational studies and post‑hoc analyses in septic shock raised alarms that etomidate might increase mortality by worsening relative adrenal insufficiency, leading some guidelines and regulators to discourage or even remove etomidate in sepsis [4]. But those were mostly non-randomized data, and prior RCTs comparing etomidate with other agents were small and gave conflicting signals about mortality. Ketamine, by contrast, is a dissociative NMDA antagonist with a very different vibe. It provides profound amnesia and analgesia, maintains airway reflexes to some degree, and has sympathomimetic properties that can increase heart rate and blood pressure by catecholamine release [5]. Those properties have made ketamine attractive in shocked patients where we’re worried that propofol or midazolam will “tank the pressure”. However, in catecholamine-depleted septic shock, ketamine’s direct myocardial depressant effects may become more apparent, and registry data suggest its hemodynamic advantage over etomidate is not as clear as many of us were taught on shift.  Old concerns that ketamine raises intracranial pressure have largely been debunked in modern neurocritical care literature, further widening its appeal.  Other agents are still in the mix. Propofol remains widely used in operating theatre practice and some EDs because of its familiarity and ease of titration, but it predictably causes vasodilation and negative inotropy, making it a frequent offender in peri‑intubation hypotension among critically ill patients [6]. Benzodiazepines (midazolam) have a slower onset, a more variable effect and a longer half‑life, and when used as primary induction agents in shock, they’ve been associated with more hypotension and delirium compared with etomidate or ketamine. Fentanyl and other opioids are often layered on for analgesia or “blunting” the sympathetic surge, but they can also precipitate abrupt hypotension and apnea in the already fragile patient. So for years we’ve been stuck between the theoretical adrenal toxicity of etomidate and the hoped‑for hemodynamic benefits of ketamine, without a large, definitive randomized trial in ED/ICU patients powered for patient‑important outcomes like mortality. Clinical Question: In critically ill adults undergoing emergency tracheal intubation in the ED or ICU, which induction agent is better, ketamine or etomidate? Reference:  Casey et al. RSI Investigators and the Pragmatic Critical Care Research Group. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. NEJM. 2025 Dec Population: Critically ill adults (≥18 years) undergoing or planned to undergo tracheal intubation in an ED or ICU, where the treating clinician intended to use either ketamine or etomidate for induction, conducted at six EDs and eight ICUs in the US. Excluded: Known or suspected pregnancy, prisoners. acute trauma as the primary indication for intubation, immediate “crash” intubations where there was no time for randomization, known or suspected allergy or contraindication to either ketamine or etomidate, situations where the treating clinician believed that either ketamine or etomidate was specifically required or contraindicated (strong clinician preference), or patients previously enrolled in the trial. Intervention: The Ketamine group received 1.0–2.0 mg/kg given immediately before intubation.  Treating clinicians chose neuromuscular blocking agents, pre‑ and post‑intubation vasopressors, fluids, and other medications according to local practice. Comparison: The Etomidate group received 0.2–0.3 mg/kg. Again, all other aspects of airway management and resuscitation were at the clinician's discretion. Outcomes: Primary Outcome: In-hospital death by day 28 after randomization.  Secondary Outcomes: A composite of “cardiovascular collapse” during the interval between induction of anesthesia and 2 minutes after tracheal intubation, defined as any of: Systolic BP <65 mm Hg, or A new vasopressor started or an increase in vasopressor dose, or Cardiac arrest.  Exploratory Outcomes Type of Study: A therapeutic, parallel‑group, multicenter randomized controlled trial Authors’ Conclusions: “Among critically ill adults undergoing tracheal intubation, the use of ketamine to induce anesthesia did not result in a significantly lower incidence of in-hospital death by day 28 than etomidate.” Quality Checklist for Randomized Clinical Trials: Did the study population include or focus on ED patients? Yes Were patients adequately randomized? Yes  Was the randomization process concealed? Yes Were patients analyzed in the groups to which they were randomized (intention‑to‑treat)? Yes Were patients recruited consecutively (no selection bias)? Unsure Were both groups similar with respect to prognostic factors? Yes Were all participants (patients, clinicians, outcome assessors) blinded? No Were all groups treated equally except for the intervention? Unsure Was follow‑up complete (≥80% in both groups)? Yes Were all patient‑important outcomes considered? Yes Was the treatment effect large enough and precise enough to be clinically significant? No Who funded the trial? The trial was funded by the Patient-Centred Outcomes Research Institute (PCORI), the US National Heart, Lung, and Blood Institute, and the US Department of Defence, among others; the funders had no role in study design, conduct, analysis, or manuscript preparation.  Did the authors declare any conflicts of interest? Several authors reported research funding and consulting fees from various organizations (NIH, DoD, Octapharma, monitoring companies), although none were manufacturers of ketamine or etomidate. Results: They randomized 2,365 patients with a median age of 60 years, ~42% female, and ~56% intubated in the ED.  Nearly half had sepsis or septic shock, the median APACHE II score was 18, and about 22% were receiving vasopressors in the hour before intubation.   Key Result: For critically ill adults undergoing emergency tracheal intubation in the ED/ICU, ketamine and etomidate produced similar 28-day in-hospital mortality, but ketamine was associated with more cardiovascular collapse and hypotension around the time of intubation. Primary Outcome: In-hospital death by day 28: Ketamine 28.1% vs Etomidate 29.1% Risk difference adjusted for trial site: −0.8% (95% CI: −4.5% to 2.9%). Secondary Outcomes: Open Label Open‑label: This was an open-label trial, with neither clinicians nor research staff being masked to assignment. The lack of blinding can bias both cointerventions (performance bias) and outcome measurement (detection bias), especially for outcomes that rely on clinician judgment. The primary outcome (death by day 28) may not be impacted by this, but the key secondary outcome, like cardiovascular collapse, is partly defined by starting or escalating vasopressors, which is inherently a clinician’s decision. If clinicians believed ketamine was safer or more pressure-friendly, they might delay vasopressors or, conversely, might treat etomidate patients more aggressively with prophylactic pressors, biasing the composite in either direction....

Date: January 5, 2026 Reference: Robblee et al. 2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. Headache 2025 Dec Happy New Year, SGEMers! What better way to start 2026 than with an SGEM Xtra about migraine headaches? We were originally scheduled to record this episode in December, but circumstances changed. This is another SGEM Xtra and not the typical structured critical appraisal with a checklist. It will be a conversation about what we should be doing and should stop doing when treating migraine patients in the ED based on the new American Headache Society (AHS) guidelines. However, you will find a standard SGEM nerdy critical appraisal at the end of this blog post. Migraine is one of the most common causes of headache visits to the ED, representing ~¼ of the 3.5 million annual headache-related visits in the US. Despite prior guidelines, ED practice is still all over the map, and patients sometimes leave without much relief. The AHS has just released the 2025 guideline update on parenteral pharmacotherapies and nerve blocks for adult ED migraine. To help us understand these new guidelines, we are joined by two neurologists who literally wrote the guidelines. Dr. Jennifer Robblee Dr. Jennifer Robblee (lead guideline author) is a Board‑certified neurologist and headache specialist at Barrow Neurological Institute in Phoenix. Her practice focuses on refractory migraine and status migrainosus. She trained at the University of Toronto (MD, neurology residency, MSc) and completed a headache fellowship at the Mayo Clinic Scottsdale.  Jennifer is the third eurologist to be on the SGEM. We’ve had Dr. Jeff Saver and Dr. Ravi Garg discuss thrombolytics and stroke. This will be an example that not all of neurology and emergency medicine intersect over stroke care.  Dr. Serena Orr Dr. Serena Orr (senior guideline author) is a pediatric neurologist, headache subspecialist, and director of the pediatric headache program at Alberta Children’s Hospital in Calgary. Serena has a strong interest in acute treatment of migraine, tech‑based treatment solutions, and psychosocial factors affecting migraine in kids and teens. The AHS guideline committee uses a 5-year update cycle for guidelines. Since 2016, 26 new RCTs and 20 injectable treatments, including nerve blocks (GONB, SONB, SPG) and eptinezumab.  Unfortunately, ED migraine outcomes are still not great. Only ~37% of ED patients achieve headache freedom at discharge. These new guidelines were trying to answer two questions.  Which injectable meds are effective in adults with migraine in the ED? Are nerve blocks effective in adults with migraine in the ED?  Top 5 things ED should know about the 2025 AHS Migraine Guidelines Listen to the SGEM podcast to hear Jennier and Serena discuss the top five things emergency physicians should know about the 2025 migraine guidelines. 1. Prochlorperazine IV & Greater Occipital Nerve Blocks (GONB) Are Now Level A “Must Offer” IV prochlorperazine and greater occipital nerve blocks (GONB) are Level A - must offer or adults presenting to the ED with a migraine attack requiring parenteral therapy (if no contraindications).  Questions: This is a big upgrade from 2016. Why did prochlorperazine and GONB earn Level A status in 2025? Practically, what does that look like in an ED order set? Are you imagining that everyone gets prochlorperazine? For the EM docs who have not been performing occipital nerve blocks, how steep is the learning curve? 2. Hydromorphone Is Level A “Must NOT Offer” Hydromorphone IV: Level A - Must NOT offer for migraine in the ED.  Questions: Let’s talk about opioids. Hydromorphone is now ‘must NOT offer’, what tipped the scale to Level A harm/no benefit? “Must NOT offer” seems like a strong statement (thou shalt not), is there not a potential clinical situation where an opioid still should be offered? How do we balance real‑world pressures, patient expectations, throughput, Press Ganey scores with an anti‑opioid, evidence‑based stance? It’s going to impact ED docs and not neurologists. 3. The Level B Recommendations:  Level B - “Should offer” for headache requiring parenteral therapy (Dexketoprofen IV, ketorolac IV, metoclopramide IV, subcutaneous sumatriptan, and supraorbital nerve blocks [SONB]).  Dexamethasone IV remains Level B “should offer” for recurrence prevention from the 2016 guidance.  Questions: If Level A is your starting lineup, who’s on the bench as your Level B ‘should offer’ options, and when do you pull them in? Is there a preferred sequence – dopamine antagonist first, then NSAID, then triptan, or is it more patient‑specific? How should ED clinicians think about dexamethasone? Is it still a routine add‑on, or more selective? 4. Nerve Blocks Are Mainstream GONB: Level A - Must offer. SONB: Level B - May/should offer when GONB is insufficient or not possible.  Questions: For a busy ED, how realistic is it to integrate occipital and supraorbital nerve blocks into standard migraine care? What’s the pragmatic advice on training?   Can EM doctors become competent with blocks via bedside teaching and FOAMed resources> 5. Big Evidence Gaps No meta‑analyses were possible because of significant heterogeneity in methods and outcomes. Additional ED-specific outcomes, such as pain relief at 1 hour. Asking about patient-oriented outcomes (POO) such as “Would you want this treatment again on your next ED visit?” Need ED‑specific data on eptinezumab (currently Level U for general ED use despite strong outpatient data).  Questions: If you had unlimited funding for one ED migraine randomized control trial, what would you test, and what outcome would you choose? You recommended a 1‑hour endpoint for ED trials. How does that change how we design and interpret future studies? I love the idea of the patient-centred outcome: ‘Would you want this again?’ How do we make sure future trials include that kind of measure? Five Limitations of the AHS Migraine Guideline The goal here is not to dunk on the guideline; there are limitations to any study.  This is just a nerdy conversation about how the next cycle could be improved. Listen to the SGEM Xtra podcast to hear Jennifer and Serena respond.  Limitation 1: Risk of Bias Tool & Study Quality Nuances Question: “You explicitly say that some ‘class I’ RCTs had small sample sizes or weird time points that made you less confident. From an EBM standpoint, how did you reconcile the AAN RoB categories with what we’d call imprecision and indirectness in GRADE?” Limitation 2: External Validity - Not All RCTs Were ED RCTs Question: “Many of the trials you had to work with weren’t actually done in ED settings – eptinezumab and SPG blocks being two examples. How worried should we be about extrapolating outpatient data into the ED, where patients are often later in the attack, more distressed, and maybe have different comorbidities?” Limitation 3: Active Comparators of Unclear Significance Question: “You call out trials that compare against ‘iffy’ active controls (valproate, dexamethasone, etc). In EBM terms, this muddies the signal. If you beat a weak comparator, is your drug actually good? How did you handle that when grading evidence and crafting recommendations?” Limitation 4: No Meta‑Analyses; Reliance on Narrative Synthesis Question: “From a methodological point of view, the fact that you couldn’t meta‑analyze anything limits precision and makes it hard to quantify effect sizes. How should EM clinicians interpret Level A or B recommendations that rest on narrative synthesis instead of pooled estimates?” Limitation 5: Broader Biases - Publication, Selection, and the ED Reality Question: “Zooming way out, every guideline sits on top of the published RCT iceberg. How much do you worry about publication bias, selection bias, and the fact that ED patients we see at 3 am rarely look like the trial population?” Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.  Critical Appraisal Reference: Robblee et al. 2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. Headache 2025 Dec Background: Migraine is one of the most common reasons people roll into the ED with a headache, and it’s not just “a bad headache.” It’s a chronic neurologic disorder that affects over a billion people globally and is consistently among the top causes of years lived with disability, especially in young and middle-aged adults [1.2].  In the ED specifically, migraine accounts for about one‑quarter of the ~3.5 million headache-related visits per year in the US. That’s a lot of stretchers tied up with photophobic patients in dark rooms. Clinically, migraine is defined by the International Classification of Headache Disorders (ICHD‑3). Typical attacks last 4 to 72 hours and are moderate to severe, often unilateral, pulsating, and worsened by routine physical activity. They’re commonly accompanied by nausea and/or vomiting and photophobia/phonophobia [3]. Migraine without aura is the most common type; migraine with aura adds transient focal neurologic symptoms (usually visual) that precede or accompany the headache. Diagnosis in the ED is clinical: apply ICHD‑3 criteria, look for a typical migraine phenotype, and screen for red flags (fever, meningeal signs, focal deficits, thunderclap onset, immunocompromise, anticoagulation, etc.) to rule out secondary causes. Outside the ED, acute migraine treatment usually starts with oral NSAIDs or acet

Date: December 23, 2025 Reference: Todd et al. Antihypertensive prescription is associated with improved 30-day outcomes for discharged hypertensive emergency department patients. J Am Coll Emerg Physicians Open. 2024 Guest Skeptic: Dr. Mike Pallaci is a Professor of Emergency Medicine at Northeast Ohio Medical University and a Clinical Professor of Emergency Medicine at Ohio University Heritage College of Osteopathic Medicine. He currently serves as Core Faculty for the USACS EM Residency at Summa Health System in Akron, OH where he is also Medical Director for the Virtual Care Simulation Lab, Director for the Simulation Medicine Fellowship and Vice Chair for Faculty and Resident Development. Over the course of his 24-year career in EM (15 in academics), he has worked in EDs with volumes ranging from 6,000 to 85,000 per year in urban and rural areas, in community and academic institutions, and has served as Program Director for two EM residencies. He has given lectures and published podcasts and articles in all areas of Emergency Medicine, including at the ACOEP Scientific Assembly, on the EM:RAP platform and right here on the SGEM. Prior research has resulted in book chapters, journal publications and presentations at multiple regional, national and international conferences on numerous topics including medical education, chest pain, pain management, gender bias, documentation, wellness, medicolegal issues, emergency ultrasound, hypertension and others. Case: A 47-year-old male presents to the emergency department (ED) with an ankle sprain. Admitting vital signs include a blood pressure of 210/130, which is similar on repeat measurements. He has no complaints except for ankle pain. He is in good health, has no known medical history, and has a primary care doctor whom he hasn't seen in about 6 or 7 years. Background: Hypertension is one of the most common “incidental” findings in the ED. In the US, there are over 900,000 annual ED visits with elevated blood pressure, and that number is climbing each year. Up to a third of these patients have no prior diagnosis of hypertension. Chronic uncontrolled blood pressure is strongly associated with myocardial infarction, stroke, heart failure, renal failure, and death, so these “incidental” readings are not benign. Standard outpatient care focuses on confirming the diagnosis with repeated measurements and then starting long-term therapy (lifestyle plus medications) to reduce cardiovascular events and mortality over the years, with randomized trial and meta-analytic evidence that treating hypertension reduces composite cardiovascular events and death. The ED, however, sits at an awkward intersection between chronic disease and acute care. Many patients we see with elevated blood pressure are asymptomatic or have nonspecific complaints, with no clear end-organ damage. Guidelines generally allow ED physicians considerable discretion about whether to initiate oral antihypertensives at discharge versus simply arranging follow-up. In 2025, the American College of Emergency Physicians (ACEP) published an updated policy regarding patients with asymptomatic markedly elevated blood pressure. They asked whether ED medical intervention reduces rates of adverse outcomes. They provided a Level C Recommendation that said: In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required. In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control. [Consensus recommendation] Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up. [Consensus recommendation] Previous work suggests that starting antihypertensives from the ED is safe and improves short-term blood pressure control in high-risk populations. Still, there has been very little evidence about patient-oriented short-term outcomes (myocardial infarction, stroke, heart failure, death, and ED revisits). Clinical Question: Among adult ED patients discharged with a diagnosis of hypertension and not on antihypertensive therapy, is an ED discharge prescription for an oral antihypertensive medication associated with a lower 30-day risk of severe hypertension-related adverse events, death, or ED revisits? Reference: Todd et al. Antihypertensive prescription is associated with improved 30-day outcomes for discharged hypertensive emergency department patients. J Am Coll Emerg Physicians Open. 2024 Population: Adult patients (≥18 years) seen and discharged from an ED within a single hospital system with a primary or secondary ED discharge diagnosis of essential (primary) hypertension and hypertensive urgency without prior treatment for hypertension during the previous 18 months. Excluded: Patients admitted to the hospital or to ED observation. Those who died in the ED. Patients without documented elevated blood pressure (BP 48 hours. Anyone prescribed an antihypertensive in the 18 months prior. Patients with a severe adverse event (AE) that were already present at ED discharge. Visits with missing gender or race data. Exposure: Receiving a prescription for an oral antihypertensive medication at ED discharge. Comparison: Discharged hypertensive ED patients meeting the same inclusion/exclusion criteria who did not receive an antihypertensive prescription at ED discharge. Outcome: Primary Outcome: Severe composite adverse events from hypertension within 30 days of ED discharge (Acute aortic catastrophe, Acute heart failure, Myocardial infarction, Hemorrhagic stroke, Ischemic stroke or Hypertensive encephalopathy) Secondary Outcomes: All-cause death within 30 days of ED discharge and ED revisit within 30 days of ED discharge. Type of Study: Retrospective observational cohort study Authors’ Conclusions: “Prescription antihypertensive therapy for discharged ED patients is associated with a 30-day decrease in severe adverse events and ED revisit rate.” 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? NO Was the follow-up of the subjects sufficient? UNSURE How precise are the results? YES Do you believe the results? YES Can the results be applied to the local population? YES Do the results fit with other available evidence? YES Who funded the trial? The study is explicitly described as unfunded research. Did the authors declare any conflicts of interest? NO Results: After applying the inclusion and exclusion criteria, they had 93,512 ED visits with a discharge diagnosis of hypertension. The mean age was 59 years, 57% female, 59% white, 10% received antihypertensive treatment in the ED before discharge, and 5% received an antihypertensive prescription at ED discharge. Patients prescribed antihypertensives at discharge were younger, more often male and Black, had higher systolic and diastolic blood pressure, lower comorbidity burden, were more likely to have received antihypertensives in the ED, and less likely to have prior heart failure. Key Result: One in 20 hypertensive ED patients received an antihypertensive prescription at discharge; among those who did, the adjusted odds of severe 30-day adverse events and ED revisits were substantially lower, with no difference in 30-day mortality compared with those who did not receive a prescription. Primary Outcome: Severe adverse events within 30 days 0.7% untreated vs 0.2% treated aOR 0.224 (95% CI; 0.106 to 0.416, p<0.001) Number needed to treat (NNT) 183 (95% CI; 161 to 247) to prevent one adverse event. Secondary Outcomes All cause death at 30 days: No statistical difference between groups (5 deaths in treated vs 105 untreated, aOR 1.445, 95% CI; 0.476–3.583, p=0.467). ED revisit within 30 days: Fewer in the treated group (10% vs 16%). Adjusted aOR 0.610 (95% CI; 0.547 to 0.678, p<0.001). NNT 18 (95% CI 16 to 23) to prevent one ED revisit. Individual Adverse Events: Antihypertensive therapy was significantly associated with decreased odds of acute heart failure (aOR 0.183, 95% CI; 0.056 to 0.441). No statistical difference in aortic catastrophe, MI, ischemic stroke, hemorrhagic stroke, and hypertensive encephalopathy, with some components having zero events in the treated group. 1. Residual Confounding: This is an observational treatment study, not a randomized trial, so the decision to prescribe is influenced by physician judgment and patient factors. Treated patients were younger, had less comorbidity, and were more likely to have received antihypertensives in the ED and to get follow-up prescriptions later. This suggests that they differed systematically from untreated patients. Even with multivariable adjustment and inverse probability weighting, unmeasured factors such as medication adherence, health literacy, or clinician concern could both drive the decision to treat and influence the likelihood of good outcomes. 2. Composite Endpoint: Death, severe adverse event or....ED revisit. That's kind of like a composite endpoint of you die, you have a myocardial infarction, or you sprain your ankle. As you would expect, the vast majority of patients who met one of these criteria (14,208 out of 14,978, almost 95%) had repeat ED visits. There was no significant difference in deaths. While there was a statistically significant difference in severe adverse events, the NNT to prevent one was 183,...

Date: November 27, 2025  Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: You are looking after a 65-year-old man who appears to be in septic shock. He presented after five days of fever and cough, and is now severely lethargic and hypotensive on arrival. You give him antibiotics and IV fluids immediately, but an hour later, his lactate comes back at 5, and you need to start norepinephrine to keep his MAP above 65. You put in a call to the intensive care unit (ICU) to get him transferred, and the intensivist asks you whether you have started personalized hemodynamic resuscitation targeting capillary refill time. You don’t want to sound dumb, but what the heck is personalized hemodynamic resuscitation protocol targeting capillary refill time? Background: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is the most severe end of that spectrum. Patients with sepsis have persistent hypotension requiring vasopressors to maintain MAP ≥65 mm Hg and a lactate >2 mmol/L despite adequate volume resuscitation (Sepsis‑3). In high-income countries, mortality has fallen but remains substantial.  In many settings, mortality can be between 30% to 70%. High-quality ED care requires early recognition, IV antibiotics, source control, hemodynamically directed fluids, and vasopressors. The management of septic shock has changed dramatically since the time that Ken and I started practice. We went through a period in which a very aggressive bundle of care was proposed, based on work by Dr. Emanuel Rivers, published in the NEJM in 2001. Then, we ran big trials on the components of that bundle, and found that none of them helped individually (ARISE, ProCESS & ProMISe). It was clear that these patients benefited from close attention and clinical reassessments, but aside from early antibiotics, the exact interventions needed were unclear. For a while, many people focused on trending lactate levels. We then saw the original ANDROMEDA SHOCK study, which showed that a resuscitation strategy focused on clinical assessments of capillary refill time was at least as good as a strategy focused on trending lactates. We have been left with the question of exactly how to improve capillary refill and which other targets are important. There has been a question about whether a higher MAP target might help (SGEM#90), especially in elderly patients with more baseline hypertension.  But the recent OPTRESS study showed worse outcomes with a higher MAP target in elderly septic shock patients. Therefore, aside from the consensus that providing early antibiotics is a good idea, there remain many questions about the ideal initial resuscitation strategy for septic shock patients. Clinical Question: In adult patients with septic shock, can death, duration of vital support, and/or hospital length of stay be improved by a “personalized hemodynamic resuscitation protocol targeting capillary refill time? Reference:  Hernandez et al. Personalized Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial. JAMA. 2025 Oct Population: Adults (≥18 y) with septic shock per Sepsis‑3 (vasopressors after ≥1 L IV fluid and lactate >2 mmol/L), within 4 hours of shock onset. Key Exclusions: >4 h from shock onset; anticipated surgery or dialysis within 6 h; expected survival <90 days; refractory shock; DNAR; Child‑Pugh B/C; severe ARDS; active bleeding; pregnancy; inability to assess CRT (peripheral vascular disease, hypothermia, very dark skin tone, Raynaud phenomenon). Intervention: A personalized hemodynamic resuscitation protocol targeting capillary refill time (CRT) using a 6-hour stepwise algorithm (see below). Comparison: Usual care per local protocols/guidelines. Outcome: Primary Outcome: A hierarchical composite tested with a stratified win ratio of: (1) 28-day all-cause mortality, then (2) duration of vital support (time requiring cardiovascular, respiratory, or kidney support) through day 28, then (3) hospital length of stay through day 28. Secondary Outcomes: Secondary outcomes were each of the three components of the primary outcome. Trial: This is a pragmatic, multi-center, open-label, randomized controlled trial. Authors’ Conclusions: “Among patients with early septic shock, a personalized hemodynamic resuscitation protocol targeting capillary refill time was superior to usual care for the primary composite outcome, primarily due to a lower duration of vital support.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No 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). Yes 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. Unsure The treatment effect was sufficiently large and precise to be clinically significant. Unsure Financial conflicts of interest. The researchers at each study site had to get their own fund, so this was truly researcher-driven. Although a few of these researchers have ties to industry, they do not seem to have any obvious financial conflicts of interest that would be relevant to this protocol. Results: They randomized 1,501 patients and were able to analyze 1,467. The median age was ~66 years, and 43% were female. The severity of sepsis was an APACHE II of ~18 and a SOFA of 8. Sources of infection were ~48% abdominal, ~20% respiratory, and ~20% urinary. Baseline supports included invasive ventilation ~48%, norepinephrine 100% (median ~0.21 to 0.23 µg/kg/min). Lactate median ~3.6 mmol/L. Median time from shock criteria to randomization was 2 hours (IQR 1 to 3). Key Results: Compared with usual care, CRT‑PHR produced a statistically significant advantage on the hierarchical composite, driven mainly by shorter duration of vital support, while 28‑day mortality was nearly identical between groups. Primary Outcome: Based on their stratified win ratio analysis of their composite outcome, there were 131,131 wins for the CRT-PHR group and 112,787 wins for the usual care group, resulting in a win ratio of 1.16 (95% CI 1.01-1.33, p=0.04) Secondary Outcomes:  No statistical difference in mortality (26.5% vs 26.6%, p=0.91). There was a statistical decrease of 1 day in mean vital support free days (16.5 vs 15.4). Vital sign support free days is also a composite outcome. They don’t report the specific components of this outcome, but based on the supplementary material, there doesn’t seem to be any real difference in the use of mechanical ventilation or vasopressors, and so the entire difference in this trial might come down to a 1-day difference in renal replacement therapy. There was no statistical difference in hospital length of stay (15.3 vs 16.2). 1. Unmasked Trial with Subjective Outcome Changes: Open-label trials increase the risk of performance bias. Mortality is an objective outcome and was completely unchanged here. The part of the component outcome that changed was “vital support free days”. However, treatment decisions are highly subjective and can be influenced by treatments the patient has already received. Therefore, this outcome is at high risk of bias in an unmasked trial. 2. Composite Outcomes: Composite outcomes have been discussed on the SGEM several times. They are endpoints in clinical research that combine multiple individual events. In this trial, they combined all-cause mortality, vital support and length of stay into a single measure to capture the overall effect of the intervention. Composite outcomes can be useful when individual events are too rare to provide adequate statistical power, allowing researchers to detect treatment effects with smaller sample sizes or shorter follow-up. However, composite outcomes must be interpreted cautiously because the components may vary greatly in clinical importance or frequency [1,2,3].  In addition, the trial’s reported benefit may be driven largely by less important or more common components rather than the outcomes that matter most to patients.  In this ANDROMEDA SHOCK-2 trial, there was no 28-day mortality benefit (26.5% vs 26.6%; HR 0.99), but there was a statistical difference in fewer days of vital support. Performing a hierarchical composite analysis gave a win ratio was 1.16 (95% CI 1.02–1.33; P=0.04). This means a net advantage for the CRT‑personalized resuscitation strategy. 3. Lipstick on a Pig? One of the criticisms of composite outcomes is that each outcome is valued the same. Changing the analysis into a hierarchical model with pre-specified outcomes of importance attempts to address this limitation (death first, then major morbidity and then resource utilization). Analysis typically compares each patient in the intervention arm with each patient in the control arm (or matched pairs) and determines a “win,” “loss,” or “tie” based on the highest‑priority endpoint on which the pair differs. Only if tied at that level does the comparison proceed to the next level in the hierarchy. The net effect is summarized as a win ratio (or a “stratified win ratio,” if stratified by baseline risk). The number of wins for the intervention divided by the number of wins for control (values >1 favour the intervention)....

Date: Dec 17, 2025 Reference: Pagnini F, et al. Unexpected events and prosocial behavior: the Batman effect. npj Mental Health Research. November 2025 Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine physician at Children’s National in Washington, DC. You may also know him as the host of SGEM Peds. Case: It’s been a dark, cold day in Gotham City. You’re finally on the metro heading home after a long shift. The train is packed, and you’re standing, crammed uncomfortably among all the other citizens eager to get home. Outside, you see the holiday lights and decorations, trying valiantly to shine through the flurries of snow. At the next stop, you see a visibly pregnant passenger board the crowded train car. She shuffles in and stands, holding the rail. No one around her moves. No one gets up to offer their seat. Hardly anyone even notices. You pull your coat a bit tighter around you and wonder: What’s it going to take to nudge people to be a little more helpful? Background: Prosocial behaviour is something we rely on every shift but hardly ever discuss explicitly. Psychologists typically define it as voluntary actions aimed at helping others. Examples include holding a door open, donating money, giving up your seat, or stepping in to assist a stranger. It’s an umbrella term that covers everything from simple everyday kindness to extraordinary acts of altruism. The world just saw an extraordinary example of prosocial behaviour in the Bondi Beach attack ‘hero’, Ahmed Al Ahmed. Motivations vary: empathy and concern for others, a desire to follow social norms, expectations of reciprocity, and even a wish to avoid guilt all influence prosocial behaviour. Prosocial behaviour has traditionally been studied in several primary ways. In the lab, researchers use economic games (such as dictator, ultimatum, and public goods games), staged helping tasks (such as picking up dropped pens or assisting with a “broken” computer), or vignette-based scenarios (“Would you stop to help?”). In real-world settings, classic bystander studies explore whether people intervene when someone seems in need and what situational factors (crowding, diffusion of responsibility, perceived danger) influence their decision to act or remain passive. Throughout all approaches, a key theme is that context plays a crucial role: the same individual may assist in one situation but ignore someone in another. Over the past decade, there has been increasing interest in how subtle environmental cues influence prosocial behaviour. Mindfulness research indicates that when people focus on the present moment, they may be more inclined to notice others’ needs and respond accordingly, although the evidence remains modest and not definitive. Another area of study examines "social primes." For example, images of superheroes can temporarily boost helping intentions and small acts of assistance. A related body of research on the “pique technique” demonstrates that unusual, unexpected events or requests can disrupt automatic “no” responses and increase compliance or helping, likely by pulling people out of autopilot. The “Batman effect” study we explore today extends these ideas into real-world scenarios. Could an unexpected disruption, such as a person dressed as Batman, increase a specific prosocial behaviour? For an emergency physician accustomed to crowded waiting rooms and chaotic departments, it’s an intriguing yet potentially significant question: can small, harmless environmental “shocks” encourage people to do the right thing a little more often without anyone ever having to take a mandatory module on ethics? Clinical Question: Among passengers on a crowded metropolitan subway, does the presence of an unexpected event (a person dressed as Batman) increase the likelihood that someone offers their seat to a pregnant-appearing woman, compared with no Batman present? Reference: Pagnini F, et al. Unexpected events and prosocial behavior: the Batman effect. npj Mental Health Research. November 2025 Population: Passengers in crowded cars on the Milan underground metro. Intervention: Presence of someone dressed as Batman (~3 meters away, no interaction with an experimenter pretending to be a visibly pregnant woman). Comparison: Identical set-up without Batman Outcome: Whether the seated passenger offered their seat to the (pretend) pregnant woman during a single-stop ride Type of Study: Quasi-experimental, non-randomized controlled field study. Both conditions were conducted simultaneously in different train cars and different areas of the platforms. Authors’ Conclusion: “This study suggests that unexpected events can increase prosocial behavior by momentarily disrupting automatic attention patterns and fostering situational awareness. These findings open new avenues for understanding the environmental and cognitive mechanisms underlying prosociality, and suggest potential applications for promoting kindness and cooperation in everyday settings—extending the “Batman effect” to nonsuperheroes as well.” Quality Checklist for Quasi-Experimental Studies: Is it clear what is the ‘cause’ and what is the ‘effect’? Yes Were the participants included in any comparisons similar? Unsure  Were participants in any comparisons receiving similar treatment/care other than the exposure? Yes Was there a control group? Yes Were there multiple measurements of the outcome both pre and post the intervention/exposure? No Was follow-up complete, and if not, were differences adequately described and analyzed? Yes Were the outcomes of participants in any comparisons measured in the same way? Yes Were outcomes measured in a reliable way? Unsure  Was appropriate statistical analysis used? Yes Results: They conducted 138 observations (70 control and 68 experimental with Batman). Most who offered up their seat were women (~68%) with a mean age of approximately 42 years. Key Result: Passengers were roughly three times more likely to give up their seat for a pregnant-appearing woman when Batman was present on the train compared with when he was not. Primary Outcome: Offering a seat to the pregnant woman 38% control vs 67% Batman Odds ratio (OR) = 3.39, p < 0.001 They also conducted brief follow-up interviews with the passengers who gave up their seats and asked whether they had seen Batman. Many spoke about recognizing pregnancy, social norms, education or safety. Nobody directly admitted to giving up their seat because Batman was there. In fact, 44% of those interviewed stated they didn’t see Batman at all. 1. Hawthorne Effect: When discussing this type of field experiment, it is important to mention the Hawthorne effect, which is the idea that people change their behaviour simply because they know they are being observed. In this study, a designated observer recorded whether passengers offered their seat to the pregnant woman. It is not specified how the observer tried (or did not try) to blend into the environment. It is possible that some passengers realized they were being observed, which could have influenced their actions. 2. Confounding: We applaud the authors for attempting to avoid confounding by concurrently conducting experiments with two research teams in different train cars and areas of the platform. The train cars also had to have all seats occupied with no more than five people standing between seats. Ultimately, this was not a randomized experiment. While they looked at Batman vs No Batman scenarios, that may not be the only thing that differs amongst the groups represented in their respective train cars, which was not measured or reported. In an exaggerated example, what if the car with Batman was full of nuns while the other car had a more heterogeneous smattering of society? Did people give up their seats because Batman was there or because they were or were not nuns (assuming that nuns are more charitable)? We also don’t know if the behaviour of the “pregnant” experimenter changed at all between scenarios. Did she always choose to stand in the same place? Did she make or avoid eye contact with the people around her? Were there other environmental factors that made her easier or more difficult to notice? 3. Outcome Measurement: The outcome of interest was the number of people who gave up their seats to the pregnant woman. Based on the methods, it looks like there was only one observer. The study findings may have been more robust if they had more than one observer and reported inter-rater reliability. I’m reminded of the selective attention test, where the viewer is tasked with counting how many times players pass a ball without noticing the gorilla that walks in and out of the frame. 4. Loss to Follow Up: Among the 138 observations, 70 instances of prosocial behaviour were observed. Of those, only 52 (74%) were interviewed during follow-up. This makes us wonder: What about the people who weren’t interviewed? Would they have provided us with more insight or breadth about their reasons for giving up the seat? Would some of the people who weren’t interviewed in the experimental design have stated that they saw Batman? 5. Generalizability: The experiment was conducted in the Milan metro system. There are likely differences in cultural or societal norms that make the findings of this study less generalizable to all transit systems worldwide. One example may be that the number of stops or the distance between stops varies. Shorter distances between stops and more frequent stops could encourage more people to give up their seats to pregnant women as their stop approaches. Is it actually the Batman Effect? This threat to validity hurts me a little bit to admit…because my confirmation bias says “Of course it was the presence of Batman who was responsible for people doing good!” But I mean, who is Batman?...

Reference: Binder ZW et al. “Ultrasound-Guided Nerve Block for Pediatric Femur Fractures in the Emergency Department: A Prospective Multi-Center Study.” Academic Emergency Medicine, 2025. Date: November 24, 2025 Dr. Lauren Westafer Guest Skeptic: Dr. Lauren Westafer is an Associate Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School, Baystate. She is the co-founder of FOAMcast and a researcher in pulmonary embolism and implementation science.  Dr. Westafer serves as the research methodology editor for Annals of Emergency Medicine.  Case: A 9-year-old boy presents to the emergency department after a trampoline injury. He was at a party with his friends and they were all bouncing together and competing to see who could bounce the highest. The boy fell down on his right leg and a friend accidentally landed on it. On your exam, the boy is in significant pain and has a deformity of his right leg. You do not note any additional injuries. X-rays confirm a mid-shaft femur fracture. You administer some IV morphine, but the boy is still whimpering in pain. One of the other attending physicians on shift who happens to be an ultrasound enthusiast, suggests using an ultrasound-guided nerve block as a way to manage the boy's pain. The boy’s parents ask “What is that?” Background: Femur fractures are one of the most painful injuries in pediatric patients and frequently require hospital admission for definitive treatment, often with long ED stays prior to operative management. Traditional pain management for these injuries relies heavily on IV opioids, which have well-documented side effects including nausea, respiratory depression, and sedation. Increasing public awareness of the opioid crisis has also led to growing parental concern over opioid exposure in children. There is growing interest in opioid-sparing pain control methods. The fascia iliaca compartment nerve block (FICNB) is a regional anesthesia technique that targets the femoral nerve and adjacent sensory nerves to provide localized pain relief. While landmark-based FICNB techniques have been used successfully in adult patients, recent studies suggest that ultrasound guidance improves the accuracy and safety of these procedures. However, evidence on the effectiveness and safety of ultrasound-guided FICNB in pediatric patients, particularly when performed by emergency physicians in real-world ED settings, remains limited.  Clinical Question: In children with femur fractures, is ultrasound-guided FICNB more effective at reducing pain compared to systemic analgesia? Reference: Binder ZW et al. “Ultrasound-Guided Nerve Block for Pediatric Femur Fractures in the Emergency Department: A Prospective Multi-Center Study.” Academic Emergency Medicine, 2025. Population: Children aged 4–17 years presenting to the ED with isolated, acute femur fractures. Excluded:  Patient with neurovascular compromise, multi-trauma, GCS ≤13, bilateral fractures, allergy to anesthetics, prisoners, pregnancy. Intervention: Ultrasound-guided fascia iliaca compartment nerve block (FICNB) performed with ropivacaine or bupivacaine Comparison: Systemic analgesia administered at discretion of ED treating team Outcome: Primary Outcome: Reduction in pain intensity at 60 minutes using the Faces Pain Scale–Revised (FPS-R). Secondary Outcomes: Reduction in pain at 240 minutes, opioid consumption (oral morphine equivalents per hour), occurrence of adverse events, and emergency department (ED) length of stay. Trial: Prospective multi-center observational study conducted at 12 pediatric emergency departments in the US and Australia. Some sites performed FICNB. Other sites did not. Dr. Zachary Binder Guest Author: Dr. Zachary Binder is a pediatric emergency medicine attending physician at UMass Memorial Health and Associate Professor at UMass Chan Medical School. He is the Director of Point-of-Care Ultrasound for the Department of Pediatrics and the medical school. Authors’ Conclusions: Children who received FICNB had greater reductions in pain intensity and required less opioid medication than those who did not. This is the largest prospective study evaluating the ultrasound-guided FICNB performed on children in the ED, and its findings support the procedure’s use for pediatric femur fracture pain management. 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? Yes 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 Do the results of this study fit with other available evidence? Yes.  Funding of the Study: No financial conflicts of interest Results: They included a total of 114 participants (54 in the FICNB group and 60 in the non-FICNB group).  The mean age was ~10 years old, with ~20% female. Fractures were mostly displaced (91% vs 83%), while open fractures were rare (~2%). Most had received opioids before enrollment (96% vs 88%).  FICNBs were performed by attendings (37%), fellows (33%), or residents (30%) under supervision. Half were performed or supervised by attendings with advanced POCUS training. Key Results: Children who received FICNB had greater reduction in pain compared to those who did not, without more adverse events or longer ED LOS. Primary Outcome (Pain reduction at 60 min) There was a mean decrease of 3.8 points (95% CI, 3.1 to 4.6) in the FICNB group compared to a decrease of 0.8 points in the non-FICNB group (95% CI, -0.2 to 1.9).  That was a difference of 3.0 (95% CI, 1.7 to 4.3).  Secondary Outcomes When it came to pain reduction at 240 min, there was a mean decrease of 3.6 points (95% CI, 2.6 to 4.5) in the FICNB group vs. 1.7 points (95% CI, 0.7 to 2.7) in the non-FICNB group. That was a difference of 1.9; (95% CI, 0.5 to 3.2). The FICBN also received less opioids after enrollment measured as oral morphine equivalents per hour (OME/hr). This was 0.3 in the FICBN group vs. 1.1 in the non-FICBN group). This was a difference of 0.8 (95% CI, 0.4 to 1.1). ED length of stay in both groups was 6.1 hours with overlapping 95% CI. There was not much difference in adverse events between the two groups (5.6% FICNB vs 8.3% non-FICNB), with no serious complications attributable to FICNB. One patient in the FICNB group had apnea but had also received ketamine, fentanyl and midazolam.    Listen to the SGEM podcast to hear Zack respond to our five nerdy points. Selection Bias Twelve sites were included. The proportion of physicians able to perform the nerve block ranged from 25-100% of the faculty. There were four sites that did not routinely perform FICNB. For the sites that did perform the nerve block, it was only performed when someone trained to do it was on shift (which makes sense). Patients may also have been missed for other reasons such as maybe it was too busy on shift or there was a fast disposition from ED to the operating room. However, this also means that there is a group of eligible kids that may have been missed with this convenience sampling. How do you think this selection bias may have impacted the results of the study? Performing FICNB We can’t imagine that a young child is going to be thrilled seeing a long needle being introduced to the leg that is already broken. How do you do this practically? Are you having to give any additional medications for anxiolysis prior to this? Are you worried about the patient moving during this process? Any tips on how to fit this into the workflow of a busy ED shift? One other thing that we were looking for was whether or not all of these blocks were successfully placed on the first attempt or did some require multiple attempts? Ultrasound Training and Competencies We were impressed that in this study, the nerve block was performed by a mix of attending physicians (37%) and fellows and residents under supervision. What does it take to train someone to perform this nerve block? How do you determine they are capable enough to be credentialed? Generalizability It’s mentioned in the paper that four of the 12 sites involved in this project did not routinely perform FICNB. It’s also mentioned that at some of these sites, not performing FICNB would be considered substandard care. This is quite a variation even amongst academic children’s hospitals which may make this practice less generalizable to the community or rural settings.  What do you think are some of the biggest barriers and challenges in having this practice be adopted more widely? Is it the lack of trained staff? Buy-in from orthopedic colleagues? Patient and Family Experience While the primary outcome of pain reduction was very patient-oriented, we can’t help but wonder, did you collect any additional data about the experience of patients or families? Were they overall satisfied with the care they received nerve block or not? Did any express preference for nerve block or systemic analgesia? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion. SGEM Bottom Line: Ultrasound-guided fascia iliaca compartment nerve blocks were associated with clinically meaningful pain reduction and less opioid use for pediatric femur fractures in the ED without prolonging length of stay. Case Resolution: After discussing the different options available for pain control w

Date: December 4, 2025 Guest Skeptic: Dr. Jestin Carlson – Long-time listener, second-time guest.   Reference: Reinaud et al. Reporting of Noninferiority Margins on ClinicalTrials.gov: A Systematic Review. JAMA Netw Open. 2025 Case: You are working with a resident who asks you about a new thrombolytic they heard about on the SGEM for acute ischemic stroke.  This new treatment was found not to be inferior to the existing thrombolytic, but they are not sure how the paper reached that conclusion.  You start to discuss noninferiority margins when the resident asks you, “Are the noninferiority margins reported on ClinicalTrials.gov consistent with the final publications?” Background: A non-inferiority (NI) trial asks whether a new strategy is “not unacceptably worse” than an established, effective strategy by more than a pre-specified amount. The non-inferiority margin (Δ) or delta is the largest loss of effectiveness we would tolerate in exchange for another advantage (lower cost, easier logistics, fewer adverse effects). Regulators and methods groups emphasize that Δ must be clinically justified, pre-specified, and not chosen after seeing the data. The Δ is then tested using a one-sided hypothesis procedure or, equivalently, by checking whether the confidence interval for the treatment difference stays within Δ. For example, a new medicine to treat hypertension lowers patients’ systolic blood pressure by 1 point more than the standard treatment but causes gastrointestinal (GI) upset in 50% of patients.  That difference may be statistically significant, but clinically it doesn’t result in a net benefit for the patients since so many of them get GI upset.  Ideally, the noninferiority margins should be set up before the trial is conducted to minimize bias.  Many modern ED trials rely on NI logic (TNK vs tPA for stroke, non-operative treatment of appendicitis, Simple Aspiration versus Drainage for Complete Pneumothorax, etc).  However, prior work suggested poor reporting of noninferiority margins with reporting rates as low as 2.6% for studies published between 2012 and 2014.  That was over 10 years ago...hopefully we have improved since then.  Clinical Question: What proportion of registered noninferiority randomized trials report the noninferiority margin at registration, and how consistent are margins between ClinicalTrials.gov and corresponding publications? Reference: Reinaud et al. Reporting of Noninferiority Margins on ClinicalTrials.gov: A Systematic Review. JAMA Netw Open. 2025 Population: All registered non‑inferiority trials on ClinicalTrials.gov with primary completion 2010–2015 (Stage 1) and all first‑posted 2022–2023 (Stage 2). Excluded: Nonrandomized, single-arm, phase 1–2/2–3, diagnostic/screening trials where noninferiority was only a secondary outcome. Exposure: Presence of a prespecified noninferiority margin reported on ClinicalTrials.gov (at registration / during enrollment / after primary completion / in posted results). Comparison: Descriptive contrasts across timepoints and between the registry and corresponding publications (consistency). Outcome: Primary Outcome: Proportion reporting the noninferiority margin at registration on ClinicalTrials.gov. Secondary Outcomes: Timing of first reporting (registration, during enrollment, after completion, or in posted results); proportion reporting margin in posted results; proportion reporting margin in the corresponding publication; justification of margin; consistency between registry and publication; reporting of primary analysis population and Type I Error. Type of Study: A systematic review of registered randomized trials’ methods reporting. Authors’ Conclusions: “Reporting of the noninferiority margin on ClinicalTrials.gov was low (3.0% in 2010–2015 sample, 9.2% in 2022-2023 sample). Because margins are central to design and interpretation, mandatory reporting of trial design and the noninferiority margin at registration would improve transparency and reliability of noninferiority trial results.” Quality Checklist for Systematic Review: Was the main question clearly stated? Yes Was the search detailed and exhaustive? Yes  Were the inclusion criteria appropriate? Yes Included studies sufficiently valid? Yes Results similar from study to study? Yes Any financial conflicts of interest? Authors do not report any financial conflicts of interest. Results: In the 2010 to 2015 cohort (n=266), 60% were industry‑funded; most evaluated drugs/biologics (~67%); parallel‑arm designs predominated (94%); open‑label was common (49%); adults‑only accounted for 74%; and the median planned sample size was 304 (IQR 63 to 545). The 2022 to 2023 cohort (n=327) showed similar patterns with more adult-only studies (83%) and a median planned sample size 228 (IQR 50 to 406). Key Result: Very few trials pre-specified a Δ at registration, a super majority reported a Δ in their publication and registry‑to‑publication consistency could only be evaluated in a handful of studies. 2010 to 2015 sample (n=266) Only 8 trials (3%) reported the planned noninferiority margin at registration. 31 trials (11.7%) first reported a margin after registration (11 during enrollment; 20 after primary completion). Of 132 trials with results posted on ClinicalTrials.gov, 79 (59.8%) reported the noninferiority margin in the posted results. Corresponding publications were found for 208 trials (2010–2015 sample); 196/208 (94.2%) publications reported the noninferiority margin, and 86/196 (41.3%) justified it. 2022 to 2023 sample (n=327) 30 trials (9%) reported the margin at registration (a modest improvement but still low); only 6 of these justified. When margins were reported in both the registry and the publication, they were identical in the 5 trials that reported margins at registration and in publication; margins in posted results and publications were consistent for all but 1 of 63 trials. Registry Transparency: ClinicalTirals.gov lacks a mandatory, structured field for trial design type and noninferiority margin. The authors suggest mandatory fields to prevent untraceable post-hoc margin changes. Building and maintaining trust in the scientific literature depends on ensuring we are honest and transparent in the scientific process.  This includes transparency in registration.  Potential for Bias: Post-hoc or late specification of margins can bias conclusions. A margin change after seeing the data can turn a noninferior result from “fail” to “pass”. This would be like p-hacking or HARKing (hypothesizing after results are known). Overinterpreting Non-inferiority Trials: The goal of non-inferiority trials is exactly that...to determine if one treatment is not inferior to another. It does not prove whether the treatment is effective.  In addition, even if margins are pre-specified, they can be clinically meaningless. Readers still need to appraise whether the Δ represent something the patient would consider non-inferior.  Single Trial Registry: This study used a single registry (ClinicalTrials.gov) and did not search the study protocols. There are many registries where clinical trials can be registered, including the Australian New Zealand Clinical Trials Registry, the Chinese Clinical Trial Registry and EU Clinical Trials Register, to name a few.  How these results generalize to other registries is unknown. Ensuring Consistency with Reporting: FDA guidance and the CONSORT extension for noninferiority trials emphasize pre-specification and justification of margins. We should expect this in both registration and publication.  In addition, journals, editors, and reviewers may insist that the author report not only the margins at the time of publication but also whether the margins were published at the time of registration.  Comment on the Authors’ Conclusion Compared to the SGEM Conclusion: We generally agree with the authors’ conclusions.  SGEM Bottom Line: Non-inferiority margins need to be pre-specified, justified, and clinically acceptable, and this new review shows we often can’t verify that from the trial registry alone. Case Resolution: You tell the resident that when you read a noninferiority trial, check the publication for margin justification, when possible, verify pre-specification in the trial registry or protocol and reflect on whether the margin is clinically relevant. Treat noninferiority claims cautiously if the margin is not prospectively registered. Clinical Application: Be skeptical when reading the results of a non-inferiority trial and cross-check them against what is reported on clinicaltrials.gov if it was registered there.  What Do I Tell the Patient? N/A Keener Kontest: Last week’s winner was Brad Roney. He knew the pain was defined by the International Association for the Study of Pain (IASP) as: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Listen to the SGEM podcast for this week’s question. If you know, then send an email to [email protected] with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode. Other FOAMed: First10EM - You Don't Understand Non-Inferiority Trials (and neither do I) Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.   Additional Readings & Resources: D'Agostino RB Sr, Massaro JM, Sullivan LM. Non-inferiority trials: design concepts and issues - the encounters of academic consultants in statistics. Stat Med. 2003 Jan 30;22(2):169-86. doi: 10.1002/sim.1425. PMID: 12520555. Kaul S, Diamond GA. Good enough: a primer on the analysis and interpretation of noninferiority trials. Ann Intern Med. 2006 Jul 4;145(1):62-9. doi: 10....

Date: November 26, 2025 Reference: Ray et al. Emergency Department Visit Frequency Among Adults with Chronic Abdominal Pain: Findings From the 2023 US National Health Interview Survey. AEM November 2025. Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine in the UK and an evidence-based medicine advocate. She's a seasoned knowledge translator with her PaperinaPic infographics.   Case: You are mid-shift in what feels like the never-ending winter of emergency medicine, and you hear the sigh as your resident picks up the chart of the next patient to be seen. Wondering if the resident requires coffee or support, you ask what is wrong. “I’m good, it’s just this is the third patient with acute worsening of abdominal pain they’ve had for years that I’ve seen this week. What’s going on?” Background: Abdominal pain is a frequent reason for presentation to the emergency department (ED), generating over 13 million visits in the US in 2022. As emergency care providers, we are taught to think of the worst-case diagnoses (aneurysmal, ischaemic, an ectopic pregnancy, appendicitis, etc). Once the “bad stuff” is excluded, it’s tempting to breathe a sigh of relief and “not my concern”. However, there is an estimated population prevalence of chronic abdominal pain of around 22 per 1,000 person-years. According to the International Association for the Study of Pain, this is defined as abdominal pain without a clear diagnostic explanation that lasts for 3 months or more. Often, patients with these symptoms have been diagnosed with “functional” abdominal pain, although more recent terminology uses “Disorders of Gut-Brain Interaction”. Managing patients with acute-on-chronic pain syndromes in the ED can be very challenging, particularly if continuity of care is lacking for their chronic condition. This has been addressed to some extent by the GRACE-2 guidance on managing recurrent low-risk abdominal pain, which de-emphasizes repeated routine imaging and recommends opioid-minimizing strategies for symptom management. Clinical Question: Do people with chronic abdominal pain have higher rates of ED utilization than those without? Reference: Ray et al. Emergency Department Visit Frequency Among Adults with Chronic Abdominal Pain: Findings From the 2023 US National Health Interview Survey. AEM November 2025. Population: Adult respondents to the National Health Interview Survey 2023 who completed the question on demographics, pain, healthcare seeking behaviours, disability, mental health, past medical history and social determinants of health. Exclusion: The entire survey excludes people without a permanent household address, active-duty military personnel or civilians on military bases, and residents of long-term care facilities. For this study, the authors also excluded people reporting a history of cancer, Crohn’s disease and ulcerative colitis and those who were pregnant. Exposure: Chronic abdominal pain (CAP) was defined by the authors as reporting pain “most days” or “every day” over the prior three months, and being “bothered by” abdominal, pelvic or genital pain “somewhere between a little and a lot” or “a lot” over the prior three months. Comparison: Adults without chronic abdominal pain. Outcomes: Primary Outcome: ED visits in the prior 12 months. Secondary Outcomes: Mental health status, physical comorbidities, disability, and social determinants of health. Type of Study: Secondary analysis of a cross-sectional interview study. Dr. Michael Ray This is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Michael Ray is an Assistant Research Professor, Department of Emergency Medicine at George Washington University School of Medicine & Health Sciences. Known as a pain researcher. Clinically practiced as a chiropractor in an outpatient setting, which led to an interest in chronic pain and transition to academia. Authors’ Conclusions: This nationally representative analysis suggests that individuals with CAP have significantly higher ED utilization and face greater burdens of disability, mental health conditions, comorbidities, and SDOH-­related barriers. These findings highlight the potential value of addressing BioPsychoSocial factors to reduce ED reliance and support comprehensive care for CAP patients. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Unsure Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias? Unsure Have the authors identified all important confounding factors? Unsure Was the follow-up of subjects complete enough? N/A How precise are the results? The numbers are large, so they are likely to be reasonably precise, but formal measures of uncertainty, such as credible intervals, aren’t presented in the paper. Do you believe the results? Yes  Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Funding of the Study? National Research Scientist Award via George Washington University, and the Authors declared no conflicts of interest. Results: Just over 4.5 million (2.8%) of the nearly 163 million respondents reported Chronic Abdominal Pain. The chronic abdominal pain group had higher proportions of female sex (66% vs 50%) and age 55 to 64 (23% vs 15%), with similar race/ethnicity distribution. Key Result: Reporting Chronic Abdominal Pain was associated with an increased frequency of ED attendance. Primary Outcome: 1% of people with CAP reported one ED visit over the last 12 months, compared to 11.7% of people without. 16.9% had visited 2 to 4 times compared with 5.2%. Secondary Outcomes: Chronic abdominal pain was associated with increased incidence of anxiety, depression, physical comorbidities, challenges accessing healthcare, economic instability and limitations in social and employment function. Recall Bias: By conducting a secondary analysis of the US National Health Interview Survey, you are obviously limited by how the original survey's designers chose to collect the data. Much of the data depends on patients’ recollections, which we know can be flawed. People who go to the ED with their pain may well remember the days of pain more clearly than those who did not or could not seek healthcare. Do you have any information or a sense of how the NHIS measures up against other cohorts where the data can be triangulated Exclusions & Missing Data: The dataset includes many potential confounding factors, such as comorbidities and some social determinants of health. However, the entire survey excludes people without a permanent household address, and there doesn’t seem to be information around alcohol or substance use, which could plausibly be associated with chronic pain and contact with healthcare. How much do you think that challenges your findings? Outcome Measurement: The NHIS does not link ED visits to a specific presenting complaint, so some “excess” ED use among chronic abdominal pain respondents may reflect unrelated issues. In addition, modelling excluded asthma and injury. Excluding injury makes sense, but why exclude asthma? Multiple Comparisons: You acknowledge in the paper that the multiple comparisons you have done increase your risk of Type 1 error. This is where you find something that meets the criteria for statistical significance purely by chance. However, you deliberately chose not to apply a statistical adjustment, such as a Bonferroni correction. Could you talk us through that? Residual & Bidirectional Confounding: Although models adjusted for demographics, disability, mental health, PMH, and SDOH, unmeasured or imperfectly measured factors (access to specialty care, pain catastrophizing, prior imaging availability) could partly explain the associations. You note complex bidirectional relationships among CAP, mental health, disability, and SDOH that a cross-sectional model cannot fully resolve, which is an inherent limitation of observational designs. What do you think its implications might be for the individual patient and care provider? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We broadly agree with the authors’ conclusions, but would emphasize the need to be very cautious about inferring causation in either direction. SGEM Bottom Line: Adults reporting chronic abdominal pain report more ED attendances than those without, and report higher levels of physical, psychological and social comorbidities. Dr. Kirsty Challen Case Resolution: You empathize with your resident, noting that it can be frustrating when patients present to the ED with chronic problems. However, you help her frame this in the context of the impact on multiple areas of the patient’s life of chronic pain. Clinical Application: ED providers should recognize that people presenting with chronic abdominal pain are more likely to have physical and psychological comorbidities and be disadvantaged in terms of social determinants of health. What Do I Tell the Patient? We know that patients with chronic abdominal pain often have challenges in other parts of their lives. Is there anything else we can help with? Keener Kontest: The last episode’s winner was Scott Luce. He gave four examples of c-collars with geographic locations from the US (Aspen, Philly, Miami Jr and NY Ortho). Listen to the SGEM podcast for this week’s question. If you know, then send an email to [email protected] with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode. Now it is your turn, SGEMers. What do you think of this episode on chronic abdominal pain and ED utilization?...

Date: November 8, 2025 Reference: Millin M, et al., Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries – A NAEMSP Comprehensive Review and Analysis of the Literature, Prehospital Emergency Care, Aug 2025. Guest Skeptic: Clay Odell, BSN, NRP, RN, is a Paramedic Firefighter with Newport (NH) Fire-EMS. He is a past Chief of the NH Bureau of Emergency Medical Services. Previous positions he held are Trauma System Coordinator for the State of NH, Executive Director of Upper Valley Ambulance in Fairlee VT, and a flight crew member at Dartmouth Hitchcock Advanced Response Team. Clay has been a paramedic since 1985 and has been a registered nurse since 1997. Case: Your EMS unit responds to a 911 call for a hunting accident. You arrive to find the patient sitting on the tailgate of his truck. He tells you he fell out of his deer stand, approximately 20 feet, landing on his head. He walked out of the woods about a mile after the fall. His chief complaint is head and neck pain. He has a Glasgow Coma Scale (GCS) score of 15, a hematoma and laceration above his left eye, and he is quite tender over the cervical spine region. You observe your colleagues trying to apply a rigid cervical collar without moving the patient’s neck. It goes about as well as usual, meaning the patient's head is moved a bit. Maybe more than a bit. He then decides he hates the collar and rips it off. He adamantly refuses all attempts to apply a soft collar or improvised towel roll. On arrival at the trauma center, you give a handoff report, and the team leader demands to know why the patient is not in a collar. The patient overhears this and rather profanely informs everyone, "you ain't putting no *F-ing* collar on me". Background: Prehospital care for suspected SCI has two competing imperatives, limiting secondary cord injury while avoiding iatrogenic harm. Historically, EMS prioritized rigid immobilization (long backboard + rigid cervical collar) based on the fear that post-injury movement could precipitate delayed neurologic deterioration. In the last two decades, emergency care has shifted toward selective spinal motion restriction (SMR) and earlier collar removal when appropriate. This reflects a better understanding of risk, test performance, and harms from prolonged immobilization. In the ED, validated decision tools (NEXUS and Canadian C‑spine Rule) help identify very‑low-risk patients who do not need imaging; when imaging is needed, modern multidetector CT outperforms plain radiography for clinically significant cervical spine injury (CSI). A large Western Trauma Association cohort (10,276 patients) found CT sensitivity of 98.5% with a negative predictive value of ~100% for clinically significant injuries. The misses were rare and occurred in patients with focal neurologic deficits, who then warranted an MRI [1]. Prehospital protocols increasingly emphasize minimizing time on a backboard and avoiding prolonged collar use because of pressure injury and other morbidities. A systematic review by the East Association for the Surgery of Trauma (EAST) supports collar removal after a negative high-quality CT in an obtunded adult. They highlight the downstream harm from extended immobilization without added benefit [2]. Pediatrics and geriatrics remain special populations. NEXUS shows high sensitivity in children, though confidence intervals are wider in the very young.  Clinicians should have a low threshold for imaging in older adults, who are vulnerable to serious cervical spine injuries from low-energy mechanisms [3]. Clinical Question: In trauma patients with potential SCI, what is the evidence that post‑injury movement causes delayed neurologic deterioration, and what are the benefits and harms of prehospital spinal immobilization and SMR? Reference: Millin M, et al., Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries – A NAEMSP Comprehensive Review and Analysis of the Literature, Prehospital Emergency Care, Aug 2025. Population: Human (and some animals) with potential spinal cord injuries that addressed one of four predefined questions(pathophysiology of delayed neurologic injury, harms of immobilization, effectiveness of immobilization/SMR at limiting movement, and the relationship to delayed neurological injury). Exclusions: Manikin/simulation‑only studies, abstracts without full publication, editorials, other reviews/meta-analyses, guidelines, book chapters, and non-English full manuscripts. Intervention: Prehospital spinal immobilization (long backboard + cervical collar) and SMR (cervical collar ± vacuum splint/ambulance cot) Comparison: No immobilization vs immobilization or alternative immobilization strategies. Outcome: Primary Outcome: Effectiveness of immobilization/SMR at limiting movement and relationship to delayed neurological injury. Secondary Outcomes: Harms of immobilization/SMR (airway/respiratory compromise, raised ICP, pressure ulcers, delays to care, increased imaging, pain), and associations between hypoperfusion/hypoxia and worse neurologic outcomes. (See Tables 2-4 summarized in the paper.) Type of Study: Comprehensive review with no meta-analysis Authors’ Conclusions: There are no data in the published literature to support spinal immobilization and spinal motion restriction as standard of care. Efforts aimed to reduce the use of cervical collar should be considered, and the use of backboards and full body vacuum splint should be limited to the point in time of active patient extrication.  Quality Checklist for Therapeutic Systematic* Reviews: (Yes/No/Unsure) * This is the list we use for SR, while the study in question was called a “Comprehensive Review.” The main question being addressed should be clearly stated. Yes The search for studies was detailed and exhaustive. Yes Were the criteria used to select articles for inclusion appropriate? Yes Were the included studies sufficiently valid for the type of question asked? Unsure Were the results similar from study to study? No Were there any financial conflicts of Interest? No Results: The review synthesized 115 manuscripts spanning prehospital and hospital settings, adult and pediatric populations, and diverse geographies and time periods. The authors did not pool a single set of patient demographics due to the heterogeneity of designs and questions. Key Results: No definitive evidence that routine immobilization/SMR prevents delayed neurologic injury, while harms are common. Primary Outcome: Limiting movement (biomechanical surrogates) results are mixed. No randomized trials were found showing that collars/boards prevent secondary spinal cord injury. In the best-known observational comparison (immobilized vs. not), immobilization was associated with more neurologic disability. A before-and-after system study (moving from routine backboards to SMR) found no increase in delayed deficits. Secondary Outcomes: Harms were common with negative airway/respiratory effects, increased ICP,skin breakdown, delays in care, increased imaging, and pain. Dr. Millin is an emergency and EMS physician, retired from full-time faculty at Johns Hopkins University in Baltimore, and now runs a non-profit wilderness EMS agency in Maryland. He is also the lead author of this comprehensive review, and we asked him five nerdy questions.  Heterogeneity: The review necessarily combined diverse designs (case series, retrospective cohorts), different exposures (movement vs perfusion/hypoxia), and varied outcomes (motion metrics vs patient-important neurologic outcomes). Such heterogeneity limits inferences, and the authors appropriately did not attempt to meta-analyze the data. Risk‑of‑Bias: While selection and abstraction processes are detailed, the report does not describe a formal risk‑of‑bias (RoB) tool. This is a common expectation in systematic reviews. They could have used the ROBINS‑I, which helps assess the risk of bias in the results of non-randomized studies that compare the potential benefit and harm of two or more interventions [4]. Without a structured RoB assessment, confidence in causal interpretations is limited. Screening: The title/abstract was screened by a single reviewer. This may increase the chance of missed eligible studies. Best practice is for two independent reviewers to screen titles and abstracts and to review full texts independently, resolving discrepancies through discussion or a third reviewer. This process improves the validity, transparency, and reproducibility of systematic reviews [5,6,7]. Language & Publication Bias: The authors limited their search to English-language full texts. This can introduce language bias. In addition, narrative syntheses with small or observational studies are also vulnerable to publication bias, with negative studies less likely to be published. Surrogates Outcomes. Several included papers focus on movement reduction as a surrogate for patient-important outcomes (neurologic deficits). Surrogate-oriented outcomes (SOO) do not reliably translate into patient-oriented outcomes (POOs). Comment on Authors’ Conclusion Compared to SGEM Conclusion:  I, Clay Odell, believe the results, and I think this is likely as good evidence as we’re ever going to get regarding the clinical utility (or not) of cervical collars. This may be sufficient evidence for some EMS medical directors to reduce the emphasis on c-collars, but there will remain skeptics. I wonder if the NAEMSP will adopt these conclusions into their official position statement. We agree that routine, prolonged immobilization is not evidence-based and carries harm, and that minimizing backboard time is good practice. We would frame the conclusion more cautiously and prioritize oxygenation/perfusion, use manual stabilization/SMR selectively,...

Date: November 12, 2025 Reference: Taccone et al. Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury The TRAIN Randomized Clinical Trial. JAMA 2024 Guest Skeptic: Dr. Alex Weiler is an Emergency Department staff physician in the Peterborough Regional Health Centre and is an associate professor with Queen's University Department of Family Medicine.  This podcast was recorded live at the Kawartha EM Conference in beautiful Peterborough, Ontario.   Case: A 48-year-old woman presents with a sudden, severe headache and brief loss of consciousness. CT/CTA confirms aneurysmal subarachnoid hemorrhage (SAH). She is coiled and admitted to the intensive care unit (ICU) with an external ventricular drain. On ICU day 3, Hb is 8.4 g/dL (or as we say in Canada 84 g/L), she is not actively bleeding, Glasgow Coma Scale (GCS) of 10 with fluctuating attention, and her expected ICU stay is clearly >72 hours.  Background: Acute brain injury (ABI) can occur for a variety of reasons, including aneurysmal SAH (like in this case) or trauma. Anemia is common in patients with ABI and can worsen cerebral hypoxia. For decades, ICU transfusion practice drifted toward “restrictive” triggers (Hb <7 g/dL or <70g/L) based on trials in mixed ICU populations. However, brain-injured patients may not behave like the average ICU patient. The brain is uniquely sensitive to oxygen delivery, and secondary ischemia strongly predicts poor neurological outcomes. Small single-center studies and physiologic work suggested higher hemoglobin could improve brain tissue oxygenation; however, prior randomized evidence has been sparse or inconclusive in discrete ABI subgroups (traumatic brain injury [TBI], SAH), leaving real uncertainty about the optimal transfusion threshold for this population. The TRAIN trial was designed to answer a practical question that matters at the bedside: in adults with ABI who are anemic but not exsanguinating, does a liberal transfusion strategy improve downstream neurological outcomes compared with a restrictive strategy? Clinical Question: In adults with acute brain injury (TBI, aneurysmal SAH, or ICH) who are anemic (Hb <90 g/L), does a liberal RBC transfusion threshold (transfuse when Hb <90 g/L) compared with a restrictive threshold (transfuse when Hb <70 g/L) improve 6-month neurological outcomes? Reference: Taccone et al. Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury The TRAIN Randomized Clinical Trial. JAMA 2024 Population: Adults (18 to 80) in 72 ICUs across 22 countries with TBI, SAH, or ICH. They needed to have an Hb <90 g/L within 10 days of injury and an expected ICU stay of ≥72 hours. Exclusions:Hb >90 g/L, GCS 3 with fixed/dilated pupils, GCS >13 at randomization, active bleeding, expected ICU stay <3 days, prior neurological disease, pregnancy, inability to receive transfusion; others are listed in the flow diagram. Intervention: Liberal strategy (transfuse when Hb <90 g/L for 28 days). Comparison: Restrictive strategy (transfuse when Hb <70 g/L for 28 days). Outcome: Primary Outcome: Unfavourable neurological outcome at 180 days, GOS‑E 1 to 5 (death to severe disability). Secondary Outcomes: 28-day mortality; composite of death or organ failure at day 28; organ failure; ICU/hospital LOS; distribution (“shift”) of GOS‑E; prespecified serious adverse events (cerebral ischemic events, VTE, infections, TRALI, anaphylaxis). Type of Study: A multicenter, pragmatic, parallel group, open-label, RCT Authors’ Conclusions: “Patients with acute brain injury and anemia randomized to a liberal transfusion strategy were less likely to have an unfavorable neurological outcome than those randomized to a restrictive strategy.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the ED. No The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. No  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. Yes Financial conflicts of interest. Funded by non-profit sources, and the sponsors had no role in design/analysis/reporting. Minor author disclosures unrelated to the intervention were reported. Results: 820 completed the trial, with 806 having the primary outcome (393 liberal; 413 restrictive). Mean age 51 and 46% women. The type of brain injury was ~59% TBI, 23% SAH, 18% ICH overall. GCS at randomization was 6 [IQR 3–8] and was Hb 85 g/L [IQR ~80 to 88]. A median of two units (IQR 1–3) were transfused in the liberal vs 0 units (IQR 0–1) in restrictive, giving an absolute mean difference 1.0 unit (95% CI 0.87–1.12). Key result:  A liberal threshold (Hb <90 g/d) reduced unfavourable neurological outcome at 180 days compared with a restrictive (Hb <70 g/L). Primary Outcome: Unfavourable GOS E 1–5 at 180 days was 63% liberal vs 73% restrictive ARR 10% (95% CI 3.6–16.5) RR 0.86 (95% CI 0.79–0.94), p=0.002. NNT 10 to prevent one additional unfavourable outcome Secondary Outcomes: No statistical difference in 28-day mortality: 21% liberal vs 23% restrictive; RR 0.95 (95% CI 0.74–1.22) No statistical difference in the composite outcome of death/organ failure at day 28, organ failure, or ICU LOS Serious adverse events were similar between groups 1. Performance Bias: Bedside teams knew the assignment (open-label), which can bias outcomes even with masked assessors. The investigators acknowledge awareness of group assignment and incomplete assessment of co-interventions as a limitation.  2. Detection Bias: Cerebral infarction was identified at clinicians’ discretion rather than by systematic imaging, risking underascertainment bias (detection bias). The authors appropriately called the serious adverse event (SAE) data exploratory. 3. Analysis Bias: The primary analysis excluded patients who withdrew consent post‑randomization (modified Intention-to-Treat analysis [mITT]). While common, exclusion after randomization can erode the protection of randomization. A pure ITT analysis better preserves unbiased comparisons. Attrition and missing data can bias estimates (the authors did perform sensitivity analyses, which were consistent). 4. Heterogeneous Acute Brain Injury Etiologies: Pooling TBI, SAH, and ICH increases generalizability but risks effect modification across pathologies. Subgroup analyses largely aligned, but power for interaction is limited. We need to be skeptical of subgroup findings because of multiplicity and low power.  5. Non‑Standardized Neuroprognostication: Prognostication practices were not standardized across centers, which can influence functional outcomes and mortality decisions. The authors correctly note this as a limitation. While mortality was similar between groups, this can mitigate but not eliminate this potential bias. Comment on the Authors’ Conclusion Compared to the SGEM Conclusion: We generally agree with the authors’ conclusions. SGEM Bottom Line: An anemic brain is not a happy brain. In adults with acute brain injury and Hb ≤90 g/L, targeting a 90 g/L transfusion threshold modestly improved 6-month functional outcomes vs a 70 g/L trigger, without a mortality signal and with fewer cerebral ischemic events. Case Resolution: This patient’s Hb was 84 g/L. Therefore, we suggest giving her a transfusion of one unit of packed red blood cells to keep her Hb ≥ 90 g/L. Dr. Alex Weiler Clinical Application We need to remember that this applies to: Adults (18–80) with ABI (TBI, aneurysmal SAH, ICH) in the first 10 days, not actively bleeding, expected to require ICU care ≥72 h, and with Hb between 70 to 90 g/L. Outside of this group (massive hemorrhage, exsanguination, pregnancy, severe comorbidity extremes), extrapolate cautiously. When Hb drops below 90 g/L in eligible ABI patients, it’s reasonable to transfuse RBCs to target at least this threshold, aiming to reduce unfavourable neurological outcomes by ~10%. Use shared decision-making with neurocritical care about triggers, especially if there is clinical concern for cerebral ischemia. Don’t expect a 28-day mortality benefit or shorter ICU stays. The signal here is better functional recovery, not survival. And don’t forget to maintain standard ABI bundles (BP, oxygenation/ventilation, fever control, DVT prophylaxis). What Do I Tell the Patient/Family?  After a brain injury, the brain needs plenty of oxygen to heal. The oxygen is carried in the blood by hemoglobin. When hemoglobin levels are too low, the brain may not get enough oxygen, which can make recovery harder. Your hemoglobin is too low. We recommend a blood transfusion now to bring the hemoglobin up to a safer range. This is part of our effort to give the brain the best chance to heal. Keener Kontest: Last week’s winner was Steven Stelts from NZ. He knew the pending legislation to address HCW violence is the Save Healthcare Workers Act (H.R. 3178 / S. 1600), which would establish federal criminal penalties for assaulting healthcare workers.  Listen to the SGEM podcast for this week’s question. If you know, then send an email to [email protected] with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode. Remember to be skeptical of anything you learn,...

Date: October 17, 2025 Dr. Kristen Panthagani Guest Skeptic: Dr. Kristen Panthagani is an emergency medicine resident and Yale Emergency Scholar at Yale New Haven Hospital. She’s a physician-scientist, having completed her MD/PhD at Baylor College of Medicine. She’s also well known as a science communicator, creator of You Can Know Things which helps explain science in a way everybody can understand, with an emphasis on addressing health rumors and explaining evidence-based medicine. This SGEM Xtra is inspired by piece in the New England Journal of Medicine titled, Training Health Communicators-The Need for a New Approach. It covers the shifting landscape of how and where people are getting health information, specifically social media. It also provides some key competencies to keep in mind as we train healthcare professionals and scientists to communicate in these spaces. The idea of "social media" has existed for a long time. Check out the book Writing on the Wall by Tom Standage to learn more. We last covered the topic of science communication on a SGEM Xtra with Sarah Mojarad where she gave us five tips for science communication. Today we have five themes from your article to discuss. Listen to the SGEM Xtra podcast to hear Dr. Panthagani discuss these themes in detail. Shifting Information Sources People’s habits are changing. They are going to different sources to get health information, and we have to adapt and evolve to stay relevant. The idea of "talk with your doctor if you have questions" is often impractical if people cannot get timely appointments in clinic. Websites for universities and organizations can be reputable sources, but health information is not always presented at the recommended health literacy level. People are not fans of the top-down, “I am the high and mighty institution or organization. Let me tell you what to do” approach anymore. So where are people turning for health information? People are increasingly getting their information from social media. Over half of adults in the US report getting health information from social media. It is unlikely that we can simply tell people to stop using social media for this purpose.   Putting a Face to the Message How can we harness social media? The typical dry and stiff presentation with text-heavy slides at a scientific conference is unlikely to grab people’s attention. People gravitate toward authenticity. A more raw, informal style may be resonate more compared to a polished, rehearsed message "Be a real person." These were tips about style of communication. What tips do you have for creating content? If it's boring to you, it's probably boring for your audience. Don't do stuff you hate. If you like writing, don't create reels. Find ways to write articles, commentary, Substack, etc. You don't have to do it all. Bidirectional Communication Traditional health communication has been top-down from institutions/organizations to the consumer. There is a difference between information dissemination versus communication. Information dissemination is one direction. Communication is bi-directional Listen to the audience Be careful that the scientific understanding of a term (ex. "immunity") may not be the colloquial understanding. Data is not enough. Unite over shared values. Bidirectional communication requires time and effort. Don't feel obligated to respond to every comment. Read the comments to gauge understanding and identify points of confusion. Acknowledging Uncertainty This is a sore spot when it comes to the communication that came during the Covid-19 pandemic. We have to acknowledge that this was a really tough time. We confronted a novel disease and pathogen. The language around topics like vaccines, social distancing, masking, did not really acknowledge that these interventions are not perfect. Guidance changed based on new and emerging data. This is difficult and requires balancing the simplicity of the message with the nuance. We did not do a good job communicating nuance and uncertainty in the early data. How will the public receive scientists acknowledging uncertainty when there are other voices (who may lack knowledge or expertise) proclaiming their message loudly and confidently? People may appreciate nuance more than we give them credit for. Sometimes saying, "I don't know" can actually built trust. Be Nice Dr. Panthagani has a Substack article about why criticizing “anti-vaxxers” backfires. In it she brings up a distinction between shame and guilt from research Brene Brown. Guilt focuses on the behavior and the decision. Shame attacks the character of the person.  Not surprisingly, making people feel stupid, calling them stupid, or being quick to label them doesn’t really work when it comes to effective science communication. Using shame-based methods makes things worse Find ways to connect over shared values. Keep in mind Graham’s hierarchy of disagreement. We want to be refuting the central point that is being made and do so respectfully. We can disagree without being disagreeable. The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over 10 years to less than 1 year using the power of social media. So, patients get the best care, based on the best evidence. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. References: Rooney MK, Santiago G, Perni S, et al. Readability of patient education materials from high-impact medical journals: a 20-year analysis. Journal of Patient Experience. 2021;8:2374373521998847. doi:10.1177/2374373521998847 Mishra V, Dexter JP. Comparison of readability of official public health information about covid-19 on websites of international agencies and the governments of 15 countries. JAMA Network Open. 2020;3(8):e2018033. doi:10.1001/jamanetworkopen.2020.18033 https://www.kff.org/public-opinion/kff-health-information-and-trust-tracking-poll-health-information-and-advice-on-social-media/

Date: October 30, 2025 Reference: Boes et al. Prevalence of violence against health care workers among agitated patients in an urban emergency department. October 2025 AEM 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. Case: It's 7:34 pm. You just took a sip of your portable espresso machine coffee from your favourite Batman cup. It's been 34 minutes into your Tuesday overnight shift. Things are a little crazy, but you are proud of yourself for getting your day colleague out on time. Just then, your second-year resident walks briskly towards you and sits down next to you, an air of fluster about her. She is trying to keep her cool, but you can see her hands are trembling as she is putting in orders for the patient she just saw. You ask her what's up, and she responds, "The intoxicated patient in bed 12 just threatened to punch me when I told him I couldn't give him more pain medications. He said pretty awful things about me, called me names, and cursed at me... they called over security... but I still feel a little shook up about it... " She looks down and shakes her head, and then looks back at you and asks, "How often does this actually happen? Violence against us?" Background: Violence toward clinicians is not a rare event in the ED but rather a predictable occupational hazard. The Canadian Association of Emergency Physicians (CAEP) has called ED violence “unacceptable,” urging a system-wide, zero-tolerance culture and coordinated mitigation efforts across hospitals, EMS, and law enforcement. Their formal CAEP Position Statement on violence in the ED summarizes scope, risk factors, and policy recommendations for prevention and reporting [1]. In the US, the American College of Emergency Physicians (ACEP) maintains a consolidated resource hub on ED workplace violence, including policy statements and advocacy for federal legislation (OSHA standards and the SAVE Act) to mandate prevention programs and establish penalties for assaults on healthcare workers. ACEP’s 2022-member poll found 85% of respondents reported violence had increased in their ED over the prior five years, with 45% saying it had greatly increased. The 2024 follow-up highlighted that >90% feared threats or attacks in the prior year. These data align with the day-to-day experience of emergency physicians and underscore persistent underreporting and inadequate institutional responses [2]. Both CAEP and ACEP emphasize practical approaches such as environmental design, staffing and security policies, de-escalation training, standardized reporting, and partnerships with law enforcement. At the same time, they reject the idea that violence is “part of the job.” Clinical Question: Among ED patients with, what is the prevalence of violent events against health care workers, and how does that compare with events formally reported to the hospital? Reference: Boes et al. Prevalence of violence against health care workers among agitated patients in an urban emergency department. October 2025 AEM Population: ED patients from a locked observation unit at Hennepin County Medical Center (Minneapolis, MN). Exclusions: Patients known to be in custody at the time of the encounter were excluded from data collection. Exposure: Agitation, defined as an Altered Mental Status Score (AMSS) ≥ +1 (range from −4 to +4). Observers then recorded whether the encounter included verbal abuse, a threat of violence, or a violent act against a health care worker. Comparison: N/A Outcome: Primary Outcome: Assault against any health care worker, defined by Minnesota state statute as an act with intent to cause fear of immediate bodily harm or death, or intentional infliction/attempt to inflict bodily harm. Secondary Outcomes: Verbal abuse of health care workers by agitated patients (distinct from threats), defined as harsh/insulting/derogatory language or gestures intended to frighten, humiliate, or belittle. Type of Study: A secondary analysis of two prospective, observational studies conducted in the ED setting. This is an SGEMHOP, and we are pleased to have the lead author on the episode, Dr. Brian Driver. He is a faculty emergency physician and Director of Clinical Research in the Department of Emergency Medicine at Hennepin County Medical Center. Authors’ Conclusions: “Verbal abuse, threats of assault, and violent acts occurred frequently in ED patients with agitation and were underreported.” 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? Yes Have the authors identified all-important confounding factors? Unsure Was the follow-up of subjects complete enough? Yes How precise are the results? Unsure  Do you believe the results? Yes Can the results be applied to the local population? Unsure  Do the results of this study fit with other available evidence? Yes Funding of the Study. None is stated in the manuscript, while the authors declare no conflicts of interest. Results: Across 17,873 screened encounters, 4,609 (26%) involved agitation (AMSS ≥ +1). Alcohol or drug intoxication was present in 4,108 (89%) encounters. Among agitated patients, the median age was ~36 to 39 years, about 50% were male, and the cohort included a substantial proportion of Black, non-Hispanic patients (40–46% across violence strata). The study took place in a locked ED observation unit within an urban safety‑net hospital with ~100,000 annual visits. Key Result: Among agitated ED encounters, assaults were common, formal reports of verbal abuse were rarely reported, while most violent acts were reported. Only 0.5% (9/1,786) of verbal-abuse events and 61.9% (224/362) of violent acts were formally reported to the hospital. Listen to the SGEM podcast to hear Brian answer our five nerdy questions. External Validity: This was a single-center analysis in a locked ED observation unit that preferentially rooms patients with suspected intoxication. While you suggest similar patients would otherwise be mixed in general ED beds, concentrating intoxicated, agitated patients may change the observed prevalence and risk environment. Measurement Bias and Lack of Inter-Rater Reliability. Trained observers used standardized definitions, but inter-rater reliability was not reported, and observers were embedded in the clinical setting (not blinded), which can introduce observation/expectation bias. This is particularly important for subjective constructs like “verbal abuse.” Comparator Misalignment & Underreporting Bias: The “formal report” comparator aggregated events from anywhere in the ED, not just the studied unit or only agitated patients. Using the same denominator (n=4,609) overestimates reporting percentages and biases toward the null in observed–reported differences. Institutional reporting is also known to be incomplete. Don't these differences limit the interpretation of the magnitude of underreporting?  Ascertainment Constraints: The authors note constraints such as language limitations (inability to capture some non-English events), areas not observed (triage), and binary counting at the encounter level (not tallying multiple events per visit). Each can attenuate or distort true prevalence. Could this not systematically shift some of the point estimates? Descriptive Design: As a prevalence study, it does not adjust for potential drivers of violence (staffing, throughput, intoxication level, and de-escalation availability), limiting inference about determinants or modifiable factors. These confounders make it challenging to know how best to address the problem of violence based on this data set. Comment on the Authors’ Conclusion Compared to the SGEM Conclusion: We generally agree with the author that the rate of violence in agitated patients against health care workers is high and under-reported. SGEM Bottom Line: Violence against ED staff is common and substantially underreported, especially for verbal abuse. Dr. Suchi Datta Case Resolution: You tell your resident that, sadly, her experience is not singular and that violence against healthcare workers is a problem, especially amongst agitated patients. You encourage her to report the incident, as there needs to be more documented encounters to help facility advocacy on a systemic level. You also provide her with some resources to help process her trauma. She is very thankful and goes on to talk to you about how the encounter made her feel. You take a walk outside to the trauma bay and, after some breathing exercises, feel strong enough to come back and continue running the ED the rest of the night. Clinical Application: Be careful around agitated patients. Make sure you accurately report incidents of violence. We need to advocate for systemic changes to protect healthcare workers as per ACEP and CAEP. This includes more robust prevention, reporting, and accountability. Violence should not be part of our job. What Do I Tell My Patient? N/A Keener Kontest: Last week’s winner was Dr. Steven Stelts from New Zealand. He knew Magnesium got its name from Magnesia, a region in Thessaly, Greece. This is an area known in ancient times for its deposits of minerals and stones containing magnesium. Listen to the SGEM podcast for this week’s question. If you know, then send an email to  [email protected] with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode. Now it is your turn, SGEMers....

Reference:  Boutin A, et al. Removable Boot vs Casting of Toddler’s Fractures: A Randomized Clinical Trial. JAMA Pediatr. Published April 2025. Date: July 23, 2025 Dr. Andrew Tagg Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder and website lead of Don’t Forget the Bubbles (DFTB). Case: A two-year-old boy presents to your pediatric emergency department (ED) with a limp and refusal to bear weight. His parents aren’t exactly sure what happened. They were at the park and suspected that he might have twisted his leg coming down a slide. On your exam, he does not have a fever. He does not have any swelling or deformity of his bilateral lower extremities. You order X-rays, which confirm a nondisplaced spiral fracture of the distal tibia, a classic toddler’s fracture. After you disclose his diagnosis, his worried parents ask you, “A fracture? Does that mean it’s broken? Will he need to get a cast? He’s such an active little guy, typically.” Background: Toddler’s fractures are subtle, nondisplaced spiral fractures of the tibia. They typically occur in children between the ages of 9 months and 4 years. They often present in children who are just beginning to walk, hence the term “toddler’s fracture.” These kids can come in with inability to bear weight, a limp, or nonspecific pain. Another challenge is that the history you get may or may not help guide you. These injuries usually result from low-energy trauma, such as a twisting injury during a fall. That can happen multiple times a day when you’re learning to walk! The mechanism of injury is so subtle sometimes that parents or caretakers may not recall any inciting event. The findings on X-ray can be quite subtle as well. AP and lateral views may reveal a very small hairline fracture that’s easily missed. In some situations,  X-rays will be negative despite clinical exam findings suggestive of a toddler’s fracture. In those situations, repeated X-rays in a week or so can show some evidence of periosteal reaction. The traditional management has included immobilization with a long leg or short leg cast, based on the belief that toddlers are unlikely to limit activity independently and require rigid immobilization to promote healing and pain relief. However, growing concerns about the discomfort, skin breakdown, need for follow-up visits, and potential complications from casting have led to interest in less restrictive treatments. such as removable walking boots. Clinical Question: In children with radiographically confirmed toddler’s fractures, is treatment with a removable walking boot noninferior to a circumferential cast? Reference:  Boutin A, et al. Removable Boot vs Casting of Toddler’s Fractures: A Randomized Clinical Trial. JAMA Pediatr. Published April 2025. Population: Children aged 9 months to 4 years with radiograph-visible tibial toddler’s fractures seen in 4 Canadian pediatric emergency departments. Exclusion: Presented more than 5 days after injury or had an increased risk for pathological fracture or delayed healing Intervention: Removable prefabricated walking boot. Parents were told to use the boot for one week, then use it as needed for symptoms for up to three weeks. This was based on caregiver discretion, with no scheduled follow-up. Comparison: Standard circumferential casting. This varied across sites: Two sites did a long-leg splint in the ED, followed by a fiberglass cast. Another site did a short or long leg splint/cast in the ED, followed by a long leg fiberglass cast. The final site placed a short-leg splint in the ED, followed by a short-leg fiberglass cast. The casts were applied within seven days of the ED visit. Two sites had casts that were peelable, meaning they could be removed by caregivers at home. The other two sites had patients return to the clinic for cast removal. Outcome: Primary: Evaluation Enfant Douleur (EVENDOL) pain score at 4 weeks Secondary: Return to activity, complications, caregiver satisfaction, care burden, healthcare utilization. Trial: Pragmatic, multicenter, assessor-masked, noninferiority randomized clinical trial Authors’ Conclusions : In this multicenter randomized clinical trial examining the management of children with TF, a removable boot without physician follow-up was noninferior to circumferential casting with respect to pain recovery. While there was a clinically relevant but not statistically significant trend toward more skin complications in the boot group, there was no difference in caregiver satisfaction, and the boot strategy demonstrated reduced childcare-related challenges Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes 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. Yes 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. Yes Financial conflicts of interest. Some authors reported grant funding from healthcare institutions or relevant foundations, but no direct industry sponsorship from Big Boot Results: They enrolled 129 children in the study, with 65 children randomized to the boot group and 64 children randomized to the cast group. The mean age was 2.2 years. Key Results: Removable boot was non-inferior compared to circumferential casting in the management of children with Toddler Fractures. Primary Outcome: This was pain at 4 Weeks on the EVENDOL scale. The non-inferiority margin was defined as 2 points on the EVENDOL scale. The boot group had a EVENDOL mean score of 1.2 (SD 1.5) while the cast group had a mean score of 1.8 (SD 2.1). We mentioned before that they did both an intention-to-treat and per-protocol analysis. The upper bound of the confidence interval was well below the threshold of 2, supporting non-inferiority. Secondary Outcomes: Children treated with a boot were more likely to return to their usual activities by four weeks, with over three-quarters back to normal compared to just 41% in the cast group. This was a difference of 36% (95% CI 9-63%). By 12 weeks, everyone had returned to normal weight bearing and baseline activities. Any other positives for the boot group? They also reported fewer day-to-day challenges. Bathing was easier. Only 41% in the boot group moderately/strongly agreed that bathing the child was a challenge compared to 72% of the cast group (Difference -32%, 95% CI -47 to -18%). There was less need to carry their child around (44% vs 68%; Difference -22%, 95% CI -27 to -15%). Skin complications like mild redness or pressure sores were slightly more common in the boot group, but these were not statistically significant (difference of 22%, 95% CI -6 to 50%). These were generally minor and picked up early. Overall satisfaction was high in both groups; 80% satisfied in the boot group compared to 70% in the cast group (difference 9%, 95% CI -20 to 39%). Though caregivers in the boot group were more likely to say they'd choose the same treatment again mainly because of the care burden and inconvenience of getting the cast placed and removed. There was no difference in unplanned doctor visits or repeat X-rays between the two groups. Radiograph-Visible Fractures Only This study only included radiograph-visible toddler fractures, the clear, obvious ones. But a large chunk of toddler’s fractures don’t show up on the initial X-ray. Those occult injuries may have different trajectories and pain profiles, and we often treat them similarly in practice. So, while the findings are robust for visible fractures, we can’t automatically apply them to every limping toddler with a presumed injury and a normal X-ray. The fracture morphologies included were also interesting. Toddlers' fractures are classically nondisplaced spiral fractures. This study included buckle fracture and transverse fractures too. They even included a few fractures with very minimal displacement, albeit those types of fractures only represented a smaller portion of the population. This feature may add a bit to the generalizability and makes us wonder…could we adopt the less is more approach for even more fracture types? Masking and Bias: The Pragmatic Trade-Off This was a pragmatic trial, which is great for real-world relevance, but only the outcome assessors were blinded. Parents and clinicians knew exactly which treatment was given, which might influence how they reported things like activity levels or skin problems. That’s a potential source of reporting bias, especially when dealing with subjective outcomes. Still, the fact that the EVENDOL scores, assessed blindly via video, aligned with parental reports adds some weight to the findings. Harms vs Benefits: What Matters Most? The boot came out ahead in terms of day-to-day practicality. It’s easier to bathe. There’s less carrying. The kids also returned to their activities quicker. That’s huge for families. Skin complications in the boot group were more common. Most of these (92%) were mild erythema but there were a few minor pressure sores. What’s more meaningful to parents? A slightly higher risk of a rash or being able to get through a week without plastic-wrapping their child’s leg for every bath?...

Date: October 10, 2025 Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department.  Case: A 37-year-old man presents to the emergency department (ED) with severe right-sided flank pain.  The pain started about eight hours ago as a vague discomfort in his right flank, but it has gotten progressively worse and now is radiating to his groin. Patient reports nausea, an increased urge to urinate and noticing blood in his urine on one occasion. The patient denies prior medical or surgical history. Upon ED arrival, his vital signs are normal. Physical examination revealed a stated age patient in distress due to severe right flank pain, prominent right-sided costovertebral angle tenderness, and absence of abdominal tenderness or guarding. While strongly considering renal colic in differential diagnosis and reaching for the bedside ultrasound, you are wondering if a single dose of a non-steroidal anti-inflammatory (NSAID) will be enough to relieve this patient’s pain, or should you add Magnesium or Lidocaine? Background: Renal colic is a common and extremely painful emergency department (ED) complaint encountered in the ED that frequently recurs. The nonsteroidal anti-inflammatory drugs (NSAIDs) given intravenously or intramuscularly (IM) are frequently used as first-line therapy. However, about 30% of ED patients receiving NSAIDS require rescue analgesia in the form of opioids. Opioid use, though effective, is limited at times due to the potentially dangerous adverse effects. Thus, there might be a role for other non-opioid classes of drugs to be co-administered with NSAIDs for relief of renal colic. Magnesium sulfate (MgSO₄) has been suggested as a possible treatment option. It may blunt ureteral smooth muscle spasm by antagonizing calcium influx in smooth muscle and by N‑methyl‑D‑aspartate (NMDA) receptor antagonism. These are mechanisms that can reduce visceral pain and augment other analgesics. Small ED trials and meta‑analyses suggest MgSO₄ can reduce pain scores and opioid use in renal colic, though the evidence base has been limited and heterogeneous [1]. Another suggested treatment modality for renal colic is intravenous lidocaine. We looked at this treatment on SGEM#202 and were unimpressed with the efficacy. Systemic lidocaine blocks voltage‑gated sodium channels and appears to modulate central sensitization and visceral pain pathways. In ED populations, systematic reviews indicate IV lidocaine offers variable analgesia with a mixed signal for benefit, and renal colic–specific RCTs suggest it may be inferior to ketorolac and best considered (if at all) as part of a multimodal strategy rather than as monotherapy [2]. Clinical Question: In adult ED patients with suspected renal colic receiving IM diclofenac, does adding IV magnesium sulfate or IV lidocaine increase the proportion achieving ≥50% reduction in pain at 30 minutes compared to a saline placebo? Reference: Toumia M, Sassi S, Dhaoui R, et al. Magnesium Sulfate Versus Lidocaine as an Adjunct for Renal Colic in the Emergency Department: A Randomized, Double-Blind Controlled Trial. Ann Emerg Med 2024 Population: The study enrolled adults aged 18 to 65 years with suspected acute renal colic and a pain score of 5 or more on a 10-point numerical rating scale (NRS). Exclusions: Pregnancy/breastfeeding; NSAID, MgSO₄, or lidocaine contraindication or allergy; renal/hepatic dysfunction; analgesic use in prior 6 h; bleeding diathesis or GI hemorrhage; significant CAD/arrhythmia; seizures; peritoneal signs; altered mental status; anticoagulation; hemodynamic instability; morphine allergy. Intervention: All patients received 75 mg IM diclofenac. The intervention groups then received either 1g IV MgSO₄ (10 mL) over 2-4 minutes or 1.5 mg/kg IV lidocaine (10 mL) over 2-4 minutes. Comparison: Placebo(10 mL normal saline) after 75 mg IM diclofenac. Outcome: Primary Outcome: The proportion of participants achieving at least a 50% reduction in the NRS score at 30 minutes after drug administration. Secondary Outcomes: Need for rescue analgesia, time required for 50% pain reduction, proportion of participants with persistent pain (NRS>2) at 90 minutes, frequency of adverse events, and frequency of return visits to the ED for renal colic recurrence. Type of Study: Prospective, multicenter, randomized, double‑blind, placebo‑controlled, 3-arm trial conducted from November 2022 to August 2023 in three academic hospital EDs and one regional hospital ED in Tunisia. Authors’ Conclusions: “Adding intravenous MgSO4, but not lidocaine, to IM diclofenac offered superior pain relief but at levels below accepted thresholds for clinical importance.”  Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes 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. Yes All groups were treated equally except for the intervention. Yes 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. No  Financial conflicts of interest. This study was conducted without financial support. The authors have no conflict of interest relevant to this article to disclose. Results: They screened 1,321 patients and included 840 who were randomized (280 per arm). The mean age is in the mid 40s with a fairly even male/female split. The mean baseline NRS ~8.5–8.7. Ultrasound showed stones in ~20% and pyelocaliceal dilation in over one-third of patients. Key Result: Adding IV MgSO₄ to IM diclofenac increased the proportion of patients achieving ≥50% pain reduction at 30 min and reduced rescue analgesia use, but pain score differences never reached the 1.3‑point MCID, while IV lidocaine was not superior to diclofenac alone. Primary Outcome: ≥50% NRS reduction at 30 minutes MgSO₄ + diclofenac: 227/280 (81.7%) Lidocaine + diclofenac: 204/280 (72.9%) Placebo + diclofenac: 201/280 (71.8%) MgSO₄ vs lidocaine +8.8% (95% CI 1.89–15.7, p=0.013) MgSO₄ vs control +9.9% (95% CI 2.95–16.84, p=0.004). Secondary Outcomes: Rescue analgesia: Lower need in MgSO₄ group (17.1%) versus lidocaine (22.5%) and control (28.9%). Time to 50% pain reduction: No significant differences between groups (approximately 21 minutes for all groups). Persistent pain at 90 minutes: Similar across groups (20-22.1% with NRS>2). Return ED visits: No differences (22-26%) Adverse events: Significantly more in MgSO₄ group (57.1%) versus control (22.5%), primarily facial flushing (48% MgSO₄ vs 10% Lido vs 14% placebo) Statistical vs. Clinical Significance: This study exemplifies a critical issue in clinical research: achieving statistical significance without clinical importance. While the primary outcome showed statistical significance for MgSO₄ lidocaine and even more so for control, the actual NRS differences were all below 0.5 points at every time point. In addition, no between-group differences reached the generally accepted reduction of 1.3 for being clinically important [3,4]. There are concerns in the literature about what is considered a minimally important difference (MID) or minimally clinically important difference (MCID) [5, 6]. Choice of Primary Outcome Metric: The primary outcome was the proportion of patients achieving ≥50% pain reduction rather than the actual change in pain scores. This dichotomization of a continuous variable has several problems: Loss of Information: Converting continuous NRS data to a binary outcome discards valuable information about the magnitude of pain relief. For example, a patient going from NRS 10 to 5 (50% reduction) is counted the same as a patient going from 10 to 2 (80% reduction), yet these represent vastly different clinical scenarios. Arbitrary Threshold: The 50% reduction threshold, while commonly used, may not represent meaningful relief for all patients. For example, some patients with NRS 10→5 may still require rescue analgesia, while others with NRS 10→6 (40% reduction) might be satisfied. Diagnostic Verification of Kidney Stone: The diagnosis of renal colic was based on emergency physician clinical judgment or imaging with ultrasound showing direct or indirect signs of urinary tract stones in only 58% of participants when performed. This is consistent with current radiology, emergency medicine and urology guidelines not to get imaging on all patients [7].  We cover this on the SGEM Xtra: Come Together, Right Now...Over Renal Colic. While this approach may increase real-world applicability (generalizability), the “suspected renal colic” inclusion without universal confirmatory imaging may reduce internal validity and introduce misclassification bias. A confirmed stone sensitivity analysis would have helped strengthen the findings. Adjunct to IM Rather Than IV NSAID: While acknowledging and respecting the authors’ standard of care practice of using IM Diclofenac, there are several important implications: Delayed NSAID Absorption: IM administration results in slower and more variable absorption compared to IV administration. Peak plasma concentrations occur at 20-60 minutes with IM NSAIDs versus 5-10 minutes with IV administr

Reference:  George S, et al. Effectiveness of nasal high-flow oxygen during apnoea on hypoxaemia and intubation success in paediatric emergency and ICU settings: a randomised, controlled, open-label trial. Lancet Respir Med. March 2025 Date: July 10, 2025 Guest Skeptic: Dr. Spyridon Karageorgos is a Pediatric Chief Resident at Aghia Sophia Children’s Hospital, Athens, Greece and faculty of the Pediatric Emergency Medicine MSc at Queen Mary University in London. Case: A two-year-old boy presents in the emergency department (ED) with severe respiratory distress and hypoxemia. You attempt to use some non-invasive forms of respiratory support, but he continues to have significant work of breathing and retractions. His mental status begins to decline, and he appears much sleepier than before. The team makes the decision to intubate him. You follow the steps of the pre-intubation checklist and pre-oxygenate him with 100% FiO2. As the sedative and paralytic for intubation are given, the respiratory therapist asks, “Do you also want to use nasal high flow (NHF) for apneic oxygenation during intubation?”  Background: Managing hypoxia in pediatric patients in EDs and intensive care units (ICUs) remains a challenge. Hypoxia can arise from various causes, including bronchiolitis, pneumonia, asthma, or undifferentiated respiratory failure. Ensuring timely and effective oxygenation is critical to stabilizing these patients and preventing progression to respiratory failure or cardiac arrest.  NHF oxygenation has gained traction as a respiratory support modality in both ED and ICU settings. NHF delivers humidified and heated oxygen at high flow rates, which typically exceed the patient’s inspiratory flow through nasal cannula. This mechanism not only improves oxygenation but can also help reduce the work of breathing by flushing anatomical dead space and providing some degree of positive end-expiratory pressure (PEEP). The use of NHF is considered less invasive than continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) or mechanical ventilation. It is usually better tolerated, especially by children. The use of NHF has expanded into general pediatric practice, especially for treating conditions like bronchiolitis and other forms of acute respiratory distress. But, its comparative efficacy to standard oxygen therapy in various clinical settings and patient populations remains a subject of ongoing investigation. While we would always prefer a controlled intubation, sometimes the patients we see in the ED are unstable and need to be intubated emergently. We often try to pre-oxygenate prior to intubating to maximize oxygen reserves. Previous studies have suggested that the use of NHF may reduce the risk of hypoxemia and improve first-attempt intubation . However, randomized controlled trials evaluating this practice in the pediatric population are limited. Clinical Question: In children requiring emergency intubation, does the use of nasal high-flow oxygen for apneic oxygenation reduce hypoxemia and increase the rate of successful first-attempt intubation compared to standard care? Reference:  George S, et al. Effectiveness of nasal high-flow oxygen during apnoea on hypoxaemia and intubation success in paediatric emergency and ICU settings: a randomised, controlled, open-label trial. Lancet Respir Med. March 2025 Population: Children aged 1 month to 15 years with acute hypoxic respiratory failure (SpO₂ <92% on room air) requiring emergency endotracheal intubation in EDs and pediatric and neonatal ICUs across Australia, New Zealand, and Switzerland. Exclusion: Primary nasal intubation, blocked nasal airways, elective endotracheal tube change, intubation required immediately for loss of cardiac output or respiratory arrest, location of intubation outside of ED or ICU, death Intervention: Nasal high-flow oxygen at 2L/kg/min during the apneic phase of intubation. Weight HFNC rate 0-12 kg 2L/kg/min (max 25 L/min) 13-15 kg 30L/min 15-30 kg 35L/min 30-50 kg 40L/min >50 kg 50L/min Comparison: Standard care Outcome: Primary Outcomes: Hypoxemia (SpO2 ≤90% or difference of ≥10% if they were unable to achieve a pre-intubation saturation of 100% or the patient had cyanotic congenital heart disease with a right to left shunt) and first-attempt intubation success without hypoxemia Secondary Outcomes: Total intubation attempts, re-oxygenation needs, duration of ventilation, lowest oxygen saturation throughout intubation period, length of stay, mortality, adverse events. Trial: Randomized controlled, open-label, pragmatic multicenter trial Dr. Shane George Guest Author: Dr. Shane George is a paediatric emergency and critical care physician at Gold Coast University Hospital, Australia. That’s right he’s trained in both emergency medicine and paediatric intensive care. He’s the lead for children’s critical care research for Gold Coast Health which is affiliated with the University of Queensland and Vice Chair of the Paediatric Research in Emergency Departments International Collaborative (PREDICT)  Authors’ Conclusions: The use of NHF during emergency intubation in children did not result in a reduction in hypoxaemic events or an increase in the frequency of successful intubation on the first attempt. However, in per-protocol analysis, there were fewer hypoxaemic events but no difference in successful intubation without hypoxaemia on first attempt. Barriers to the application of NHF during emergency intubation and the reasons for abandoning intubation attempts before physiological compromise should be further investigated to inform future research and recommendations for intubation guidelines and clinical practice. Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No 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. The funders (Fisher & Paykel Healthcare) provided equipment that was used during the trial but did not have a role in study design, data collection, data analysis, data interpretation, or writing of manuscript. Three of the authors reported consultancy fees, travel, and accommodations by the same company. Results: They included 969 children with 535 assigned to NHF and 534 assigned to the standard care group. Key Results: There was no statistical difference in hypoxemic events or first attempt intubation success among patients who received nasal high flow compared to standard care. Primary Outcome: Hypoxemia occurred in 61 (12.8%) of the NHF group compared to 77 (16.2%) of the standard care group (aOR 0.74; 97.5% CI 0.46-1.18, p=0.15). First attempt successful intubation without desaturation occurred in 300 (63%) of the NHF group compared to 280 (59.1%) of the standard care group (aOR 1.13; 97.5% CI 0.79-1.62, p=0.43). They also did a per protocol analysis where 45 of the intubations were removed. Hypoxemia occurred in 48 (10.8%) of the NHF group compared to 77 (16.7%) of the standard care group (aOR 0.59; 97.5% CI 0.36-0.97, p=0.017). First attempt successful intubation without desaturation occurred in 284 (64%) of the NHF group compared to 268 (58.1%) of the standard care group (aOR 1.22; 97.5% CI 0.87-1.71, p=0.19). Secondary Outcomes:   There were no statistical differences in intubation attempts, need for re-oxygenation in between intubation attempts, duration of mechanical ventilation, length of ICU or hospital stay. The rates of minor and major adverse events were similar as well. Tune in to the podcast to hear Dr. George answer our questions. Biases In this study, approximately 14% of eligible patients were not approached for inclusion due to the treating clinician’s discretion. This is separate from those who were not approached for social or compassionate reasons. Another 14% were missed for unknown reasons. This could have introduced selection bias. Do you have any insights on why the treating clinicians chose not to approach certain patients? How do you think this may have impacted the study results? The open-label design (lack of masking) meant neither clinicians nor evaluators were blinded, introducing potential performance and detection bias. What impact to you think that may have had on the trial? Standard Care When we looked at the protocol deviations in the study. It looks like there was more non-compliance in the NHF group, with most of the reasons being that clinicians seemed to have forgotten to put on the NHF. Did you happen to collect data on what “standard care” meant to clinicians involved in the study? Modified Intention-to-Treat (mITT) vs Per-Protocol (PP) Analysis  You performed two different analyses for the data: Modified Intention-to-Treat (mITT) and Per-Protocol (PP) analysis. Each type of analysis has some strengths and weaknesses. Why did you not perform a pure ITT? Your team did find a statistical difference in the rate of hypoxemia between the two groups based on the analysis performed with the per protocol analysis favoring the use of NHF. ...

Date: September 18, 2025 Guest Skeptic:  Dr. Neil Dasgupta is an Emergency Medicine (EM) physician and emergency department (ED) intensivist from Long Island, NY. He is the Vice Chair of the ED and Program Director of the EM residency program at Nassau University Medical Center in East Meadow, NY.  Reference:  Doupnik et al. Impact of telemental health on suicide prevention care in U.S. emergency departments. AEM Sept 2025 Trigger Warning: The following case scenario discusses suicide and self-harm. If you or someone you know is at risk, seek immediate help (dial 911/999/112 as appropriate, or 988 in the US/Canada for suicide & crisis support). Resources:  Substance Abuse and Mental Health Services Administration (SAMHSA) National Alliance on Mental Illness (NAMI) American Foundation for Suicide Prevention (AFSP) Case: It’s 23:15 on a Tuesday in a 10-bed rural emergency department (ED) that serves as the community’s sole hospital. A 37-year-old male arrives with a friend after texting that they “can’t do this anymore.” The friend is concerned because he has access to firearms. Triage vitals are stable. The nurse uses the ED’s standard suicide‑risk screen, which is positive. The nurse activates the service’s 24/7 telemental‑health workflow. A video cart is wheeled into the room, and a remote clinician joins the conversation. Background: Delivery of quality mental health care is one of the major difficulties affecting our EDs. Caring for these patients presents a particular kind of challenge, since establishing rapport with the patient, getting a detailed history, gathering collateral information from others, overcoming possible intoxications or toxidromes, requiring staff for continuous observation and treating physical injuries can require substantial levels of time and skills.  In addition, suicide remains a leading cause of death, and EDs are a frequent point of contact for people in crisis. Many of these encounters involve complex psychosocial factors, limited outpatient capacity, and time-sensitive safety planning. The stakes are high, and what happens in the ED can shape risk in the hours to days after discharge. As emergency physicians, we balance therapeutic alliance, thorough risk assessment, and efficient disposition in an environment built primarily for acute medical care, not longitudinal mental health follow-up. Frustration often occurs due to limited resources, high volumes, inpatient boarding and overcrowding; it can seem impossible for an ED physician to provide compassionate, nuanced, complete psychiatric care. Patients utilize the ED for mental health care because they often do not have a choice.  Sometimes that lack of choice stems from a report of suicidal thoughts, which in most communities represents a lack of capacity to make medical decisions, and EMS systems are required to transport these patients for emergent psychiatric care.  In many communities, especially in areas that have less robust access to health care in general, there are profound administrative, financial and systemic barriers to creating or maintaining a functional level of mental health care infrastructure, profoundly overburdening the services that exist and pushing those needs onto the local emergency departments.  Telemedicine (particularly telepsychiatry and broader telemental health) has become a pragmatic way to expand access to mental health expertise. This has accelerated with the pandemic-era virtual care. Programs vary widely, with some providing on-demand psychiatric prescribers, while others lean on social work, psychology, or case management. Integration with the ED team and the electronic health record (EHR) can be excellent in some settings and minimal in others. Despite legislative progress in the US, including the Affordable Care Act and the Addiction Equity Act, reimbursements remain poor for the care of such patients, severely limiting access to care.  As with many other challenging issues, for lack of a better option, the ED becomes the entryway to any portion of the healthcare system. For rural and critical‑access hospitals, telemedicine can be the difference between no specialist input and round-the-clock access. But the question that matters to front-line EM clinicians is not just “Is telehealth available?” It’s “Does telehealth meaningfully improve the way we deliver suicide‑prevention care in the ED?”And, even if processes improve, do those changes translate into better patient-oriented outcomes (POO) such as reduced attempts, ED revisits, or suicide deaths? Clinical Question: Among US hospital-affiliated EDs, is having access to telemental health associated with greater routine use of recommended suicide‑prevention practices? Reference:  Doupnik et al. Impact of telemental health on suicide prevention care in U.S. emergency departments. AEM Sept 2025 Population: 606 EDs in the US associated with a general medical hospital Excluded: EDs in government hospitals (VA/DoD), specialty hospitals (orthopedic), rehabilitation hospitals, and independent children’s hospitals (surveyed separately). Freestanding EDs not affiliated with a general hospital. Exposure: ED use of telemental health (telepsychiatry/telemental services available to the ED).  Comparison: EDs without telemental health. Analyses stratified by critical‑access hospital status and adjusted for ED/hospital characteristics.  Outcome: Primary Outcome: Routine use of six recommended suicide‑prevention practices Assessment of current suicidal intent/plans Past suicidal thoughts/behaviours Access to lethal means Standard approach to discharge planning Routinely scheduling follow-up Lethal‑means restriction counselling. Secondary Outcomes: Prevalence and characteristics of ED telemental health programs (staffing, hours, and EHR integration). Type of Study: A National cross-sectional survey with stratified probability sampling and nonresponse weighting. Dr. Stephanie Doupnik This is an SGEMHOP, and we are pleased to have the lead author on the episode, DrStephanie Doupnik is an Assistant Professor of Pediatrics and Health Policy and Director of the Division of Pediatric Hospital Medicine at Vanderbilt University Medical Center. Dr. Doupnik’s research has been funded by the National Institute of Health and focuses on the implementation of mental health services and suicide prevention care in EDs and hospitals, including the use of telehealth. Authors’ Conclusions: “Telemental health care is widely used across all types of EDs, and EDs with telemental health care are more likely to use suicide prevention practices. Critical-­access hospitals rely on telemental health care to a great extent and need better access to telehealth psychiatry and EHR information sharing. Quality Checklist for Reporting of Survey Studies (Yes/No/Unsure)? Were hypotheses or aims explicitly stated? Yes Were operational definitions of the predictor (independent) and outcome (dependent) variables provided? Yes Were participant eligibility criteria (inclusion and exclusion) explicitly stated? Yes Were participants recruited using an acceptable recruitment strategy? Yes Were participants selected by a random/probability sampling strategy? Yes Was the sample size appropriate? Unsure Were participants randomly assigned into groups/ conditions? N/A Was the response/participation/recruitment rate provided? Yes Was the attrition rate acceptable? Unsure Was the attrition rate treated appropriately in data analyses? Yes Were the chosen statistical tests appropriate to address hypotheses or research questions? Yes Did the study include a formative research or pilot phase? Yes Were the measures provided in the report (or in a supplement) in full? Yes Were all measures of established validity, or was a validation procedure undertaken by the authors? Unsure Was the study sample described in terms of key demographic characteristics? Yes Was the data collection process described with sufficient detail for it to be replicated? Yes Were generalizations of findings restricted to the population from which the sample was drawn? Yes Was the study approved by a relevant institutional review board or research ethics committee? Yes Did participants provide informed consent (or assent, where relevant)? Yes Were funding sources or conflicts of interest disclosed? Yes  Results: Of 977 eligible EDs, 606 responded (62%), weighted to 4,321 EDs nationally. Responders more often were rural, smaller, and critical‑access hospitals with nonresponse weights applied. Overall, 68% of responding EDs reported using telemental health. Lower ED volume, smaller bed size, and critical‑access status were associated with higher telehealth use. Key Result: Over two-thirds of US emergency departments use telemental health. Secondary Outcomes:  Availability: More than 80% of telehealth EDs reported 24/7 coverage, with critical‑access EDs reporting they were more likely to have 24/7 access (81% vs 64%).  Staffing: Telepsychiatrists/prescribers available in 68% of non-CAH programs vs 54% in CAHs. CAHs relied more on private contractors/other systems.  EHR Integration: Telehealth clinicians could view the EHR in 64% of non-CAHs vs 28% of CAHs; documentation privileges 64% vs 35%.  Post‑ED Follow‑Up: Only about one quarter of programs provided any follow-up after discharge. Listen to the SGEM podcast to hear Stephanie answer our five nerdy questions. Self‑Report & Social Desirability Bias: Outcomes were ED leaders’ reports of “routine” practice. Without chart audits or direct observation, overestimation is plausible, especially for practices perceived as best‑practice (lethal‑means counselling). How did you mitigate this issue? Cross‑Sectional Design & Confounding:Telehealth presence ma

Date: Sept 16, 2025 Reference: Prada et al. Evaluation of the evidence on acetaminophen use and neurodevelopmental disorders using the Navigation Guide methodology. Environ Health. August 2025 Guest Skeptic: Dr. Andrew Martin is an emergency physician practicing in Jacksonville, Florida.  Case: A 27-year-old at 24 weeks’ gestation presents to the emergency department (ED) with fever (38.6 °C), myalgias, and sore throat. She took 650 mg of acetaminophen (Tylenol) six hours ago with partial relief. She hesitated to repeat the dose after reading online posts about “Tylenol and autism.” She has no abdominal pain, no vaginal bleeding, and normal fetal movement. Vitals otherwise stable; pharynx erythematous, no exudate. She asks, “Is it safe to take another dose, or could this hurt my baby’s brain later?” Background: Acetaminophen (paracetamol) is the most used analgesic–antipyretic in pregnancy. A recent prospective cohort study suggests ~40 to 65% of pregnant people report using it. They are typically using acetaminophen for headache, myalgias, or fever, with most use being short and intermittent. Alternatives, particularly non-steroidal anti-inflammatory drugs (NSAIDs), carry well-described fetal risks in late gestation. This is one of the reasons why acetaminophen remains the default first-line choice [1,2]. Biologically, acetaminophen crosses the placenta and achieves fetal levels like maternal levels, making the developing brain theoretically exposed during critical windows [3]. This has motivated a large observational literature examining whether prenatal exposure is linked to later neurodevelopmental outcomes such as ADHD and autism. Meta-analyses generally report small associations (summary effects around 1.2 to 1.3) and signal stronger effects with longer duration of use, though heterogeneity in exposure measurement and outcome ascertainment is substantial.  Professional bodies, including the American College of Obstetricians and Gynecologists (ACOG) and the Society of Obstetricians and Gynecologists of Canada [SOGC], continue to recommend acetaminophen for appropriate indications at the lowest effective dose and shortest duration. At the same time, they do acknowledge ongoing research and the limitations of observational data (including confounding by indication). For emergency clinicians, the practical tension is familiar. The dilemma is that untreated maternal fever and significant pain can themselves harm pregnancy, yet patients are increasingly asking about possible long-term neurodevelopmental potential harms of using acetaminophen.  Clinical Question: Is acetaminophen exposure during pregnancy associated with ADHD, ASD, or other neurodevelopmental disorders (NDDs) in children? Reference: Prada et al. Evaluation of the evidence on acetaminophen use and neurodevelopmental disorders using the Navigation Guide methodology. Environ Health. August 2025 Population: Observational studies assessing children of pregnant individuals for neurodevelopmental outcomes. Excluded: Postnatal exposures, non-human studies for the primary analysis, non-original publications, and duplicate reports from the same cohort. Exposure: Prenatal acetaminophen (maternal self-report, biomarkers such as meconium/cord blood, or medical records/prescription registries). Comparison: Children who were not exposed prenatally to acetaminophen, or those exposed to alternative analgesics. Outcome: Primary Outcome: NDDs (particularly ADHD and ASD) and related symptomatology measured by clinical diagnoses, medication use, or validated behavioural scales. Secondary Outcomes: Timing and dose–response patterns, broader cognitive/behavioural domains (language & executive function), and triangulation across design types. Type of Study: Systematic review using the Navigation Guide methodology with a qualitative synthesis (no meta-analysis) due to substantial heterogeneity. Authors’ Conclusions: “Our analyses using the Navigation Guide thus support evidence consistent with an association between acetaminophen exposure during pregnancy and increased incidence of NDDs. Appropriate and immediate steps should be taken to advise pregnant women to limit acetaminophen consumption to protect their offspring’s neurodevelopment.” Quality Checklist for Systematic Review: The main question being addressed should be clearly stated. Yes The search for studies was detailed and exhaustive. Unsure Were the criteria used to select articles for inclusion appropriate? Yes Were the included studies sufficiently valid for the type of question asked? Unsure Were the results similar from study to study? No Were there any financial conflicts of Interest? Yes Result: They searched PubMed (primary) through Feb 25, 2025, with confirmatory checks in Web of Science and Google Scholar. A total of 46 studies were included.  The studies consisted of a mix of prospective cohorts, retrospective/historical cohorts, sibling-controlled cohorts, and two case-control studies.  Sample sizes ranged from ~100 to a national registry scale (Sweden’s registry cohort included 2.5 million births). Key Result: The preponderance of studies reported positive associations between prenatal acetaminophen exposure and ADHD/ASD or related symptoms, with dose–response suggested in several biomarker and prospective cohorts. However, some sibling-controlled analyses attenuated associations toward null, and overall heterogeneity was high. Of 46 studies, 27 reported positive associations, 9 null, and 4 inverse (protective) associations. Several higher-quality or biomarker-based studies suggested dose-response relationships. No pooling into a meta-analysis due to heterogeneity 1) Exposure Misclassification: Most contributing cohorts ascertained prenatal acetaminophen exposure via maternal self-report during pregnancy or post‑partum recall, or from prescription/registry data that do not fully capture over-the-counter use. The authors’ own risk‑of‑bias summaries flag the exposure domain as a frequent concern, and they rate retrospective self-report, especially when collected after child diagnosis, as high risk for recall bias. In contrast, biomarker studies (meconium, cord blood, maternal plasma/urine) mitigate recall bias and, in several instances, suggest dose–response, but they remain snapshots that imperfectly reflect timing and cumulative dose. The review also highlights how low-sensitivity exposure measurement can deflate associations. An example is the large Swedish sibling‑analysis cohort that reported 7.5% use based on midwife interviews, despite contemporaneous sources indicating ~50 to 60% use. This implies substantial underascertainment (misclassification bias or ascertainment bias) that likely biases the estimate toward the null and compounds loss of power in within-family models. Together, these exposure‑measurement limitations should make us more cautious in both the direction and magnitude of observed associations in the qualitative synthesis. 2) Residual Confounding: Although many included studies adjusted for a broad set of factors (maternal age, socioeconomic status, smoking, alcohol, illness, fever, and infection) and some used negative‑control exposure periods or propensity approaches, the review acknowledges that unmeasured and residual confounding remain possible. Importantly, the authors did not implement a quantitative bias analysis (E‑values, probabilistic bias analysis) to bound the strength of confounding necessary to explain the findings. They explicitly list this as a limitation of the review. Given that indications for acetaminophen (fever, pain, intercurrent infection) may themselves relate to neurodevelopmental outcomes and can be difficult to measure with sufficient granularity, any qualitative conclusion about “persistence after adjustment” should be interpreted skeptically. 3) Outcome Heterogeneity & Variable Ascertainment:  The review pools evidence across disparate outcome definitions: registry-based clinical diagnoses (ICD‑coded ADHD/ASD), ADHD medication use, and multiple validated behavioural scales (CBCL, SDQ), often at different child ages and with parent vs teacher report. This heterogeneity in outcome measurement (plus differences in timing of assessment) creates non-comparability that complicates causal interpretation and precludes valid pooling. Appropriately, the authors do not conduct a meta-analysis, citing the substantial heterogeneity in exposure assessment, outcome measures, and confounder adjustment. Risk‑of‑bias summaries also show concerns in the outcome domain for some outcome types. Mixing clinical diagnoses, proxy markers (medication), and symptom scales across varied ages increases measurement error and between-study variability, limiting the precision and generalizability of the qualitative synthesis. 4) Search Scope & Evidence‑Grading: The search strategy relied on PubMed as the primary database with confirmatory checks in Web of Science and Google Scholar. No additional eligible studies were identified beyond PubMed, and no discussion of searching the grey literature.  Heavy reliance on a single primary database risks missing studies indexed elsewhere or gray literature, potentially introducing retrieval bias.[4] In addition, while the Navigation Guide offers a structured approach, the authors note that its numeric domain‑averaging can imply unwarranted precision and assign equal weight to domains even when certain biases (confounding, exposure error) likely dominate. They attempted sensitivity analyses (excluding lowest‑scoring papers and up-weighting confounding) but acknowledge the framework’s default “moderate” rating for observational evidence could skew certainty assessments. These methodological choices reasonably reflect transparency but also represent limitations of the review’s grading and synthesis. ...

Date: August 12, 2025. This is an SGEM Xtra, and today, we’re putting on our conference lanyards and boarding passes to talk about one of the most exciting events in the global EM calendar, IncrEMentuM 2026. For those who did not attend IncrEMentuM 2025, it set the bar incredibly high. From the moment delegates walked into the venue in Murcia, Spain, there was a buzz that felt like the early days of SMACC. The conference felt electric, global, and unapologetically fun. The talks were short, sharp, and full of energy, blending the best evidence with stories you’d remember long after the conference ended. On-stage simulations pushed the boundaries of what a medical conference could be, while debates in the concourse were full of healthy skepticism. Between sessions, the networking was amazing. One minute you could be sipping coffee next to EM legend Scott Weingart, and the next minute swapping resuscitation hacks with a new friend from across another continent. And, of course, the Spanish hospitality shone through. Paco, Carmen and the whole Incrementum team made everyone feel welcome, well fed, and everyone left wanting more. Well, you are in luck. Lightning is going to strike again on April 22 to 24, 2026, back in beautiful Murcia. Today, I am joined by three amazing Canadian EM physicians and educators who will be presenting in Murcia. Dr. Sara Gray has been known to run codes with the grace of a symphony conductor. Dr. Chris Hicks is like the Yoda of resuscitation: wise, calm, and occasionally cryptic. And finally, Dr. David Carr, the master of pearls, pitfalls, and the occasional “I-can’t-believe-that-just-happened” story. Having these three superstars on the SGEM reminds me of what a deep bench of medical educators we have in Canada. We are consistently punching above our weight in the #MedEd world. Today's podcast is not about Canada but rather the amazing things Spanish EM educators are doing. Five Questions for the Panellists Listen to the SGEM Xtra podcast to hear Sara, Chris and David respond. What can people expect from IncrEMentuM 2026? How is it different from your typical EM conference with endless PowerPoint karaoke & bad coffee? How does IncrEMentuM compare to the SMACC conferences? What will each of you be bringing to the stage in 2026 in Murcia? Beyond the great talks, why should someone hop on a plane to Murcia, and what are you looking forward to the most? IncrEMentuM 2026: April 22 to 24 in Murcia, Spain. Be prepared or be unprepared. Come for the evidence, stay for the tapas, and leave with new skills, new friends, and maybe a few “you-had-to-be-there” stories. The SGEM will be back with a structured critical appraisal, trying to cut the knowledge translation (KT) window from over ten years to less than one year, using the power of social media, so patients get the best care, based on the best evidence. Recuerda ser escéptico de todo lo que aprendas, incluso si lo escuchaste en The Skeptics’ Guide to Emergency Medicine.

Date: August 12, 2025 Article: FDA Approved and Ineffective by Jeanne Lenzer and Shannon Brownlee. June 5, 2025. The Lever. Jeanne Lenzer Guest Skeptic: Jeanne Lenzer is a long-time medical investigative journalist and returning SGEM guest. Her previous work, including the book The Danger Within Us, explored how conflicts of interest and weak evidence can endanger patient care. In this new project with The Lever, Jeanne analyzes how the FDA approves drugs that often don’t meet basic efficacy standards. I think many people assume that if a treatment is FDA-approved, surely it must work. However, people may be shocked to find out about the FDA’s drug approval process and how ineffective or harmful medications make it to market. Most patients and doctors have no idea that the FDA has quietly flipped the drug approval process on its head by putting most drugs on the market before they are shown to be safe or effective, with the promise that they will do those studies after they are on the market. Studies have shown that once a drug is on the market, patients do not want to enter or remain in clinical trials because they are convinced they’re being deprived of a proven treatment, and failure to enroll sufficient patients is one reason postmarket studies are delayed or never conducted. Once a drug is on the market, the FDA can require postmarket testing, but the due dates are often set so many years in the future that the patent will have run out. Take the controversial new Alzheimer’s drug, Leqembi, which causes brain bleeds, swelling and death. The manufacturer is required to conduct safety studies and report annually to the FDA.  However, neither the FDA nor the company will release the safety data until the final report is due. This will be in 2036, 13 years after it’s been on the market. This can be considered a guaranteed win for Pharma and a bad deal for patients. The FDA has fallen so low that the agency introduced a new term, “dangling approvals” for drugs approved before clinical benefit was proved and then allowed to remain on the market even after the post-marketing studies fail. Richard Pazdur, head of oncology at the FDA, defended the agency’s refusal to order certain cancer drugs off the market even after their post-market studies failed, saying “A failed trial, doesn’t mean a failed drug.” Well, true and true, but the idea is that drugs were supposed to be proven to work before they go on the market, not after. And with Pazdur’s and the FDA’s reasoning, any bad drug could remain on the market forever. And a few have. A two-year investigation by Lenzer and Brownlee found 429 FDA approvals (2013–2022) where the majority of drugs were authorized on inadequate evidence of effectiveness, with heavy reliance on surrogate outcomes, frequent lack of replication, and slow/absent confirmatory trials. The highlighted real-world harm and cost and call for regulators and clinicians to re-center on patient-oriented outcomes (POO) before widespread adoption. The article gives a few stories about FDA-approved drugs that turned out to cause harm without any benefit. One example was the drug Elmiron: Elmiron (pentosan polysulfate sodium) was approved in 1996 by the FDA for interstitial cystitis (chronic bladder pain) FDA approval was given without solid evidence of effectiveness FDA allowed approval on the condition that a follow-up study be done to confirm efficacy The follow-up study took 18 years to complete and showed no benefit over placebo Despite this, Elmiron remained on the market Not just a lack of benefit, but there were reported cases of harm Elmiron was associated with cases of a rare eye disease called pigmentary maculopathy that resulted in vision loss or blindness. It was also associated with severe colitis and dozens of deaths Bottom line is a drug with no proven benefit and significant harms stayed on the market for nearly 30 years A cautionary tale of systemic FDA failure to protect patients There were other examples in the articles: Avastin (bevacizumab): Initially approved for metastatic breast cancer via progression-free survival (PFS) surrogate; later trials failed to show survival benefit; approval was withdrawn for that indication, but surrogate-based oncology approvals have continued apace. Copiktra (duvelisib): Approved on surrogates; subsequent data suggested earlier death vs comparator and serious harms; FDA restrictions only years later. ProAmatine (midodrine): Repeatedly rejected; ultimately approved under Subpart H with promised post-market evidence that never convincingly materialized. Special Guest Skeptic: Dr. Jerome Hoffman. He is a longtime friend of the SGEM, a mentor and a true thought leader in evidence-based medicine (EBM). Dr. Hoffman has critically appraised stroke studies, challenged the tPA (alteplase) hype, and now serves as the analytical lead behind this FDA investigation. Four Questions for Jeanne & Jerry Listen to the podcast to hear their answers to these and other questions. What are the four standards the FDA claims to use when approving drugs? Control Group: Patients taking the drug were compared to a control group that was given a placebo or a comparator drug. Replication: At least two “well-controlled” trials showed the drug was effective. Blinding (Masking): Subjects in the studies and the doctors who cared for them don’t know which patients are on the drug and which are in the control group. Clinical Endpoint: The studies measured the drug’s effect on patients’ survival or function rather than a surrogate measure. Of the hundreds of drugs analyzed, how many meet all four?  Therefore, 44% of these drugs met two or fewer of the FDA's four core criteria for approval. 73% percent of drugs approved by the FDA did not meet the agency’s four foundational standards required to show they work as expected. More than half of drug approvals were based on preliminary data rather than sound evidence that patients had fewer symptoms, improved function, or lived longer. Fifty-five of the 429 drugs approved met only one of the four standards needed to show that a drug is safe and effective; 39 drugs met none of them. Which category of drugs seems to be the worst offender, and why? Oncology was the standout concern: of 123 cancer drugs, 2.4% (3/123) met all four criteria; 29 met none. 81% of cancer approvals used surrogates (progression-free survival) rather than overall survival. What changes are needed? Do we fix the FDA, or start from scratch? Key Take Home Points: Even giving them the benefit of the doubt, nearly ¾ of drugs failed to meet all four of the standards. Cancer drugs are among the worst, often approved on flimsy surrogate endpoints like tumour shrinkage. Elmiron, for example, stayed on the market for nearly 30 years despite never being shown to work and causing blindness in some patients. The FDA is funded largely by industry through user fees, leading to deep structural conflicts of interest. Clinicians must remain skeptical, dig deeper into the evidence, and resist the assumption that “FDA-approved” means “safe and effective.”  SGEM Bottom Line: Being approved by the FDA doesn’t mean a drug is effective or even better than a placebo. All we can conclude is that the FDA approved the drug. We need to be skeptical, look at the primary evidence, and be willing to question the system. People may not know, but the SGEM tagline came from a lecture given by Dr. Hoffman. He concluded the lecture by encouraging the audience to be skeptical, even of him.  Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. Other SGEM Episodes: SGEM Xtra: The Danger Within Us SGEM Xtra: No Retreat, No Surrender - Thrombolysis for Acute Ischemic Stroke SGEM Xtra: Jerome Hoffman - Legend of Emergency Medicine

Reference: Jessen et al. Pharmacological interventions for the acute treatment of hyperkalaemia: A systematic review and meta-analysis. Resuscitation 2025 Date: August 6, 2025 Guest Skeptic: William Toon is a paramedic who, this past May achieved over 50 years of continuous EMS certification. His professional path has taken him from front-line paramedic to national presenter, expert witness, flight medic, EMS program director, and senior training executive with a doctorate in Higher Education. Case: A 65-year-old patient presents to the emergency department (ED) with general weakness, mild abdominal cramping, and nausea over the past 12 hours. The patient has poorly controlled type 2 diabetes, heart failure with reduced ejection fraction, and chronic kidney disease stage 4 on hemodialysis. The patient missed their last dialysis appointment two days ago. The patient takes several medications for kidney disease and blood pressure, including a potassium-sparing diuretic. His ECG shows peaked T-waves. Stat chemistry reveals a serum potassium of 6.5 mmol/L. He is not yet oliguric and is hemodynamically stable. The team must initiate pharmacologic treatment immediately while preparing for possible escalation to dialysis. Background: Hyperkalemia is a potentially life-threatening electrolyte abnormality frequently encountered in the ED. It’s common in patients with chronic kidney disease, diabetes, or those on renin-angiotensin-aldosterone system (RAAS) inhibitors. While treatments like insulin, beta-agonists, and calcium gluconate are well-known, the comparative efficacy and safety of pharmacologic agents used to rapidly reduce serum potassium remain uncertain. Clinicians must balance rapid action with safety when choosing treatment for hyperkalemia. Understanding which pharmacologic interventions work best and how quickly they act is vital to optimizing care. Unfortunately, much of the existing data on hyperkalemia treatment is derived from small or methodologically limited trials. Clinical Question: What is the effectiveness of pharmacological interventions in the acute treatment of hyperkalemia compared to standard care, placebo, or other interventions in adults? Reference: Jessen et al. Pharmacological interventions for the acute treatment of hyperkalaemia: A systematic review and meta-analysis. Resuscitation 2025 Population: Adult patients with hyperkalemia (typically defined as serum potassium ≥5.0 mmol/L). Studies included varied populations such as those with CKD, dialysis patients, and acutely ill inpatients. Exclusions: Patients under 18 and those receiving non-pharmacologic interventions (dialysis) were excluded. Intervention: Any acute pharmacological intervention to mitigate the harmful effects of hyperkalemia or to lower potassium levels. Comparison: Placebo, standard care, or head-to-head comparisons of other pharmacologic interventions. Outcome: Primary Outcome: Change in serum potassium from baseline at specific time points (1, 2, 4, and 6 hours). Secondary Outcomes: Proportion of patients achieving normokalaemia, adverse events (hypoglycaemia), need for rescue therapy (dialysis), and all-cause mortality. Type of study: Systematic review and meta-analysis Authors’ Conclusions: “Evidence supports treatment with insulin in combination with glucose, inhaled or intravenous salbutamol, or the combination. No evidence supporting a clinical effect of calcium or bicarbonate for hyperkalaemia was identified.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. No The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Yes There was low statistical heterogeneity for the primary outcomes. No The treatment effect was large enough and precise enough to be clinically significant. Yes Who funded the trial? No financial support was provided for the study. Did the authors declare any conflicts of interest? No relevant conflicts of interest disclosed. Results: Studies included adult patients with hyperkalemia from EDs, inpatient wards, and dialysis units. Ages ranged widely, with a predominance of patients with chronic kidney disease (CKD) and cardiovascular comorbidities. Key Result: Sodium zirconium cyclosilicate and insulin-glucose regimens were most effective in lowering serum potassium within four hours, while other agents had limited short-term impact. Primary Outcome: At four hours, insulin-glucose reduced potassium by an average of 0.8 mmol/L, and sodium zirconium cyclosilicate by 0.67 mmol/L. SPS (sodium polystyrene sulfonate) and patiromer showed smaller and delayed effects. Secondary Outcomes: Hypoglycemia occurred in 17% of insulin-treated patients. Dialysis was needed in 6.2%. Mortality rates were not significantly different among treatment groups. Substantial Clinical and Methodological Heterogeneity: One of the most important limitations of this SRMA was the considerable heterogeneity in study design, patient populations, baseline potassium levels, and definitions of hyperkalemia. For example, some studies included only CKD patients, while others focused on acutely ill hospitalized individuals or dialysis-dependent populations. Furthermore, the timing of outcome measurements varied, making direct comparisons difficult. This heterogeneity undermines the consistency of pooled estimates and limits the applicability of the findings to specific ED populations. Risk of Bias in Primary Studies: Many of the included trials had methodological weaknesses, including poor allocation concealment, lack of masking, and incomplete outcome data. Several studies did not clearly describe their randomization procedures. These issues increase the risk of performance and detection bias, especially when subjective outcomes or clinician decisions like the need for dialysis. The GRADE framework used by the authors appropriately rated much of the evidence as “low” or “very low” certainty for key comparisons. These biases raise doubts about the internal validity of the SRMA conclusions and highlight the need for better-quality trials in this domain. Co-Interventions and Protocol Variability: A recurring issue was the use of multiple simultaneous treatments across arms, such as combining insulin, beta-agonists, and calcium gluconate in varying doses and sequences. This practice, while clinically realistic and pragmatic, muddled the attribution of treatment effect to any single agent. In real-world ED settings, polytherapy is common, but in research, this confounds the estimation of the independent effectiveness of each drug. Without stratified analyses that control for such co-interventions, it is difficult to know whether observed reductions in potassium were due to one agent or the combination of agents. This limits the SRMA’s ability to inform what might be the best therapeutic option. Sample Sizes and Few Events: Despite including over 100 studies, many of the comparisons within the SRMA were based on small individual trials with limited numbers of participants and few outcome events. As an example, data on adverse effects like hypoglycemia or need for dialysis were inconsistently reported and often underpowered to detect differences. The lack of data leads to wide confidence intervals and imprecise point estimates, which weaken the clinical significance and reproducibility of the findings. Lack of Focus on ED-Specific Contexts: Though the SRMA is highly relevant to emergency medicine, only a minority of included studies were conducted in ED settings. Many trials were hospital-based or conducted in specialized units like nephrology wards, and some included stable outpatient populations. This matters because ED patients often present with more acute symptoms, comorbidities, and a need for rapid intervention. Additionally, drug availability and workflow constraints in the ED differ from other settings. Therefore, the external validity of the findings to ED practice is limited, and the SRMA may not fully capture the nuances of time-sensitive decision-making in the ED environment. Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusions but would emphasize the limited certainty and highlight the need for better patient-oriented outcome data before changing practice broadly.  SGEM Bottom Line: Insulin-glucose remains a reliable first-line agent for acute hyperkalemia management, but newer agents like sodium zirconium cyclosilicate show promise and may play a complementary role. Case Resolution: You administer 10 units of IV insulin with an amp of D50 and initiate inhaled albuterol. You consult nephrology and start sodium zirconium cyclosilicate, which is available in your ED. Repeat potassium at four hours drops to 5.4 mmol/L. No dialysis is needed. William Toon Clinical Application: This SRMA reaffirms insulin-glucose as the first-line treatment for hyperkalemia in the ED. It also supports adding beta-agonists when needed, de-emphasizing bicarbonate and sodium polystyrene sulfonate in acute settings, and suggests newer agents like SZC for future integration into your ED’s hyperkalemia protocol. However, it does not mean we should not use calcium gluconate or chloride in patients with hyperkalemia. These agents are not meant to lower potassium levels, and it would be inappropriate to have expected them to do so. The SRMA did not demonstrate a patient-oriented outcome (POO) of benefits. We should interpret the findings cautiously. The absence of evidence of benefit is not the same as evidence of no benefit. Therefore, calcium should not be abandoned for the acute treatment of hyperkalemia solely based on this SRMA. ...

Date: August 11, 2025 Dr. Gillian Schmitz Guest Skeptic: Dr. Gillian Schmitz is a board-certified Emergency Physician practicing at The Naval Medical Center in San Diego. She is also a former President of the American College of Emergency Physicians (ACEP). This SGEM Xtra is inspired by the 1992 film A League of Their Own. Unlike our previous pop culture references like Buffy the Vampire Slayer, Star Trek, Batman, Top Gun, Ted Lasso and Mission: Impossible, this story is based on real events. The All-American Girls Professional Baseball League (AAGPBL) was created in 1943 and lasted until 1954. This league gave over 600 women a chance to play pro baseball. For the SGEMers who may not have seen this movie, here is a summary. A League of Their Own (1992) is a sports drama directed by Penny Marshall that tells the fictionalized story of the real-life All-American Girls Professional Baseball League. It was formed during World War II when many male baseball players were serving overseas. The film follows sisters Dottie Hinson and Kit Keller as they join the Rockford Peaches and navigate the challenges of playing professional baseball in a male-dominated society. With a blend of humour, heart, and historical insight, the film highlights themes of gender roles, perseverance, and the lasting bonds formed through sport. Top 5 Themes from “A League of Their Own” As chosen and interpreted by Dr. Gillian Schmitz. Listen to the SEGM podcast to hear her full description of what the quotes mean to her. “I don’t have ball players. I have girls.” – Jimmy Dugan This quote reflects how society has historically minimized women’s capabilities in professional arenas. Emergency medicine, like baseball in the 1940s, has not always welcomed women without skepticism. Concerns about femininity, perception, and acceptance parallel the gender biases faced by women in emergency medicine leadership today. Even ‘proper’ women had concerns, expressing their worries about the ‘masculinization’ of these pioneer female athletes. Sound familiar? We have done several shows on the SGEM illustrating the gender inequity in the house of medicine. SGEM#352: Amendment – Addressing Gender Inequities in Academic Emergency Medicine SGEM Xtra: From EBM to FBM – Gender Equity in the House of Medicine SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease SGEM#248: She Works Hard for the Money – Time’s Up in Healthcare SGEM Xtra: Money, Money, Money It’s A Rich Man’s World – In the House of Medicine SGEM Xtra: I’m in a FIX State of Mind “Why should you go? To say for once you actually did something… something special.” – Kit to Dottie This line speaks to the deep calling many women in emergency medicine feel. It reminds us of the early emergency medicine pioneers who were often told they were wasting their time. Yet they pressed forward, driven by the belief they could make a real difference. That passion to do something special, despite the challenges, still drives many of us in emergency medicine today. If you want to do something special, despite the challenge, then head over to FemInEM.org led by Drs. Dara Kass, Esther Choo, Jenny Beck-Esmay and the legend of emergency medicine, Dr. Diane Birnmaumer.  We also recently did an SGEM Xtra: This is My Fight Song - FeminEM 2.0. They are doing some amazing things, advancing gender equity in emergency medicine, improving reproductive healthcare delivery in emergency departments, mentorship and being champions of change. “You know, if I had your job, I’d kill myself.” – John Lovitz This moment of dry sarcasm reflects the burnout and emotional toll our specialty can bring. But it also highlights that, despite the difficulty, emergency medicine remains the best job in the world for many. I couldn’t imagine doing anything else. Emergency medicine still lights me up. “You gotta go where things happen.” – Marla’s Dad This is the heart of advocacy, leadership, and frontline emergency medicine. Whether it’s in the trauma bay or on Capitol Hill, women in emergency medicine are making things happen and often leading the way. You want to feel fulfilled? Go where things happen… or make them happen. “It’s supposed to be hard. If it wasn’t hard, everyone would do it. The hard is what makes it great.” – Jimmy Dugan This is the quintessential emergency medicine quote. The job is hard. The leadership path is hard. Breaking barriers is hard. But that’s what makes it great and worth doing. It’s that difficulty that shapes us, connects us, and gives meaning to what we do. Some final thoughts on the movie A League of Their Own? The movie reminds us that history is full of stories about women rising to the challenge, creating new paths, and demanding space at the table. Progress has been made, but there is still more work to be done. This includes representation in leadership and issues of gender pay gaps. There’s still much to challenge and change, but also much to celebrate. Emergency medicine has its league of extraordinary women, like Dr. Diane Birnbaumer, Dr. Judith Tintinalli, Dr. Dara Kass and many more. They continue to change the game, one shift, one policy, one pitch at a time. What pop culture topic with a strong female message should the SGEM cover next? Send an email to [email protected] with “Xtra” in the subject line. Who knows, you might be a future guest skeptic on the SGEM. The SGEM will return to start Season#14 with a structured critical appraisal of a recent publication.  We will continue to strive to reduce the knowledge translation window from over ten years to less than one year, leveraging the power of social media. Our ultimate goal is for patients to get the best care, based on the best evidence. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Reference: Otterness et al. The Use of TENS for the Treatment of Back Pain in the Emergency Department: A Randomized Controlled Trial. AEM Aug 2025 Date: August 22, 2025 Guest Skeptic: Dr. Lauren Westafer is an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School, Baystate. She is the co-founder of FOAMcast and a researcher in pulmonary embolism and implementation science.  Dr. Westafer serves as the research methodology editor for Annals of Emergency Medicine. Case: A 44-year-old man presents to the emergency department (ED) with low back pain after bending to pick up his child. He has pain in his left lower back that is worse when he moves. He has no fever, chills, weakness, or numbness. He has well-controlled hypertension and no history of recent antibiotic use or drug use. The patient has no midline tenderness, is without neurological deficit, and has no red flag features on history and physical exam. He took 500 mg of acetaminophen a few times without significant relief. Background: Back pain is one of the most common reasons patients seek ED care, with an estimated 2.5 million ED visits for back pain each year. After dangerous diagnoses such as spinal epidural abscess, cord compression, and ruptured abdominal aortic aneurysm have been excluded, the next challenge for emergency clinicians is analgesia to improve the patient’s pain and mobility. Unfortunately, there are numerous causes of musculoskeletal low back pain, rendering a single treatment course inconsistently effective for all-comers. Many pharmacological and non-pharmacological therapies have been tried with limited efficacy.  Acetaminophen (Williams et al Lancet 2014) Muscle relaxants (Friedman et al JAMA 2015) NSAIDs (Machado et al Ann Rheum Dis 2017) Steroids (Balakrishnamoorthy et al Emerg Med J 2014) Benzodiazepines (Friedman et al Ann Emerg Med 2017) Cognitive Behavioral Therapy and mindfulness (Cherkin et al JAMA 2016) Chiropractic (Paige et al JAMA 2017) Physical therapy (Paolucci et al J Pain Research 2018) Acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013) One treatment that can be very effective but comes with very real potential harms is opioids. The American College of Emergency Physicians (ACEP) has addressed the issue of opioid use in patients being discharged home after an acute episode of pain. They give a Level C Recommendation saying: Do not routinely prescribe, or knowingly cause to be co-prescribed, a simultaneous course of opioids and benzodiazepines (as well as other muscle relaxants/sedative-hypnotics) for treatment of an acute episode of pain in patients discharged from the emergency department (Consensus recommendation).  Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological modality that administers low-intensity electrical stimulation to inhibit nociceptive pain signals. The efficacy of TENS devices in acute low back pain is uncertain. Clinical Question: Is transcutaneous electrical nerve stimulation (TENS) more effective at relieving back pain than sham TENS? Reference: Otterness et al. The Use of TENS for the Treatment of Back Pain in the Emergency Department: A Randomized Controlled Trial. AEM Aug 2025 Population: Adult ED patients (≥18 yr) with thoracic or lumbar back pain of at least moderate severity when research assistants were present (Mon–Fri, 8a–8p). Exclusions: Patients with suspected spinal cord injury or infectious etiology, fractures, hemodynamic instability, allergy to standard analgesics, pacemakers, and those with skin conditions precluding TENS application were excluded. Intervention: Two cutaneous TENS adhesive pads above and below the point of maximal tenderness with TENS unit set at a point just below the pain threshold and gradually increased for up to 30 minutes. Comparison: Sham TENS pads applied but no electrical current. Patients were told they might or might not feel pulses. Outcome: Primary Outcome: Absolute reduction in pain (0–10 NRS) from baseline to 30  Secondary Outcomes: Administration of rescue medications, change in pain severity, patient satisfaction with assigned treatment, and whether patients would recommend the same treatment Trial: Single-center randomized controlled trial Dr. Kara Otterness This is an SGEMHOP, and we are pleased to have the lead author on the episode, Dr. Kara Otterness. She is originally from Illinois and graduated from Drexel University College of Medicine and completed her Emergency Medicine residency training at NYU/Bellevue. She joined the Stony Brook EM faculty in 2015. She is passionate about teaching, medical education and currently serves as one of the assistant program directors at Stony Brook.  Dr. Otterness has been a guest skeptic on SGEM#96.  Authors’ Conclusions: “TENS was more effective than sham TENS at reducing pain severity in adult ED patients with back pain.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes 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). No  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. Yes 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: The total cohort consisted of 80 patients. The mean age was 46 years. It was evenly split between female and male patients. The vast majority had lumbar pain (86%), 40% traumatic and 33% recurrent pain. Roughly half of patients had tried self-care with over-the-counter medications, and 31% had used heat.   Key Results: TENS produced a greater reduction in 30-minute pain than sham and reduced the need for rescue meds, with higher satisfaction and similar functional measures. Primary Outcome: The mean difference in change in pain scores was 1.2 (95% CI 0.5-1.9) p=0.002 Secondary Outcomes: Overall, secondary outcomes favoured the intervention. Rescue medications were administered to a higher proportion of patients in the sham TENS group (73% vs 45%), and more patients rated the degree of pain relief as better or much better in the TENS group (55% vs 26%). More patients in the intervention group were satisfied with their treatment (78% vs 50%). Listen to the SGEM podcast to hear Kara respond to our five nerdy points.  Convenience Sample: This trial used a convenience sample of patients enrolled only when research assistants were available (weekday business hours). Restricting recruitment in this way creates a risk of selection bias and limits generalizability because the study population may differ systematically from all ED back-pain patients. For example, patients who present to the ED at night and on weekends may have different injury mechanisms, comorbidities, pain severity or expectations. Compromised Masking: Although the trial was designed to be patient and assessor-mask, most patients correctly guessed their group allocation (95% TENS and 83% sham). When masking is not maintained, especially for subjective outcomes like pain scores, patients’ expectations can influence reported outcomes (placebo/nocebo effects). This can inflate the apparent benefit in the intervention arm, a form of differential measurement bias. True allocation concealment and maintaining blinding integrity are central to avoiding biased estimates of effect in RCTs. However, it is difficult to think about how such an intervention could be delivered without patients guessing correctly. Clinical vs Statistical Significance: The trial’s primary outcome did reach statistical significance (mean pain reduction difference 1.2 points, 95% CI 0.5–1.9) p =0.002. However, the effect size was close to or below many published minimum clinically important difference (MCID) thresholds for acute pain of around 1.5 on a 0–10 scale. Overemphasis on statistical significance without weighing clinical relevance can lead to the adoption of interventions that improve scores in a way that is detectable to researchers but not perceptible or valuable to patients. Small Sample Size: Patient recruitment in the ED is notoriously difficult due to difficulties staffing research staff at all hours of the day and during acute conditions. The authors recruited an adequate number of patients (n=80) for their power analysis; however, this resulted in large confidence intervals and ranges. Small studies are more vulnerable to random error and chance imbalances in prognostic factors, even with randomization. This increases the likelihood that the observed effect could be an overestimate (small-study effect) and reduces confidence in the precision of the result. Single-Centred: Because the trial was conducted in a single ED, the findings may not translate directly to other practice environments. Results from a tertiary academic centre (often with more resources, specialist staff, and research infrastructure) may not reflect community EDs, rural settings, or different health systems. Patient demographics, case mix, staff expertise, and even equipment quality can influence both the feasibility of the intervention and its observed effect. Without replication in multiple, diverse sites, the applicability of this trial’s results to the broader population of ED back-pain patients remains uncer

Reference:  Othman AA, et al. Combined ketamine and midazolam vs. midazolam alone for initial treatment of pediatric generalized convulsive status epilepticus (Ket-Mid study): A randomized controlled trial. Pediatric Neurology. June 2025 Date: May 27, 2025 Dr. James Chamberlain Guest Skeptic: Dr. James Chamberlain is a pediatric emergency medicine attending physician at Children’s National Hospital in Washington, DC where he is the Director of Data Analytics and Informatics for the Division of Emergency Medicine. He is also a Professor of Emergency Medicine and Pediatrics at George Washington School of Medicine and Health Sciences. He has led or co-led two large national trials of status epilepticus and is starting a third, the Ketamine adjuvant for Established Status Epilepticus Treatment Trial (KESETT). Case: A two-year-old boy with a known seizure disorder is brought to the emergency department (ED) by his family for a seizure at home. The episode is described as generalized tonic-clonic activity which self-resolved after about a minute. He was post-ictal afterwards and has not fully returned to baseline. He has not had any recent fevers or illnesses. During your conversation with his parents, he starts seizing again. You administer two doses of a benzodiazepine, but the seizure continues. You give an additional levetiracetam load, which stops the seizure activity, and he is admitted to the hospital for observation. Afterwards, a medical trainee you are working with says to you, “I read that there’s been interest in other medications like ketamine in the treatment of seizures. Do you think there would have been any benefit in giving ketamine earlier?” Background: We often see children presenting with seizures in the ED. Currently, the standard of care recommends the use of benzodiazepines such as midazolam as first-line treatment. Midazolam, but not the other benzodiazepines, can be given intravenously, intramuscularly, intranasally, or as a buccal paste. Sometimes this works and stops the seizure activity. Sometimes it does not. Seizures that are refractory to treatment are dangerous and can lead to neuronal injury, long-term deficits, or even death. We want to stop seizure activity as quickly as we can. The typical management of seizures is to give a benzodiapene. If that does not work, give a second dose. If that still doesn't stop the seizure, then administer another anti-seizure medication like levetiracetam, fosphenytoin, or valproate. There’s been increasing interest in the use of ketamine for seizures. There are several factors that make ketamine potentially a very powerful drug for status epilepticus. Ketamine is an NMDA receptor antagonist and therefore theoretically should break the vicious cycle of status. There have been dozens of animal studies in at least 4 different species demonstrating efficacy as early treatment of status. In some of these studies, ketamine and other NMDA receptor antagonists are neuroprotective. In humans, ketamine is widely used for super refractory status, when all other medications have failed. Estimates are that it is about 70% effective for this indication. We have a long track record of using ketamine safely in the emergency department setting and growing experience in EMS. Ketamine is well tolerated, short-acting, and preserves protective airway reflexes and ventilation. Even very large accidental overdoses have been well tolerated. The one caveat is that we don’t know if all these safety parameters hold in the condition of status epilepticus, but limited case series have not shown safety problems. Currently, it is not part of conventional therapy for pediatric status epilepticus, but there is thought that it may work synergistically with benzodiazepines in stopping seizures. Clinical Question: Is ketamine combined with midazolam more effective than midazolam alone in the treatment of pediatric generalized convulsive status epilepticus? Reference:  Othman AA, et al. Combined ketamine and midazolam vs. midazolam alone for initial treatment of pediatric generalized convulsive status epilepticus (Ket-Mid study): A randomized controlled trial. Pediatric Neurology. June 2025 Population: Children 6 months to 16 years presenting with generalized convulsive status epilepticus without prior treatment with antiseizure medications (ASMs) for the current episode. This was defined as clinically detectable generalized tonic-clonic convulsions that persist or recur without regaining consciousness in between for longer than 5 minutes. Exclusions: Previous treatment with ASM, traumatic brain injury (TBI), conditions associated with increased intracranial pressure, hypertension, glaucoma, hyperthyroidism, pheochromocytoma, end-stage kidney or liver disease, cardiac disease, history of alcohol intake, hypoglycemia, hyperglycemia, inborn errors of metabolism, known allergy or contraindication to study drugs, known or suspected psychiatric disorder, failure to get IV access in first 5 minutes of stabilization, cessation of seizures within the first 5 minutes, and failure to obtain informed consent. Intervention: IV ketamine (2 mg/kg) plus IV midazolam (0.2 mg/kg) Comparison: IV placebo plus IV midazolam Outcome: Primary: Cessation of clinical seizures at 5 minutes post-drug administration Secondary: Need for repeat midazolam during the first 15 minutes of study timeframe, seizure cessation at 15, 35, and 55 minutes, seizure control, adverse events (hypotension, hypertension, arrhythmia, emergence phenomenon, rash), need for intubation, and mortality. Type of Study: Randomized, two-group, parallel, 1:1 superiority, double-masked, placebo-controlled trial Authors’ Conclusions: “Ketamine-midazolam combination may be more effective than midazolam alone for the initial treatment of pediatric GCSE, but this should be confirmed in future research.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes 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. Yes 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. Yes Financial conflicts of interest. No financial conflicts of interest Results: They included 144 children. Half were assigned to the ketamine and midazolam group, and the other half were assigned to the placebo and midazolam group. The most common causes of generalized convulsive status epilepticus include febrile seizures and known epilepsy. Eleven percent had a CNS infection, and four percent had other or unknown etiologies. Key Results: The combination of ketamine and midazolam was superior to midazolam alone in treating children with generalized convulsive status epilepticus. Primary Outcome:  In the combined ketamine and midazolam group, 76.4% of patients had cessation of seizure activity compared to 20.8% of the patients who only received midazolam. Risk Ratio (RR) 3.7 (95% CI: 2.3 to 5.9, p< 0.001) Secondary Outcomes:   The ketamine and midazolam group also had higher percentages of seizure cessation at 15, 35, and 55 minutes. The ketamine and midazolam group had lower percentages of requiring repeat midazolam (23.6% vs 79.3%) or endotracheal intubation (4.2% vs 20.8%). Selection Bias The authors screened 251 patients for eligibility. They excluded around 40% because they didn't meet the inclusion criteria. There was a long list of exclusion criteria. While some of the conditions they excluded could be determined quickly, there are others listed, such as conditions associated with increased intracranial pressure, hyperthyroidism, pheochromocytoma, inborn errors of metabolism, and known or suspected psychiatric disorders that need some time to work up. We’re not sure how they were able to make determinations of all of those potential medical problems before enrollment. This may lead to a selection bias. Primary Outcome Their primary outcome was the cessation of clinical seizure activity, but what about subclinical seizures? One of the challenges in the ED of treating seizures is that we can give medications that stop the clinical seizure activity we can see. Afterwards, when the patient has stopped clinically seizing but is sleepy and has not returned to baseline, we have to try and figure out if they are still not back and baseline because they are post-ictal, sedated from all of the seizure medications, or subclinically seizing. Fortunately, subclinical status is less common in children. It is possible they missed subclinical seizures in this trial, which are important to recognize and treat. From an evidence-based medicine perspective, valid outcome measures are those that are objective, reliably assessed, and aligned with patient-important endpoints. EEG serves as a critical tool to meet these standards in the context of seizure management. Unfortunately, its absence in this trial limits the internal validity and the generalizability to other centers where EEG is routinely used in managing status epilepticus. Future and ongoing studies of status epilepticus in the United States will require placement of a rapid EEG to obviate this ascertainment bias and improves the rigor of the outcome assessment,...

Date: July 10, 2025 Guest Skeptics: Professor Timothy Caulfield is a Canadian professor of law at the University of Alberta, the Research Director of its Health Law Institute. His area of expertise is in legal, policy and ethical issues in medical research and its commercialization. This is another SGEM Xtra book review. Tim was our guest skeptic a few years ago, discussing his book called Relax, Dammit! A User’s Guide to the Age of Anxiety. He is back on the SGEM to discuss his latest book called The Certainty Illusion: What You Don't Know and Why It Matters. I asked Tim several questions about his book. Please listen to the podcast to hear his responses.  Questions for Professor Caulfield The book is structured into three main parts. In Part I: The Science Illusion, you examine how scientific language and imagery are co-opted to confer credibility on dubious claims. You discuss how quantum physics has been misappropriated by the wellness and alternative medicine industries. Why do you think "quantum" has become such a powerful marketing tool? The phrase "It’s Science!" is often used to shut down debate. What are the dangers of weaponizing the language of science? You talk about Zombie Science (ideas that refuse to die despite mountains of evidence). I’ve given a lecture for the Gateway Centre of Excellence in Rural Health on zombie ideas about hospital crowding. What is a good example of zombie science in health and wellness? At the end of Part I, you introduce ‘The Humility Fix" as a potential solution. Can you explain why intellectual humility is a necessary antidote to misinformation? In Part II: The Goodness Illusion, you unpack how concepts of health, sustainability, and morality are manipulated to create a false sense of certainty. You explore things like "health halos," in which terms like "clean," "organic," and "natural" are used to mislead consumers. Can you expand on that concept? You list 12 words in total that you call the "Devious Dozen". These are a set of misleading or overhyped health and wellness claims that exploit public perception and create a false sense of certainty. These terms and concepts are often used in marketing, politics, and public discourse to manipulate consumers and reinforce misinformation. Do you have a couple of favourites? You also talk about how virtue signalling and ideological narratives shape public opinion, often overriding evidence-based reasoning. The idea that our desire to do what’s "right" can be exploited through misleading claims about health, wellness, and even sustainability. What’s an example of this in the medical field, and how can healthcare professionals push back against it? You also discuss the White Hat Bias in this section of the book. It is a phenomenon where research findings are distorted in the service of what is perceived as a noble or righteous cause. This bias leads to the overrepresentation of certain findings, particularly in fields like public health, nutrition, and medicine, where there is strong societal motivation to support outcomes. Who coined the term White Hat Bias? Can you give an example of the White Hat Bias from the COVID-19 pandemic? In Part III of the book, you discuss The Opinion Illusion. This delves into how the digital age has fueled an economy of opinion, where ratings, reviews, and social media influence create misleading perceptions of truth and expertise. How has the “opinion economy” shaped modern decision-making? How has this shift impacted our ability to discern truth from misinformation? You highlight the influence of online reviews and rankings. Why do people trust anonymous reviews more than expert opinions or personal recommendations? What role do algorithms play in distorting our perception of consensus and credibility?  The book isn’t all doom and gloom. You do offer some solutions for navigating this chaotic information environment.  What would it look like if you could design an ideal system for verifying the credibility of online opinions? How can individuals cultivate a healthier skepticism toward online rankings without becoming entirely cynical? What role do educational institutions and policymakers play in addressing the certainty illusion in digital spaces? You mention that authenticity itself has been commodified. Do you think there is a way to reclaim genuine trust in reviews and expert opinions? What’s the most surprising or unexpected thing you discovered while researching The Certainty Illusion? That’s it for this SGEM Xtra. Remember, the SGEM is about cutting the knowledge translation (KT) window down from over ten years to less than a year, but ultimately, it’s about patients getting the best care, based on the best evidence. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

Reference: Kemal et al. Emergency department utilization by youth before and after firearm injury. AEM July 2025 Date: July 28, 2025 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine in the UK and an evidence-based medicine advocate. She's a seasoned knowledge translator with her wonderful PaperinaPic infographics.   Case: Your non-US emergency department (ED) has recently been shaken by the attendance of a teenager with a gunshot injury. Subsequent investigation has found he attended a different hospital in the region six weeks ago with a stab wound. The team wonders if that attendance was an opportunity to intervene. Background: Firearm injuries are now the leading cause of death in youth in the United States, surpassing motor vehicle collisions.[1] While the immediate clinical management of gunshot wounds is well covered in emergency medicine training, there is less clarity around what happens before and after that ED visit. Could we identify these high-risk youth earlier? Do patterns of ED use provide clues for intervention? The ED often serves as the primary healthcare contact point for youth exposed to community violence. Some youth injured by firearms may have prior ED visits for mental health crises or minor injuries, presenting opportunities for preventative strategies. But are we missing these cues? Additionally, once youth survive a firearm injury, they face elevated risk for repeat injury, psychological trauma, and even death. Understanding post-injury healthcare utilization may reveal missed chances for intervention, particularly in general EDs that may lack pediatric-specific resources. Clinical Question: Do youth with firearm injuries have increased emergency department utilization before and after their injury compared to their peers? Reference: Kemal et al. Emergency department utilization by youth before and after firearm injury. AEM July 2025 Population: Youth aged 10 to 19 years who had an index ED visit for a firearm injury in 2019 across eight US states, identified from the Healthcare Cost and Utilization Project database. Exclusion: Youth who lacked the data to assess 90 days before or after the index injury, and those without longitudinal ED visit linkage, injuries from non-power firearms, and recurrent visits with firearm injury. Exposure: Having sustained a firearm injury as indexed by an ED visit. Comparison: ED utilization by the same patients in the 90 days before and after the firearm injury. Outcomes: Primary Outcome: Number and types of ED visits 90 days before and after the index firearm injury. Secondary Outcomes: Types of ED visits and recurrence of trauma. Type of Study: Retrospective cohort study using linked administrative claims data. Dr. Samaa Kemal This is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Samaa Kemal is an early-career pediatric emergency medicine clinician-investigator at Ann & Robert H. Lurie Children's Hospital of Chicago. Her work is primarily focused on the intersection of violence and health equity in children. Her research priorities are focused on developing and implementing novel and effective solutions to prevent violent injuries and subsequent adverse outcomes in children.  Authors’ Conclusions: “Youth have high rates of ED utilization before and after firearm injury. Half of firearm-injured youth receive their emergency care exclusively in general EDs. Implementing firearm injury prevention and intervention efforts in all ED settings is critical.” 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? Yes Have the authors identified all important confounding factors? No 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? No Do the results of this study fit with other available evidence? Yes Funding of the Study? Eunice Kennedy Shriver National Institute of Child Health and Human Development Results: The median age was approximately 17 years; predominantly male and from racially minoritized groups. Key Result: Youth frequently used EDs before and after injury, suggesting opportunities for early identification and intervention. Primary Outcome: 12.8% of youth had at least one ED visit in the 90 days before the firearm injury, and 22.1% had at least one in the 90 days after. Secondary Outcomes: Of those with post-injury ED visits, 26% had recurrent trauma; mental health and assault-related visits were common. Listen to the SGEM podcast to hear Samaa answer our five nerdy questions.  Confounding by Indication and Unmeasured Covariates: One of the primary threats to internal validity in observational studies is confounding. This is especially true when data sources like administrative datasets lack key clinical variables. In this study, firearm-injured youth were not matched to potential confounders such as socioeconomic status, prior trauma history, or mental health diagnoses beyond what was coded. How do you think these unmeasured confounders bias the estimates of associations, because differences in post-injury ED use may reflect underlying vulnerabilities rather than the effect of firearm injury? Linkage, Follow-up and Dependence on Datasets: You chose these states because you considered that the linkage between ED and inpatient databases was most accurate. Could you talk us through that? How do you assess the accuracy of linkage? Misclassification of Exposure or Outcome Using Administrative Codes: The reliance on ICD-10 and Clinical Classification Software codes in the Healthcare Cost and Utilization Project (HCUP) databases raises the risk of misclassification bias. Diagnosis codes may be inconsistently applied, and key distinctions such as intentional vs. unintentional firearm injury or severity of psychological outcomes might be missed. Such misclassification is particularly problematic if it differs systematically between groups, which could attenuate or exaggerate true differences in ED utilization. What steps did you take to mitigate against misclassification bias? Lack of Information on Non-ED Care and Social Determinants of Health: The study's reliance solely on ED and inpatient data from the HCUP SID and SEDD datasets omits health care utilization in outpatient, urgent care, or community mental health settings. This may underestimate or misrepresent total healthcare use, particularly for youth who might shift to non-ED resources post-trauma. How do you think this gap could bias interpretations about the burden on emergency services, thus threatening external validity when generalizing to broader healthcare utilization patterns? Temporal Ambiguity and Reverse Causation Risks: Although the study uses a pre-post design anchored on the injury date, temporal ambiguity remains a concern. Reverse causation refers to a scenario where the outcome is not solely a consequence of the exposure, but rather that both the exposure and outcome share a common underlying cause, or that the outcome may have even predatedor influenced the exposure. For example, higher ED utilization post-injury could be attributed not only to the firearm event itself but also to progressive deterioration from unmeasured pre-existing factors. What do you think about the potential for reverse causation? Comment on the Authors’ Conclusion Compared to the SGEM Conclusion: The authors’ conclusions are supported by the data but should be interpreted with caution. While they call for adapting interventions to all general EDs, this study cannot determine whether such interventions would be effective. SGEM Bottom Line: Firearm-injured youth frequently present to the ED both before and after injury, representing potential missed opportunities for prevention and follow-up care. Case Resolution: The second ED visit wasn't entirely unpredictable. The best predictor of future behaviour is often past behaviour. Recognizing this pattern, your hospital begins piloting a violence intervention program targeting youth with prior ED visits for assault or behavioural concerns. The plan on collect data and see if the intervention has a positive impact. Dr. Kirsty Challen Clinical Application: ED providers could use visit history to flag high-risk youth and advocate for violence intervention referrals, social work consults, or follow-up care plans. However, there is a lack of evidence that such interventions would be effective. Further studies are needed to test various interventions, especially in non-pediatric EDs. What Do I Tell the Patient? You have had a couple of visits to the ED recently. We are worried about you. Are you interested in talking to someone about the violence in your life? Keener Kontest: The last episode’s winner was David Pecora. He knew that STI we were looking for was Syphilis. The word syphilis comes from the mythic Greek shepherd, Syphilus, who was cursed by the god Apollo with a dread disease Listen to the SGEM podcast for this week’s question. If you know, then send an email to [email protected] with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode. Now it is your turn, SGEMers. What do you think of this episode on youth firearm injury and ED utilization? What questions do you have for Samaa and their team? Post your comments on social media using #SGEMHOP. The best social media feedback will be published in AEM. Remember to be skeptical of anything you learn,...

Reference: Bourke EM, et al. PEAChY-O: Pharmacological Emergency Management of Agitation in Children and Young People: A Randomized Controlled Trial of Oral Medication. Annals of Emergency Medicine. Feb 2025 Date: April 29, 2025 Guest Skeptic: Dr. Brad Sobolewski, is a pediatric emergency medicine physician at Cincinnati Children’s Hospital and Professor of Pediatrics at the University of Cincinnati College of Dr. Brad Sobolewski Medicine. He is the creator of the PEMBlog and host of PEM Currents: The Pediatric Emergency Medicine Podcast. Brad is passionate about using digital media to translate complex clinical concepts into engaging, accessible educational content. His work centers on advancing knowledge sharing through innovative, tech-forward approaches to medical education. Case: A 14-year-old girl with no known medical or psychiatric history presents to the emergency department (ED) with her family for aggression. Her parents tell you that they have been getting into arguments a lot recently. Today, she became so angry that she started punching and kicking the walls at home. You interview the girl and perform your physical examination, and determine that there are likely no medical diagnoses contributing to her aggression, nor that she has sustained any injuries requiring immediate management. After you leave the room and her parents enter, you hear them get into another argument, and she gets more agitated. The staff try a combination of de-escalation techniques, but she continues to be aggressive and starts threatening the staff. A nurse working with you asks, “I don’t think our de-escalation techniques are working. Do you want to give her something to help calm her down? We have olanzapine or diazepam here. Which one do you want to give?”  Background: Pediatric agitation can be defined as a clinical state characterized by heightened motor activity, emotional arousal, and often aggressive or disruptive behavior outside of expected developmental norms. It can be triggered by many things like underlying psychiatric disorders, medical conditions (like delirium, hypoxia, or metabolic disturbances), substance intoxication or withdrawal, and situational stressors, such as hospitalization or separation from caregivers​. In the ED setting, pediatric agitation presents unique challenges. Not only can it compromise the safety of the child, caregivers, and medical staff, but it can also delay care and exacerbate underlying conditions​. When a child presents with extreme agitation or aggression, the first step is to take a broad, thoughtful approach. We can’t just assume it’s a psychiatric issue. Medical causes like hypoglycemia, intoxication, or even something like new-onset diabetic ketoacidosis can present this way. Missing these diagnoses could be dangerous. Once we’ve ruled out organic causes, the focus shifts to early recognition and de-escalation. We try to identify the signs that a child is becoming more agitated before they escalate further. The goal is to intervene early and often with non-pharmacologic strategies. This can mean adjusting the environment: dimming the lights, reducing noise, giving the child space, or removing extra staff from the room. Sometimes something as simple as offering a snack, a drink, or a comfort item can make a big difference. Re-direction, distraction, and using calm, supportive language can also go a long way. Of course, there are times when those strategies aren’t enough, and we may need to use physical restraints or medications. But that should never be our starting point. The overarching goal is to approach these situations with empathy and respect. Support the child and their family while protecting everyone’s safety, including our own. There’s no perfect medication for agitation so it really depends on the situation. If the child is cooperative, start with an oral option. It gives the child a bit of control and helps avoid the trauma of restraint or an IM injection. When oral meds aren’t possible and the child poses a risk to themselves or others, IM options may be necessary. In those cases, it’s important to know what medications (dosing, onset, and potential side effects) are available and what local protocols recommend. The choice also depends on why the child is agitated. Antipsychotics, benzodiazepines, antihistamines, or even ketamine all have a role, but each comes with considerations based on the child’s history and the clinical scenario. Whatever we use, the goal is to reduce distress safely and respectfully, while keeping everyone protected. Brad I have actually done a whole podcast series in collaboration with the EMSC innovation and Improvement Center and emDocs on agitation. Clinical Question: Is oral olanzapine or oral diazepam more effective in achieving successful sedation in pediatric patients with acute severe behavioral disturbances? Reference: Bourke EM, et al. PEAChY-O: Pharmacological Emergency Management of Agitation in Children and Young People: A Randomized Controlled Trial of Oral Medication. Annals of Emergency Medicine. Feb 2025 Population: Children ages 9 to 17 years presenting to the ED with acute severe behavioral disturbances (Sedation Assessment Tool score of +1 to +3) that persisted despite nonpharmacological management that the clinician deemed to require oral medication Excluded: Known allergy or contraindication to the study medication, pregnant patients, history of known long QT syndrome, reversible organic cause contributing to agitation, parent/guardian request/refuse study drugs, treating clinicians decided alternative route, drug, or therapy was more appropriate Intervention: Oral dose of olanzapine​. Comparison: Oral diazepam. Outcome: Primary: Successful sedation (Sedation Assessment Tool (SAT) score ≤ 0 without need for additional sedation one-hour post-randomization)​. Secondary: Parent/guardian and medical staff satisfaction, medication-related adverse events, length of stay, disposition, and whether the participant ingested medication. Trial: Open-label, multicenter, randomized controlled trial. Authors’ Conclusions: “There was no evidence that oral olanzapine resulted in a greater proportion of participants with acute severe behavioral disturbance achieving successful sedation at one hour post randomization than oral diazepam. Neither medication resulted in any serious adverse events; however, approximately 40% of participants in each group did not achieve successful sedation.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes 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. No Financial conflicts of interest. No financial conflicts of interest Results: They enrolled 348 patients across nine sites. 176 were in the olanzapine group and 172 were in the diazepam group. Median age was around 15 years, with slightly more female patients. Key Results: Oral olanzapine and diazepam had similar efficacy in achieving successful sedation in children with acute severe behavioral disturbance. However, 40% of participants in each group were not successfully sedated. Primary Outcome: In the olanzapine group, 61% of participants were successfully sedated compared to 57% from the diazepam group. (aRD 3.6%, 95% CI -6.7 to 14, p=0.49). 10% of patients in both groups received additional sedation medication prior to measurement of the primary outcome. Secondary Outcomes: There was not much difference between the two groups in many of these outcomes. 2% in each group had a study-related adverse event (aRD 0.5%, 95% CI -4.2 to 5.3) by first hour post randomization. There were a few more adverse events up until time of discharge or 48 hours after discharge, 3% in the olanzapine group compared to 4% in the diazepam group. This difference was not clinically significant (aRD -3.6%, 95% CI -7.9 to 0.6). Further episodes of behavioral disturbance (23% olanzapine vs 26% diazepam) and requirement for mechanical restraints were also similar between the two groups. Selection Bias During the study, 491 patients were eligible but not enrolled. We are not certain why these patients were missed. Additionally, one of the inclusion criteria was that the patient had a behavioral disturbance that persisted despite nonpharmacological management, and the clinician determined required oral medications. We must acknowledge that while this is pragmatic, there is a great degree of subjectivity in that decision. There is a related trial including patients who received IM medications. Caution with Disparities We are glad that the authors included ethnicity in the patient demographics. We must acknowledge that despite our best efforts, we are not perfect, and disparities are present in the care we provide [1]. In the United States, studies demonstrate children of color are less likely to get pain medications for fractures or appendicitis and more likely to get mistriaged in the emergency department. These disparities exist in mental health and management of behavioral crises as well. One retrospective cohort study on children hospitalized with mental health crises with data

Date: July 9, 2025 Guest Skeptics: Dr. Cindy Bitter is an Associate Professor in the Division of Emergency Medicine at Saint Louis University. She has a Master’s in Bioethics, and she is passionate about EM capacity building and physician resilience, especially improving wellness through time in nature.    Dr. Amy Bi is a graduate from the SSM Health Saint Louis University Emergency Medicine residency and the University of Missouri School of Medicine. She is interested in continuing medical education, orange theory, and travelling. This is an SGEM Xtra episode, which takes us back to the late '90s to explore the intersection of pop culture and professional practice through the lens of Buffy the Vampire Slayer. It's similar to the episodes we did about Star Trek, Top Gun, Dark Knight, Ted Lasso, and The Pitt. Cindy reached out to me about a presentation she made at the HumanisEM conference. It's an interdisciplinary conference that explores the intersections of the Health Humanities and Emergency Medicine, started in 2023. The presentation at the conference was inspired by a conversation with female residents about why Buffy remains a must-watch show for young professionals, especially in medicine. In the lecture, we explore lessons from the show that resonate with emergency physicians and healthcare professionals. Click on the LINK for a copy of the slides. There may be some people like me who are not familiar with the show. Buffy the Vampire Slayer premiered in 1997 and ran for seven seasons. Its central premise was that the seemingly dumb blonde chick who is the first to get killed in horror movies is trained to fight back. Ultimately, the monsters were symbols of the challenges we face on the way to growing up and creating a meaningful life. The show hid a healthy dose of existential philosophy under the quips, music, and 90s fashion, and continues to gain fans more than 20 years after it ended. Career Advice from Buffy the Vampire Slayer Honour Your Calling Quote: “You talk about slaying like it’s a job, it’s not. It’s who you are”. What’s My Line? Part 2; S2, ep 10. Writer: Marti Noxon Our path in medicine is somewhat different than the “one girl in all the world” who is destined to fight the forces of darkness, but there are analogies. Buffy sometimes struggles with her calling but ultimately accepts her path (Prophecy Girl). And she shows that this is not a single event, but something she chooses every day (What’s My Line, Anne, Amends). We come to medicine with our own set of strengths and skills, choose our path, and actively reaffirm it as we complete years of education and residency training. There are certainly challenges in our healthcare system, but there is also connection and sometimes even joy. Meeting Challenges Quote: “Bottom line is, even if you see 'em coming, you're not ready for the big moments. No one asks for their life to change, not really. But it does. So, what are we, helpless? Puppets? No. The big moments are gonna come. You can't help that. It's what you do afterwards that counts. That's when you find out who you are.” Becoming, part 1; S2, ep 22. Writer: Joss Whedon Quote: “From now on, we won’t just face our worst fears, we will seek them out. There’s only one thing in this world more powerful than evil, and that’s us.” Bring on the Night; S7, ep 10. Writer: Marti Noxon with Douglas Petrie Medical school, residency, and even attending life are filled with learning from students, residents, coworkers, nurses, colleagues, and administrators. We must incorporate new evidence into our practice, learn from mistakes, and improve for future encounters. New situations come at us all the time; it’s how we strategize and confront them that counts. That might mean reading up on disease presentations we do not see often or practicing high-acuity, low-occurrence procedures. Knowing we are prepared for the challenges we see can give us confidence. Work-Life Balance and Leaning into your Humanity Quote: “It’s the 90s, the 1990s in point of fact. I can do both. Clark Kent has a job, I just want to go on a date… If the apocalypse comes, beep me.” Never Kill a Boy on the First Date; S1, ep 5. Writer: Rob Des Hotel & Dean Batali Quote: “You know how you’re always trying to save, oh, every single person in the world? Did it ever occur to you, you are one of them?” You’re Welcome. Angel S5, ep 12. Writer: Joss Whedon, David Greenwalt, David Fury One theme in the early seasons of BtVS is the tension between Buffy’s duties as a Slayer and her desire to have a normal life. This sometimes goes awry, as her efforts to continue her normal high school activities find her hexed (Witch), rendered helpless by a cursed Halloween costume (Halloween), and almost eaten by a lizard demon (Reptile Boy). But eventually, she finds a path that provides her a stable-ish home life and meaningful friendships while being a Slayer. In season five, Buffy cuts herself off from her emotions, worrying that the burdens of being the slayer are turning her to stone. To be successful and avoid burnout, we must process the sorrows we encounter and lean into the joy. We often make tough choices without full information, doing the best we can with less-than-optimal situations. Sometimes we can offer reassurance that a patient’s symptoms are not dangerous, sometimes we must tell patients or families about an impending death, sometimes the best we can offer is a comforting presence and minimizing suffering. We must offer ourselves the same grace we give so freely to others. Challenging Dogma Quote: “I appreciate your thoughts on the matter, in fact I encourage you to always challenge me when you feel it’s appropriate. You should never be cowed by authority. Except, of course, in this instance, when I am clearly right and you are clearly wrong.” I Only Have Eyes for You; S2, ep 19. Writer: Marti Noxon Much of what we do in EM is not well-grounded in the medical evidence, but it is important to seek out new evidence and stay current in the literature. And acknowledge things that are tradition or “dogma” rather than evidence-based. Some of us will even choose to contribute to expanding that evidence base! But it is crucial to be a critical reader of the literature even if research “isn’t your thing”. This is especially important to me as an attending - I ask our senior residents to teach me something every shift - sometimes from an article they read, a podcast I haven’t listened to, or a new technique with ultrasound. Being a Girl and A Badass  Quote: “Yes, date, and shop, and hang out, and go to school, and save the world from unspeakable demons. You know, I want to do girly stuff”. Faith, Hope and Trick; S3, ep 3. Writer: David Greenwalt Quote: “Did we not put the “grr” in girl? Living Conditions,S4, ep2. Writer: Marti Noxon Replace “demons” with “diseases,” and you have a pretty good mission statement for Women in Medicine. Buffy starts the show as a stereotypical high school girl, more interested in clothes and popularity than academics or saving the world. As she grows into her role, she incorporates her fashion sense into the job, patrolling in her favourite orange tank top and her “stylish yet affordable” boots. She is physically strong, but never feels the need to suppress her feminine side to fulfill her duties as Slayer. Likewise, we can be our authentic selves and show our personality while fulfilling our professional roles - wear those colourful scrubs or your favourite rhinestone barrette on duty. Final thoughts about what you learned from the TV series Buffy the Vampire Slayer Seeking Mentorship and Asking for Help  Quote: “Sometimes the most adult thing you can do is ask for help when you need it.” Grave, S6, ep 22. Writer: David Fury The mentor/ surrogate father relationship between Buffy and her Watcher, Mr. Giles is one of the best-developed relationships in the show. Mr. Giles loses his position in the Watchers Council over his affection for his charge. Several new Watchers are sent, but Buffy leaves the Council when it proves unwilling to support her objectives. After some months without a formal mentor, Buffy again asks Giles to be her Watcher. Even after she completes her formal training, she recognizes her need for mentorship and seeks out Mr. Giles’ help. In the final season of the show, Buffy becomes a mentor, responsible for all the potential Slayers who have not yet been called. She tries to train them, but early on, they lack the strength and the focus needed to take on the role. In the series finale, she finds a way to share her power with the Potentials, building an army to defeat evil.  Finding Your Team - The Power of Friendship It cannot be summarized into a single quote from the show, as it happens so many times that a one-liner doesn’t capture the theme, but… Buffy’s friends are known as the Scoobies, and each of them plays an important role in her mission. This is called out by one of the villains as a reason that Buffy has lasted longer in the role of Slayer than most. As Buffy draws strength from her friends, our relationships with our families, friends and coworkers can help us through rough times. Women in EM must lift each other, sharing resources, collaborating on scholarly activity, and even socializing, which can remind us that we don’t have to do it alone. Criticisms/Controversies Though celebrated for its feminist themes, the show has also been critiqued for embodying a narrow brand of feminism. Issues include: Costume choices catering to the male gaze Outdated jokes and stigmas (e.g., gay panic, slut-shaming, fat-phobia) Toxic behaviours that go unaddressed I justify my belief that Buffy is a feminist text by going back to the principles of feminist bioethics

Reference: Arnold CG, et al. Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule. Acad Emerg Med. Jan 2025 Date: May 7, 2025 Dr. Sandi Angus Guest Skeptic : Dr. Sandi Angus is a Paediatric and Adult Emergency Medicine Registrar in the Shrewsbury and Telford Hospital NHS Trust. She is passionate about paediatric EM, wellbeing and medical education. Case: A ten-year-old boy presents to your emergency department (ED) after being involved in a motor vehicle collision at high speed. Emergency Medical Service (EMS) tells you that he was properly restrained. His parents were also in the vehicle and are currently being brought to the ED as well. He appeared a bit dazed initially, but he has had a Glasgow Coma Scale (GCS) score of 15 throughout transport. Your primary survey is unremarkable. He complains of some abdominal pain, although you note a soft abdomen on exam and no seatbelt sign. As you complete your secondary survey, he vomits once, which is non-bloody. A medical trainee working with says to you, “He says his stomach hurts and threw up. Do you think we need to CT scan his abdomen?” Background: Intra-abdominal injury (IAI) in children is a significant concern for emergency physicians. This is particularly true in cases of blunt trauma. Although relatively uncommon compared to adults, IAIs in children can be life-threatening. We have to identify them early and manage them appropriately. The organs most frequently injured include the spleen, liver, and kidneys, but any abdominal organ can be affected​. Diagnosing IAIs in pediatric patients poses a unique challenge. Children often present with subtle clinical findings, and the physical examination can be unreliable due to factors such as altered mental status, distracting injuries, or the child’s inability to articulate their symptoms​. Imaging modalities like computed tomography (CT) are the gold standard for diagnosis, but CT use must be balanced against the risks of ionizing radiation. Traditionally, clinicians relied heavily on their clinical gestalt, but this approach can miss injuries or lead to unnecessary imaging. The risks of CT imaging are not inconsequential. Children are more radiosensitive than adults, and for each  abdominal or pelvic scan, the lifetime risks of cancer are 1 per 500 scans, irrespective of the age at exposure. However, this is actually very small compared with the background risk of developing cancer in a lifetime, which is 1 in 3, so if your scan is clinically justified, the benefit is likely to outweigh the potential harm [1]. To improve diagnostic accuracy and minimize unnecessary CT scans, clinical decision rules (CDRs) or “tools” have been developed. One such tool, the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rule for intra-abdominal injuries, identifies children at very low risk of clinically important IAIs, aiming to safely reduce CT utilization​ [2-3]. This rule was composed of seven variables, all of which could be collected on history and physical exam. There was no need for labs or imaging in this decision rule. These seven variables were: Evidence of abdominal wall trauma or seat belt sign GCS <14 and blunt abdominal trauma Abdominal tenderness Thoracic wall trauma Complaint of abdominal pain Decreased breath sounds Vomiting If all seven variables were negative, the child was at very low risk of having intra-abdominal injury requiring intervention and the decision rule recommended against a CT scan. Despite the benefits of existing decision rules, the question remains how best to apply these tools when only one or two PECARN criteria are positive—a clinical gray zone not well characterized in earlier validation studies. Understanding the individual performance of PECARN rule components in predicting IAI is crucial for refining decision-making in pediatric trauma care. Clinical Question: What is the risk for intraabdominal injuries requiring acute intervention (IAIAI) in children with one or two positive PECARN intraabdominal injury rule variables? Reference: Arnold CG, et al. Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule. Acad Emerg Med. Jan 2025 Population: Children <18 years with blunt torso trauma Excluded: Injury occurring >24 hours before ED presentation, penetrating trauma, pre-existing neurological disorder preventing reliable abdominal exam, pregnancy, transfer from another hospital with prior abdominal imaging. All patients who were negative for the original PECARN prediction rule or had more than two variables present. Intervention: Application of the PECARN intraabdominal injury prediction rule with one or two positive variables Comparison: None Outcome: Primary Outcome: Intraabdominal injury undergoing acute intervention (death caused by IAI, therapeutic laparotomy, angiographic embolization, blood transfusion, or ≥2 nights of IV fluids). Secondary Outcomes: Any intraabdominal injury (injuries to the liver, spleen, urinary tract, gastrointestinal tract, pancreas, gallbladder, adrenals, vasculature, or fascial defects).  Trial: Planned secondary analysis of a prospective multicenter observational study Authors’ Conclusions: “Few children with blunt torso trauma and one or two PECARN predictor variables present have IAIAI. Those with GCS score <14, however, are at highest risk for IAI.” Quality Checklist for Clinical Decision Rules: Did the study population include or focus on those in the emergency department? Yes Where was the study conducted (external validity)? Six emergency departments in the United States Were the patients included in the study representative of those with the problem? Yes Were all important predictor variables and outcomes explicitly specified? Yes Is this a prospective, multicenter study including a broad spectrum of patients and clinicians (Level II study)? Yes Did clinicians interpret individual predictor variables and score the clinical decision rule reliably and accurately? Unsure (not detailed clearly in the abstract) Is this an impact analysis of a previously validated clinical decision rule (Level I study)? No For a Level I study, was the impact on clinician behavior and patient-centric outcomes reported? N/A Was the follow-up sufficiently long and complete? Yes Was the effect large enough and precise enough to be clinically significant? Yes Who funded the trial? Eunice Kennedy Shriver National Institute of Child Health and Human Development Did the authors declare any conflicts of interest? No conflicts declared Results: The original study included 7,542 children with blunt torso trauma across six emergency departments. Of those children, 2,986 (39.6%, 95% CI 38.5 to 40.7) had one or two PECARN positive variables. The median age was 9.8 years and slightly over half (56%) were male. CT scans were obtained in 1236 (41%) of the patients. Key Results: Few children with one or two positive PECARN rule variables had IAI, with the highest risk in those with GCS <14. The presence of isolated abdominal pain, vomiting, or tenderness was not associated with IAI. Primary Outcome: Of the 1,639 patients who had one variable positive, 21 (1.3%, 95% CI 0.8-2) had intra-abdominal injuries undergoing acute intervention. Of the 1347 who had two variables positive, 27 (2%, 95% CI 1.3-2.9) had intra-abdominal injuries undergoing acute intervention. Secondary Outcome: Of those 2986 patients enrolled, 227 (7.6%, 95% CI 6.7-8.6) had intra-abdominal injuries. They also broke it down by each individual variable and how many patients were diagnosed with intra-abdominal injury and intra-abdominal injury undergoing acute intervention. GCS≤14 was the most important individual predictor variable for intra-abdominal injury undergoing acute intervention. Inclusion Criteria: It’s important to review the inclusion criteria from the original study because we do not think this clinical decision rule should be applied indiscriminately to every child with abdominal trauma. A large proportion of the children included in the original study had some pretty severe mechanisms of injury (32% from motor vehicle collisions, 19% were struck by a vehicle, and 13% due to fall from height. Be careful in applying this clinical decision tool to less severe mechanisms. They excluded patients who had injury that occurred over 24 hours ago. Many of us may have encountered a patient in the emergency department who complains of belly pain from a blunt abdominal injury a day ago and were perhaps seen at an urgent care facility or tried to wait it out. Although they were not part of the patient population in this study, would it be inappropriate to use this clinical decision tool on those patients? Partial Verification Bias: In this secondary analysis, only around 40% of patients included had CT scans. What about those who did not? In the original derivation study, there was one patient with a splenic laceration who returned after being discharged from the ED without imaging who underwent splenic artery embolization. It is possible that some of these patients who did not undergo CT scan still had intra-abdominal injuries that were missed. This does highlight the primary outcome that they defined as IAI undergoing acute intervention. It is arguably more patient oriented, they missed some IAI but maybe it was not clinically significant. I’ve admitted low grade splenic or liver laceration to the hospital who were observed without any intervention except a repeat hemoglobin before being sent home. Spectrum Bias: Subpopulations with only 1–2 rule variables may not fully represent all blunt trauma pre

Reference: Solnick et al. Sex Disparities in Chlamydia and Gonorrhea Treatment in US Adult Emergency Departments: A Systematic Review and Meta-analysis. AEM June 2025 Date: June 24, 2025 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. Case: A 24-year-old woman presents to the emergency department (ED) with a two-day history of dysuria, lower abdominal discomfort, and abnormal vaginal discharge. She is sexually active with multiple male partners and does not consistently use condoms. A urine nucleic acid amplification test (NAAT) is sent, and the patient is clinically diagnosed with a possible sexually transmitted infection (STI). She is not in acute distress, has no fever, and requests discharge after symptom control. Background: STIs such as chlamydia and gonorrhea remain significant public health concerns in the United States (US), particularly among young adults. EDs are increasingly serving as critical access points for STI screening and treatment. However, emerging evidence suggests that treatment practices may differ by patient sex, raising concerns about potential inequities in care delivery. Women are disproportionately affected by the long-term sequelae of untreated STIs, including pelvic inflammatory disease, ectopic pregnancy, and infertility. Despite this, treatment disparities may exist. Men presenting with STI symptoms often receive expedited care, while women, even when symptomatic or diagnosed, may not receive timely or adequate treatment. Potential explanations include differing clinical presentations, provider bias, and system-level barriers such as follow-up challenges or diagnostic uncertainty. Chlamydia and gonorrhea can present with a range of symptoms or be asymptomatic, which complicates timely diagnosis and treatment. While the Centers for Disease Control and Prevention (CDC) guidelines recommend empiric treatment in cases of high clinical suspicion, especially when patients may be lost to follow-up, the extent to which these guidelines are equitably applied across sexes remains uncertain. Clinical Question: Are there sex-based disparities in the treatment of chlamydia and gonorrhea among adults presenting to US emergency departments? Reference: Solnick et al. Sex Disparities in Chlamydia and Gonorrhea Treatment in US Adult Emergency Departments: A Systematic Review and Meta-analysis. AEM June 2025 Population: Adults (≥18 years) presenting to US EDs with testing for chlamydia or gonorrhea. Exclusions: Pediatric patients, individuals with incomplete demographic or treatment data, and those not diagnosed in the ED. Exposure: Receipt of appropriate antibiotic treatment during the ED visit. Comparison: Male versus female patients. Outcomes: GC/CT positivity, empiric treatment rates, and discordance between treatment and test results stratified by sex. Type of Study: Systematic review and meta-analysis Dr. Rachel Solnick This is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Rachel Solnick is an Assistant Professor of Emergency Medicine at the Icahn School of Medicine at Mount Sinai. Her research focuses on HIV prevention, STI care, and maternal health, with an emphasis on expanding access to high-quality reproductive and sexual healthcare for all emergency department patients. She is the PI of an NIH Career Development Award studying the implementation of HIV pre-exposure prophylaxis (PrEP) for ED patients diagnosed with STIs during telephone callbacks. Authors’ Conclusions: “Significant sex-based disparities exist in ED empiric antibiotic treatment for GC/CT. Females were 3.5 times more likely than males to be potentially under-treated. These findings underscore the need for targeted interventions to reduce disparities and improve treatment accuracy. Interpretation is limited by study heterogeneity and incomplete sex-specific data.” Quality Checklist for Systematic Review: The main question being addressed should be clearly stated. Yes The search for studies was detailed and exhaustive. Yes Were the criteria used to select articles for inclusion appropriate? Yes Were the included studies sufficiently valid for the type of question asked? Yes Were the results similar from study to study? No Were there any financial conflicts of Interest? None reported Results: The included 19 studies comprised 32,592 ED patients who were tested for STIs and analyzed. The heterogeneity of the prevalence estimates had I2 values of 92.6% or higher.   Key Result: Female patients were much less likely to receive recommended antibiotic treatment compared to male patients, while males were much more likely to be over-treated compared to females. Among patients with laboratory-confirmed chlamydia or gonorrhea pooled estimate was 3.5 for females being under-treated relative to males. We asked Rachel five nerdy questions. Listen to the SGEM podcast to hear her responses. 1. Chart Review: These often lack the granularity that can contextualize treatment decisions. For instance, the data may not include symptom severity, provider rationale, or specific patient-provider discussions about treatment. These missing nuances could explain some of the apparent disparities, such as if certain patients refused treatment or if providers made decisions based on clinical judgment not reflected in coding. This limitation introduces potential misinterpretation of the observed treatment gaps, particularly in distinguishing between provider omission and justified clinical discretion. 2. Risk of Bias: You used the Joanna Briggs Institute (JBI) Critical Appraisal Tool for cross-sectional studies to assess the methodological quality of studies included in your systematic review. This version of the tool includes eight domains, focusing on areas such as inclusion criteria, valid and reliable measurement of exposure and outcomes, and appropriate statistical analysis. Why did you select the JBI rather than the ROBINS-I (Risk Of Bias In Non-randomized Studies - of Interventions) for observational studies? The overall assessment indicated that the included studies were at low to moderate risk of bias. Most studies received favourable assessments across most domains. However, concerns were raised in specific areas, particularly regarding the reliability of outcome measurement and management of confounding, which contributed to variability in the quality ratings. 3. High Heterogeneity: The heterogeneity in this study was 92.6% or greater, indicating considerable variability in study results beyond what would be expected by chance alone. This variability may stem from differences in study design, geographic regions, patient populations, ED workflows, diagnostic practices, or definitions of empiric treatment. While the authors used a random-effects model to account for between-study differences, such heterogeneity limits the precision and generalizability of the pooled estimates. It also complicates interpretation, as the aggregated results may mask important contextual factors that influence treatment disparities across different healthcare settings. Why not do a narrative review and not meta-analyze the data? 4. Confounding Bias Due to Unadjusted Estimates: The study did not adjust for any variables. Important factors such as sexual history, prior STI diagnoses, or socio-economic status may not have been fully captured or adjusted for. These unmeasured variables could influence both the likelihood of receiving treatment and the likelihood of infection, thus affecting the estimated association between patient sex and treatment rates. The presence of unaccounted confounders could either exaggerate or underestimate the true magnitude of the disparity. 5. Generalizability: The findings are drawn from studies that used data collected in specific health systems and regions, which may not reflect broader national practice patterns. None of the studies came from the western US or focused on patients from rural communities. Comment on the Authors’ Conclusion Compared to the SGEM Conclusion: We generally agree with the authors’ conclusions.  SGEM Bottom Line: There is a high amount of UNDER-treatment (women>men) and OVER-treatment (men>women) in patients clinically diagnosed with chlamydia or gonorrhea in US EDs. Case Resolution: You diagnose the 24-year-old patient with suspected chlamydia based on symptoms and epidemiologic risk. Despite a pending confirmatory test, the ED team adheres to CDC guidelines and provides empiric treatment. The patient is counselled on safer sex practices and linked to local STI follow-up services. Dr. Suchi Datta Clinical Application: EDs should consider guideline-based STI treatment protocols across all patient demographics. Clinical decision support and workflow optimization may help mitigate disparities and improve timely care for all patients. What Do I Tell the Patient? I would do some shared decision making and say something like…You may have a sexually transmitted infection. If you're not sure you will be able to come back to the ED for treatment or to get your results, then it’s reasonable to treat you today with antibiotics to make sure we don't miss an infection. "  Keener Kontest: Last week’s winner was David Pecora. He knew Peter Gabriel was the original lead singer for the band Genesis.  Listen to the SGEM podcast for this week’s question. If you know, then send an email to [email protected] with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode. Now it is your turn, SGEMers. What do you think of this episode on sex-based disparities in the treatment of STIs? What questions do you have for Rachel and her team?...

Reference: Ye et al. Preoxygenation strategies before intubation in patients with acute hypoxic respiratory failure: a network meta-analysis. Frontiers in Medicine. 2025 Feb Date: June 12, 2025 Guest Skeptic:  Dr. Aine Yore is an Emergency Physician, practicing in the Seattle, Washington area for over twenty years. She is the former president of the Washington chapter of ACEP, and her career focus outside of clinical practice has been largely devoted to health care policy. Case: A 68-year-old woman presents in acute respiratory distress. She is febrile, hypoxemic, and meets criteria for sepsis. A chest x-ray reveals multilobar pneumonia. After managing her sepsis, her oxygenation remains poor, with saturations in the 88-92% range despite supplemental oxygen via a nonrebreather mask, and she now shows signs of worsening fatigue. You determine she requires endotracheal intubation, but note that she is at high risk for peri-intubation complications or even death, and wonder if there is a strategy you can utilize to reduce this risk? Background: Acute hypoxic respiratory failure (AHRF) represents a life-threatening emergency where pulmonary gas exchange becomes insufficient to maintain adequate oxygenation. It commonly arises from a variety of conditions, including pneumonia, acute respiratory distress syndrome (ARDS), sepsis, and exacerbations of chronic lung disease (ex, chronic obstructive lung disease). In such patients, intubation is often required, but the procedure itself introduces additional risk. Nearly 25% of patients undergoing emergency intubation in the context of AHRF experience profound desaturation (SpO₂ < 80%) during the procedure. Preoxygenation is a cornerstone of airway management, designed to extend the “safe apnea time” by denitrogenating the lungs and optimizing oxygen reservoirs. The aim is to minimize peri-intubation hypoxia, which is a known predictor of morbidity and mortality. Commonly used pre-oxygenation strategies include: Conventional oxygen therapy (COT), such as non-rebreather masks. High-flow nasal cannula (HFNC) provides warmed, humidified oxygen at high flow rates and can generate low levels of positive end-expiratory pressure (PEEP). Non-invasive ventilation (NIV) provides pressure support to enhance alveolar ventilation and decrease the work of breathing. Combinations of strategies like HFNC with NIV or bag-valve mask. Despite the widespread use of these techniques, clinical uncertainty persists regarding the most effective and safest strategy for preoxygenation in AHRF. This knowledge gap has led to multiple randomized controlled trials (RCTs) on the subject. Clinical Question: What is the optimal pre-oxygenation strategy in patients requiring intubation for acute hypoxic respiratory failure? Reference: Ye et al. Preoxygenation strategies before intubation in patients with acute hypoxic respiratory failure: a network meta-analysis. Frontiers in Medicine. 2025 Feb Population: Adults with AHRF defined as a respiratory rate >30/min, FiO₂ requirement ≥50% to maintain SpO₂ ≥90%, or PaO₂/FiO₂ < 300 mmHg within four hours of enrollment. Exclusions: Studies involving reviews, conference abstracts, case reports, or lacking full text. Intervention: Pre-oxygenation with Noninvasive Mechanical Ventilation, High Flow Oxygen via Nasal Cannula, or some combination of the above. Comparison: Conventional oxygen therapy (COT) or other preoxygenation. strategies. Outcome: There was no primary outcome explicitly stated. Outcomes included incidence of desaturation (SpO₂ < 80%) during intubation, lowest SpO2 during intubation, post-intubation complication rate, intensive care unit (ICU) length of stay (LOS) and ICU Mortality Type of Study: Network Meta-Analysis (NMA) Authors’ Conclusions: “Preoxygenation with HFNC appears to be the safest and most effective approach prior to intubation in patients with AHRF compared to other strategies”. Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. Yes The assessment of studies were reproducible. Unsure The outcomes were clinically relevant. No The treatment effect was large enough and precise enough to be clinically significant. Unsure Who funded the trial? Not stated Did the authors declare any conflicts of interest? No conflicts declared Results: Their search found 11 RCTs containing 2,874 patients with average ages ranging from mid-40s to 60s. Key Result: Outcomes: Incidence of Severe Hypoxia (SpO2 HFNC>COT, meaningful effect size Lowest SpO2 during intubation: HFNC+NIV>HFNC+COT>NIV>HFNC>COT, effect size not meaningful Post-intubation Complication Rate: HFNC>HFNC+COT>HFNC+NIV>NIV>COT, effect size not statistically significant ICU Length of Stay: HFNC>COT>NFNC+NIV>NIV, effect size not statistically significant ICU Mortality: HFNC>HFNC+NIV>HFNC+COT>NIV>COT, effect size not statistically significant 1. What Is A Network Meta-Analysis (NMA)? An NMA is an analytical method that allows for the comparison of multiple treatments simultaneously when some or all the treatments have never been directly compared in a head-to-head trial [1]. A key advantage of NMAs is that they can also rank treatments based on their effectiveness or safety. It provides outputs such as surface under the cumulative ranking (SUCRA) curves, which help identify the most effective or safest option [2]. Here’s a way to understand an NMA. Let’s say you want to compare four flavours of chewing gum: Cherry, Grape, Cheese, and Sewage. You have lots of market data comparing them, but, like the Highlander, there can be only one! But nobody has ever compared Cherry and Grape directly! And we need to prove which is best. An NMA can use a combination of direct and indirect evidence to compare them and determine the Ultimate Champion. Direct evidence would include the head-to-head comparisons. Cherry was a lot better than Sewage, of course. And Grape was marginally better than Cheese, and everything was better than Sewage, which is just objectively bad. The NMA will indirectly compare Cherry to Grape and can give you a reasonable sense of confidence as to which is better. 2. How Do You Critically Appraise An NMA? It is like the structured critical appraisal used to probe an SRMA for its validity.  There are quality checklists for NMA (PRISMA and CINeMA) [3,4]. What’s the PICO question? How exhaustive was the search? What was the quality of the included studies (Risk of bias assessment) Transitivity assumption? What statistical model was used (Bayesian/Frequentist), and what was the heterogeneity? How precise were the results? Was the effect size clinically relevant? Were there any COIs?  One thing specific to NMAs is transitivity, which is different than heterogeneity? Heterogeneity refers to statistical variability in results among studies comparing the same interventions. In contrast, transitivity is the idea that we can validly compare two treatments indirectly through a common comparator [5]. Heterogeneity is assessed, not globally, but within each treatment arm (direct comparisons). If there were three studies comparing Grape to Cheese flavoured gum, those studies themselves need to be similar. There are some highly quantitative statistical tools for this, and also some that are more vibe-based, as in this study. Additionally, an NMA requires internal cross-checking to ensure there is little inconsistency for the results to be valid. If Grape scored higher than Cheese flavour, and Cherry scored higher than Grape, yet Cheese scored higher than Cherry, the data is inconsistent, and an NMA may not be able to provide valid indirect evidence. The tests for inconsistency are also technical, and there are multiple methods of performing them. Assuming that your data is not too heterogeneous, and no inconsistencies are found, you can compute the rank order. This is done with a tool called SUCRA – Surface Under Cumulative Ranking Curve. This gives you a percentage of how likely a given flavour is to be the best. It’s normalized, so the percentages will not add up to 100%. In our Gum Challenge, Cherry might score 90% and Grape 75%, Cheese 10%, and Sewage 1%. What this tells you is that both Cherry and Grape are pretty good, but there’s a small margin between the two. First, you assess heterogeneity within each direct comparison. Then you consider whether the network appears transitive by comparing PICO elements. Finally, you check for inconsistency, which is the statistical signal that transitivity might not hold. 3. Effect Sizes vs Rank Order: One key advantage of NMAs is that they not only estimate effect size but are also able to rank the efficacy and/or safety of an intervention. Ranking of treatments can provide clinicians, guideline writers and policy-makers choices based on the probability of each intervention being the most effective or safest option. Ranking can also be a weakness of the NMA method if there is over-interpretation of the rank order. This may lead to a conclusion which is inaccurate. It doesn’t just matter that a given treatment was better than another, but by how much. Both Grape and Cheese flavours taste better than sewage, but let’s be honest, Cheese-flavoured gum is only a little better than sewage, and you may not capture that effect size if you only look at the rank orders. The study we are reviewing today looks at several different treatments that were not different from placebo (in this case, conventional oxygen therapy), yet it generated rank orders and included these results in its conclusions. And in the one outcome to truly have a meaningful statistical effect size,...

Date: June 2, 2025 Dr. Andrew Tagg Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder and website lead of Don’t Forget the Bubbles. This is another SGEM Xtra that talks about what we can learn about being physicians from certain pop culture (TV and Movies). Past episodes include: Star Trek Made Me A Better Physician Lead Me On – What I Learned from Top Gun Holding Out for a Hero – Lessons from The Dark Knight Yeah, Might Be All that You Get – How Ted Lasso Made Us Better Doctor, Doctor – Paging Dr. Robby (The Pitt) Five EM Lessons from Mission Impossible Movies Precision Under Pressure: Ethan Hunt doesn’t get extra time or perfect conditions — and neither do we. Whether defusing a bomb or managing a crashing patient, calm execution under pressure saves lives. The Team is Everything: Hunt may be the face, but he’s nothing without Luther, Benji, and the crew. Medicine is no different: the best outcomes happen when we trust our team and play to each other’s strengths. Always Question the Intel: Just because it’s in the mission briefing doesn’t mean it’s true. Skeptical medicine is about challenging the “received wisdom” and verifying it before acting — just like a good IMF agent would Know Your Exit Strategy: Whether escaping a vault or de-escalating a high-stakes family discussion, always have a way out. Good clinicians plan for failure just as much as success — that’s what keeps patients (and careers) safe. Mission Fatigue is Real: Even Ethan looks wrecked sometimes. Adrenaline is not a sustainable fuel. We need to rest, recover, and recalibrate — especially if we want to perform at a high level over decades. The SGEM will return with a structured critical appraisal of a recent publication. We will continue to strive to reduce the Knowledge Translation (KT) window from over ten years to less than one year, leveraging the power of social media. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Date: May 14, 2025 Dr. Ross Prager Guest Skeptic: Dr. Ross Prager is an Intensivist at the London Health Sciences Centre and an adjunct professor at Western University. His expertise in critical care medicine is complemented by his research interests in critical care ultrasound and evidence-based knowledge translation. This is an SGEM Xtra episode. The inspiration was a thread Ross posted on X: Here are 10 lessons they don't teach in medical school (but should) that I've learned the hard way over the years. He shared ten hard-earned lessons from his clinical life that never made it into the standard curriculum. These lessons are rooted in humility, human connection, and the everyday realities of medical practice.  1. Patients Don’t Care How Much You Know, but How You Make Them Feel Sit down with your patients — standing can seem rushed. Recognize emotions: “I imagine this must be stressful.” Be human. It’s OK to say “I don’t know” or admit fallibility. Patients value authenticity over perfection. 2. You’re Remembered by Your Worst Moments When stress hits, your true self emerges — that is what people remember. Grace under pressure matters more than glory during routine. 3. Stop Trying to Impress People with Knowledge Competence is shown, not shouted. The best clinicians are present and kind, not performative. 4. Being Keen Is Not a Crime Passion is a virtue, not a vice. Don’t hide your enthusiasm. It’s a sign you care. 5. Med School and Residency Are Long Job Interviews Every rotation, every shift, every colleague — it all counts. Build your reputation day-by-day with kindness, work ethic, and humility. 6. Absence of Evidence ≠ Evidence of Absence Not everything is backed by RCTs — that doesn’t mean it’s invalid. Clinical observation and physiologic rationale matter (e.g., vasopressors). As always, be skeptical of the lack of evidence, too. 7. Character Is How You Treat People Who Don’t Supervise You It’s easy to be kind to your boss. Your true self shows in how you treat nurses, janitors, and trainees. 8. Focus on Diagnosis First, Treatment Second Most medical harm arises from misdiagnosis, not mismanagement. Think ten times harder about “what’s going on” before “what should we do?” 9. Don’t Postpone Living Until After Residency If you're waiting for life to get better after training, you're doing it wrong. Find joy now. Build habits of balance early — your future self will thank you. 10. Remember the Spark Recall your first patient: the awe, the uncertainty, the honour. When burnout creeps in, revisit that moment. Reconnect with your “why.” Final Thought from Dr. Prager: “Medicine is not just about answers, it’s about presence. Our best tool is our humanity.” The SGEM will be back next episode with a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window from over ten years to less than one with the power of social media. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics' Guide to Emergency Medicine.