The Skeptics Guide to Emergency Medicine Dr. Ken Milne

Reference: Albers GW et al. TIMELESS Investigators. Tenecteplase for Stroke at 4.5 to 24 Hours with Perfusion-Imaging Selection. NEJM Feb 2024

Date: April 12, 2024

Guest Skeptic: Dr. Vasisht Srinivasan is an Emergency Medicine physician and neurointensivist at the University of Washington and Harborview Medical Center in Seattle, WA. He is an assistant professor in Emergency Medicine, Neurology, and Neurosurgery at the School of Medicine at the University of Washington.

Case: A 70-year-old woman was brought into the emergency department by EMS after her family reported she was having trouble talking.  They noticed this earlier in the day and let her rest, but when she had trouble moving her right arm, they called 911.  Initial evaluation by medics revealed right hemiplegia, a right facial droop, left gaze deviation, and aphasia.  When she arrives in your ED, her family tells you she was last seen normal about 12 hours ago.  A code stroke is activated, and the initial CT head shows no signs of hemorrhage or early ischemic changes.  A CT angiogram shows a proximal middle cerebral artery occlusion.  CT perfusion showed a 10 mL core and 189 mL penumbra.  As you speak to your stroke team, the question of thrombolysis comes up, as her core is quite small, and the stroke may still be very early in its time course.

Background: The question of thrombolysis for acute ischemic stroke dates back nearly 30 years to the initial NINDS trial published in 1995 [1].  Since that time, numerous studies and analyses have been undertaken to categorize the potential benefits and potential harms associated with thrombolysis in stroke [2-8]. We have discussed this issue multiple times on the SGEM including:



* SGEM#29: Stroke Me, Stroke Me

* SGEM#70: The Secret of NINDS

* SGEM Xtra:Thrombolysis for Acute Stroke

* SGEM Xtra: Walk of Life

* SGEM#297: tPA Advocates Be Like – Never Gonna Give You Up



With the pentad of thrombectomy trials published in 2015 [9-13] and the extension of the thrombectomy window in 2018 following the publication of DAWN [13] and DEFUSE-3 [15], the standard of care has now shifted to mechanical thrombectomy for large vessel occlusion, though thrombolysis is still used up to 4.5 hours from onset of symptoms.





We have looked at the issue of EVT with or without thrombolytics on the SGEM a few times.



* SGEM#137: A Foggy Day – Endovascular Treatment for Acute Ischemic Stroke

* SGEM#292: With or Without You – Endovascular Treatment with or without tPA for Large Vessel Occlusions

* SGEM#297: tPA Advocates Be Like – Never Gonna Give You Up

* SGEM#333: Do you Gotta Be Starting Something – Like tPA before EVT?

* SGEM#349: Can tPA Be A Bridge Over Trouble Waters ...

Reference:  Drysdale SB et al. Nirsevimab for Prevention of Hospitalizations due to RSV in Infants. N Engl J Med. 2023

Date: March 29, 2024

Guest Skeptic: Dr. Michael Cosimini is a pediatrician in Portland Oregon. He is the designer of Empiric Game, a medical editor and contributor to Pediatrics Reviews and Perspectives (PedsRAP) and the digital media editor at Academic Pediatrics. He is passionate about podcasting and serious games for medical education.

Case: A 4-month-old twin girl is brought by her parents to the emergency department (ED) for respiratory distress. She has had congestion, a runny nose, and a cough for the past three days. Her parents think her breathing has been getting worse, and she is breathing faster. On your examination, you see that she is tachypneic with a respiratory rate of 66 breaths per minute. You also note subcostal retractions. Her oxygen saturation on room air is 86%. After nasal suctioning, she remains tachypneic, but her oxygen saturation remains under 90%. A viral swab comes back positive for respiratory syncytial virus (RSV). The decision is made to put her on supplemental oxygen via nasal cannula and admit her to the hospital for close observation. Her parents tell you, “She has a twin brother at home. We heard about this new vaccine for RSV. Does it work?”

Background: RSV is a major cause of respiratory illness in young children. It is common in bronchiolitis which leads to symptoms like coughing, wheezing, and difficulty breathing. RSV is a major reason why infants are hospitalized for respiratory issues, especially during the fall and winter months when RSV infections are more prevalent. 

It’s hard to think about RSV without recalling the quote “Don’t just do something, stand there!” Because there have been so many things that we’ve tried for bronchiolitis that really don’t seem to have had much effect including hypertonic saline (SGEM#157), high-flow nasal oxygen (SGEM#228), corticosteroids, bronchodilators, etc  (SGEM#167).  One thing that has also been tried but not covered on the SGEM is a “vaccine” for RSV. 

Attempts at developing a vaccine against RSV go back decades. The first significant effort to develop an RSV vaccine occurred in the 1960s. A formalin-inactivated RSV vaccine (FI-RSV) was developed and tested in infants and young children. However, instead of protecting against RSV, the vaccine led to worsened infection in many children resulting in some being hospitalized and two deaths. This tragic outcome slowed the development of an RSV vaccine for years. Over the next three decades, researchers sought to understand the immune response to RSV infections and explore potential vaccine targets other than the inactivated virus.

During the 2000s, advances in molecular biology, immunology, and vaccine technology rekindled scientists’ efforts in RSV vaccine development. Researchers began exploring various approaches, including protein subunit vaccines, vectored vaccines, live-attenuated vaccines, and mRNA vaccines. Over the last decade, several RSV vaccine candidates have entered clinical trials. These trials have included vaccines for infants, older children, and at-risk adults, such as the elderly and pregnant women (intending to provide passive immunity to newborns). While some RSV vaccine candidates have shown promise, the challenge has been to find a vaccine that is safe, effective, and can provide long-lasting immunity.

In 2022 in the European Union and UK and 2023 in the US and Canada approved Nirsevimab to prevent RSV.

Reference: Harrison et al. Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol. AEM March 2024.

Date: March 27, 2024

Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals.

Case: It’s a Friday evening at the end of the academic year in the Paediatric Emergency Department (ED) and you are with the parents of a 15-year-old girl who has been brought in acutely intoxicated from an unofficial “School’s Out” party. Although your patient has recovered and is now fit for discharge, her parents are very worried that this may mean she is at more risk in the future.

Background: We know that alcohol is a major cause of mortality and morbidity across the world [1] and that ED attendance due to it is rising [2,3]. We also know that adults who attend ED with alcohol-related problems are at an increased risk of death in the following year [4]– in fact, we discussed exactly that in SGEM#313 where we agreed that increasing frequency of alcohol-associated ED visits was associated with increasing mortality.

However, we haven’t previously looked at the effect of alcohol in this specific vulnerable age group.



CLINICAL QUESTION: IS A FIRST ED PRESENTATION RELATED TO ALCOHOL ASSOCIATED WITH INCREASED MORTALITY IN ADOLESCENTS AND YOUNG ADULTS?



Reference: Harrison et al. Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol. AEM March 2024.



* Population: Patients aged 12-29 with ≥1 ED visit in Ontario 2009-15.



* Excluded: Patients not resident in Ontario, those who were not eligible for OHIP 2 years before and 3 years after, and those with an alcohol-related ED visit in the 2 years before study commencement.





* Intervention: Any visit related to alcohol

* Comparison: No visits related to alcohol

* Outcomes:



* Primary Outcome(s): Mortality at 1 year

* Secondary Outcomes: Mortality at 3 years, cause of death, predictors of death.





* Type of Study: Retrospective cohort study.



This is an SGEM HOP and we are pleased to have the lead author Dr. Daniel Myran on the show. Dr. Myran is the Canada Research Chair, Social Accountability, University of Ottawa Investigator, Assistant Professor, Department of Family Medicine, University of Ottawa, Associate Scientist, Ottawa Hospital Research Institute with a Cross Appointed School of Epidemiology and Public Health, University of Ottawa



Authors’ Conclusions: “Incident ED visits due to alcohol in adolescents and young adults are associated with a high risk of 1-year mortality, especially in young adults, those with concurrent mental health or substance use disorders, and those with a more severe initial presentation.”



Quality Checklist for Observational Cohort 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? Unsure

* 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? The confidence intervals are well away from zero, so precise enough.

* Do you believe the results? Yes

* Can the results be applied to the local population? Yes and unsure

* Do the results of this study fit with other available evidence?

Reference: Marx et al. Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial. Am J Respir Crit Care Med. 2023

Date: March 22, 2024

Guest Skeptic: Dr. Richard Malthaner holds the prestigious position of Chair/Head of the Division of Thoracic Surgery and serves as the Director of the Thoracic Robotic Program at Western University’s Schulich School of Medicine and Dentistry. Dr. Malthaner currently serves as the Vice President of the Canadian Association of Thoracic Surgeons and is the founder of the Skeptik Thoracik Journal Club.

Case: A 25-year-old female medical student presents with right chest pain and dyspnea.  Chest x-ray (CXR) shows a “complete pneumothorax.”

Background: The first time we got together to discuss chest tubes was on SGEM#129. That episode had two questions. The first question was in a trauma patient, how clinically useful is a CXR after putting in the chest tube?

The answer we came up with was to put the tube on the correct side, within the triangle of safety, and within the pleural space. Continue to obtain a CXR post chest tube knowing it will probably not change management. Be more concerned if the patient is doing poorly or the tube is not draining.

The second question we tried to answer was does chest tube location matter? The answer is that the part of the location that matters in these situations is that the chest tube is safely placed on the correct side and in the pleural space.

The next time were talking chest tubes was not in trauma patients but rather in patients with their first large spontaneous pneumothorax in SGEM#300. We only had one question asking if they all needed a chest tube. The bottom line for that episode was it’s reasonable to provide conservative management in a patient with large first-time spontaneous pneumothoraxes if you can ensure close follow-up.

We have looked at other chest-related issues with other guest skeptics. SGEM#339 looked at the optimal anatomical location for needle decompression for tension pneumothorax with Dr. Rob Edmonds. That study did not support the claim that the second intercostal space-midclavicular line is thicker than the fourth/fifth intercostal space-anterior axial line.

The most recent time we have explored something involving chest tubes was with guest skeptic Dr. Chris Root (SGEM#355). We wanted to know if the size of the chest tube matters in hemodynamically stable patients with traumatic hemothorax. That was a multicenter, non-inferior, unblinded, randomized, parallel assignment comparison trial that reported small percutaneous catheters were non-inferior to large open chest tubes for traumatic hemothorax. 

Patients can present with a spontaneous pneumothorax. This is defined as air in the pleural space between the lung and the chest wall with no obvious precipitating factor. It can occur in existing lung disease (secondary spontaneous pneumothorax) or with no known underlying lung pathology (primary spontaneous pneumothorax).

Chest tube drainage remains the reference first-line treatment of primary spontaneous pneumothorax, however, complications occur in 9–26% of such cases. A less invasive alternative approach is simple aspiration, which could be an option. The best way to manage a first primary spontaneous pneumothorax episode remains unclear.



Clinical Question: Is simple aspiration non-inferior to chest tube drainage for first-line lung e...

Date: March 16, 2024

This is an SGEM Xtra episode. Yes, that is two back-to-back SGEM Xtra episodes. The critical appraisal that was lined up for this week’s episode got delayed due to some scheduling problems with clinical responsibilities. You can access all the slides for this episode from this LINK and see the presentation on YouTube.

This episode is from a talk I gave a few years ago on social media for knowledge translation. How this technology could make the world a better place. I’ve come to recognize that many SGEMers are not very familiar with the best movie decade of all time, the 1980’s. Therefore, I created this talk using the Matrix as a more contemporary theme from the late 1990’s early 2000’s.

The Matrix was a groundbreaking movie created by Lana and Lily Wachowski and released in 1999. It started a movie franchise blending science fiction and action in a visual masterpiece. The first movie introduces us to a dystopian future in which humanity is unknowingly trapped inside the Matrix, a simulated reality created by intelligent machines to distract humans while using their bodies as an energy source or batteries. Thomas Anderson (Mr. Anderson), a computer programmer by day and a hacker named Neo by night, discovers the truth about the Matrix. He is drawn into a rebellion against the machines, led by Morpheus and Trinity. Neo is believed to be “The One,” a prophesized hero destined to end the war between humans and machines. The film explores themes of reality, freedom, and control.

Like Morpheus in The Matrix, “all I’m offering is the truth, nothing more”.



“What if I told you”…Morpheus never says that in The Matrix. Yet “what if I told you” is one of the most well-known Memes. There are many quotes from movies that are wrong/misquoted. Here are three examples of movie misquotes. For a list of the top ten movie misquotes click on the LINK:



* Play it again Sam (Casablanca 1942): That line is never said in the movie Casablanca. Humphrey Bogart actually says ”You played it for her, you can play it for me. If she can stand it, I can. Play it!”.

* Luke, I am your father (Star Wars V The Empire Strikes Back 1980): The actual line by Darth Vader is “No, I am your father.”

* If you build it, they will come (Field of Dreams 1989): James Earl Jones says“People will come, Ray.”



Back to the lecture, Morpheus sitting in the chair wearing cool sunglasses and offering Neo the red and blue pill never said “What if I told you”. In the actual dialogue in the scene, Morpheus says: “Do you want to know what ‘it’ is?”.



What it is for today’s lecture is the problem with knowledge translation and how it can be addressed with Social Media. Trinity tells Neo in The Matrix “It’s the question that drives us, Neo. It’s the question that brought you here. You know the question, just as I did. In the movie, the question was “What is the Matrix”? For this lecture, the question is “How long does it take for high-quality clinically relevant information to reach the patient?



There are a few answers to the question of how long knowledge translation takes in medicine. One answer is from Dr. John Jackson who was a British Neurologist. He said,

Date: March 6, 2024

This is an SGEM Xtra created from a lecture I gave for the Rural Ontario Medical Program (ROMP) ICE Camp Retreat in Collingwood, Ontario last month. ROMP helps Ontario medical students & residents arrange core & elective rotations in rural Ontario. An old friend, Dr. Matt De Stefano invited me to give a lecture to the PGY-3 Emergency Medicine Residents. Matt said it could be a talk on anything so I decided to create a new presentation called “A Philosophy of Emergency Medicine”

This lecture was inspired by the wonderful Professor Melanie Trecek-King. She is a science educator from the USA and has an amazing website called Thinking is Power. I bought a T-shirt from Melanie that says “Be curious, be skeptical and be humble”. Such great wisdom from an amazing science communicator.

For the presentation at ROMP, I made a friendly amendment to Melanie’s three items substituting that last piece of advice “Be Humble” (which is very important) with “Be Teachable” for the audience of PGY3 Emergency Medicine Residents.

If you are interested in seeing all the slides they can be downloaded from this LINK or you can watch the episode on YouTube.



Be Curious: The lecture started not with a 1980s cultural reference but rather with a recent cultural reference from the TV show Ted Lasso. Be Curious, not judgmental.

This was a great show for a variety of reasons and we are planning to do a special SGEM Xtra episode on how the lessons we learned from Ted Lasso made us better. 



Be Skeptical: This is the second important part of my EM philosophy. Carl Sagan is arguably one of the most famous skeptics ever. He in part inspired this knowledge translation project called the Skeptics’ Guide to Emergency Medicine. Probably one of his most famous quotes was that “extraordinary claims require extraordinary evidence”



Be Teachable: The third philosophical point I wanted to make about Emergency Medicine was to encourage you to Be Teachable. This does not just apply to when you are a resident but also when you become an attending physician. You will not always be right.



Be Kind: One more super important thing that you should consider as part of your EM philosophy is to be kind. It is something I learned from Dr. Brian Goldman. Brian is the host of the amazing CBC show White Coat Black Art and has authored several great books. One of the best books he wrote was called The Power of Kindness – Why Empathy is Essential in Everyday Life.



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 ten years to less than one year using the power of social media. So, patients get the best care, based on the best evidence.

If you would like a copy of all the slides used in this presentation simply click on the LINK and you can see all the slides on YouTube.





Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.