87 episodes

Meet 'em, greet 'em, treat 'em and street 'em

The Skeptics Guide to Emergency Medicine Dr. Ken Milne

    • Education
    • 4.7 • 54 Ratings

Meet 'em, greet 'em, treat 'em and street 'em

    SGEM#369: Romeo is Bleeding – Does He Need a RePHILL?

    SGEM#369: Romeo is Bleeding – Does He Need a RePHILL?

    Date: June 18th, 2022

    Reference: Crombie et al. Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. The Lancet Haematology 2022

    Guest Skeptic: Dr. Casey Parker is a Rural Generalist that includes in his practice emergency medicine, anaesthesia and critical care. He is also now a fully fledged “sonologist”. Casey currently splits his time between Broome, a small rural hospital in the remote Kimberley region of Western Australia, and a large tertiary ED in sunny Perth.

    Case: You are working in the emergency department (ED) and receive a call from the Advanced Care Paramedics who are at the scene of a stabbing. Apparently, two rival gangs (Jets and Sharks) had a rumble. The young man has been stabbed in the abdomen and lost a lot of blood. The patient is tachycardic (120 beats/minute), hypotensive (80/60 mmHg) and looks very pale. They have two large bore intravenous (IV) access and are planning to bring them to your ED as soon as possible. The paramedic asks you, “we have saline, and we also have red-cells and this fancy new lyophilised plasma.  Should we give our shocked patient saline or plasma / red cells en route to the ED?”  What do you advise him? 

    Background: The use of fluids in trauma resuscitation has been studied in a number of trials in recent years. A lot of observational data has been collected from the battlefields of Iraq and Afghanistan.

    The Control of Major Bleeding After Trauma (COMBAT) Trial was published in the Lancet in 2018. It was a pragmatic, randomised, single-centre trial done at the Denver looking at the use of plasma in the prehospital setting. This trial did not show a statistical mortality benefit within 28 days of injury. First10EM and REBEL EM both did a review of the COMBAT trial. 

    The Prehospital Air Medical Plasma (PAMPer) trial was published in NEJM, also in 2018.  The goal of this trial was to determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock. This trial did report that prehospital administration of plasma was safe and resulted in lower 30-day mortality. PAMPer was reviewed by First10EM and The Bottom Line. 

    The traditional teaching in trauma is to replace blood with blood products, so we would expect that we should see a benefit if we used blood and plasma instead of saline alone for the initial resuscitation.



    Clinical Question: In the resuscitation of pre-hospital trauma patients with hemorrhagic shock is there a patient-oriented benefit to using blood and plasma over 0.9% saline?



    Reference: Crombie et al. Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. The Lancet Haematology 2022



    * Population: Adult patients 16 years of age or older suffering traumatic injury resulting in shock believed to be due to a traumatic haemorrhage. Shock was defined as a systolic BP less than 90 mmHg or an absent radial pulse. 



    * Exclusions: Patients known to refuse blood produces,

    • 27 min
    SGEM#368: Just A Normal Saline Day in the ICU – The PLUS Study

    SGEM#368: Just A Normal Saline Day in the ICU – The PLUS Study

    Date: June 12th, 2022

    Reference: Finfer et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. NEJM 2022.

    Guest Skeptic: Dr. Aaron Skolnik is an Assistant Professor of Emergency Medicine at the Mayo Clinic Alix School of Medicine and Consultant in the Department of Critical Care Medicine at Mayo Clinic Arizona.  He is board certified in Emergency Medicine, Medical Toxicology, Addiction Medicine, Internal Medicine-Critical Care, and Neurocritical Care.  Aaron is a full-time multidisciplinary intensivist.  He is the Medical Director of Respiratory Care for Mayo Clinic Arizona and is most proud of his position as medical student clerkship director for critical care.

    Case: A 62-year-old man is brought in by EMS from home with lethargy and hypotension.  Chest x-ray is clear, labs are remarkable for a leukocytosis of 16,000 with left shift; exam is notable for left flank pain and costovertebral tenderness.  Straight catheter urinalysis is grossly cloudy, and pyuria is present on microscopy.  Blood pressure is 85/50 mmHg.  You wonder which IV fluid should you order?



    Background:  There has been a longstanding debate about which intravenous fluid is the best for volume resuscitating critically ill patients.  We’ve known for some time that albumin is bad for injured brains, and that hydroxyethyl starch solutions have been associated with kidney injury and mortality.  Since then that debate has broadly centered on the choice between what we will call “abnormal saline” (0.9% sodium chloride), and balanced crystalloid solutions, meaning those with a chloride composition closer to plasma such as lactated ringer’s or Plasma Lyte 148.

    Early work suggested potential harm from 0.9% saline, that may be partly driven by kidney injury associated with the administration of high-chloride content IV fluids.



    In the last few years, the pendulum has swung back and forth.  Two large, cluster-randomized trials (SMARTand SALT-ED) showed a small benefit to the use of balanced crystalloids in preventing a composite outcome of Major Adverse Kidney Events within 30 days (aka MAKE-30).

    Then, the BaSICS trial (a multicentred RCT done in 75 Brazilian ICUs) came along and compared saline to Plasma-Lyte at what the authors deemed slow and fast infusion rates.  We reviewed that last time on SGEM#347. There was no interaction between fluid type or rate of infusion with the primary outcome of 90-day survival.  Among 19 secondary outcomes, which should only be considered hypothesis generating, SOFA scores and neuro SOFA scores at day seven were worse in the balanced crystalloid group.

    Now we have the PLUS trial, from Australia and New Zealand to add to the medical literature on this issue.



    Clinical Question: Is the 90-day mortality in critically ill adult patients lower with the use of Plasma-Lyte 148, a balanced crystalloid solution, for fluid resuscitation and therapy, than with the use of normal saline?



    Reference:  Finfer et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. NEJM 2022.



    * Population: Patients 18 years or older, admitted to 53 ANZ ICUs over 38 months, whom the treating clinician deemed to need fluid resuscitation and were expected to be in the ICU on three consecutive days.



    Exclusions: Patients with specific ICU fluid requirements, those who received disqualifying fluid prior to enrollment (> 500 mL in the ICU),

    • 24 min
    SGEM#367: GRACE2 – Low-Risk, Recurrent Abdominal Pain

    SGEM#367: GRACE2 – Low-Risk, Recurrent Abdominal Pain

    Date: May 24th, 2022

    Reference: Broder et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department. AEM May 2022

    Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com

    Case: A 33-year-old male presents to the emergency department (ED) complaining of abdominal pain. He states he has had the same pain for more than 10 years, and no one has ever been able to figure out what is going on. He doesn’t have any specific symptoms today, including no fever, vomiting, diarrhea, or urinary symptoms. His vital signs are normal. His abdomen is diffusely tender, but without any surgical findings. You review his chart and note that he has had five CTs performed in the last year at your hospital alone, all of which were negative. You are worried about the cumulative radiation dose he has received but find it hard to exclude significant pathology on history and physical. After all, even patients with chronic abdominal pain can develop a new acute issue like appendicitis.

    Background: The Society of Academic Emergency Medicine (SAEM) has launched an initiative called GRACE which stands for Guidelines for Reasonable and Appropriate Care in the Emergency Department.

    The first GRACE publication looked at low risk chest pain, and in my opinion, they filled a very valuable role. Most guidelines focus on a single emergency visit in isolation, but a patient who presents to the emergency department recurrently with the same symptoms may require a different approach. In the context of recurrent chest pain, they made eight key recommendations. The SGEM bottom line was there is moderate level of evidence that ACS can be excluded in adult patients with recurrent, low-risk chest pain using a single hs-troponin below a validated threshold without further diagnostic testing in patients who have a CCTA within the past two years showing no coronary stenosis.

    The writing group of GRACE-2 wanted to look at clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the ED. Through consensus, four questions were developed and then a systematic review of the literature was performed. This literature was then synthesized to come up with recommendations, following GRADE methodology.

    GRADE stands for Grading of Recommendations, Assessment, Development, and Evaluation, it was pioneered at McMaster University, in creating rigorous, transparent, and trustworthy guidelines on common clinical problems for EM physicians that are not always directly studied in EM research activities.

    There can be many presentations for low-risk abdominal pain. We have covered cannabis hyperemesis on SGEM#318 and SGEM#46 and pediatric gastroenteritis on SGEM#254.



    Clinical Question: What are the recommendations for managing patients with low-risk, recurrent, previously undifferentiated abdominal pain in the ED?



    Reference: Broder et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department. AEM May 2022

    This is an SGEMHOP episode which means we have the lead author on the show. Dr. Joshua Broder is the Residency Program Director and Vice Chief for Education In the Divisi...

    • 46 min
    SGEM#366: Relax, Don’t Do It – Skeletal Muscle Relaxants for Low Back Pain

    SGEM#366: Relax, Don’t Do It – Skeletal Muscle Relaxants for Low Back Pain

    Date: May 13th, 2022

    Reference: Abril et al. The Relative Efficacy of Seven Skeletal Muscle Relaxants. An Analysis of Data From Randomized Studies. J Emerg Med 2022

    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 and specifically the use of ketamine. His twitter handle is @PainFreeED.

    Case: A 45-year-old man without a significant past medical history presents to your emergency department (ED) with two days of severe lower back pain after shoveling some dirt. The pain is 10/10 in intensity, gets worse with bending, turning, and prolonged walking. He denies numbness or paresthesia in both lower extremities, as well as bowel or bladder dysfunctions. A heating pad and acetaminophen has not helped with the pain. On examination, he is in moderate distress and has prominent tenderness to palpation at the bilateral paralumbar region and intact neurovascular examination. You diagnose him with a lumbar muscle strain and plan to prescribe him a non-steroidal anti-inflammatory (NSAID) while setting expectations. However, the patient wonders if you can give him something that can relax his back muscles and take his pain away.

    Background: Low back pain (LBP) is one of the most encountered ailments in clinical practice and is responsible for 2.6 million visits to U.S. EDs annually (1). Many patients with acute LBP experience substantial improvement in the first month, but up to one third report persistent back pain, and 1 in 5 report some limitations in activity. These persistent symptoms are associated with high costs, including those related to health care, and indirect costs from missed work or reduced productivity (2).

    Many pharmaceutical treatments besides opioids have been tried to address acute LBP pain with limited success (SGEM#87 and SGEM#173). These include: acetaminophen (Williams et al Lancet 2014), steroids (Balakrishnamoorthy et al Emerg Med J 2014) and benzodiazepines (Friedman et al Ann Emerg Med 2017). Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line medication therapy for patients with LBP despite a lack of evidence of efficacy (Machado et al Ann Rheum Dis 2017),

    There are several non-pharmaceutical treatments that have also been tried to treat LBP. They include: CBT and mindfulness (Cherkin et al JAMA 2016), chiropractic (Paige et al JAMA 2017), physical therapy (Paolucci et al J Pain Research 2018) and acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013). Unfortunately, none of these other treatment modalities has high-quality evidence supporting their use.

    Skeletal muscle relaxants (SMRs) are a frequently used in the ED and at discharge for acute back pain management and include methocarbamol, cyclobenzaprine, orphenadrine, carisoprodol, tizanidine, metaxalone, and baclofen. Estimates suggest up to 35% of patients with nonspecific low back pain are pr...

    • 26 min
    SGEM Xtra: She Blinded Me with Science Communication

    SGEM Xtra: She Blinded Me with Science Communication

    ,Date: April 19th, 2022

    Guest Skeptic: Sarah Mojarad is a Lecturer in Advanced Writing, #SciComm, & Mis/disinfo topics • Kavli Fellow • Reed Awardee.

    This is an SGEM Xtra episode. When planning a brief trip to Los Angeles for the EMRAP One Conference, I remembered that Sarah is from LA. I thought to myself, perhaps she would come on the SGEM as a special guest. I’m happy to say Sarah graciously accepted the invitation.

    We recorded the episode sitting outside on the patio at the Luskin Conference Centre. It is an example of how twitter can be a great way for making new friends.

    When I reached out to Sarah for a topic for the podcast she suggested five tips for science communication (SciComm) using social media. She shared with me a short YouTube video she had made for students interested in SciComm. We based our discussion on that video. It is clearly not an exhaustive list of tips but it did serve as the basis of our discussion. You can hear our conversation on the SGEM Xtra Podcast.



    Five Tips for Science Communication



    Tip #1: Be Yourself

    I think this is such an important piece of advice. Authenticity really resonates with people. One of the best compliments I received recently was from a wonderful dental student named Ellie from Schulich School of Medicine and Dentistry. We met at an Interprofessional Educational event, and she said it was so great to meet someone IRL who is so much like their twitter feed.

    Follow me and you will find out I am a huge advocate for evidence-based medicine (EBM), love Star Trek TOS, have a dog named Loki the Dog of Mischief, upset other physicians like neurologists when discussing the evidence for tPA in acute ischemic stroke, I think the 80’s is the best era for music/movies, and have been known to play BatDoc at times.



    Tip #2: Don’t’ Be Afraid of Failing

    Another great tip. One of the best presentations I gave was about my many failures. The joke was that first grade was the longest two years of my life because I needed to repeat grade one. I failed to get into medical school the first time. I felt guilty and inadequate when I could not complete my orthopaedic residency. These and so many other “failures” that cause a lot of pain over the years.



    However, as Maya Angelou said: “Without defeats, how do you really know who the hell you are? If you never had to stand up to something – to get up, to be knocked down, and to get up again – life can walk over you wearing football cleats. But each time you do get up, you’re bigger, taller, finer, more beautiful, more kind, more understanding, more loving. Each time you get up, you’re more inclusive. More people can stand under your umbrella.”



    Tip #3: Find A Mentor

    I have had many mentors over the years. These include amazing people like: Dr. Kirsty Challen, Dr. Andrew Worster, Dr. Dara Kass, Dr. Michelle Johnson, Dr. Rick Bukata, Dr. Chris Carpenter and many, many more people who have helped me get where I am today.

    Tip #4: What Do You Want to Say?

    What is your message? Do you have a story, a narrative or goal in mind? My goal for the SGEM is to provide structured critical appraisals of the recent literature and probe it for i...

    • 31 min
    SGEM#365: Stop! It’s Not Always Hammer Time

    SGEM#365: Stop! It’s Not Always Hammer Time

    Date: April 16th, 2022

    Reference: Blom et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021

    Guest Skeptic: Dr. Matt Schmitz, Pediatric Orthopedics, Adolescent Sports Medicine and Young Adult Hip Preservation Surgeon at San Antonio Military Medical Center in Texas.





    Disclaimer: The views and opinions of this blog and podcast do not represent the United States Government or the US Military.





    Case: A 55-year-old man comes into the emergency department (ED) for increasing knee pain and decrease in function. He’s had an anterior cruciate ligament (ACL) repair and used to run marathons. However, he is finding it more difficult to even put his socks on. Physical exam shows varus deformity at the knee, decreased range of motion, crepitus, no locking and neurovascularly intact distal. X-rays show severe, tri-compartment arthritis.

    Background: Musculoskeletal complaints are one of the most common presentations to emergency departments. Often emergency physicians are assessing, treating, and answering patients question about orthopedic surgical procedures. How good is the evidence for the most common elective procedures?

    Before we answer that question, let’s remind everyone that only a small number (2.8%) of interventions published in SRMA and relevant to emergency medicine have unbiased and strong evidence for improved outcomes (SGEM#361).

    This is a broader problem in medicine. Tricoci et al. JAMA Feb 2009 looked at the ACC/AHA guidelines from 1984 to 2008. They found 53 guidelines with 7,196 recommendations. Only 11% of recommendations were considered Level A, 39% were Level B and 50% were Level C.

    An update was published by Fanaroff et al in JAMA 2019. The level of high-quality evidence had not changed much when looking at the ACC/AHA guidelines from 2008-2018. There were 26 guidelines with 2,930 recommendations. Now Level A recommendations were down to 9%, Level B 50% and Level C 41%.

    Time to turn our skeptical eye to the evidence for elective orthopaedic procedures.



    Clinical Question: What is the effectiveness of common elective orthopaedic procedures compared with no treatment, placebo, or non-operative care?



    Reference: Blom et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021



    * Population: Meta-analyses of randomised controlled trials



    * Exclusions: Network meta-analyses (when pairwise meta-analyses were available), narrative reviews, systematic reviews that did not pool data or do a meta-analysis, and meeting abstracts





    * Intervention: Surgery

    * Comparison: No treatment, placebo, or non-operative care

    * Outcome: Quality and quantity of evidence behind the ten most common elective orthopaedic surgeries and comparisons with the strength of recommendations in relevant national clinical guidelines.



    Authors’ Conclusions: “Although they may be effective overall or in certain subgroups, no strong, high quality evidence base shows that many commonly performed elective orthopaedic procedures are more effective than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations.”

    Quality Checklist for Therapeutic Systematic Reviews:



    * The clinical question is sensible and answerable.  Yes/Unsure

    * The search for studies was detailed and exhaustive. Yes

    • 22 min

Customer Reviews

4.7 out of 5
54 Ratings

54 Ratings

DJ General Delivery ,

Amazing Free Open Access Medicine Content.

The SGEM (skeptics guide to emergency medicine) has been providing evidence based reviews and high quality fun education to emergency physicians for 9 years now. Dr Milne is entertaining, organized, and a world renowned educator in EBM and emergency medicine. What sets him apart is the quality of the topics and papers reviewed, coupled with his skill and fairness at looking at the impact of new information on patient care and work in day to day emergency medicine. As a rural academic emergency physician, this is my go-to source for keeping up with topics. I highly recommend for all students, residents, and practicing emergency professionals including MD’s, Nurses, PAs, and Paramedics. For rural physicians, this is a great way to stay current with useful emergency medicine topics.

Gorsh ,

Political

I am here to learn about emergency medicine....not to be preached to about race relaions...ughhh.

JGC Photos ,

Very informative

Very informative and Dr. Milne is very knowledgable.

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