87 episodes

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

The Skeptics Guide to Emergency Medicine Dr. Ken Milne

    • Education
    • 4.7 • 56 Ratings

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

    SGEM Xtra: The Matrix – Social Media for Knowledge Translation

    SGEM Xtra: The Matrix – Social Media for Knowledge Translation

    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,

    • 35 min
    SGEM Xtra: A Philosophy of Emergency Medicine

    SGEM Xtra: A Philosophy of Emergency Medicine

    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.

    • 21 min
    SGEM#432: SPEED, Give Me What I Need – To Diagnose Acute Aortic Dissections

    SGEM#432: SPEED, Give Me What I Need – To Diagnose Acute Aortic Dissections

    Reference: Gibbons et al. The sonographic protocol for the emergent evaluation of aortic dissections (SPEED protocol): A multicenter, prospective, observational study. AEM February 2024.

    Date: February 28, 2024

    Guest Skeptic: Dr. Neil Dasgupta is an emergency medicine physician and ED intensivist from Long Island, NY.  He is the Vice Chair of the Emergency Department at Nassau University Medical Center in East Meadow, NY, the safety net hospital for Nassau County.

    Case: A 59-year-old man walks into your community emergency department (ED) complaining of chest pain. It is described as a ripping sensation that radiates to his back. His vital signs are all normal and the ECG done at triage does not show an occlusive myocardial infarction. The chest x-ray is unremarkable, and his troponin is not elevated. You suspect an acute aortic dissection (AoD). However, your CT scanner is offline for two hours of scheduled maintenance. He will need to be transferred to the tertiary care center which is 35 minutes away by ground EMS if it is a dissection. Your Spidey senses are tingling, and you don’t want to wait for the CT scanner to be back online to make the diagnosis. Arrangements are made for him to be transferred stat to the tertiary hospital while he is still stable. You wonder if a quick POCUS examination looking for three sonographic findings while waiting for the paramedics could help determine the likelihood of this being an AoD.

    Background: We recently covered acute aortic syndrome (AAS) on SGEM#430. AAS has been called the lethal triad and includes aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer [1]. It is a rare but deadly condition that can present in atypical ways leading to delays in diagnosis and an associated increase in mortality.

    This episode is going to focus on acute aortic dissection (AoD) which is classified into two major types according to the Stanford classification system: Type A and Type B. This system is based on the location of the tear and helps guide treatment strategies.

    Type A dissections Involves the ascending aorta and may extend into the descending aorta. It’s more common and more dangerous than Type B, as it can lead to serious complications like rupture into the pericardial space leading to cardiac tamponade, aortic valve insufficiency, or myocardial infarction. Symptoms may include more severe chest pain radiating to the back, loss of consciousness, or symptoms of stroke if the blood supply to the brain is affected. Type A AoDs generally require an emergent trip to the operating room as soon as they are identified to reduce the likelihood of a terrible outcome.

    Type B dissections occur in the descending aorta only, after it has passed the arteries that supply blood to the arms and head. They are less common than Type A and usually less immediately life-threatening, but still serious and potentially fatal if not treated properly. Symptoms can include sudden onset of pain in the back or abdomen, depending on the exact location and extent of the dissection. The pain is often described as tearing or ripping.

    Speed is important in making the diagnosis of an AoD due to the associated increase in mortality with delays [2,3]. We know from last week that clinical decision tools (CDTs) are not ready for prime time. This is consistent with the American College of Emergency Physicians (ACEP) which does not recommend the routine use of clinical decision rules in suspected cases of AoD [4].

    • 34 min
    SGEM#341: You Make Me Feel Like a Natural Treatment

    SGEM#341: You Make Me Feel Like a Natural Treatment

    Reference: Li, T., & Gal, D. (2023). Consumers prefer natural medicines more when treating psychological than physical conditions. Journal of Consumer Psychology 2023,

    Date: February 23, 2024

    Guest Skeptic: Ethan Milne is a Marketing PhD student at the Ivey Business School (Western University). He researches how moral outrage and status-seeking personalities motivate social media aggression, and how retribution can motivate consumer donations.

    Case: A 20-year-old male presents to the emergency department with palpitations. After a good history, directed physical examination and appropriate investigations you suspect he is suffering from a major depressive disorder (MDD) with a comorbidity of anxiety.  He is not a threat to himself or others and wants assistance. You arrange for him to be followed up by his family physician to discuss possible treatment options which include medications. He expresses concern that taking a synthetic drug to treat his depression wouldn’t allow him to be his authentic self.

    Background: Major Depressive Disorder, commonly known as depression, is a significant mental health condition. Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease. It affects an estimated 5-10% of the population at any given time, with variations depending on demographic factors such as age and gender. It is generally more common in women than in men and can occur at any age, although it often first appears during late adolescence to mid-20s [1].



    The National Institute of Health (NIH) estimates that around 8.3% (21.0 million) of US adults over 18 have experienced a major depressive episode in the last year. Various factors can increase the risk of developing MDD, including genetic predisposition, personal or family history of depression, major life changes, trauma, stress, and certain physical illnesses and medications. Depression has been reported to be most prevalent among young women aged 12-17 (29.2%) [2].

    The current diagnostic criteria for MDD are outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR). These criteria serve as a guideline for clinicians to diagnose depression. To be diagnosed with MDD, a person must experience at least one of the two symptoms for at least two weeks:



    * Depressed Mood: Most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).

    * Loss of Interest or Pleasure: Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.



    The person must also have five or more of the following symptoms during the same 2-week period, and these symptoms represent a change from previous functioning.



    * Significant Weight Loss or Gain (or decrease or increase in appetite nearly every day)

    * Insomnia or Hypersomnia: Trouble sleeping or sleeping too much nearly every day.

    * Psychomotor Agitation or Retardation: Noticeable by others, not merely subjective feelings of restlessness or being slowed down.

    * Fatigue or Loss of Energy: Nearly every day.

    * Feelings of Worthlessness or Excessive or Inappropriate Guilt: Nearly every day, not merely self-reproach or guilt about being sick.

    * Diminished Ability to Think or Concentrate (or indecisiveness, nearly every day)

    * Recurrent Thoughts of Death: Recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

    • 48 min
    SGEM#430: De Do Do Do, De Dash, Dash DAShED – Diagnosing Acute Aortic Syndrome in the ED.

    SGEM#430: De Do Do Do, De Dash, Dash DAShED – Diagnosing Acute Aortic Syndrome in the ED.

    Reference: McLatchie et al and DAShED investigators. Diagnosis of Acute Aortic Syndrome in the Emergency Department (DAShED) study: an observational cohort study of people attending the emergency department with symptoms consistent with acute aortic syndrome. EMJ Nov 2023.

    Date: February 11, 2024

    Guest Skeptic: Nirdosh Ashok Kumar, Emergency Medicine Specialist – Aga Khan University Hospital, Karachi, Pakistan.

    Case: A 66-year-old female with a history of smoking, hypertension, and type-2 diabetes presents to the emergency department (ED) with syncope while walking her dog. She complains of retrosternal chest pain radiating to her jaw. She is bradycardic, hypotensive, and tachypneic.

    She is received in the resuscitation room. Monitors have been attached, and intravenous (IV) access has been achieved and IV analgesia has been given. The ECG shows sinus tachycardia with non-specific ST-T changes. The chest x-ray is unremarkable. However, she is still in severe pain. A post-graduate year 2 (PGY-2) resident asks you if it could be a ruptured abdominal aortic aneurysm, aortic dissection, or angina.

    Background: The diagnosis of acute aortic syndrome (AAS) is commonly delayed or missed in the ED. AAS has been referred to as the “lethal triad” that incorporates aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU) [1].  It is a rare condition with a high mortality rate and can present in atypical ways. It affects approximately 4,000 people per year in the United Kingdom [2] and 43,000 to 47,000 people per year in the USA [3]. The annual incidence rate of AD ranges between 2.9 and 7.2 per 100,000. [4-8]

    The misdiagnosis rate is estimated to be between 16% and 38%6,[9-19] with a diagnostic delay of up to 24 hours for 25% of cases, and mortality follows a linear increase of 0.5% per hour in the first 48 hours. [20]

    A retrospective observational study from Canadian researcher, Dr. Robert Ohle was published in CJEM in 2023. This study found that between 2003 and 2018, there were 1,299 cases of AAS in Ontario, the largest province in the country. It reported an overall annual incidence rate of 0.61 per 100,000 people which is much lower than previously reported rates. The study also highlighted the significant mortality rate associated with AAS, with a one-year mortality rate decreasing from 47.4% to 29.1%, and ED mortality at 14.9%​​. [21]

    When looking specifically at atraumatic chest pain presentations to the ED, it is estimated the incidence of AAS is one in 980. [22] It can be like looking for a needle in a haystack of chest pain patients. The gold standard for diagnosing AAS is to perform a CT aorta angiogram (CTA). However, scanning everyone chest pain patient would have a very low diagnostic yield [23,24], expose many patients to unnecessary ionizing radiation and end up being very costly. It would be great if there was a validated clinical decision tool (CDT) to help clinicians be more selective in using CTA to diagnose AAS.

    Some CDTs have been devised and tested for diagnosing AAS. [25,26] The Aortic Dissection Detection Risk Score (ADD-RS) is one CDT that has been derived and tested. Four studies with methodologic limitations were included in an SRMA of the ADD-RS and published in AEM 2020. [27] The authors concluded that patients with an ADD-RS score of ≤ 1 with d-dimer 500 ng/mL have high sensitivity for ruling out AASs. However, it is unclear if it is good enough for clinicians to use, better than clinical gestalt [28,29], and an impact analysis has not been done to determine if it would lead to fewer CTAs and d-dimers being performed.



    Clinical Questions: What are the characteristics of ED attendances with possible AAS, how effective are existing clinical decision tools (ADD-RS, Canadian Guideline, Sheffield, AORTAs) and the use of CTA in an undifferentiated cohort of...

    • 35 min
    SGEM #429: It’s CT Angio, Hi. I’m the Problem. It’s Me. For Pediatric Oropharyngeal Trauma

    SGEM #429: It’s CT Angio, Hi. I’m the Problem. It’s Me. For Pediatric Oropharyngeal Trauma

    Reference: Curry SD, et al. Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma. Laryngoscope. March 2023

    Date: January 30, 2024

    Guest Skeptic: Dr. Alexandra (Ali) Espinel is an Associate professor of pediatrics and otolaryngology at Children’s National Hospital and George Washington University. She is also the director of the Pediatric Otolaryngology Fellowship at Children’s National Hospital.

    Case: You’re working the morning shift in the emergency department (ED) when you encounter a 3-year-old boy and his family. His parents tell you that he was getting ready to go off to daycare and brushing his teeth while standing on a step stool by the sink. He slipped and the toothbrush poked him in the back of the mouth. Initially, his parents noticed that he was bleeding from his mouth and saw what looked like a wound towards the back of his throat. The boy cried immediately afterwards but has otherwise been acting like himself. On your exam, you notice a small penetrating intraoral injury just lateral to the soft palate without evidence of continued bleeding. His parents ask you, “Is he going to be, okay? We’re glad he’s not bleeding anymore. Do you think he needs any imaging to see if he hurt anything?”

    Background: Kids like to put things in their mouths. Kids like to run around. Sometimes, kids may fall while having something in their mouth which may cause damage to their oropharynx.

    The ensuing damage can vary. It could be blunt trauma or penetrating trauma. We get concerned about injuries to the soft palate because of possible deep space neck infection and the risk of injury to the carotid artery behind it which has been associated with thrombosis, dissection, and cerebral infarctions.

    These super scary complications have been reported in the literature but seem relatively rare. We have many clinical decision tools for imaging in pediatric head trauma [1] or abdominal trauma [2]. But we do not have any of the same tools for oropharyngeal injury which means that there is wide variation about which imaging studies are ordered.



    Clinical Question: What is the role of CT angiography (CTA) in the diagnosis and management of pediatric oropharyngeal trauma?



     Reference: Curry SD, et al. Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma. Laryngoscope. March 2023



    * Population: Patients 18 years old with trauma to the oropharynx. They included meta-analyses, systematic reviews, randomized control trials (RCTs), case-control and cohort studies, case series and case reports.



    * Excluded: Oropharyngeal trauma combined with other severe head injury or multisystem trauma, not primary research, non-English publication





    * Intervention: CTA

    * Comparison: No CTA

    * Outcome: radiologic and clinical outcomes including infection, injury to vasculature, cerebrovascular injury, and neurologic abnormalities.

    * Type of Study: Systematic Review and Meta-Analysis of diagnostic studies.



    Authors’ Conclusions: “Imaging with CTA yielded radiological abnormalities in a few instances. These results do not support the routine use of CTA in screening pediatric oropharyngeal trauma when balanced against the risk of radiation, as it rarely resulted in management changes and was not shown to improve outcomes.”

    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 was assessed for common forms of diagnostic research bias. Yes.

    * The assessment of studies was reproducible. Yes

    • 18 min

Customer Reviews

4.7 out of 5
56 Ratings

56 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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