The Skeptics Guide to Emergency Medicine Dr. Ken Milne

Reference: Snelling et al. Ultrasonography or radiography for suspected pediatric distal forearm fractures. New England Journal of Medicine June 2023

Date: July 19, 2023

Guest Skeptic: Dr. Casey Parker is a Rural Generalist that includes in his practice emergency medicine, anesthesia, and critical care. He is also a fully-fledged ultrasonographer. Casey currently splits his time between Broome, a small rural hospital in the remote Kimberley region of Western Australia, and a large tertiary ED in sunny Perth. He has been a guest skeptic on the SGEM multiple times. He is also the creator of the amazing #FOAMed website, Broome Docs.

Case: It is a steady Saturday afternoon in your rural emergency department (ED). The triage nurse calls you to have a look at a child who has arrived with his parents in ED after falling from a bouncy castle at a birthday party.  He is six years old and appears to be in pain with his left wrist swaddled in an ice pack.  He tells you that he was attempting “a double backflip like Spiderman” when he landed heavily on the outstretched hand – this happened about an hour ago. Clinically there is some swelling and tenderness over the distal radius but no deformity.  He has good perfusion and no neurological symptoms in the hand. Because it is a small, rural ED there is no radiographer on site but they can be called in if we would like to get an X-ray…. or there is a portable bedside ultrasound machine in the next room ready to go. The child’s mother tells you that the X-ray tech was also at the party having a great time with her children. So, the question is: should we call in our x-ray tech in and disrupt her party fun or just use the ultrasound machine to diagnose this possible fracture?

Background: We have covered pediatric wrist fractures a few times on the SGEM. This includes SGEM#19 way back in 2013 reporting a bandage wrap is a safe alternative to traditional casting for children with greenstick fractures. More recently, the amazing Dr. Tessa Davis covered the FORCE trial on SGEM #372 which looked at buckle fractures and compared immobilization in a cast or splint vs. a soft bandage and they found no difference in pain scores or functional outcomes.

The use of bedside ultrasound to diagnose uncomplicated wrist injuries in children has been studied in several diagnostic prospective, observational trials to compare its accuracy to traditional plain film X-rays [1-5].  Most of these trials have shown diagnostic sensitivity and specificity above 90% when compared to X-ray as a gold standard.  This same research team from Queensland in Australia have also published a paper describing the learning curve for novices in detection of forearm fractures in kids [6]. 

In 2022 Mobasseri et al published a review of 9 such diagnostic studies and concluded that from an orthopedic perspective that the accuracy was not acceptable, the lack of a randomized controlled trial meant that there was not enough data to support the use of ultrasound over X-ray as an initial diagnostic test [7].

There have been no randomized trials that have compared the patient-centered, functional outcomes after a wrist injury based upon the choice of initial diagnostic test modality.



Clinical Question: In children with non-deformed distal forearm injuries, does the use of ultrasound as an initial diagnostic test result in inferior functional outcomes?



Reference: Snelling et al. Ultrasonography or radiography for suspected pediatric distal forearm fractures. New England Journal of Medicine June 2023

Date: August 30, 2023



Reference: Griffey et al. The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics. AEM August 2023

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.

This is the last show for Season#11. It has been a great year with the addition of PedEM SuperHero Dr. Dennis Ren. We have some exciting news to cap off the end of this amazing year. Suchi will be joining the SGEM faculty as part of the Hot Off the Press team.

Case: A 28-year-old male with a history of type-1 diabetes mellitus presents to the emergency department (ED) with increase in thirst and light headedness. He is otherwise healthy. Blood glucose in triage is 489 mg/dl (27.2 mmol/L). Venous blood gas (VBG) shows an acidosis with a pH of 7.21. Electrolytes show a gap of 21. The patient’s symptoms begin to improve after initial intravenous (IV) fluid administration of one litre of 0.9% saline. The patient states he has had multiple “diabetic emergencies” in the past and usually ends up in the intensive care unit (ICU) on a drip. He is wondering, “Hey doc, do I have to go back to the ICU strapped to an IV pole?” The flow nurse has similar questions for you and wants to know if she should clear out a bed in the critical care bay so that the patient can have appropriate nursing requirements for an insulin infusion. Your resident is eager to go ahead and sign off on the diabetic ketoacidosis (DKA) insulin order set and the ICU attending’s “Spidey senses” are going off. They are on the phone asking you if you already have another admission for them on this busy day. However, the ICU is full and the patient will likely be boarding in your ED for a bit before coming upstairs. Just as all this is happening, you notice how the waiting room is filling up and you can hear the sirens of approaching ambulances becoming louder. You take a deep breath, and you think to yourself…let the squid games begin.

Background: DKA is a common yet potentially fatal condition seen in patients with type 1 diabetes. It accounted for roughly 8.9 ED visits /1000 adults with diabetes [1]. DKA results in over 500,000 annual hospital days with estimated annual hospital costs of over $5 billion [2].

Despite how common and expensive the management of DKA can be, we have only looked at it once on the SGEM. That was an episode covering the practice changing randomized control trial published in NEJM by Dr. Nathan Kuppermann from the PECARN Team for pediatric DKA [3]. They reported that the type of intravenous fluids (0.45% NaCl or 0.9% NaCl) or speed of infusion did not appear to make a clinically important difference (SGEM#255).

Because of the complexity of care around managing DKA, the typical approach is an insulin drip with ICU level of care for all degrees of severity. Increased resource utilization around this can prolong ED length of stay, especially in the context of a busy hospital or a global pandemic.

However, over the past 20 years, there is burgeoning evidence that fast-acting subcutaneous insulin analogs could be a potential treatment option for mild to moderate severity DKA including a 2016 Cochrane SRMA [4]. If proven to be a safe and effective management strategy, this would eliminate the need for an insulin drip and opens new options for management and disposition of DKA patients from the ED.

Date: August 20th, 2023

Reference: Milne WK, Challen K, Young T. Skeptics’ Guide to Emergency Medicine Season #10 Book

Guest Host: Dr. Kirsty Challen is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). She completed undergrad and postgrad training in North West England, acquiring a History of Medicine BSc, a PhD in Health Services Research, an anesthesiologist husband and four children along the way. She is Chair of the Royal College of Emergency Medicine Women in Emergency Medicine group, and involved with the RCEM Public Health and Informatics groups. Kirsty also produces all those wonderful Paper in a Pic Infographics summarizing each SGEM episode.

Guest Skeptic: Dr. Tayler Young is a second year Family Medicine resident at Queen’s University in Kingston, Ontario, Canada. Her interests are quality improvement, Free Open Access Medical Education (FOAMEd) and point of care ultrasound (POCUS).

This is an SGEM Xtra to announce that SGEM Season #10 is now available as a FREE pdf book. The SGEM provided the content and Tayler designed the book. She has designed infographics for the Emergency Medicine Ottawa Blog and has summarized SGEM Season #8 and Season #9 with the Avengers and Batman themes.

Tayler chose a Harry Potter theme for Season #10 as she is a huge fan of the films and the books. Her favorite character is Norbert the dragon who was secretly hatched by Hagrid in Book 1.

Kirsty’s favourite character from the Harry Potter series (being a woman in academic EM, still a male-dominated world – see SGEM #352 on the gender pay gap and our Xtra from October 2021 with the wonderful Dr. Suchi Datta about gender inequity) is Hermione Granger. She is the competent skilled witch who faces pushback for knowing the answers and ostracism for not fitting in. She also confesses to having a soft spot for Neville Longbottom, who is quietly ignored and disregarded until trouble really happens and he comes through with the sword of Gryffindor.



SEASON #10 Foreword by Dr. Kirsty Challen



Harry Potter arrived in our consciousness in 1997 as an unsupported orphan venturing into the magical world for the first time, facing the ever-present but initially under-appreciated threat of Voldemort with Ron and Hermione. The Skeptics Guide to Emergency Medicine was a few years behind, emerging into the #FOAMEd-o-sphere in 2012, but as Harry and his world developed through the books, so has the SGEM.

This 10th Edition arrives as advocates of Evidence-Based Medicine continue to tackle the forces of misinformation and pseudoscience. Like Voldemort rising slowly back to power, many in the Ministry of Magic office of academic medicine failed to spot or believe the level of influence social media would have in the world of 2023. Ken Milne was an early adopter of using social media to narrow the knowledge tra...

Date: August 14, 2023



Reference: Ma et. al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet 2023

Guest Skeptic: Dr. Mike Pallaci is a Professor of Emergency Medicine (EM) for the Northeast Ohio Medical University, and an Adjunct Clinical Professor of EM for the Ohio University Heritage College of Osteopathic Medicine. He has been program director for two EM residency programs, and is currently a core faculty member for the EM residency at Summa Health System in Akron, OH, where he also serves as the Medical Director of the Virtual Care Simulation Lab.

This episode originated because of a thread Mike posted on the social media site formerly known as Twitter.  The tweet said: “I am sick and tired of some non-EM docs/specialists slamming EM when we don’t aggressively lower BP in ICH.” It certainly got a lot of attention.





It got a lot of attention both on the positive side (mostly from EM docs who share the frustration) and on the negative side from some neurologists who didn’t seem to particularly care for the premise of the tweet or for the generally positive response. It started out with venting on Twitter about an unpleasant interaction with one of Mike’s partners and turned into a week-long discussion that culminated in an invitation to be the guest skeptic on the SGEM to critically appraise INTERACT-3.

Mike backed up his position on blood pressure (BP) lowering using evidence. Specifically, he pointed out that the evidence behind the guidelines re BP management in intracranial hemorrhage (ICH) is relatively weak.

This received a mixed response on Twitter. Most EM physicians shared the frustration and made positive comments. Some neurologists disagreed with the premise of the tweet and challenged it.

I responded by posting the 2013 SGEM episode on INTERACT-2 (SGEM#73) which showed no statistical difference between intensive (140 mmHg) and guideline directed (180 mmHg).  In 2017, the SGEM reviewed the ATACH-2 trial (SGEM#172) which showed similar results.

A meme was also posted of Charlton Heston from the classic movie the Ten Commandments. It emphasized that GUIDElines are not GODlines. The literature should inform and guide our care, but it should not dictate our care. This is a core principle of evidence-based medicine (EBM). Often the available evidence on a specific medical question is weak. We still need to apply our clinical judgement and ask the patient about their values and preferences.

Case: A 67-year-old male presents to the emergency department obtunded with left hemiplegia.  Symptoms began just prior to presentation.  His blood pressure (BP) is 194/110 mmHg.  CT reveals a hemorrhage in the right internal capsule, suggestive of acute hypertensive hemorrhagic stroke.  Should the blood pressure be treated?  If yes, what should the target blood pressure be? How quickly do we want to get there? And are there any other physiologic variables we want to be aggressive about controlling in the early treatment window?

Background: We have covered the common issue of elevated BP after ICH on a href="https://thesgem.

Reference: Easter JS et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Annals of Emergency Medicine 2014.

Date: July 10, 2023

Guest Skeptic: Dr. Joe Mullally is a paediatric trainee in the Welsh paediatric training program and interested in Paediatric Emergency Medicine. He is a student in the Paediatric Emergency Medicine Masters Program through Queen Mary University in London in collaboration with the Don’t Forget the Bubbles team.

Background: Children have big heads proportionally to their body compared to adults which makes them more at risk of traumatic brain injury (TBI). Computerized tomography (CT) is commonly used in the emergency department in the diagnosis of TBI. But we’re always trying to balance the potential harms and potential benefits in medicine. A CT scan does mean radiation to the pediatric brain which can increase the risk of leukemia or brain cancer later [1]. Thankfully, clinically important intracranial injuries are rare in children [2]. So, should we CT scan children with minor head injury?

The SGEM covered pediatric concussions and head imaging in SGEM #112 and the NEXUS II Pediatric Head CT Decision Instrument in SGEM #225. Today we’re talking about three other popular clinical decision rules (PECARN, CATCH, and CHALICE). But we also want to know, how do those rules compare to physician judgement?



Clinical Question: What is the diagnostic accuracy of clinical decision rules and physician judgment in identifying clinically important traumatic brain injuries (TBI) in children with minor head injury?



Reference: Easter JS et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Annals of Emergency Medicine 2014.



* Population: Children less than 18 years of age presenting with head injury to a level 2 pediatric trauma center in the United States between 2012-2013. These children have to have 1) history of signs of blunt injury to the head 2) GCS scores ≥13, 3) injury within the previous 24 hours prior to presentation, 4) physician concern for potential TBI



* Excluded: Heightened TBI risk (GCS24 hours after injury





* Intervention: CT vs no CT

* Comparison: Comparison of PECARN, CHALICE, CATCH, physician judgement, and physician practice

* Outcomes:



* Primary Outcome: “Clinically important TBI” defined as death from TBI, need for neurosurgery, need for intubation >24hrs for TBI, or hospital admission >2 nights for TBI.

* Secondary Outcomes:

TBI on scan

TBI requiring neurosurgery (craniotomy, elevation of skull fracture, monitoring of intracranial pressure, or intubation for elevated intracranial pressure)





* Type of Study: Single center prospective cohort study



Authors’ Conclusions: “Of the 5 modalities described (PECARN, CATCH, CHALICE, physician judgment and physician practice),

Date: July 21, 2023

Reference: McDonald et al. Patterns of change in prehospital spinal motion restriction: a retrospective database review. AEM July 2023

Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM.

Case: A 42-year-old is struck in the face by a slowly moving I-beam at work. He has a brief loss of consciousness (LOC) and then awakens and is ambulatory on scene. Emergency Medical Services (EMS) is called and on arrival the patient is walking but has obvious facial trauma and is complaining of some neck pain. He has midline neck tenderness but no limb numbness or paresthesia. As an EMS crew member, you are tasked with deciding what method of spinal motion restriction to use.

Background: We have covered head injuries including concussions multiple times on the SGEM. This has included looking at the Canadian CT Head Rules/Tools (SGEM#106, SGEM#266, and SGEM#272). We have also covered concussions (SGEM#112, SGEM#331, and SGEM#362).

Another core element of emergency department (ED) and pre-hospital care is the assessment for potential spinal injuries [1,2].  Patient care and positioning has evolved over time, previously routine spinal immobilization (SI) was with a cervical spine collar, placement on a long, rigid backboard, and straps or head blocks.



Over time this has evolved to spinal motion restriction (SMR) with more variable use of cervical collars, patient positioning, and accessories such as head rolls and tape [3-4]. This has evolved due to recognition of some of the adverse effects of immobilization as well as limitations to its benefits.

The role of the cervical collar itself varies by jurisdiction and it is not entirely clear which devices and procedures are most effective at reducing potentially harmful spinal motion [5-11]. Existing research on SMR confirms decreases in the use of long backboards and increases in collar-only treatment [12-14].  Some of this research has observed substantial under-treatment among patients who met criteria for precautions, as well as some patients with confirmed injuries who received no treatment from EMS [15-16].

Other studies have observed no increase in the diagnosis of cervical spine injuries, however, variable practice and the possibility of patients not receiving appropriate treatment remains a concern [17-18]. In order for standards for acute management of spinal injuries to progress, we must optimize patient protection and limit harm [19].



Clinical Question: How has the rate of pre-hospital spinal immobilization/spinal motion restriction changed from 2009 to 2020?



Reference: McDonald et al. Patterns of change in prehospital spinal motion restriction: a retrospective database review. AEM July 2023



* Population: EMS patients with traumatic injuries



* Excluded: None





* Intervention: Spinal immobilization/spinal motion restriction