92 episodes

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

The Skeptics Guide to Emergency Medicine Dr. Ken Milne

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

    SGEM#344: We Will…We Will Cath You – But should We After An OHCA Without ST Elevations?

    SGEM#344: We Will…We Will Cath You – But should We After An OHCA Without ST Elevations?

    Date: September 8th, 2021

    Reference: Desch et al. The TOMAHAWK Investigators. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation. NEJM 2021.

    Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. He heads curriculum and conference for the academic year and is passionate about resident education on- and off-shift, from procedural to evidence-analytical. 

    Dr. Kaushal Khambhati is also a fourth-year resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program.  He is interested and experienced in healthcare informatics, previously worked with ED-directed EMR design, and is involved in the New York City Health and Hospitals Healthcare Administration Scholars Program (HASP).

    Five Rules of the SGEM Journal Club

    Case: A 70-year-old woman is found unresponsive and apneic at home by her partner.  EMS arrives and finds the patient in monomorphic ventricular tachycardic (VT) cardiac arrest. She has a history of hypertension and non-insulin dependent diabetes mellitus. The paramedics achieve return of spontaneous circulation (ROSC) after CPR, advanced cardiac life support (ALCS), and Intubation.  She arrives in the emergency department (ED) with decreased level of consciousness and shock.  The EKG shows sinus tachycardia with nonspecific changes and no ST segment elevations, Q waves, or hyperacute T waves.  Her point-of-care ultrasound (POCUS) shows appropriate-appearing global ejection fraction and no marked wall motion abnormalities.  Cardiology has been consulted and asks for a neurology consultation given her mental status.

    Background: The American Heart Association estimates there are approximately 350,000 EMS-assessed out-of-hospital cardiac arrests (OHCAs) in the United States per year. Half of these arrests are witnessed with the other half being un-witnessed. Many of these OHCAs are due to ventricular fibrillation or pulseless VT. Defibrillation is the treatment of choice in these cases but does not often result in sustained ROSC (Kudenchuk et al 2006).

    Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients. There is evidence that taking those patients with ROSC and EKG showing STEMI directly for angiography +/- angioplasty is associated with positive patient-oriented outcomes.

    The AHA has a statement with recommendations based on the available data. They suggest to perform catheterization and reperfusion for post-arrest patients with ST-segment elevation, even if the patient is comatose  However, there is no consensus if this strategy should be employed in patients without ST-segment elevation (Yannopoulos et al, Circulation 2019).

    The 2015 AHA Guidelines make the following recommendations:

    * Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG (Class I, LOE B-NR).

    * Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG (Class IIa, LOE B-NR).

    Lemke et al 2019 published a multicentre RCT done in the Netherlands looking at patients without ST segment elev...

    • 28 min
    SGEM#343: Doctors are Doctors So Why Should It Be, You and I Should Get Along So Awfully – Weight Bias in Medicine

    SGEM#343: Doctors are Doctors So Why Should It Be, You and I Should Get Along So Awfully – Weight Bias in Medicine

    Date: August 31st, 2021

    Reference: McLean et al. Interphysician weight bias: A cross-sectional observational survey study to guide implicit bias training in the medical workplace. AEM Sept 2021

    Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine.

    Case: You are working in the emergency department (ED) with the new resident, one of whom is overweight. You overhear his colleagues wonder where he went, chuckling, and one of them comments that “he probably went for second breakfast.” Realizing that these residents are making fun of their colleague’s weight, you decide to address the issue.

    Background: We have talked about biases many times on the SGEM. Usually when we use the term bias it is in the context of something that systematically moves us away from the “truth”. Science does not make truth claims and the term is used as a shorthand for the best point estimate of an observed effect size.

    An example in the medical literature would be selection bias. This is when subjects for a research study are not randomly selected. This can skew the results and impact the conclusions.  Another example would be publication bias. Studies with “positive” results are more likely to be published while those with “negative” results are more likely to end up in the bottom of the file drawer.

    There are many other types of bias in the practice of medicine. Some of my favourite ones are anchoring bias, base-rate neglect, and hindsight bias. For a description of these and many more check out Dr. Pat Croskerry list of 50 cognitive biases in medicine. You can also click on the codex for an extensive list of different biases.

    This SGEM episode focuses on a kind of bias as defined by the common English language as “a particular tendency, trend, inclination, feeling, or opinion, especially one that is preconceived or unreasoned”. It is a sense of prejudice or stereotyping and the formation of a foregone conclusion independent of current evidence.

    There are many biases in the house of medicine. We have discussed some of them on  the SGEM. They include things like age, gender, socioeconomic status, race, and other factors. The gender pay gap is one of the topics that has been spoken about most on the SGEM. A paper by Wiler et al AEM 2019 showed females in academic emergency medicine were paid ~$12,000/year less than their male colleagues (SGEM#248).

    The September 2021 issue of AEM is a special issue focusing on biases in emergency medicine. It includes articles on racial, ethnic and gender disparities. One specific topic jumped out as something that has not received much attention, weight bias. There is literature on physicians’ weight biases towards patients and patients’ weight bias towards physicians. However, there is limited information on physician-to-physician weight bias.

    Clinical Question: What is the prevalence of interphysician implicit, explicit, and professional weight bias?

    Reference: McLean et al. Interphysician weight bias: A cross-sectional observational survey study to guide implicit bias training in the medical workplace. AEM Sept 2021

    * Population: Practicing physicians and physicians-in-training in North America

    * Excluded: Those who did not consent; did not identify as physicians or physicians-in-training; or were not currently residi...

    • 40 min
    SGEM#342: Should We Get Physical, Therapy for Minor Musculoskeletal Disorders in the ED?

    SGEM#342: Should We Get Physical, Therapy for Minor Musculoskeletal Disorders in the ED?

    Date: August 27th, 2021

    Reference: Gagnon et al. Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial. AEM 2021

    Guest Skeptic: Dagny Kane-Haas is a physiotherapist who also has a master’s degree in Clinical Science in Manipulative Therapy.

    Case: A forty-year-old woman presents to the emergency department (ED) with a sore lower back after moving some boxes at home over the weekend. She tried acetaminophen with limited relief. Her pain is eight out of ten on the zero-to-ten-point numeric pain rating scale (NPRS). She has no red flags (TUNA FISH) and is diagnosed as having mechanical back pain without imaging as per ACEP Choosing Wisely. You know mechanical low back pain is difficult to treat effectively and are trying to set expectations. While preparing her for discharge you wonder if seeing a physiotherapist before going home from the ED would improve her outcome.

    Background: Acute and chronic back pain has been covered many times on the SGEM. There is no high-quality evidence that acetaminophen, NSAIDS, steroids, diazepam, muscle relaxants or combinations of pharmacologic modalities provide much relief.

    * SGEM#87:Let Your Back Bone Slide (Paracetamol for Low-Back Pain)

    * SGEM#173: Diazepam Won’t Get Back Pain Down

    * SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain

    * SGEM#304: Treating Acute Low Back Pain – It’s Tricky, Tricky, Tricky

    We do know that opioids are very effective at reducing many types of pain including muscular skeletal pain. However, opioids have many side effects and concerns about substance misused.

    The ACEP 2020 clinical policy on the use of opioids states:

    “Preferentially prescribe nonopioid analgesic therapies (nonpharmacologic and pharmacologic) rather than opioids as the initial treatment of acute pain in patients discharged from the emergency department. For cases in which opioid medications are deemed necessary, prescribe the lowest effective dose of a short-acting opioid for the shortest time indicated.” (Level C Recommendation)

    There are several non-pharmaceutical treatments that have also been tried to treat low back pain. They include: Cognitive Behavioural Therapy 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). None of these other treatments has high-quality evidence supporting their use.

    We have covered a randomized control trial looking at acupuncture to treat painful conditions presenting to the ED, including acute back pain,

    • 27 min
    SGEM#341: Are the AAP Guidelines for the Evaluation and Management of the Well-Appearing Febrile Infant the Answer to a Never Ending Story?

    SGEM#341: Are the AAP Guidelines for the Evaluation and Management of the Well-Appearing Febrile Infant the Answer to a Never Ending Story?

    Date: August 19th, 2021

    Reference: Pantell et al. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics 2021

    Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC.

    Case: A 25-day-old, full-term boy presents to the emergency department with fever. His parents report that he felt warm that evening, and they found that he had a rectal temperature of 38.2°C (100.8°F). He has an older sister at home with a cough and rhinorrhea. Overall, he has no symptoms and appears well. He has continued to feed normally and produce wet diapers. The parents ask you, “Do you really think he needs any additional testing? He probably caught something from his sister, right?”

    Background: Parents often bring their infants to the ED with concerns about fever. They can develop a real “fever fear” or “feverphobia” and often need reassurance that fever alone is not dangerous. We have talked about pediatric fever and fever fear with Dr. Anthony Crocco from Sketchy EBM back on SGEM#95 and made a “Ranthony” video on the topic. The American Academy of Pediatrics says that

    “…fever, in and of itself, is not known to endanger a generally healthy child.  In contrast, fever may actually be of benefit; thus, the real goal of antipyretic therapy is not simply to normalize body temperature but to improve the overall comfort and well-being of the child.” 

    However, fever without source in infants less than three months of age represents a significant diagnostic dilemma for clinicians. Several clinical decision instruments had been developed previously, including the Rochester (Jaskiewicz et al 1994), Boston (Baskin et al 1992) and Philadelphia (Baker et al 1993) criteria to help clinicians stratify the risk of significant bacterial infections. A new clinical decision instrument called the Step-by-Step approach was reviewed on SGEM#171.

    SGEM#171 Bottom Line: If you have availability of serum procalcitonin measurement in a clinically relevant time frame, the Step-by-Step approach to fever without source in infants 90 days old or younger is better than using the Rochester criteria or Lab-score methods. With the caveat that you should be careful with infants between 22-28 days old or those who present within two hours of fever onset.

    We have been trying to optimize our approach to evaluating and managing febrile infants for more than four decades.  Our goal is to identify the febrile infants with urinary tract infection, bacteremia, and bacterial meningitis (or what was referred to as serious bacterial infections) while simultaneously trying to spare them from invasive and potentially unnecessary procedures like lumbar punctures or the possible iatrogenic consequences of empiric antibiotics or hospitalization.

    Several risk stratification tools have been published over the years. These clinical decision instruments included subjective clinical criteria along with pre-determined thresholds for lab criteria like white blood cell count (WBC) and immature to total neutrophil ratio. Unfortunately, these criteria may not be appropriate in the current era. In fact, the Modified Boston and Philadelphia Criteria for invasive bacterial infections may misclassify almost a href="https://pediatrics.aappublications.org/content/145/4/e20193538?ijkey=3bc803ec1955973028aed80e2d7bc03bf9cf9d59&keytype2...

    • 32 min
    SGEM#340: Andale, Andale Get An IO, IO for Adult OHCA?

    SGEM#340: Andale, Andale Get An IO, IO for Adult OHCA?

    Date: August 12th, 2021

    Reference: Daya et al. Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation 2020

    Guest Skeptic: Missy Carter is a PA practicing in emergency medicine in the Seattle area and an adjunct faculty member with the Tacoma Community College paramedic program. Missy is also now the director for Difficult Airway EMS course in Washington State

    Case: An EMS crew arrives to your emergency department (ED) with a 58-year-old female who suffered a witnessed ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA). They performed high-quality CPR and shocked the patient twice before giving amiodarone via intraosseous (IO). After giving hand off the medic tells you she had difficulty finding intravenous (IV) access and went straight to an IO. She wonders if she should have spent more time on scene trying to get the IV versus the tibial IO she has in place.

    Background: We have covered OHCA multiple times on the SGEM. This has included the classic paper from Legend of EM Dr. Ian Stiell on BLS vs. ACLS (SGEM#64), the use of mechanical CPR (SGEM#136), and pre-hospital hypothermia (SGEM#183).

    The issue of amiodarone vs lidocaine has also been covered on SGEM#162. This was the ALPS randomized control trial published in NEJM 2016. The bottom line from that SGEM critical appraisal was that neither amiodarone or lidocaine were likely to provide a clinically important benefit in adult OHCA patients with refractory VF or pulseless ventricular tachycardia.

    We did do an episode on IO vs IV access for OHCA (SGEM#231). This was a critical appraisal of an observational study published in Annals of EM (Kawano et al 2018). The key result was that significantly fewer patients had a favorable neurologic outcome in the IO group compared to the IV group. However, we must be careful not to over-interpret observational data. There could have been unmeasured confounders that explained the difference between the two groups.

    In recent years there has been an effort to lower the cognitive load in the pre-hospital setting and focus resources on the interventions that positively effect patient outcomes. There has been a trend to place supraglottic devices over intubation with some evidence to support this move (SGEM#247).  Another trend is to use IO access over IV access to free up pre-hospital providers to focus on more meaningful interventions.

    Clinical Question: Does it matter if you give antiarrhythmic medications via IV or IO route in OHCA?

    Reference: Daya et al. Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation 2020

    * Population: Adult patients with non-traumatic out-of-hospital cardiac arrest and shock refractory ventricular fibrillation or pulseless ventricular tachycardia after one or more shocks anytime during resuscitation.

    * Excluded: Patients who had already received open-label intravenous lidocaine or amiodarone during resuscitation or had known hypersensitivity to these drugs

    • 22 min
    SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease

    SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease

    Date: August 7th, 2021

    Guest Skeptic: Dr. Susanne (Susy) DeMeester is an Emergency Physician practicing at St. Charles Medical Center in Bend, Oregon. She has been very involved with EMRAP’s CorePendium as the cardiovascular section editor and has a chapter coming out soon on women and acute coronary syndrome.

    Dr. DeMeester was on SGEM#222 as part of the SGEMHOP series. She was the lead author of a study looked at whether an emergency department algorithm for atrial fibrillation management decrease the number of patients admitted to hospital.

    The SGEM Bottom Line: There are clearly patients with primary atrial fibrillation who can be managed safely as outpatients. There are no evidence-based criteria for identifying high-risk patients who require admission, so for now we will have to rely on clinical judgement.

    This SGEM Xtra episode is the result of some feedback I received from a listener following SGEM#337 episode on the GRACE-1 guidelines for recurrent low-risk chest pain.

    The person lamented that it would be nice if a cardiac case scenario was of a female patient. This made me review past SGEM episodes which confirmed there has been a gender bias. While there were a half-dozen episodes that did have female patients, they were the minority. So, I felt a good way to address the issue would be to invite an expert like Dr. DeMeester to discuss this gender bias.

    There is a difference between gender and sex. Despite having different meanings they are often used interchangeably. Gender refers to social constructs while sex refers to biological attributes.

    This is not the first SGEM episode that has addressed the gender gap in the house of medicine. I had the honour of presenting at the 2019 FeminEM conference called Female Idea Exchange (FIX19).

    My FIX19 talk was called from Evidence-Based Medicine to Feminist-Based Medicine. It looked at the three pillars of EBM: relevant scientific literature, clinicians, and patients. I realized that each of the three pillars contained biases against women. In the presentation, multiple references were provided to support the claim that a gender gap does exist.

    The conclusion from the FIX19 talk was that we should be moving from Evidence-Based Medicine (nerdy and male dominated) to Feminist-Based Medicine (recognizing the inequities in the house of medicine) to Gender-Based Medicine (acknowledging the spectrum of gender and sexuality) and ultimately to Humanist- Based Medicine.

    The SGEM did a regular critical appraisal of a recent publication with Dr. Ester Choo (SGEM#248). It covered the study published in AEM looking at the continuation of gender disparities among academic emergency physicians (Wiler et al AEM 2019).

    We also did an entire SGEM Xtra episode with Dr. Michelle Cohen on the broader issue of the gender pay gap (a href="https://www.thesgem.

    • 26 min

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