Date: December 30th, 2018

Happy New Years to all the SGEMers out there in the #FOAMed world.  It is time to reflect upon 2018 and look forward to 2019. Last year we named 2017 the year of FeminEM and celebrated 15 amazing women in emergency medicine. This year I am going to highlight five of my personal favourite episodes from 2018.

It was very difficult to pick just five episodes from all the excellent episodes recorded in 2018. One of the questions I am frequently asked (besides do you pick the music first) is which episode I like the best. The answer is always the same…the one I am currently working on at the time.

Another difficulty was not to include an SGEMHOP episode in the top five. These are all fantastic episodes done in collaboration with Academic Emergency Medicine (AEM) and three great guest skeptics (Drs. Bond, Heitz and Morgenstern). It combines the best of both worlds (traditional publication and social media). To give a shoutout to just one SGEMHOP episode felt wrong, so I consciously excluded them being eligible.

Here are my favourite five SGEM episodes from 2018. Do you agree with these selections? What was your favourite SGEM episode this year? Please post your response in the comment section.

#5 Don’t Give Up – The Power of Kindness with Brian Goldman

Dr. Goldman is an Emergency Medicine physician who works at Mount Sinai hospital in Toronto. He is the host of the CBC radio show White Coat Black Art and the author of the bestselling books The Night Shift and the Secret Language of Doctors. Dr. Goldman had a fantastic new book published in 2018 called The Power of Kindness: Why Empathy is Essential in Everyday Life.

I had the pleasure of interviewing Brian at the 2018 Canadian Association of Emergency Physicians (CAEP) conference in Calgary, Alberta this summer. We sat down in a cafe and discussed kindness until they closed and asked us politely to leave. I wanted to know whether kindness was from nature or nurture, if healthcare workers’ empathy is dulled over the years and if we can do anything to be more kind.

#4) I Can See Clearly Now the Collar is Gone – Thanks to the Triage Nurse

We all work with some amazing nurses in the emergency department. This SGEM episode featured one of those awesome nurses, Alison Armstrong. She is an emergency department nurse from the London Health Science Centre in London, Ontario. Alison is also a TNCC Course Director, Trauma Program Coordinator and Canadian C-Spine Rule Nurse Champion.

Alison and I reviewed a paper in Annals of EM by the prolific group out of Ottawa. Their observational study wanted to know if emergency department triage nurses can apply the Canadian C-Spine Rule (tool) to adult blunt trauma patients and safely clear the c-spine?

The results were that triage nurses removed 41% of immobilize...

Date: December 21st, 2018

Happy holidays to all the SGEMers.  For everyone in the Northern hemisphere, let it snow, let it snow, let it snow. For those in the Southern hemisphere, I suggest you listen to the Tim Minchin song about having white wine in the sun. Regardless of where you are, I hope everyone can spend some quality time with family and friends.

2018 has been a year of growth for the SGEM with more than 37,000 subscribers.  We needed to upgrade our server twice to prevent it from crashing with all the traffic. The SGEM is also available on all podcasting platforms not just iTunes.

The SGEM has been so successful because of listeners like you, #FOAMed friends, the guest skeptics, SGEMHOP Team (Justin, Corey and Chris), PaperinaPic producer (Kirsty) and my best friend Chris Carpenter.

The goal of the SGEM continues to be to cut the knowledge translation window down from over ten years to less than one year. It does this by doing a structured critical review of a recent publication and then shares the information using the power of social media. We want patients to get the best care based on the best evidence.

As many of you know, 2018 was also difficult year near the end for me with the passing of my father in November. I was on the edge of burnout. This experience taught me that it is OK not to be OK, vulnerability is a strength not a weakness, not to be afraid to ask for help, to take care of myself, and that this too shall pass. Thank you very much for everyone who supported me through this challenging time.

As a holiday gift, please accept this PDF book of Season#5 of the SGEM. You will find links to all your favourite episodes. There is a new PaperinaPic chapter with all of Kirsty Challen’s infographics. You will also find a new chapter highlighting the theme music that inspires the SGEM.

Don’t Panic…Chris Carpenter’s chapter on evidence based medicine, Justin Morgenstern’s (First10EM) simplified guide to approaching the literature and Anthony Crocco’s SketchyEBM chapter are all still part of the book.

Please feel free to share this 236 page book via your social media networks (email, Facebook, Twitter, Google+, etc).

If you are looking for the inspiring theme music from each of the SGEM episodes you can now find them on Spotify. Of course most of them come from the best musical era, the 1980’s.

This knowledge translation project continues to be part of the free open access to medical education movement (FOAMed).

Date: December 13th , 2018

Reference: Murata et al. Acetaminophen and febrile seizure recurrences during the same fever episode. Pediatrics. 2018

Guest Skeptic: Dr. Damian Roland is a Consultant at the University of Leicester NHS Trust and Honorary Associate Professor for the University of Leicester’s SAPPHIRE group. He specialises in Paediatric Emergency Medicine and is a passionate believer that education exists to be shared (#foamed).

Damian is part of the Don’t Forget the Bubbles (DFTB) team. They published an epic paper to determine the transit time of a Lego head (Tagg et al). The primary outcome was the FART (Found and Retrieved Time) score. Bowel habit were standardized before the trial started using the SHAT (Stool Hardness and Transit) score. The story was picked up by the BBC, Forbes and even talked about by James Corden on the Late, Late Show. 

Case: An 18-month-old presents having had a febrile convulsion (febrile seizure) at home. The seizure lasted no more than a minute and now having been in the department for a couple of hours the infant is back to their normal selves. Observations are normal except a low-grade fever and there is a clear focus in a right otitis media for an infection. You start to counsel the parents with likely outcomes for the future and immediate safety netting advice. You tell the parents that regular antipyretics won’t stop another febrile convulsion occurring and they should really only be used to help their child when they are distressed with a fever. After you leave the room a student who had witnessed the consultation asks you why you said you couldn’t stop febrile convulsions when a recent publication from Japan has clearly shown that regular rectal acetaminophen significantly reduces the risk of recurrence?

Background: Febrile seizures are very common and very, very scare for care-givers and parents. During winter periods a typical emergency department may well see a child a day presenting with a febrile seizure

There was a SRMA by Rosenbloom et al. (Eur J Paediatr Neurol 2013) that concluded antipyretics were ineffective in reducing the recurrence of febrile seizures in children.

SGEM#95 covered this paper with Pediatric Super Hero Anthony Crocco. Our bottom line was that antipyretics appear to offer no significant improvement in the recurrence rates of febrile seizures in children.

Fever fear is a real concern for parents and they often come to the emergency department for evaluation and reassurance. 

The American Academy of Pediatrics guidelines say “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.”

Standard advice has always been that the regular administration of an antipyretic won’t reduce the risk of recurrence but a recent publication in Pediatrics has challenged this position.

Date: December 4th, 2018

Guest Skeptic: Dr. Steven Novella is a Yale Neurologist, host and producer of the popular science podcast called the Skeptics Guide to the Universe and executive editor of Science Based Medicine blog.

This is an SGEM Xtra book review. I had the privilege of interviewing Dr. Novella about the new book by the Skeptics’ Guide to the Universe (SGU).  I would like to recognize the influence the SGU had on inspiring the SGEM. The SGU has been a big part of my skeptical journey and contributed greatly to my critical thinking skills.

Listen to the SGEM podcast on iTunes or your favourite podcast app hear Dr. Novella and me discuss how SGU got started, their new book, how to encourage critical thinking with students and colleagues, how he discusses pseudoscience with colleagues and patients and a few other topics.

Five Frivolous Questions for Dr. Novella:

* Star Trek or Star Wars?

* Best Captain, Picard or Kirk?

* If you could have one today, flying car or transporter?

* Dinner with Newton or Galileo?

* Would you rather visit Mars or a moon of Jupiter?

The SGEMers can order a copy the SGU book for themselves and as a gift by clicking on this BOOK LINK or on the picture below.

The SGEM will be back next episode with a structured critical review of a recent publication trying to cut the knowledge translation window from over ten years to less than one year using the power of social media.

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

Date: December 6th , 2018

Reference: Perkins et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. NEJM 2018.

Guest Skeptics: Jay Loosley is the Superintendent of Education at Middlesex-London Paramedic Service. Jenn Doyle is a paramedic educator at Middlesex-London Paramedic Service.

Case: A 51-year-old man experiences a cardiac arrest on the street. You are the first provider on scene with Emergency Medical Services (EMS) and start high-quality Cardiopulmonary Resuscitation (CPR). A cardiac defibrillator is hooked up and the patient is in ventricular fibrillation. He is unsuccessfully shocked. An oral airway is placed, peripheral intravenous (IV) line started successfully and the paramedic asks her partner if you want to administer IV epinephrine?

Background: The AHA has five steps in the Chain-of-Survival for out-of-hospital cardiac arrest (OHCA).

* Step One– Recognition and activation of 911

* Step Two– Immediate high-quality CPR

* Step Three– Rapid defibrillation

* Step Four– Basic and advanced EMS

* Step Five– Advanced life support & post arrest care

We are going to discuss Step Four that focuses on rapid access to advanced cardiac life support (ACLS) skills such as intubation and intravenous drug therapy.

This step is controversial, and we have covered it on the SGEM with the classic OPALS trial by Legend of Emergency Medicine Dr. Ian Stiell (SGEM#64). This was a before and after study to see if advanced cardiac life support (ACLS) techniques, including IV epinephrine, would improve survival to discharge.

While there was an improvement in return of spontaneous circulation (ROSC) and survival to hospital admission there was not an increased survival to hospital discharge. There was also no increase in survivors with good neurological outcomes with ACLS.

There have been a number of papers published since OPALS that support the findings of not using ACLS drugs like epinephrine for OHCA (Olavseengen et al. JAMA 2009, Hagihara et al. JAMA 2012 and Cournoyer et al. AEM 2017).

We reviewed the Cournoyer et al cohort study as part of the #SGEMHOP series with Academic Emergency Medicine (AEM). It demonstrated better ROSC with ACLS but not better survival to hospital discharge (SGEM#189).

A limitation of these studies is their observational nature. There is one randomized control trial on epinephrine for OHCA by Jacobs et al. published in Resuscitation 2011. This Australian trial showed better ROSC with epinephrine but not better survival to hospital discharge in 534 patients.

Unfortunately, the trial failed to achieve their sample size for a variety of reasons which left it underpowered. This means there is a lack of high-quality data to rely upon in deciding whether or not to use epinephrine in OHCA situations.

Clinical Question: Does the use of epinephrine in cardiac arrest improve survival rates with a favourable neurological outcome?

Reference: Perkins et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. NEJM 2018.

* Population: Adult patients with OHCA that ACLS was started by paramedics

* Excluded: Pregnancy, age <16 years,

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Date: November 24th, 2018

As you may know, I was invited to give a keynote address on burnout at the Australasia College of Emergency Medicine 2018 Annual Scientific Meeting (#ACEM18) in Perth, Australia. This turned out to be a very meta event.

A few months leading up to the presentation my dad, Dr. Ken Milne Sr. got seriously ill. While he faced this with his usual grace and dignity, I was living on the edge of burnout.

He was admitted to hospital shortly before I was scheduled to leave for Australia. We had a number of discussions and he insisted that I go and not cancel the trip. We reviewed my keynote presentation in the hospital and he gave me the thumbs up. He was very proud and was telling all his treating physicians about his son’s honour to be talking at an international medical meeting.

I agreed to go to Australia with his blessing but promised I would live stream the presentation to his hospital bed on the SGEM Facebook page. During the talk I gave him a big shout out and shared my story about being on the edge of burnout.

Working in the emergency department we are on the edge of life and death and that can lead to burnout. Dr. Michelle Johnston (Dustfall) did a fantastic job the during the ACEM18 opening presentation highlighting what we do everyday.

The word burnout was coined by Burnout was a term coined by Herbert Freudenberger in 1974. He defined it as “a state of fatigue or frustration that resulted from professional relationships that failed to produce the expected rewards”.

There are a number of other ways to define burnout but one of the most widely known and used to assess burnout is the is the Maslach Burnout Inventory (MBI) Score. It was designed by Christina Maslach and Susan Jackson and published in 1981.

Three Components to the Maslach Burnout Inventory:

* Emotional Exhaustion

* Depersonalization

* Reduced Feelings of Personal Accomplishment

A recent study of US physicians showed that more 50% had at least one symptom of burnout. The highest prevalence of burnout (70%) was reported by emergency physicians (Shanafelt et al 2015). One of the most common reasons cited for burnout is the electronic medical record (EMR) (Shanafelt et al 2016).

Burnout can have negative consequences on physicians. It may lead to depression, suicidal ideation, illness, and increased alcohol use.

Burnout has also been associated with negative impacts on patient care including self-perceived medical error, risk of medical errors, and quality of care. If we are not healthy we cannot take good care of our patients.

Some solutions have been suggested to mitigate physician burnout. West et al 2016 published a SRMA in the Lancet on interventions to prevent and reduce physician burnout. One intervention shown to have a positive impact on reducing burnout is mindfulness-based approaches. A recent study done in Australia looked at the efficacy of mindfulness to mitigate burnout (Ireland et al 2017). It provided some evidence that mindfulness can help decrease stress and burnout scores. Whether or not mindfulness training translates into long lasting changes and better patient care remains to be seen. 

Burnout Advice from Legend of Emergency Medicine Dr. Richard Bukata:

* Pace yourself

* Don’t Overspend

* Become and Expert in Something

* Find a Safe Confidant

* Life Outside Medicine

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Date: November 10th , 2018

Reference: Kaltiso et al. Evaluation of a Screening Tool for Child Sex Trafficking Among Patients with High-Risk Chief Complaints in a Pediatric Emergency Department. AEM October 2018.

Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and clinical lecturer in Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM.

You may have noticed there was no music for the introduction. Part of the SGEM brand is to have some fun and engaging theme music to help with knowledge translation. This topic of child sex trafficking is very serious and disturbing. I struggled with what would be an appropriate song choice. After thinking about it and not coming up with something acceptable I went to twitter to ask my #FOAMed friends.

It was Minh Le Cong (@Ketaminh) who suggested no music for this episode and perhaps a period of silence. Mitochondrial Eve (@BrowOfJustice) agreed and said that she uses silence to great effect frequently. I hold both of these wise people high regard and value their opinion. I listened, and I heard what they said and that is why there was silence rather than song to introduce this SGEMHOP episode on child sex trafficking.

TRIGGER WARNING:

As a warning to those listening to the podcast or reading the blog post, there may be some disturbing things discussed. The SGEM is free and open access trying to cut the knowledge translation down to less than one year. It is intended for clinicians providing care to emergency patients, so they get the best care, based on the best evidence. Some of the material could be considered explicit, graphic, offensive, and/or upsetting. As a trigger warning, if you are feeling upset by the content then please stop listening or reading. There will be resources listed at the end of the blog for those looking for assistance.

Case: A 15-year-old girl presents to the emergency department with pelvic pain. She is with a parent and after the initial introductions and history, you have her parent leave the room to ask more sensitive questions. Upon further history, you discover that she has been having pelvic pain with genital discharge and has had more than ten sexual partners in their lifetime. Eventually, you discover that she has also been drinking alcohol and endorses that she has exchanged sex for drugs in the past.

Background: Child sex trafficking (CST) is a global human rights violation and occurs when a minor is engaged in any sex act which involves an exchange of something of perceived value, whether monetary or non-monetary (1,2).

Examples of CST include prostitution of children by others, “survival sex” (runaway/homeless children having sex in exchange for shelter or something else needed to survive), working in sex-oriented businesses, or production of child sexual abuse materials (3,4).

Statistics from the United States Human Trafficking Reporting System indicate that 85% of identified sex trafficking victims were US citizens/legal residents and 55% were minors (5).

Statistics on trafficking in persons in Canada from 2016 reveal the following (Juristat Bulletin):

* Number of police-reported incidents of human trafficking on the rise and is at the highest level since data became available in 2009 (0.94/100,00 people)

* One in three police-reported human trafficking incidents is a cross-border offence

* More than half of human trafficking incidents involve another offence, usually prostitution

* The vast majority (95%) of the victims of human trafficking are women, 72% are under 25 years of age and most of the people accused of human trafficking are male (81%).

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Date: November 6th , 2018

Reference: Sprigg et al. Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Lancet. 2018

Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the US Air Force in Virginia. This is Bob’s eighth visit to the SGEM.

DISCLAIMER: The views and opinions of this podcast do not represent the United States Government or the US Air Force.

Case: Your next patient is a stroke alert for a 67-year-old male living at a nursing home presents with severe right sided upper and lower extremity weakness noticed one hour ago while eating a meal.  He obtains a stat head CT which shows an intracerebral hemorrhage.  In addition to controlling his elevated blood pressure, you wonder if there is more you can offer this patient to improve his outcome and odds of survival.  A resident points out that tranexamic acid (TXA) has been shown to decrease mortality for other hemorrhagic conditions, and questions if that could be helpful.

Background: Stroke due to intracerebral hemorrhage (ICH) comprises approximately 20% of all strokes, but about half of all stroke deaths worldwide.  Currently the only intervention known to adjust mortality in these cases is blood pressure management.

Lowering BP in ICH cases of was covered on SGEM#73: How Low Can You Go. The AHA Guidelines were updated since those episodes and recommend the following (Hemphill et al Stroke 2015):

* For ICH patients presenting with SBP between 150 and 220 mmHg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mmHg is safe (Class I; Level of Evidence A) and can be effective for improving functional outcome (Class IIa; Level of Evidence B). (Revised from the previous guideline)

* For ICH patients presenting with SBP >220 mmHg, it may be reasonable to consider aggressive reduction of BP with a continuous intravenous infusion and frequent BP monitoring (Class IIb; Level of Evidence C). (New recommendation)

SGEM#172: Don’t Bring My Blood Pressure Down (Intensively) – The ATACH2 Trial did not support intensely lowing blood pressure. There was no statistical difference in death or disability between intensive blood pressure reduction (SBP 110-139 mm Hg) vs. standard blood pressure reduction (SBP 140-179 mm Hg) in patients with acute intracerebral hemorrhage.

TXA is a cheap drug that has been shown to improve mortality in trauma (CRASH-2), presumably due to its antifibrinolytic effect.

TXA has been discussed on the SGEM a number of times for epistaxis, trauma and post-partum hemorrhage:

* SGEM#53: Sunday, Bloody Sunday (Epistaxis and Tranexamic Acid)

* SGEM#80: CRASH-2 (Classic Paper)

* SGEM#210: (Don’t) Let it Bleed – TXA for Epistaxis in Patients on Anti-Platelet Drugs

* SGEM#214: Woman – The TXA Trial for Post-Partum Hemorrhage

Before this trial was started there were apparently only two small randomized control trials using TXA with a total of 54 patients. They provided no clear evidence for benefit or harm.

Aktuelle FOAMed Infos rund um die klinische Notfallmedizin, Notfallmedizin und Intensivmedizin, auf den Spuren vom Skeptics Guide to emergency medicine

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Date: October 30th , 2018

Reference: Raskob GE et al. Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. NEJM 2018

Guest Skeptic: Dr. Anand Swaminathan is an assistant professor of Emergency Medicine at the St. Joseph’s Regional Medical Center in Patterson, NJ. He is a deputy editor for EM: RAP and, associate editor for REBEL EM.

Case: A 43-year old woman with a history of breast cancer currently undergoing chemotherapy presents with mild chest pain. She is hemodynamically stable except for a heart rate of 105 and her pain is increased when she takes a deep breath. The chest x-ray is unremarkable, and you order a CT pulmonary angiogram (CTPA) which demonstrates a right segmental pulmonary embolism. You write a prescription for low molecular weight heparin (LMWH) and advise the patient that she will be taking shots for a couple of months. She tells you that a friend of hers had a clot in her leg and was given an oral blood thinner. She wants to know if you can prescribe that pill, so she doesn’t have to take a shot.

Background: Venous thromboembolism (VTE) occurs frequently in patient with cancer. Treatment in this group entails a number of challenges including a higher rate of thrombosis recurrence and a higher risk of bleeding. Standard therapy at this time for both symptomatic and asymptomatic VTE is with LMWH based on results from the CLOT trial (Lee 2003).

In non-cancer patients, new oral anticoagulants (NOACs) like rivaroxaban have been shown to be effective in treatment without increasing bleeding events. The NOACs also add ease of use for the patient.

We covered using rivaroxaban on SGEM#126 with VTE guru Dr. Jeff Kline. This study suggested it was safe and effective to dry start (no LMWH needed) in certain patients with DVTs and PEs.

Though these agents are frequently used in the treatment of cancer-associated VTE, there is a dearth of evidence supporting this practice, in fact, none of the major agents – dabigitran, rivaroxaban, apixaban or edoxaban have undergone a well-done, randomized controlled trial.

Clinical Question: Is edoxaban non-inferior to LMWH in the treatment of cancer-associated VTE?

Reference: Raskob GE et al. Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. NEJM 2018

* Population: Adult patients with active cancer or cancer diagnosed within the previous two years with acute symptomatic or asymptomatic deep-vein thrombosis (DVT) or pulmonary embolism (PE).

* Exclusions: See link to the list of exclusions in the Supplementary Appendix

* Intervention: LMWH for five days followed by oral edoxaban 60 mg daily for at least six months.

* Comparison: Subcutaneous (SQ) dalteparin 200 IU/kg daily (maximum dose 18,000IU) for one month followed by 150 IU/kg daily for at least five months.

* Outcome:

* Primary: Composite of recurrent VTE (DVT or segmental or more proximal PE) or major bleeding (overt bleeding associated with 2g/dL drop in hemoglobin or a transfusion of two or more units of blood during twelve-month follow up.

* Secondary: Clinically relevant non-major bleeding (CRNB), event-free survival, VTE-related death, all-cause mortality, recurrent DVT, recurrent PE. The complete list can also be found in the Supplementary Appendix.