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Date: January 31st, 2018

Reference: Frohlich LC, et al. Prospective validation of clinical score for males presenting with an acute scrotum. AEM Dec 2017.

Guest Skeptic: Dr. Melissa Langhan is an Associate Professor of Pediatric Emergency Medicine at Yale University in New Haven, CT. Melissa is passionate about clinical and translational research and focuses most of her work on the use of capnography or end-tidal carbon dioxide monitoring. In her spare time, Melissa also enjoys being the fellowship director to an amazing group of PEM trainees.   

Case: Brian is a 14-year-old male who presents to the emergency department (ED) complaining of acute onset testicular pain. He has vomited twice, but there is no history of any fever or trauma. On examination, you find a firm, swollen right testicle, and the cremasteric reflex is notably absent on that side. Your index of suspicion for testicular torsion is high. Might his examination be enough to convince the urologists to take him straight to the operating room without a preceding diagnostic ultrasound?

Background: Acute onset testicular pain can be caused by a variety of etiologies from testicular torsion to epididymitis to traumatic hematomas. Among these, testicular torsion is a time-sensitive diagnosis as this involves loss of or reduced blood supply to the testicle, which can lead to ischemia. Prompt surgical intervention greatly increases the rate of testicular salvage. Time is testis.

Clinical signs of torsion are not always straight forward or specific for this diagnosis. Ultrasound imaging of the scrotum is the gold standard for diagnosis of testicular torsion, however can lead to delays in definitive care.

The Testicular Workup for Ischemia and Suspected Torsion score, or TWIST score, was developed to risk stratify patients under the age of 18 years with an acute scrotum.

The TWIST score ranges from 0-7 and is comprised of 5 components from the history and physical examination:

* Testicular swelling (2 points)

* Hard testicle (2 point)

* Absent cremasteric reflex (1 points)

* Nausea or vomiting (1 point)

* High riding testicle (1 point).

While it has been previously validated by urologists and emergency medical personnel, it has not been validated among Emergency Department physicians.

Clinical Question: Can the TWIST score risk stratify pediatric patients presenting with acute scrotal pain and reduce the time to surgical intervention by eliminating the need for ultrasound diagnosis?

Reference: Frohlich LC, et al. Prospective validation of clinical score for males presenting with an acute scrotum. AEM Dec 2017.

* Population: Patients aged 3 months to 18 years-of-age presenting to the ED with a chief complaint of testicular pain or swelling.

* Exclusions: Pain due to trauma, symptoms for greater than one-week, previous diagnosis of testicular torsion or testicular disease, imaging already obtained.

* Predictors: TWIST Score

* Criterion Standard: A final diagnosis of testicular torsion confirmed by surgical exploration, including patients diagnosed with intermittent testicular torsion.

* Outcome:

* Primary Outcome: Diagnostic performance of the TWIST Score

Authors’ Conclusions: “In this prospective validation of the TWIST score among pediatric emergency providers, the high-risk score demonstrated strong test characteristics for testicular torsion. The TWIST score could be used as part of a standardized approach for evaluation of the pediatric acute scrotum to provide more efficient and effective care.”

Quality Checklist for Clinical Decision Tools:

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Date: January 25th, 2018

Reference: Hawkins et al. Peripheral Intravenous Cannula Insertion and Use in the Emergency Department: An Intervention Study. AEM Jan 2018

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

Case: You are caring for a patient with a fever in the emergency department and the nurse asks if you want to start an intravenous (IV) line or just draw blood. You think for a minute…your patient is not tachycardic, not vomiting, and the likelihood of discharge is very high.

Background: Emergency department patients often have peripheral IV cannula (PIVC) placed at triage for initial blood draws or “just in case” they are used during the emergency department stay or hospitalization. It is one of the most commonly performed procedures in the emergency department.

PIVC placement can lead to discomfort, infection, and use of time and other emergency department resources (Rickard et al and Stuart et al). Some studies report that up to half of these are never used (Limm et al).

Clinical Question: Can an educational intervention on the appropriate use and placement of PIVCs reduce the number of unnecessary IV placed?

Reference: Hawkins et al. Peripheral Intravenous Cannula Insertion and Use in the Emergency Department: An Intervention Study. AEM Jan 2018

* Population: Emergency department patients greater than17-years-old.

* Excluded: Triage category 1, PIVC insertion by EMS, or transfers from another hospital

* Intervention: Ten-week educational training, change champions, advertising, surveillance and feedback

* Comparison: Pre-intervention data was collected for 12 days before, and 12.5 days after, the intervention. Post-intervention data was collected one month after the intervention.

* Outcome:

* Primary Outcomes: Reduction in peripheral IV catheters placed post-intervention and usage

* Secondary Outcome: PIVC insertion cost (staff and consumables)

This is an SGEMHOP episode, so we have the lead author on the show. Tracey Hawkins is a Clinical Nurse and Researcher in the Emergency and Trauma Centre at the Royal Brisbane and Women’s Hospital, Queensland, Australia.  Since 2008, she has been undertaking research into innovative models of cardiovascular care, peripheral intravenous cannulation and emergency care.

Authors’ Conclusions: “The intervention reduced PIVC placement in the ED and increased the percentage of PIVC placed that were used. This program benefits patients and health services alike, with potential for large cost savings.”

Quality Checklist for Observational Study:

* Did the study address a clearly focused issue? Yes

* Did the authors use an appropriate method to answer their question? Unsure

* Was the cohort recruited in an acceptable way? Yes

* Was the exposure accurately measured to minimize bias? Unsure – It is hard to tell how many staff were trained/exposed (although most likely all staff would see the signs/shirts)

* Was the outcome accurately measured to minimize bias? Yes

* Have the authors identified all-important confounding factors? Unsure

* Was the follow up of subjects complete enough? Yes

* How precise are the results? Fairly tight confidence intervals around the point estimate (range 3-5%)

* Do you believe the results? Yes

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Date: January 26th, 2018

Happy New Years again SGEMers. This is just a quick SGEM Xtra episode to let you know what I am going to be trying to do in 2018 to help you cut the knowledge translation (KT) window down from over ten years to less than one year. It involves following a weekly schedule of social media interaction.

 

Weekly SGEM Schedule

 

Saturday/Sunday SGEM: A new episodes of the SGEM will be posted most Saturdays or Sundays depending on my schedule. The blog will be about 2,ooo words in length that you can read while drinking your morning coffee. Or you can listen to the 20-30 minute podcast on iTunes while working out or turn your car into a classroom while traveling to your next shift. The ultimate goal of the SGEM cutting the KT window down is for you to provide patients with the best care, based on the best evidence. We also want you to learn some nerdy critical appraisal skills in the process. But remember to skeptical, even of the SGEM.

 

 

Meme Mondays: A meme will be posted on Mondays summarizing the paper reviewed. Merriam-Webster defines a meme as “an idea, behavior, style, or usage that spreads from person to person within a culture.”  The term meme was coined by Dr. Richard Dawkins in book the Selfish Gene published in 1976. SGEMers will also be challenged to come up with a meme that delivers a key message related to the publication. Demonstrate your creativity and sense of humour by posting the meme to the SGEM blog or on Twitter. Here are a couple of websites to help you create your own meme (Meme Generator and Meme Maker).

 

Twitter Poll Tuesdays: A Twitter poll will be posted on Tuesdays with a question connected to the paper reviewed. If you are not on Twitter consider signing up and following the SGEM. Voting will be open for 24 hours. Have your voice heard and vote on the SGEM Twitter poll.

What’s the Results Wednesdays: The results of the SGEM Twitter poll will be posted on Wednesdays to the blog, Twitter and on the SGEM Facebook page. See how your vote compares to other SGEMers and provide comments. How would you interpret the poll results?

 

Thousand Word Thursdays: On Thursdays, a PaperinaPic created by the amazing Kirsty Challen will be uploaded. She takes the paper we have critically appraised and summarizes it into an infographic. We all know that a picture is worth a thousand words (Tess Flanders). Consider this infographic spaced repetition and an opportunity to digest the information visually rather than reading the SGEM blog or listen ing to the SGEM podcast on iTunes.

 

Flipping the SGEM Friday: The next paper to be reviewed on the SGEM will be announced on Fridays as part of flipping the classroom philosophy. Take a look at the abstract and get ready for the new SGEM episode. To make it even more interactive, try and guess what the theme music will be (something from the 80’...

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Date: January 15th, 2018

Reference: Sadeghirad B, et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ 2017

Guest Skeptic: Meghan Groth is an Emergency Medicine Pharmacist at the UMass Memorial Medical Center in Worcester, Massachusetts. She has contributed to the Academic Life in Emergency Medicine and EM PharmD blogs, and is a part of the ALiEM Capsules Team. 

Case: 50-year-old man presents with a one day history of sore throat, cough and low-grade fever. He is otherwise healthy with only sports related injuries. The ibuprofen did not help and he is requesting antibiotics so he can get back to work sooner.

Background: Patients present commonly to their primary care providers (PCPs) and to the emergency department (ED) with complaints of a sore throat. In the US, adults accounted for 6.6 million visits annually to PCPs and EDs for sore throat.

Along with this can come unnecessary prescriptions for antibiotics (a topic in itself), even though national guidelines recommend against routine antibiotics (NICE and ESCMID).

As more and more attention is paid to strategies for reducing the overutilization of antibiotics and the subsequent trends in antimicrobial resistance, there is a need for other strategies to provide symptomatic relief for these patients.

Acetaminophen and NSAIDs are often used to treat sore throats. While providing symptomatic relief they can also cause harm. Several studies have looked at corticosteroids and demonstrated some moderate benefit.

Corticosteroids exert an anti-inflammatory effect by inhibiting transcription of pro-inflammatory mediators in airway endothelial cells. However, previous systematic review and meta-analyses have been confounded by co-administration of antibiotics and analgesics, as well as variability in measures of efficacy among studies.

Clinical Question: Are corticosteroids effective and safe as an adjunct treatment for sore throat in addition to standard care compared with standard care alone?

Reference: Sadeghirad B, et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ 2017

* Population: Adults and or children aged five and over presenting to the emergency department or primary care settings with a clinical syndrome of sore throat (painful throat, odynophagia, or pharyngitis)

* Exclusions: Participants admitted to the hospital, immunocompromised, those with infectious mononucleosis, sore throat after surgery/intubation, GERD, croup, peritonsillar abscess, or subjects under five years of age

* Intervention: At least one dose of corticosteroid therapy

* Comparison: “Standard of care” or placebo

* Outcomes: 

* Complete resolution of symptoms at 24 hours and at 48 hours

* Mean time to onset of pain relief and to complete resolution of pain

* Absolute reduction of pain at 24 hours

* Duration of bad/non-tolerable symptoms

* Recurrence/relapse of symptoms

* Days missed from school/work

* Need for antibiotics

* Rate of adverse events related to treatment

Authors’ Conclusions: “Single low dose corticosteroids can provide pain relief in patients with sore throat, with no increase in serious adverse effects. Included trials did not assess the potential risks of larger cumulative doses in patients with recurrent episodes of acute sore throat.”

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Date: January 9th, 2018

Reference: Soleimanpour H et al. Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. Urology 2012

Guest Skeptics: Dr. Tony Seupaul is the Chairman of the Department of Emergency Medicine at the University of Arkansas. Dr. Rachel Littlefield is a PGY2 in Emergency Medicine at the University of Arkansas.

Knowledge Translation Window: A short note to point out that this paper was not published in the last year. However, it is less than ten years old so we are cutting the KT window down to less than ten years. It was selected because there has been a number of people on Facebook and Twitter talking about using lidocaine to treat renal colic. Of course we were skeptical and wanted to review the evidence.

Case: A 45-year-old male presents to the emergency department with sudden onset severe right-sided flank pain radiating to his groin that began one hour ago. He has also had nausea, vomiting, and difficulty urinating. He has never had anything like this before and is writhing around in pain, unable to get comfortable.

Background: Renal colic affects 1-5% of the US population [1]. The typical acute presentation is sudden onset of pain radiating from the flank to lower abdomen accompanied by microscopic hematuria, nausea, and vomiting [2].

The issue of renal colic a number of times on the SGEM. One issue that has been to use CT or ultrasound for the diagnosis.

A study from Bindman et al. in the NEJM 2014 demonstrated: Initial ultrasonography was associated with lower cumulative radiation exposure than initial computed tomography without significant differences in high-risk diagnosis with complications, serious adverse events, pain scores, return ED visits, or hospitalizations.”

* SGEM#97: Hippy Hippy Shake

* Bottom Line: Bedside emergency department ultrasound is safe and has several advantages over CT for the diagnosis of kidney stones.

Passing a kidney stone is very painful. Narcotics are often used for pain relief along with intravenous NSAIDs. We learned recently about the ceiling effect of ketorolac for treating moderate to severe pain in the emergency department from Sergey Motov (@PainFreeED). He showed that 10mg IV ketorolac was just as effective as 15mg IV or 30mg IV.

* SGEM#175: Dancing on the Ceiling with Ketorolac for Pain

* Bottom Line: Use 10mg IV ketorolac when treating moderate to severe pain in the emergency department.

Alpha blockers have been repeatedly tried to help with renal colic. However, there has not been high-quality evidence demonstrating efficacy.

* SGEM#4: Getting Un-Stoned (Renal Colic and Alpha Blockers)

* Bottom Line: Tamsulosin 0.4 mg OD does not seem to work for renal colic beyond the placebo effect.

* SGEM#71: Like a Rolling Kidney Stone (A Systematic Review of Renal Colic)

* Bottom Line: Tamsulosin is useless in most ED patients with ureteral colic unless their stone size exceeds at least 4mm.

*

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Date: December 19th, 2017

Reference: Perry J et al. Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. CMAJ Nov 2017

Guest Skeptic: Dr. Chris Carpenter is from Washington University, Deputy Editor of Academic Emergency Medicine and faculty member of Emergency Medicine and Critical Care course.

Case:  A 35-year-old female presents to your emergency department three-hours after the onset of a severe frontal headache.  She describes the headache as throbbing, left retro-orbital, and associated with nausea but no vomiting.  As a teenager, she had a history of frequent migraine headaches, but she cannot recall any migraine for at least ten years. The headache developed over an hour while at her desk job and was not associated with loss of consciousness, neck pain, fevers, or neurological deficits. Your physical exam is normal. Last week, your colleague missed a subarachnoid hemorrhage that was diagnosed as a ruptured cerebral aneurysm on the third emergency department visit, so you have a low cognitive threshold to initiate extensive diagnostic evaluations for any and all severe headache patients.

Background:  Headaches represent about 2% of emergency department visits annually. The severe headache patient presenting with altered mental status, fever, or preceding head trauma usually generate sufficient concern to justify further diagnostic evaluations; Most other sudden onset headache cases ultimately prove to result from benign, non-life-threatening causes like migraine headache.

Causes of sudden onset headaches include cough, exertion, and post-coital, but can also include potentially life-threatening conditions like sinus thrombosis, vascular dissection, intracerebral hemorrhage, vasospasm, and aneurysmal subarachnoid hemorrhage. [Landtblom 2002, Delasobera 2012, de Bruijn 1996, Pascual 1996, Dodick 1999]

Migraine headaches are at least 50-times more common than SAH amongst emergency department headache patients, so SAH represents a needle in a haystack for a very common chief complaint. [Edlow 2003]

Missed SAH diagnosis occurs between 12%-53% of cases with emergency department providers estimated to miss 5% of them. [Edlow 2000, Vermeulen 2007]  Unfortunately, one-fourth of aneurysmal SAH victims die within one-day and 50% of SAH survivors never return to work.

Identifying SAH early reduces these adverse outcomes if subsequent neurosurgical interventions (coiling or clipping) occur emergently. [Schievink 1997]  Therefore, the possibility of aneurysmal SAH must be considered in emergency department patients presenting with severe headaches, but in an era of Choosing Wisely and Preventing Overdiagnosis avoiding advanced imaging while simultaneously reducing missed SAH is a tremendous challenge.

Computed tomography (CT) has become increasingly available for the evaluation of headache patients over the last 30 years ago.  Early CTs were 4-slice and radiologists’ interpretative learning curves were steep.

These early CTs were imperfect (sensitivity ~90%) for identifying small amounts of blood in the subarachnoid space, so textbooks, guidelines, and several generations of emergency medicine trainees advised against a CT-only approach to rule-out aneurysmal SAH.

Instead, SAH could only be ruled out when a negative CT was followed immediately by a LP demonstrating cerebrospinal fluid (CSF) without either r...

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: December 28th, 2017

This is a special year end episode of the SGEM. It is time to reflect upon 2017 while at the same time look forward to 2018.

It has been an incredible year for a number of reasons. We had some fantastic papers to review, excellent guest skeptics and super SGEM Xtras. I am very energized to keep the momentum rolling for this knowledge translation project in 2018.

From my perspective, 2017 was the year of Females in Emergency Medicine (FeminEM). This  SGEM Xtra episode is a way to recognized some of the amazing women whose voices are changing the world of emergency medicine. The theme music is by Helen Reddy called I am Woman (1975).

Anyone who listens to the SGEM knows my favorite number is five. I tried so hard to only have five super star women to highlight. This proved to be an impossible task. The list just got longer and longer and longer. Quickly there were ten and then twelve and finally I stopped at fifteen. At least it is a multiple of the number five.

There are other women who are also super heroes of science, supporters of the SGEM but not Emergency Medicine physicians. I am just going to mention a few before I get to the FeminEM list.

Of course, there is Dr. Jen Gunter (@DrJenGunter) the gynecologist who took on Gwyneth Paltrow and GOOP. She is constantly wielding the lasso of truth. We did our first Facebook Live episode with Jen as an SGEM Xtra from the Bat Cave this fall.

That event reminds me of Cristina Roach (@TRC_Podcast) who is the co-host of The Reality Check (TRC) podcast. She and her team at TRC put out a weekly Canadian podcast that explores a wide range of controversies and curiosities using science and critical thinking. Cristina is always classy and never smart assy.

One other super hero of science is Meghan Groth (@EMpharmGirl). She has been such a great supporter and contributor to the SGEM (#81, #93, #117, #144, #169 and #174). As an Emergency Medicine Pharmacist, she always reminds me that it takes a team working together to make sure patients get the best care based on the best evidence.

 

1) Dara Kass (@DaraKass): She is the driving force and creator of FeminEM. I had the pleasure of getting to know her this year and doing a SGEM Xtra episode called

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Date: December 25th, 2017

Happy holidays to all the SGEMers. Please accept this PDF book of Season#3. It is a holiday gift from me to you to say thank you for all the support and encouragement over the last few years.

There are now close to 35,000 subscribers and the SGEM is translated into four other languages. Who would have thought back in 2012 that an emergency medicine  physician from Canada could reach so many people around the world?

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 disseminates the information using the power of social media. We want patients to get the best care based on the best evidence.

The SGEM strives to make the information accessible with the right balance of education and entertainment. This means 80’s theme music, my attempts to sing and cheesy jokes blended in with nerdy bits of methodology.  This is all in an effort to make you better at critical appraisal and remember the information.

This knowledge translation project continues to be part of free open access to medical education movement (FOAMed). I strongly believe we should share our intellectual capital and efforts with everyone around the world with no paywalls.

In keeping with that philosophy here is Season#3 of the SGEM summarized into a PDF book. All the episodes reformatted to be downloaded and shared. There is even a chapter listing all the theme music and the talented artists that create the music. This gift from me to you is meant to be shared and re-gifted with anyone else interested in providing excellent emergency care.

The SGEM would not be so successful if it were not for some very special people. It would be impossible to list everyone but I need to mention just a few. Andrew Worster (@ProfBEEM) from McMaster University, founder of BEEM and my EBM mentor who taught me it all depends. Richard Bukata (@CCMEcourses) for inviting me to the big leagues of EMA and the opportunity to teach with the amazing EMAC faculty. Jerry Hoffman who made me into the skeptic I am today. Anthony Crocco (@SketchyEBM) from SketchEBM who taught me to be a better presenter and is a PEM superhero. Chris Carpenter (@SAEMEBM) who is the smartest guy I know, tireless supporter of the SGEM and my best friend.

Then there are all the wonderful guest skeptics who have contributed to the project. We can all agree the SGEM is a much better with their wisdom and voices added to the show. Thank you so much for helping me critically appraise the papers, record the episodes and get high-quality, clinically relevant information to the patients’ bedside.

And most importantly I would like to thank all the SGEMers.  I can’t tell you how much it means to have an audience of people committed to providing patients with great care in their time of need.

Take a moment to recognize what an important role you play in so many lives. Everyone on the team from the pre-hospital setting, to the ED, in-patient, ICU and primary care providers. Patients deserve excellent care from the moment they reach out for emergency help, during their acute care and all the way to their follow-up outpatient management. We should all be striving to have a NNT of 1. Every single patient is an opportunity to help and it is a pr...

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Date: December 19th, 2017

Reference: Lesassier Hamilton A. Dissertatio Medica lnauguralis De Synocho Castrensi [Inaugural medical dissertation on camp fever]. Edinburgh: J Ballantyne, 1816.

Guest Skeptic: Dr. Robert Leeper is an assistant professor of surgery at Western University and the London Health Sciences Centre.  His practice is in trauma, emergency general surgery, and critical care with an academic interest in ultrasound and medical simulation.

This is the 200th episode of the SGEM and it is the 2017 holiday edition. The idea for this episode came after seeing a twitter photo on Halloween of Dr. Leeper (@Rob_Leeper) doing rounds dressed up as Alexander Hamilton.

To be clear, Dr. Alexander Lesassier Hamilton was a Scottish physician who lived around the early 1800s. He is a completely different person than one of the founding fathers of the United States.

The American Alexander Hamilton family was Scottish but he was born out of wedlock in Charlestown, Nevis. He was abandoned by his father and became an orphan when his mother died.

Despite his challenging start to his life, Alexander Hamilton became the first Secretary of the Treasury, established a national bank and contributed greatly to the early years of the United States of America.

However, he was a very controversial figure for a number of reasons. One reason was his embroilment in the first major sex scandal involving an American politician. He was also mortally wounded in a duel with Aaron Burr. Many people know about the American Alexander Hamilton because of the amazing Broadway musical written by Lin-Manuel Miranda.

Dr. Alexander Hamilton will be the focus of this SGEM holiday episode. He too was a controversial figure. Dr. Hamilton was reported to have been self-absorbed, shameless opportunist, scoundrel, seducer and at times a failed physician.

Dr. Hamilton published his medical thesis in 1816 called Inaugural Medical Dissertation on Camp Fever. It is a study that highlights the importance of randomization. A copy of the paper was retrieved from the achieves at McGill University with the help of a librarian at Western University. It was a 90 page document written in Latin.

Google Translate was not able to convert the Latin to English. Western University Assistant Professor of Classics and Graduate Chair Kyle Gervais said it would take a graduate student about three months working on it full time to translate the document.

The James Lind Library were very helpful. They had English copies of Dr. Hamilton’s papers. One of them was thought to have been the document given to a Latinist to produce the Latin version required by Edinburgh University for Dr. Hamilton’s medical thesis. It was this hand-written document that was relied upon for this special holiday edition of the SGEM.

Case: 23-year-old soldier presents to the medical tent with camp fever. On examination, “the pulse is frequently, full and soft. Respirations somewhat affected. Heat increased. Anorexia. Thirst. Tongue furred. Urine high coloured. Constipation.”

Background: The Peninsular War was between the Napoleon Empire and the allied powers of the Spanish Empire from 1807 to 1814. The allies consisted of Spain, Great Britain, Ireland and Portugal. They were fighting for control of the Iberian Peninsula.