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Date: October 5th, 2017

Reference: Brison et al. Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial. BMJ Nov 2016.

Guest Skeptic: Dr. Steve Joseph. Steve completed his Sport Medicine fellowship training with the Fowler Kennedy Sport Medicine Clinic in 2017. He served with the Canadian Forces as a Medical Officer and Flight Surgeon. Steve is currently an Assistant Professor in the Department of Family Medicine at Western University working at the Fowler Clinic and the Roth McFarlane Hand and Upper Limb Centre.

Case: A 43-year-old male presents to your local rural emergency department Monday morning after rolling his ankle during his usual weekend pickup basketball game. He is Ottawa Ankle Rule positive but the x-ray shows no fracture. 

Background: We have covered the Ottawa Ankle Rules (tools) early in Season#1 (SGEM#3). The Ottawa Ankle Rules are probably the most validated clinical decision instrument that have ever been published. 

The Ottawa Ankle Rules have been validated down to five years of age and can be used to safely rule out ankle fractures.

These rules were created by the team in Ottawa lead by Dr. Ian Stiell who is a Legend of Emergency Medicine. You know what they say, those who published the clinical decision instruments get to make the rules.

Ankle sprains are one of the most common and burdensome injuries and are associated with a high rate of visits to an emergency department. Current evidence and clinical standards for acute management of simple sprains (Grade I and II) is limited and not well defined. This includes the role of supervised physiotherapy acutely.

There are some smaller studies in the past that have shown elements of physiotherapy to be of benefit in athlete populations.

* Hupperets et al. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ 2009

* Janssen et al. Bracing superior to neuromuscular training for the prevention of self-reported recurrent ankle sprains: a three-arm randomised controlled trial. Br J Sports Med.

However, these studies deal with ankle sprains in a specific group as compared to a generalized emergency department population.

Clinical Question: Does a supervised physiotherapy program result in improved recovery from acute ankle sprains compared to usual care in adult patients presenting to an emergency department or urgent care clinic.

Reference: Brison et al. Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial. BMJ Nov 2016.

*

Population: Patient 16 years of age or older with a clinical diagnosis of a Grade I/II ankle sprain presenting to the emergency department or urgent care clinic within 72 hours of injury.

* Exclusion:Injury mechanisms that were inconsistent with a ligamentous sprain; the attending emergency physician determining the need for immobilization of the injured ankle or surgery based on clinical findings; presentation with concomitant injuries; other mobility limiting conditions; inability to accommodate the time intensive study protocol; and a declared plan to seek physiotherapy for treatment outside the study protocol.

* Intervention: Early supervised physiotherapy and usual care

* Comparison: Usual care (medical assessment,

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Date: September 26th, 2017

Reference: Kaufman, et al. Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial. BMJ April 17.

Guest Skeptic: Dr. Natalie May trained as an emergency physician with subspecialty paediatric emergency medicine in the UK and worked in Manchester and Oxford before moving to Australia in 2015 to work for Sydney HEMS. She’s been there for the last 18 months working in prehospital and retrieval medicine and then in Emergency Medicine. She is a medical education enthusiast and has been an editor and regular contributor to the St. Emlyn’s blog and podcast since 2012. We appeared on stage at SMACC Chicago doing a parody of Jimmy Fallon’s Tight Pants skit.

Case: You are working the afternoon shift in the paediatric emergency department. It has been the usual busy after-school, after-work time. Your shift is almost over and the department finally seems to be under control. The next patient you see is a five-month old girl who has been brought by her parents with a history of fever and vomiting in the last 24 hours.  She has not had any diarrhoea and her parents have noticed she seems particularly miserable when she is producing wet nappies (diapers), which she is doing more frequently than often. You wonder whether it might be a urinary tract infection (UTI) causing her symptoms and you explain to the parents the importance of a clean catch urine sample. They look at you in despair – all three of them are tired and they really want to go home. You know that it can take some time to get a urine sample in this age-group and wonder, is there a quicker way to get the wee?

Background: Urine samples are frequently obtained in the paediatric emergency department to rule in or rule out UTIs in those children with vomiting, fever, abdominal pain or non-specific illness.

In 2016, the American Academy of Pediatrics (AAP) reaffirmed their clinical practice guidelines for the diagnosis and management of UTIs. They state that the diagnosis of a UTI requires a urinalysis and a urine culture.

Obtaining the sample can be particularly tricky and potentially messy in children who are not yet continent. The rationale for definitive diagnosis included ensuring good antibiotic stewardship, missed UTIs can lead to renal scarring and other delayed pathology and a presumptive diagnosis can result in expensive and unnecessary imaging.

The decision to obtain an invasive sample is a clinical one. If the child looks sick and requires antimicrobial therapy then immediate collection of a urine sample through urethral catheterization or supra-pubic aspiration is recommended strongly by the AAP.

However, if the child is looks well, but the clinician determines that the febrile infant is not in the low risk group for a UTI, the AAP recommends two options. One option is to obtain the urine sample using an invasive method.

The second option is a two-step approach to identification of a UTI. This two-step process can decrease the rate of catheterization by over 30% without missing UTIs or increasing length of stay in the pediatric emergency department (Lavelle et al Pediatrics 2016).

The first step is to screen using a non-invasive collection method like a bagged urine specimen. If the sample is negative (no evidence of a UTI) then cultures may be omitted. A second step is needed if the bagged sample result is positive or shows evidence of a UTI.

Non-invasive methods are preferable for all but those at risk of neonatal sepsis or the ill ap...

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Date: September 19th, 2017

Reference: Cournoyer et al. Prehospital advanced cardiac life support for out-of-hospital cardiac arrest: a cohort study. Academic Emergency Medicine. September 2017.

Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine and the associate editor for emergency medicine simulation at the AAEM MedEdPORTAL.

Case: You are the medical director of an EMS system in a large city deciding on whether to respond to all out of hospital cardiac arrests (OHCA) with ACLS capabilities, or if resources should be directed to those candidates for extracorporeal CPR.

Background: There are about ½ million sudden cardiac arrests in the USA each year. About half of these cardiac arrests are OHCA and the survival rate is pretty poor. We have covered the topic of OHCA on the SGEM a number of times:

* SGEM#143: Call Me Maybe for Bystander CPR

* SGEM#152: Movin’ on Up – Higher Floors, Lower Survival for OHCA

* SGEM#162: Not Stayin’ Alive More Often with Amiodarone or Lidocaine in OHCA

The American Heart Association came out with updated CPR & ECC Guidelines in 2015 that included its “Chain-of-Survival”. There are five steps in the Chain-of-Survival for OHCA:

Most of us can agree with the first three steps. You need to recognize an arrest and activate your EMS system. Bystander high-quality CPR can buy you some time until defibrillation. We know that rapid application of electricity to defibrillate shockable arrhythmias save lives.

It is the fourth step in the chain that is slightly more controversial; early advanced care. This basically means rapid access to ACLS type resuscitation skills (intubation and intravenous drug therapy). The classic paper on ACLS drugs is called OPALS (Ontario Pre-hospital Advanced Life Support) study and was done by Dr. Ian Stiell and team. Ian is a #LegendofEM and we covered his classic paper on SGEM#64.

OPALS was a before and after observational study, which showed the addition of ACLS was associated with more return of spontaneous circulation (12.9% vs. 18.0%, p<0.001) and improved survival to hospital admission (10.9% vs. 14.6%, p<0.001). However, adding ACLS to the pre-hospital system did not demonstrate an improvement in survival to hospital discharge (5.0% vs. 5.1%, p=0.83). It also did not show an increase in good neurologic outcome in the survivors (78.3% vs. 66.8%, p=0.73).

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. Intravenous drug administration during out-of-hospital cardiac arrest: A randomized trial. JAMA 2009

* Jacobs et al. Effects of adrenaline on survival in out-of-hospital cardiact arrest: A randomized double-blind placebo-controlled trial. Resuscitation 2011

* Hagihara et al.

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Date: September 12th, 2017

Reference: Sinert et al. Randomized Trial of Icatibant for Angiotensin-Converting Enzyme Inhibitor-Induced Upper Airway Angioedema. J Allergy Clin Immunol Pract 2017.

Guest Skeptic: Dr. Anand Swaninathan is an Assistant Professor of Emergency Medicine at NYU/Bellevue Hospital in the Department of Emergency Medicine. He is also part of REBEL EM, The Teaching Course, EMRAP and CoreEM. 

Case: As you walk in to your shift, the nurses grab you and bring you in to bed four where a patient has just presented with tongue swelling. In the room is a 53-year-old woman who, though, not in any particular distress, has got a swollen tongue and lower lip. After a bit of history, you find out that she is taking lisinopril and you determine that this is likely angiotensin converting enzyme inhibitor (ACE-I) induced angioedema. The patient’s swelling started about three hours ago and hasn’t changed much. You place her on a monitor in a high acuity area and bring your airway equipment to the bedside and then return to your computer to take sign out. You discuss with the resident a bit on ACE-I induced angioedema and settle on a plan to observe the patient. Your resident tells you that they recently read an article in the NEJM that argued for the administration of icatibant to usher along resolution of symptoms in ACE-I induced angioedema and asks whether you should consider this treatment.

Background: ACE-I are prescribed to millions of patients in the US. Though they are relatively safe, upper airway angioedema is one of the life-threatening adverse effects that we see frequently in the Emergency Department. Though this disorder is routinely treated with medications for anaphylaxis (i.e. epinephrine, histamine blockers, corticosteroids) the underlying mechanism of action predicts that these medications will not work.

There is no well-established treatment algorithm other than airway control if the angioedema is severe and appears to be causing a mechanical obstruction and cessation of the medication.

A 2015 phase 2 study published in the NEJM (Bas et al) touted the role for icatibant in the treatment of these patients. Icatibant is a selective bradykinin B2 receptor antagonist so it acts by blocking the production of bradykinin.

Despite being heralded as “the cure,” the data set in this article was small (n=27) questioning the validity of the findings.

We covered ACE-I induced angioedema and reviewed the 2015 icatibant study on SGEM#110. Our bottom line at that time was that icatibant was an expensive drug that appears to work well for the off-label use of ACE-I induced angioedema but should be reserved for those rare cases of impending airway compromise.

Enter the CAMEO study which attempts to further elucidate whether there are going to be benefits or not of this medication.

Clinical Question: Does the administration of icatibant to patients with ACE-I induced angioedema improve outcomes?

 Reference:  Sinert et al. Randomized Trial of Icatibant for Angiotensin-Converting Enzyme Inhibitor-Induced Upper Airway Angioedema. J Allergy Clin Immunol Pract 2017.

* Population: Patients 18 years of age or older who were being treated with an ACE-I and presenting with ACE-I induced angioedema of the head and/or neck within 12 hours of symptom onset.

* Intervention: Conventional treatment plus icatibant 30 mg subcutaneously

* Comparison: Conventional treatment plus placebo subcutaneously

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Date: September 11th, 2017

Guest Skeptic: Dr. Esther Choo is an emergency physician and researcher who studies health disparities, substance use disorders, and gender bias. She obtained her MD from Yale University, did her clinical training at Yale-New Haven Hospital and Boston Medical Center, and completed a health services research fellowship at Oregon Health & Sciences University.

This is an SGEM Xtra so we will not be doing a structured critical review of a recent paper trying to cut the knowledge translation window down for over ten years to less than one year using the power of social media. The next episode of the SGEM will be a formal critical appraisal of a recent publication.

Esther recently sent shockwaves through the twitterverse with a series of tweets after the incident in Charlottesville. I reached out to Esther because she was a Super Hero of Emergency Medicine and asked her to be a guest on the SGEM.

The Ten Tweets

 

 

 

 

Five Questions for Esther

* Why did you tweet?

* What has the feedback been?

* Has there been any negative feedback?

* How do you think people should respond when faced with racism, ageism, genderism, etc?

* Would you do it all again?

 

Listen to the podcast on iTunes to hear Esther discuss these questions with me. For more information about FeminEM you can go to their website, like them on Facebook and follow them on Twitter.

Esther was asked to pick her own theme music for the episode. Listen to the SGEM podcast on iTunes to hear why she picked Stronger by Kelly Clarkson.

More Media on the Twitter Storm

* Independent – White patients ‘refusing to be treated by Asian American doctor

* Oregon Live – Portland doctor Esther Choo responds to racism in the emergency room

* Refinery 29– Asian-American Doctor Explains How She Deals With White Nationalists In The ER

* The Sacramento Bee – Hate, even in the ER: Doctor says some refuse her treatment because of her race

* The Hamilton Spectator  – Hate in the ER: Oregon doctor says some refuse her treatment because of her race

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

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Date: September 7th, 2017

Reference: Cohen et al. Acupuncture for analgesia in the emergency department: a multicentre, randomised, equivalence and non-inferiority trial. MJA 2017

Guest Skeptic: Dr. Alfred Sacchetti is a full time practicing Emergency Physician, who is also the Chief of Emergency Medicine at Our Lady of Lourdes Medical Center in Camden, New Jersey, USA, an Assistant Clinical Professor of Emergency Medicine and an Active Researcher.   In addition, Dr. Sacchetti is one of the few individuals to have lectured on the same panel with Dr. Milne and survived with his sanity and reputation intact.

Case: A 41-year-old man presents to the emergency department with an acute onset of back pain. He was putting some groceries into the car and felt something pull in his lower back.  He has no “red flags” on your history and physical examination. He is worried about taking pain pills and wants to know if acupuncture would work?

Background: One of the most common reasons to visit an emergency department is for pain. Unfortunately, pain is often poorly controlled. Inadequate pain control is called oligoanalgesia and has been recognized as a problem for years (Wilson et al).

Low back pain is an extremely common presentation to US Emergency Departments representing 2.4% or 2.7 million visits annually. The vast majority of presentations are benign in etiology but can be time consuming and frustrating for both patients and physicians.

Many different treatment modalities have been tried to treat low back pain with limited success.

* Acetaminophen Williams et al (Lancet 2014)

* Muscle relaxants Friedman et al (JAMA 2015)

* NSAIDs Machado et al (Ann Rheum Dis 2017)

* Benzodiazepines Friedman et al (Ann Emerg Med 2017)

Opioids are very effective at reducing pain. However, they come with many side effects and concerns about addiction and diversion.

ACEP has some guidelines with the American Pain Society from 2007 on the use of opioids. They state opioids should be reserved for severe, disabling pain that is not controlled or not likely to be controlled with NSAIDs or acetaminophen. This will be a challenge, considering the limited effectiveness of NSAIDs and acetaminophen.

In the face of what is being called the opioid epidemic, acupuncture has been suggested as a possible treatment modality.

Acupuncture is part of Traditional Chinese Medicine that has been around for thousands of years. It is based on the idea that the body has a life force flowing through meridians that is called chi/Qi. Disease and illness are result of chi/qi being blocked. Acupuncture is a method of placing needles into the skin to unblock the flow of chi/qi through the meridians to restore balance to the body.

There has been a great deal of research done on acupuncture to treat a variety of conditions. No convincing/high-quality evidence has been published demonstrating its efficacy. Placebo control studies using sham acupuncture have demonstrated it does not matter where you put the needles and suggests a strong placebo component.

Clinical Question: Can acupuncture provide pain relief equivalent to pharmacologic treatment ...

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Date: September 2nd, 2017

Reference: Caputo et al. EmergeNcy Department use of Apneic Oxygenation versus usual care during rapid sequence intubation: A randomized controlled trial (The ENDAO Trial). AEM 2017.

Guest Skeptic: Dr. Rory Spiegel is a clinical instructor at University of Maryland and a recent graduate of Stony Brook’s Resuscitation Fellowship. He writes an excellent blog called EM Nerd, which he describes as nihilistic ramblings.

Case: A 68-year-old female presents with shortness of breath. She has experienced fever, chills and a productive cough worsening over the past five days. Chest X-ray demonstrated bilateral infiltrates consistent with multifocal pneumonia.

Over her emergency department course the patients starts to decompensate despite high-flow nasal cannula and broad-spectrum antibiotics.  The decision is made to intubate the patient. The question arises whether apneic oxygenation should be used during the rapid sequence intubation.

Background: Much has been written regarding the benefits of apneic oxygenation (1,2). Its physiological underpinnings are sound and its logistical and resource based costs are minimal.

As such it has enjoyed widespread adoption throughout the Emergency Medicine and Critical Care world. Despite its popularity the evidence supporting its use has been less inspirational.

There have been some studies in various clinical settings (operating room, critical care and pre-hospital) that have demonstration benefit of apneic oxygenation. There are two observational studies from the emergency department showing an association between apneic oxygenation and an increased first pass success without hypoxemia and reduction in the incidence of hypoxemia during the rapid sequence intubation of patients with intracranial hemorrhage (3, 4)

The FELLOW (Facilitating EndotracheaL intubation by Laryngoscopy technique
and apneic Oxygenation Within the intensive care unit) Trial was a randomized controlled trial demonstrating no difference in desaturation rates with apneic oxygenation vs. usual care.

However, this study was performed in the intensive care unit and not in the emergency department setting (5).

Clinical Question: Does the use of apneic oxygenation in emergency department during rapid sequence intubation decreases the rate of clinically important desaturation, leading to a decrease in peri-intubation complications and death?

Reference: Caputo et al. EmergeNcy Department use of Apneic Oxygenation versus usual care during rapid sequence intubation: A randomized controlled trial (The ENDAO Trial). AEM 2017.

* Population: Emergency department patients greater than 18 years old requiring rapid sequence intubation.

* Exclusions: Patients in cardiac or traumatic arrest or if pre-oxygenation was not performed.

* Intervention: Apneic oxygenation group received standard pre-oxygenation plus 15 L/min of flow using a standard nasal cannula as well as a ETCO2 nasal cannula set at 15 L/min, both of which were started during the pre-oxygenation phase and continued throughout the apneic phase.

* Comparison: No apneic oxygenation but standard pre-oxygenation (either flush-rate oxygen via an non-rebreather-mask, a bag valve mask with PEEP valve, or a BiPAP circuit with an FiO2 of 100%)

* Outcome:

* Primary:The mean lowest oxygenation saturation between the two groups

* Secondary: Rate of first pass success, desaturation below SpO2 90%, desaturation below SpO2 80% and average time to desaturation between the two groups

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: August 26th, 2017 

Guest Skeptic: Dr. Richard Bukata is the Medical Director, The Center for Medical Education, Inc. Started Emergency Medical Abstracts in 1977. A Clinical Professor of Emergency Medicine, Los Angeles County / USC Medical Center,

Los Angeles, California.

 

Legends of Emergency Medicine: This is the final episode of the summer SGEM Xtra series called Legends of Emergency Medicine. These episodes were designed to highlight some of the pioneers and leaders of our specialty. The hope is that these episodes will give the next generation of emergency physicians access to some super stars in our field via social media.

The format of the show will be similar. We will start by finding out some a non-medical thing about the legend: What song they picked as their music for the episode and why?  Then we will tell the back story of how we first met. The more formal part of the episode asks the legend five questions. Listen to the podcast on iTunes to hear their responses.

Five Questions for Rick:

* What is the biggest positive change you have seen in emergency medicine over your career?

* What is the biggest negative change you have seen in emergency medicine over your career?

* What contribution to emergency medicine that you made are you most proud of so far?

* What advice would you give to someone who is interested going into emergency medicine?

* How do you picture emergency medicine looking in the next ten years?

Theme Music: Each legend was asked to pick theme music for their episode and explain why they picked that particular song. Rick picked Beggin’ by Fankie Valli and the Four Seasons

Other Legends of Emergency Medicine:

* Andrew (Professor BEEM) Worster

* Diane (Brickhouse of Education) Birnbaumer

* Joseph (Godfather of #FOAMed) Lex

* Ian (The Rule) Stiell

* Judy (Wrote the Book) Tintinalli

* Jerry (The Skeptic) Hoffman

I hope you enjoyed this summer SGEM Xtra series of podcasts. Don’t Panic – The SGEM will be back next month for Season#6. You can expect more critical appraisals of recent publications trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. The ultimate goal of the SGEM is for patients to get the best care based on the best evidence.

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

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Date: June 5th, 2017 

Guest Skeptic: Dr. Jerome Hoffman. Associate Program Director, Emergency Medicine & Acute Care, Professor Emeritus of Medicine and Emergency Medicine, University of California, Los Angeles.

 

 

Legends of Emergency Medicine: This is the sixth episode in the summer series of SGEM Xtras called Legends of Emergency Medicine (#LegendofEM). These episodes highlight some of the pioneers and leaders of our specialty.  I hope these episodes will give the next generation of emergency physicians access to some super stars in our field via social media.

The format of the show will be similar. We will start by finding out some a non-medical thing about the legend: What song they picked as their music for the episode and why?  Then we will tell the back story of how we first met. The more formal part of the episode asks the legend five questions. Listen to the podcast on iTunes to hear their responses.

Five Questions for Jerry:

* What is the biggest positive change you have seen in emergency medicine over your career?

* What is the biggest negative change you have seen in emergency medicine over your career?

* What contribution to emergency medicine that you made are you most proud of so far?

* What advice would you give to someone who is interested going into emergency medicine?

* How do you picture emergency medicine looking in the next ten years?

Theme Music: Each legend was asked to pick theme music for their episode and explain why they picked that particular song. Jerry picked Strange Fruit by Sidney Bachet.

Other Legends of Emergency Medicine:

* Andrew (Professor BEEM) Worster

* Diane (Brick House) Birnbaumer

* Joseph (Godfather of #FOAMed) Lex

* Ian (The Rule) Stiell

* Judy (Wrote the Book) Tintinalli

I hope you enjoy this summer SGEM Xtra series of podcasts. Don’t Panic – The SGEM will be back in the fall for Season#6. You can expect more critical appraisals of recent publications trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. The ultimate goal of the SGEM is for patients to get the best care based on the best evidence.

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

Feature image on this blog post was painted by the artist Annie Hoffman and is called Malibu Pier at Noon.