Date: June 14th, 2017

I had the pleasure of presenting at the Intra America Emergency Medicine Conference (#IAEMC17) held in Costa Rica last month. Thank you to Dr. Manrique Umana for inviting me and the conference organizers for putting on such an amazing  and educational event. I had a fantastic time meeting so many wonderful people from South, Central and North America.

I gave two talks during the conference and promised that all the material would be available for free as part of the FOAMed movement.

Talk I: Knowledge Translation in the Digital Age

The first talk was on knowledge translation (KT) in the digital age. It has been said that it can take 17 years for 14% of research to reach the patients’ bedside (Morris et al 2011).

A number of examples of the KT problem were provided. The Pathman Leaky Pipe Model was used to illustrate seven leaks in KT. Social Media (FOAMed) was offered as a possible solution to the KT problem. Criticism of social media dating back 2,500 years were discussed (Tom Standage). A short list, not a complete list, of some quality FOAMed sites were provided.

Copies of the slides can be downloaded from this link: KT in Digital Age PDF.

Talk II: Five SGEM Episodes

The second talk was five SGEM episodes selected by Dr. Manrique Umana. Manrique and his team are responsible for SGEM Global Spanish. They have done a number of translations into Spanish to remove language as a knowledge translation barrier and help cut the KT window down to less than one year. The most recent episode reviewed by the SGEM Global Spanish team is the Ottawa Heart Failure Risk Scale.

A Star Wars theme was used for the presentation with an opening crawler written in Spanish. You can click on this link to view the video (The SGEM Returns Spanish).

* Five SGEM Episodes:

* The HEART Pathway: The HEART Pathway appears to have the potential to safely decrease objective cardiac testing, increase early discharge rates and cut median length of stay in low risk chest pain patients presenting to the emergency department with suspicion of acute coronary syndrome.. SGEM#151

* Medical Expulsive Therapy for Kidney Stones: Expulsive therapy is unnecessary for ureteric stones < 5mm. There is some weak evidence that tamsulosin may help passage of larger stones (5 to 10 mm). SGEM#154

* Simple Abscesses and Antibiotics: The addition of TMP/SMX to the treatment of uncomplicated cutaneous abscesses represents an opportunity for shared decision-making. SGEM#164<...

SGEM#170: Don’t Go Breaking My Heart – Ottawa Heart Failure Risk Scale Podcast (escuche el audio): GlobalSGEM-Spanish-170 ¡Hola a todos! Nosotros somos Manrique Umaña y Wilfredo Gómez, somos sus anfitriones para este episodio de “La Guía para Escépticos para Medicina de Emergencias o SGEM”. Este es un proyecto de transferencia de conocimientos iniciado en el 2012 por […]

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Date: June 5th, 2017

Reference: Baharoglu et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet 2016.

Guest Skeptic: Dr. Robert Edmonds is an Emergency Medicine staff physician in Newport News, VA and a recent graduate of the University of Missouri-Kansas City EM residency.

DISCLAIMER – The views and opinions of this podcast/blog do not reflect the views and opinions of the US Air Force, the United States Government, or Langley Air Force Base.

Case: Your next patient is a 68-year-old with sudden onset right sided hemiparesis and facial droop.  Non-contrast head CT shows a hemorrhagic stroke.  On review of the patient’s medications you notice the patient is taking daily aspirin. You wonder if they would benefit from a platelet transfusion.

Background: In the US, daily or every other day aspirin use has been reported to be as high as 61% in adults aged 65 or older (Ajani et al Am J Prev Med 2006).  Taking antiplatelet therapy prior to a hemorrhagic stroke raises the risk of death by 27% and in high income countries more than 25% of patients with incident intracerebral hemorrhages were taking antiplatelet therapy (Thompson et al Neurology 2010).  Many physicians are faced with patients with intracerebral hemorrhage on antiplatelets, and how to best manage them.

The reversal of antiplatelet medications in intracerebral hemorrhage was covered in a Best Available Evidence (Martin and Conlon Ann Emerg Med 2013). It stated that “none of these studies showed a mortality benefit or improved functional outcome with platelet transfusion in patients with spontaneous or traumatic intracerebral hemorrhage who were receiving antiplatelet medications.”

That review further elaborated that for these patients there were “no compelling data currently supporting the use of platelet transfusion” and that “it would be within the standard of care to withhold platelet transfusion in patients with either spontaneous or traumatic intracerebral hemorrhage who are receiving antiplatelet therapy.”  The review did note that the existing evidence at that time were all based on relatively small and retrospective.

However, recommendations from the neurosurgical perspective differ.  A 2010 World of Neurosurgery literature review on the topic by Campbell et al “at present, the literature contains insufficient information to establish any guidelines or treatment recommendations. In light of this, the current authors have proposed a protocol for antiplatelet reversal in both spontaneous and traumatic acute ICH.”

Clinical Question: Does platelet transfusion reduce death or dependency in acute hemorrhagic stroke for patients on antiplatelet agents?

Reference: Baharoglu et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet 2016.

* Population: Adults 18 years or older with non-traumatic intracerebral hemorrhage with a GCS of greater than seven in whom platelets could be transfused within six hours of symptom onset and used antiplatelet therapy for at least seven days.

* Exclusions: Epidural or subdural hematoma, underlying aneurysm or arteriovenous malformation, planned surgery within 24hrs,

SGEM#171: Step-by-Step Approach to the Febrile Infant Podcast: GlobalSGEM Spanish 171 Enfoque Paso a Paso ¡Hola a todos! Mi nombre es Manrique Umaña, soy su anfitrión para este episodio de “La Guía para Escépticos para Medicina de Emergencias o SGEM”. Este es un proyecto de transferencia de conocimientos iniciado en el 2012 por el Dr. Ken Milne […]

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Date: June 3rd, 2017

Reference: Sierink et al. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet August 2016.

Guest Skeptic: Dr. Marcel Emond is an Associate Professor, Laval University, Emergency Physician at the Level 1 Trauma Center of the CHU de Québec, a Senior Clinician-Scientist, Chair of CAEP Trauma and Injury prevention committee, BEEM faculty member and the host of SGEM Global French.

Case: A 53-year-old woman in good health is brought in by ambulance after a motor vehicle collision. She did not lose consciousness but did bump her head.  Her main complaint is chest pain with difficulty breathing. She is tachycardic, tachypnic and has some mild abdominal pain. You suspect a flail chest on your clinical examination.  A FAST examination is performed and is negative.

Question: Should trauma patients get an immediate total-body (pan scan) CT or should you do usual X-rays followed by selective CT scanning?

Background: When we assess head or cervical spine injuries there are good clinical decision tools available to Emergency Physicians to guide our care (Canadian CT Head Rules and Canadian C-Spine Rules).

However, when we assess major trauma that includes chest, abdominal and pelvic trauma, the initial radiologic evaluation is left to the treating physician’s judgement. There is no validated clinical decision tool to help guide our decisions.

Many studies (most retrospective) have assessed the use of pan scanning as an initial radiologic evaluation. Huber-Wagner et al (Lancet 2009) showed a mortality reduction in a retrospective database study of patients who have had a pan scan.  The NNT varied from 17 to 32 according to the injury severity.

A systematic review by the authors of the present study confirmed a possible benefit of the pan scan, but it showed a need for a well-designed, large, prospective randomized clinical trial with patient oriented outcomes (Sierink et al 2012).

Reference: Sierink et al. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet August 2016.

* Population: Adults (18 years or older) with severe injury, suspicion of life-threatening injuries or compromised vital signs.

* Exclusions: Pregnant, referred from another hospital, low-energy trauma with blunt injury mechanism, stab wound in only one body region, and patients too unstable to undergo a CT scan who require CPR or immediate operation because death is imminent

* Intervention: Immediate total-body CT scan (vertex to pubic symphysis)

* Comparison: Standard ATLS guideline directed workup that included chest and pelvic x-rays, FAST scan and followed by selective CT scans of individual body regions.

* Outcome:

* Primary: In-hospital mortality at initial hospital or secondary hospital if transfer occurred

* Secondary: 24 hour and 30 day mortality, imaging time, time to diagnosis, length of stay (LOS) in the trauma room or ICU, number of days of mechanical ventilation. cumulative radiation dose, serious adverse events, transfusion requirements, number of missed injuries and hospital costs.

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Date: May 24th, 2017

Reference: Georgiou et al. Efficacy and Safety of Nonoperative Treatment for Acute Appendicitis: A Meta-analysis. Pediatrics 2017.

Guest Skeptic: Dr. Ross Fisher is a Paediatric Surgeon in Sheffield, England. When he is not waxing lyrical about presentation skills (P Cubed) over at ffolliet.com, giving the Greatest Presentation in the World at SMACC or expounding his views on paediatric trauma management he can be found at Sheffield Children’s Hospital principally dealing with surgical oncology, vascular access and all sorts of neonatal surgical problems.

Case: It is 7pm on a quiet evening in the emergency department and Bobby comes in. He’s 12 years old and complains of a belly ache, pointing to his right iliac fossa pain. It has been going on for about 36 hours now, initially peri-umbilical and associated with nausea, poor appetite and malaise.  It has increased in severity and is now localized in his right iliac fossa. He is particularly worried as he is ice hockey captain. Their hockey team is playing in the regional finals in two weeks’ time. His blood work shows an elevated WBC count and the ultrasound is consistent with acute uncomplicated appendicitis (AUA).

Background: Appendicitis is the most common paediatric surgical emergency. It has a lifetime risk of over 7% but the peak incidence is in the second decade of life. Acute, uncomplicated appendicitis if promptly diagnosed can be effectively treated by surgery, the recovery from which, is relatively short.

There is a small but increasing number of publications in the adult literature proposing management of the problem using simply intravenous antibiotics. This is called Non Operative Treatment of Appendicitis (N.O.T.A). This would avoid the risks of general anaesthesia, any surgical scar and allow quicker return to full activity.

We have covered N.O.T.A. on the SGEM#115 – Complicated. Appendicitis management used to be so easy. The diagnosis was made, the surgeon was called and the appendix was removed.

For over a century the mainstay treatment of acute appendicitis has been an appendectomy. There have been refinements to the surgical procedure since Fitz first described it in 1886. My approach in this case would be to remove the appendix thru a small, 3cm incision particularly in a boy: less number of scars, quicker procedure, similar pain relief and recovery. In girls I would probably use a laparoscope.

REBEL EM covered the issue of N.O.T.A. in adults when it reviewed a pilot study by Dr. David Talan (Ann Emerg Med 2016). Paediatric surgery is completely separate from adult surgery and the implications of practice in adults is not the same in children. There is not a lot of cross over for physicians who have both an adult and paediatric practice in the understanding that children are different.

Clinical Question: Is non-operative treatment (N.O.T.) for acute uncomplicated appendicitis safe and effective in children?

Reference: Georgiou et al. Efficacy and Safety of Nonoperative Treatment for Acute Appendicitis: A Meta-analysis. Pediatrics 2017.

* Population: Paediatric patient under 18 years of age diagnosed w...

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Date: May 19th, 2017

Reference: Willman et al. Do heroin overdose patients require observation after receiving naloxone? Clinical Toxicology 2017.

Guest Skeptic: Dr. Richard Hamilton (@RJHamiltonMD) is Chair of the Department of Emergency Medicine at Drexel University College of Medicine. He is also the host of EMToxCast and gave a talk at the Association of Academic Chairs of Emergency Medicine Annual Retreat called: Can Social Media Save Emergency Medicine?

Case: A 45-year-old male arrives via emergency medical services (EMS) complaining that he wants to be discharged. EMS states they found him unresponsive and with paraphernalia consistent with intravenous heroin use. His prehospital vital signs were oxygen saturation of 89% and respiratory rate of six breaths per minute prior to administration of oxygen and 1 mg of naloxone. After naloxone administration he is alert and oriented times three with a normal pulse oximetry and clear lung fields. It is 20 minutes after he received naloxone and he is asking to be discharged.

Background: Heroin use has been increasing in the USA since 2007 (1). Opioids depress the heart rate and breathing and overdoses can result in death. With the increase in heroin use there has also been an increase in the number of heroin deaths (2).

Naloxone is the specific treatment for heroin overdoses and is becoming widely available to first responders of all sorts (Police, Fire, First Aiders, lay people and EMS). It is an opioid antagonist that binds competitively to opioid receptors in the central nervous system and gastrointestinal tract. It can be administered in multiple ways (intranasal, subcutaneously, intramuscularly, intravenously, nebulization or endotracheal tube).

The American Heart Association (AHA) discussed opioid overdoses and the use of naloxone Part 10: Special Circumstances of Resuscitation in their 2015 Guidelines (3). There were two new recommendations.

One was about education and naloxone training and distribution. The second new recommendation was about opioid overdose treatment.

CanadiEM summarized the Top 5 changes to AHA 2015 Guidelines in a series of infographics (4). One infographic focused on Special Circumstances and said “trained providers should administer naloxone to respiratory arrest patients with suspected opioid overdose. Lay-people likely to see opioid overdoses may be trained to administer naloxone during targeted BLS training” (5).

Some heroin users may refuse further treatment or transport to the emergency department after receiving naloxone in the field and awaking. If transported to hospital, they may also refuse further treatment or observation in the emergency department.

Three Clinical Questions: 

* What are the medical risks to a heroin user treated with naloxone who refuses transport to the emergency department?

* When a heroin user is treated in the emergency department with naloxone how long must they be observed before discharging?

* How effective is naloxone administration in heroin users by first responders and bystanders and what are the risks associated with naloxone distribution programs?

Reference: Willman et al. Do heroin overdose patients require observation after receiving naloxone? Clinical Toxicology 2017.

* Population: Patients suspected of heroin overdose

* Intervention: Naloxone administration (by first responders or byst...

SGEM#172: Don’t Bring My Blood Pressure Down (Intensively) – The ATACH2 Trial Podcast: SGEMglobal-Spanish-172 ¡Hola a todos! Mi nombre es Manrique Umaña, soy su anfitrión para este episodio de “La Guía para Escépticos para Medicina de Emergencias o SGEM”. Este es un proyecto de transferencia de conocimientos iniciado en el 2012 por el Dr. Ken Milne […]

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Date: May 12th, 2017

Reference: Ireland et al. A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners. Medical Teacher 2017.

Guest Skeptic: Dr. Diane Birnbaumer is a Senior Clinical Faculty at Harbor-UCLA Medical Center in Torrance, CA. She is also an Emeritus Professor of Medicine at the David Geffen School of Medicine at UCLA.

Case: A resident comes to you looking for advice. He is having trouble feeling tired, short-tempered and it is affecting his work interactions and personal sense of satisfaction with his job. You suspect he is suffering from early burnout.

Background: Burnout is certainly a hot topic, and mindfulness has hit the front pages of the New York Times and Time Magazine, putting it front and center in the public eye. Burnout was a term coined by Herbert Freudenberger in 1974 (1). There are a number of ways to define burnout but one of the most widely known is by Maslach, known for the Burnout Inventory (MBI) Score. It has three components including emotional exhaustion, depersonalization and reduced feelings of personal accomplishment (2). Some ACEP members know about the MBI as it has been available as part of the Wellness Booth at the ACEP Scientific Assembly for over 20 years.

Physicians have reported a high level of burnout. A recent study of US physicians showed that more 50% had at least one symptom of burnout. Emergency physicians reported the highest prevalence of burnout at around 70% (3).

Burnout can have negative consequences on physicians and may lead to depression (4), suicidal ideation (5), illness (6), and increased alcohol use (7). It has also been associated with negative impacts on patient care including self-perceived medical error (8), risk of medical errors (9), and quality of care (10 and 11). Many factors are correlated with burnout during emergency medicine residency (12), and a significant concern is the number of young physicians identified as suffering from burnout early in their careers.

A systematic review and meta-analysis has been published on interventions to prevent and reduce physician burnout (13). One intervention shown to have a positive impact on reducing burnout is mindfulness-based approaches.

Mindfulness is paying attention to both the internal and external world, being in the present moment and being non-judgmental. Mindfulness meditation was started about 2,500 years ago by Buddha, not to cure illness but rather to end mental suffering. It spread out from Northeastern India near Nepal and eventually was discovered by the Western world in the 1,800’s with British Colonization.

There was another wave of mindfulness into the west in mid 20th Century. The Beatles were a huge part of bringing meditation and mindfulness to the West when they became practitioners. It was in 1975 that a group of individuals started the Insight Meditation Society in Massachusetts.

Then in 1979 a molecular biologist from MIT named Dr. Jon Kabat-Zinn started the Mindfulness Based Stress Reduction (MBSR) program that consisted of an 8-week course. It was first used as an adjunct to regular medical treatment for patients with chronic pain and other chronic illnesses.

Researchers have been looking at the therapeutic effects of mindfulness ever since.

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Date: May 1st, 2017

Reference: Poonai et al. Point-of-care ultrasound for non-angulated distal forearm fractures in children: test performance characteristics and patient-centered outcomes. Acad Emerg Med May 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

SGEM HOP: This is another SGEM Hot Off the Press with Academic Emergency Medicine. Here is a reminder of how this special edition of the SGEM works:

* A paper that has been submitted, peer-reviewd, and accepted for publication in AEM is selected.

* The SGEM puts its skeptical eye upon the

manuscript using the modified BEEM critical appraisal tool.

* One of the authors is invited to discuss their work on the SGEM podcast.

* A special SGEM Hot Off the Press blog is posted and the podcast is uploaded to iTunes the week the paper gets published.

* SGEMers have one week to interact directly with the author via social media (SGEM blog, Twitter or Facebook) with the best feedback being published with a summary of the review in AEM.

Case: You are working in your community emergency department when an anxious father brings in his eight year old who was playing at the park, and tripped and fell onto his outstretched right hand. He has pain over the distal forearm with mild swelling and no deformity. You’ve gotten pretty good with point of care ultrasound, and are curious about how good it is to diagnose forearm fractures.

Background: Point of care ultrasound (POCUS) has become the stethoscope of the 21st century in emergency medicine. POCUS can be used for so many conditions and we have done a number of shows on the topic:

* SGEM#41: Ultra Spinal Tap (Ultrasound Guided Lumbar Puncture)

* SGEM#94: You Better Think Ultrasound for Acute Abdominal Aneurysm

* SGEM#97: Hippy Hippy Shake – Ultrasound Vs. CT Scan for Diagnosing Renal Colic

* SGEM#119: B-Lines (Diagnosing Acute Heart Failure with Ultrasound)

* SGEM#124: Ultrasound for Skull Fractures – Little Bones

* SGEM#153: Simulation for Ultrasound Education

Pediatric fractures are a common type of injury seen in the emergency department. The most common type of fractures seen in children are distal forearm fractures.

Fractures are a painful condition and appropriate analgesic should be provided to avoid oligoanalgesia. It has been shown that children represent one group known t...