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Date: March 24th, 2016

Guest Skeptic: Dr. Chris Bond. Chris is an emergency physician and clinical lecturer at the University of Calgary. He is currently the host of CAEP Casts, which highlights educational innovations from emergency medicine residency programs across Canada. Chris also has his own #FOAMed blog called Standing on the Corner Minding My Own Business (SOCMOB).

Lead Author: Dr. Elyse Pelletier. Elyse works at the Centre de Recherche CHU de Québec, Population Health and optimal Health Practices Unit. She is also in the Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada.

Case: A 21-year-old male is standing on the corner, minding his own business (SOCMOB) when he is hit in the head with a bat and suffers a severe traumatic brain injury. He is brought into the trauma room and appears to have an isolated head injury. He does not open his eyes to pain, does not speak, and he withdraws to painful stimuli. His Glasgow Coma Score is 6 and after intubating him, his left pupil is sluggish and 5 mm while his right is 3 mm and reactive. You decide to give a hyperosmolar solution for his suspected increased intracranial pressure (ICP) while he is being transported to the CT scanner. You ask for a bag of mannitol, but someone asks whether hypertonic saline will be more effective for this patient?

Background: Severe traumatic brain injury (TBI) is associated with a high morbidity and mortality and is a common injury seen in Canada (Turgeon et al and Zygun et al). In severe cases, increased intracranial pressure (ICP) may happen and generate secondary cerebral injuries following decreased cerebral perfusion pressure and ischemia. Increased ICP is strongly associated with mortality and unfavorable neurological outcomes (Giulioni and Ursino).

* Several interventions have been proposed to manage ICP:

* Cerebrospinal Fluid Drainage (Bullock et al) – This is basically where an external ventricular drain is inserted into one of the ventricles of the brain to drain off CSF when the ICP is increasing.

* Decompressive Craniectomy (Bullock et al) –  This removes a piece of skull to allow the swollen brain to expand and thus reduce ICP.

* Barbiturate Coma (Guidelines) – This is a last ditch effort when all other medical and surgical therapies have failed. Barbiturates are postulated to decrease ICP by a number of mechanisms such as lowering vascular tone and cerebral metabolism. Unfortunately, the RCTs of barbiturate comas were all done in the 80s, when standard care was prolonged hyperventilation, fluid restriction and steroids.

One therapeutic intervention to treat increased ICP is the use of hyperosmolar solutions. Mannitol is the most frequently administered hyperosmolar solutions and is the solution recommended by the clinical practice guidelines (Guidelines). Mannitol is considered the gold standard for hyperosmolar therapy in the treatment of ICP (Guidelines, Brown et al,  and Sakowitz et al).

Recently, hypertonic saline solutions have been receiving support in treatment of increased ICP in TBI because of their volume expansio...

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Date: March 10th, 2016

Guest Skeptic: Dr. Tim Platts-Mills. Tim is an Assistant Professor of Emergency Medicine; Director, Clinical Research; Co-Director of Geriatric Emergency Medicine at the University of North Carolina. His career goal is to improve the quality of emergency care for older adults through research, research mentorship, and support of the larger community of geriatric emergency medicine researchers. Tim’s research group is currently developing a protocol to screen for elder abuse in the emergency department. He also serves as a decision editor in geriatrics for Annals of Emergency Medicine.

Case: 78-year-old female with history of osteoporosis trips and falls while rushing between flights at the airport. She arrives to your emergency department with right wrist pain and after your evaluation you order an x-ray that reveals a Colles’ fracture. No other injuries are identified. After you assess her response to emergency department analgesia (acetaminophen) and splint the fracture, you prepare to discharge her so that she can catch the next flight home and you contemplate the pros and cons of various pain medications. Personally, if you suffered a wrist fracture, you would favor whatever analgesic provided sufficient relief to return to daily activity, and nothing more than that. You decide to ask the patient for her pain management preferences, but you wonder what the role is for emergency department shared decision-making in geriatric patients.

Background: Most clinicians are familiar with informed consent or informed decision making but may not be as familiar with the concept of shared decision making (SDM). Valerie Billingham in 1998 is credited with proclaiming “nothing about me without me” at the Salzburg Global Seminar. This statement succinctly captures the vision that medicine must always consciously respect human dignity. Her statement is credited as the genesis for “Shared Decision Making” (SDM) in medical decision-making.

* Key elements to SDM (Barry and Edgman-Levitan NEJM 2012):

* Patient and the doctor collaborate on reaching a decision about a management strategy for a given problem

* It first requires a situation where more than one reasonable option exists

* SDM also requires that a patient be given the information they need to choose among the competing acceptable strategies

* It shifts focus from “disease” and towards understanding patients’ experience of illness

* Barry states that SDM is the pinnacle of patient-centered care

The Affordable Care Act of 2010 in the United States emphasizes SDM that includes communication strategies to help patients collaboratively choose the best treatment option.

Although the 3-prongs of Evidence Based Medicine include research evidence, clinician expertise, and patient preferences, medicine has too often underemphasized the unique perspectives of patients and caregivers.

Clinical Question: Does shared decision-making for analgesic selection in older adults discharged home from the emergency department with acute musculoskeletal pain improve pain relief?

Reference: Holland et al. A Prospective Evaluation of Shared Decision-Making Regarding Analgesics Selection for Older Emergency Department Patients with Acute Musculoskeletal Pain. Acad Emerg Med 2016

* Population: Adults >60 years old with acute, moderate-to-severe (pain greater than or equal to 4/10 on a 0-10 scale) musculoskeletal pain discharged home from the emergency department.

* Exclusion: Cognitive impairment (Six Item Screener score of 3 or less), pain for >1 month, daily use of opioid pain medication prior to current pain onset,

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Date: March 6th, 2016

Guest Skeptic: Dr. Simon Carley. Simon is Professor of Emergency Medicine in Manchester, England. He is a keen educator and loves sharing what he knows through the blog and podcast at St. Emlyn’s.

Case: You are working hard in the emergency department. It is a busy night and you are working flat out dealing with the stream of patients. In the middle of this busy night one of your nurses asks you to resite an IV on an 80-year-old lady with confusion and urosepsis. You had placed the IV yourself under ultrasound guidance earlier and it took some time and effort. The line has ‘fallen out’ and she needs re-siting before heading off to the ward. Your nursing colleague asks if you want to glue this one to stop it from getting pulled out?

Background: Placement of an IV is arguably the most common invasive procedure in the emergency department. It is almost routine for our sicker patient and yet it is not without risk.

IVs can act as a source of infection, are restrictive to patient movement, require monitoring and can fall out requiring replacement. All of these factors take time away from other aspects of clinical care and put patients at risk.

It is also fair to say that every clinician will remember the IV that took them ages to site, only for it to fall out later.

Back in 2012, Cliff Reid on the Resus.me site reviewed two papers looking at the use of tissue glue to secure central venous catheters and the results looked good. I am also aware of the use of glue amongst our anaesthetists to secure arterial lines in young children. These are both examples of “high stakes” lines. Glue is used to secure the line as it will be difficult and potentially dangerous for them to be removed and it makes sense to me and others to use it for securing them.

The glue used is cyanoacrylate glue, or skin glue as we know it. For peripheral IVs the question is slightly different.

We still need to question whether we need to place as many IVs in the ED as we do. A paper reviewed on the St.Emlyn’s website back in 2013 showed that in an Australian ED fewer than 60% of peripheral IVs were used for anything more than taking blood. So clearly they are not as high stakes as our CVC and arterial lines.

However, some clearly are and in the case described we really do not want our IV to fall out and our patient may come to harm if they have delays in IV fluids or antibiotics.

The bottom line is that for many of our patients the securing of the IV is an important clinical intervention.

Clinical Question: Does the addition of skin glue decrease the failure rate of emergency department inserted peripheral intravenous catheters compared to standard peripheral intravenous catheter care?

Reference: Simon Bugden et al. Skin Glue Reduces the Failure Rate of Emergency Department- Inserted Peripheral Intravenous Catheters: A Randomized Controlled Trial. Ann Emerg Med 2015

* Population: Adult emergency department patients requiring IV cannulation for therapeutic intervention.

* Excluded: Allergy/irritation to skin glue or standard IV catheter securement material; presence of infection near the IV site, upper limb phlebitis, or venous thrombosis; high likelihood of intentional IV removal (ex: agitated patient); and non-English speaking patients without an interpreter.

* Intervention: Fixation of the IV with one drop of glue at the peripheral IV skin site and one drop of glue under the peripheral IV catheter hub. There is a

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Date: February 12th, 2016

Guest Skeptic: Dr. Robert Edmonds. Bob is a third year Emergency Medicine Resident at the University of Missouri at Kansas City. Prior to medical school, he graduated from the US Air Force Academy, and when he completes his training will rejoin the Air Force for nine years as an Emergency Medicine physician.

Case: A 24-year-old female presents to the emergency department with palpitations. She feels anxious but is hemodynamically stable and her ECG demonstrates supra ventricular tachycardia (SVT). This condition has happened several times before and she hates the medication she is usually given in the emergency department that makes her feel like she is dying.

Background:  Patients with SVT often present to the emergency department. Life in the Fast Lane has a good blog posting about SVT.

Restoring patents back to a sinus rhythm can be done in a number of ways, including electrical, pharmacologic, and non-pharmacologic. For the hemodynamically unstable patient, synchronized cardioversion is usually the preferred treatment.

If they are not hemodynamically unstable, a variety of drugs have been used to stop SVT such as adenosine, calcium channel blockers, and beta blockers. It is the adenosine that people find particularly upsetting and is probably why the woman in this case is anxious about having her heart temporarily stop again.

Another way to convert patients that does not include drugs or electricity uses the mammalian dive reflex. This is used more often in children than in adults. Smith et al also published a review article on this method. The patient puts their face in an ice-cold bath. I have used this one time successfully on a patient who did not want to have adenosine again.

Carotid massage can also be tried but has the risk of adverse outcomes in elderly patients.

The Valsalva manoeuvre is a non-invasive way to convert patients from SVT to sinus. It increases the myocardial refractory period by increasing intrathoracic pressure, thus stimulating baroreceptors in the aortic arch and carotid bodies increasing vagal tone.

The effectiveness of the Valsalva manoeuvre for conversion of SVT was on SGEM#67. It was a systematic review by Smith et al that included three studies. Only one was from the emergency department setting and demonstrated a conversion rate of only 19%.

Clinical Question: Can a modified Valsalva manoeuvre help convert stable patients presenting to the emergency department with SVT to a sinus rhythm more often than a standard Valsalva manoeuvre?

Reference: Appelboam et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet 2015.

* Population: Adult patients presenting to the emergency department with SVT (Ten Hospitals in the United Kingdom: two teaching hospitals, eight district general hospitals).

* Inclusion: Over 18 years of age with a narrow complex tachycardia (QRS duration less than 0.12 seconds on ECG).

* Excluded:

* Unstable patients with systolic blood pressure less than 90mmHg

* Patients with an indication for immediate cardioversion

* Those in atrial fibrillation or flutter

* Suspected atrial flutter requiring a trial of adenosine

* Any contraindication to the Valsalva manoeuvre (aortic stenosis, recent MI, glaucoma, or retinopathy)

* Inability to perform Valsalva, lie flat, or have legs lifted

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Date: February 2nd, 2016

Guest Skeptic: Dr. Justin Morgenstern. Justin is an emergency physician and the director of simulation education at Markham Stouffville Hospital in Ontario. He loves skepticism and medical education, especially when it is free and open access. He is the author of the #FOAMed blog First10EM.com and is an associate editor of Emergency Medicine Cases.

Case: A 64-year-old woman presents to the emergency department with fever, urinary symptoms, and altered mental status. You diagnose her with sepsis with a probable urinary source. You rapidly provide empiric antibiotics and initiate fluid resuscitation. You are ready to send her up to the ICU for monitoring when your nurse asks, “shouldn’t we give her some acetaminophen for her fever?”

Background: If you work in emergency medicine, you are aware of the continuous debate about fever. Is it harmful? Is it helpful? Should it be treated? We did a great episode (SGEM#95) on pediatric fever with Dr. Anthony Crocco from SketchyEBM.

When it comes to children, the American Academy of Pediatrics says: “…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.”

Dr. Crocco also did a great RANThony on the whole fever fear topic a few years ago. However, we are not talking pediatric fever today but rather adult ICU patients with fevers.

There are two opposing schools of thought about the value of fever in infection. One side argues that fever causes an increased metabolic stress than might be detrimental to already sick patients. The other side points out that fever is a natural immune response designed to fight infection. So eliminating this natural line of defence could make sick patients even sicker. Unfortunately, there has been little high quality evidence to answer this question – until now.

Clinical Question: Does regular administration of intravenous acetaminophen in febrile ICU patients being treated for a known or suspected infection impact the number of ICU-free days?

Reference: Young P et al. Acetaminophen for Fever in Critically Ill Patients with Suspected Infection. NEJM 2015

* Population: ICU patients 16 years or older with a temperature of 38°C or higher and being treated for a known or suspected infection.

* Exclusion criteria: Acute brain disorders; liver dysfunction; post cardiac arrest where current or anticipated temperature control was required; rhabdomyolysis; pregnancy; previous enrolment.

* Intervention: Acetaminophen 1 gram intravenous every six hours

* Comparison: Placebo (5% dextrose in water) intravenous every six hours

* Outcome:

* Primary outcome: ICU free days at day 28 (death counted as zero ICU free days)

* Secondary outcomes: All cause mortality at 28 and 90 days, number of days alive, ICU and hospital length of stay, hospital free days, number of days free from inotropes or vasopressors, mechanical ventilation, and renal replacement therapy. Physiological and laboratory-related outcomes.

Author’s Conclusions: “Early administration of acetaminophen to treat fever due to probable infection did not affect the number of ICU-free days.”

Quality Checklist for Randomized Clinical Trials:

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Date: January 20th, 2016

Guest Host: Dr. Chris Carpenter is from Washington University, Deputy Editor of Academic Emergency Medicine and faculty member of Emergency Medical Abstracts.

Guest Skeptics: Dr. Kara Otterness from Stony Brook University Hospital on Long Island.  Kara is an assistant clinical professor of Emergency Medicine at Stony Brook.

Dr. Salim Rezaie is from University of Texas Health Science Center at San Antonio. Salim is an associate clinical professor of Emergency Medicine/Internal Medicine at the University of Texas Health Science Center at San Antonio, Texas. He is the creator/founder of the REBEL EM Blog and REBEL Cast.

Case: A 23-year-old healthy woman presents with right eye pain. She states she felt a foreign body sensation yesterday and then overnight, it became painful. Her visual acuity is 20/20 bilaterally and she doesn’t wear corrective lenses. Instillation of tetracaine drops results in complete resolution of the pain. On your slit lamp examination, you see a small corneal abrasion outside of the visual axis with no evidence of ulceration and no foreign body. You update the patient’s tetanus, prescribe her an antibiotic drop and prepare to discharge her when she approaches you and states, “the pain is starting to come back. Can I have that bottle of medicine you used before to take home with me?”

Background: Corneal abrasions account for approximately 10% of eye related visits to the Emergency Department, making them one of the most common eye related presentations (Verma and Kahn). The cornea is highly innervated, and even small abrasions can cause significant pain. Pain control is one of the fundamental goals of emergency medical care. The first documented use of topical ophthalmologic anesthetics was in 1818. A cocaine derivative was employed to effectively block nerve conduction in the superficial cornea and conjunctiva (Rosenwasser).

However, a number of proposed dangers limit the use of topical anesthetic agents for the treatment of corneal abrasion associated pain. These dangers include delayed healing secondary to mitosis inhibition and decreased corneal sensation. The latter issue is of concern because of the potential for the abrasion to progress to an ulcer without the patient noticing. Additionally, these agents may have direct toxicity to corneal epithelium with prolonged use, leading to increased corneal thickness, opacification, stromal infiltration, and epithelial defects. The fear of these complications has led to the pervasive teaching that topical anesthetics should never be used for outpatient management of corneal abrasions. This is reflected in the condemnation of their use in major Emergency Medicine textbooks including Rosen’s and Tintinalli’s.

Based on this, we have been reluctant to give these agents to patients in spite of the fact that we know they’ll improve pain levels.

Clinical Question: Can emergency department patients with simple corneal abrasions be safely discharged home with a prescription for a topical anesthetic drop?

Reference: Swaminathan A, Otterness K, Milne K, Rezaie S. The safety of topical anesthetics in the treatment of corneal abrasions: A review. J Emerg Med 2015

* Population: Adult patients with a corneal abrasion

* Excluded: Animal studies, case reports, case series and non-English

* Intervention: Topical anesthetic drops (proparacaine, tetracaine or bupivacaine)

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Date: January 20th, 2016

Guest Skeptic: Meghan Groth (@EMPharmGirl). Meghan is the emergency medicine pharmacy specialist at the University of Vermont Medical Center, and an adjunct professor of pharmacy at the Albany College of Pharmacy and Health Sciences.

Case: A 34-year-old male presents to your emergency department with complaints of severe nausea for the past 24 hours. He’s vomited a number of times at home and on a scale of zero to ten (ten being the worst nausea he’s ever experienced), he rates his current nausea at an eight. As the triage nurse brings him back to get settled into his room, you observe him holding an emesis basin and dry heaving. He has no significant past medical history and no known drug allergies.

Background: Nausea and vomiting is a very common complaint for patients presenting to the emergency department, accounting for almost five million visits in the US each year.

Currently available antiemetic treatments include ondansetron, droperidol, metoclopramide, promethazine, and prochlorperazine. Ondansetron is the most commonly administered medication in US emergency departments. Despite this, it takes about 30 minutes for intravenous ondansetron to work, which isn’t ideal in patients on the verge of vomiting.

There are studies showing commonly used antiemetic drugs are not superior to placebo in undifferentiated emergency department patients. We covered one of those studies with Eve Purdy on SGEM#101 called Puke – Antiemetics in Adult Emergency Department Patients.

A number of studies have evaluated the use of isopropyl alcohol inhalation for nausea, but these have primarily been in the postoperative setting. A recent Cochrane Review by Hines et al found that isopropyl alcohol inhalation was more effective than placebo in reducing the number of subjects requiring rescue anti-emetics but not as effective as standard anti-emetic therapy.

That Cochrane review also found that other aromatherapies like peppermint oil did not have any good evidence to support their use in treating postoperative nausea and vomiting.

Clinical Question: Does nasally inhaled isopropyl alcohol reduce nausea in adult emergency department patients?

Reference: Beadle, et al. Isopropyl alcohol nasal inhalation for nausea in the emergency department: a randomized controlled trial. Ann Emerg Med 2015

* Population: Adult patients presenting to an urban tertiary care emergency department with chief complaint of nausea or vomiting.

* Exclusions: Patients with an allergy to isopropyl alcohol, were unable to inhale through the nares, if they were unable to read or write in English, or had altered mental status (including intoxication). Other exclusions included patients who had received an antiemetic (including nasally inhaled isopropyl alcohol) or psychoactive drug or a medication known to potentially produce nausea when exposed to alcohol (eg, disulfiram, metronidazole, cefoperazone).

* Intervention: Nasal inhalation of an isopropyl alcohol pad for no more than 60 seconds (at study start, after two minutes and after four minutes). If nausea was relieved at any time, subjects were instructed to not further inhale.

* Comparison: Nasal inhalation of a pad saturated in normal saline

* Outcome:

* Primary outcome: Nausea score at 10 minutes post treatment using an 11-point verbal numeric response scale (0 being “no nausea” to 10 being “worst nausea imaginable”).

* Secondary outcomes: Patient satisfaction scores on a 5-point Likert scale (1 being “very unsatisfied” to 5 being “very satisfied”),

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Date: January 14th, 2016

Guest Skeptics: Dave Harrison, Carl Berdahl and Todd Schneberk are Emergency Medicine residents in the Department of Emergency Medicine at the Keck School of Medicine of the University of Southern California.

Reference: Ringh et al. Mobile-Phone dispatch of Laypersons for CPR in Out-of-Hospital Cardiac Arrest. NEJM June 2015 

Case: A 78-year-old man with a history of hypertension and coronary artery disease suddenly collapses at home in front of his wife. She calls 911 but is unable to get on her knees and provide CPR due to her comorbidities.

Background: Sudden cardiac arrest is common with approximately 500,000 cardiac arrests each year in the USA. More than half of these cardiac arrests are out of hospital cardiac arrests (OHCA) and the survival rate is pretty poor.

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.

* Step One – Recognition and activation of the emergency response system

* Step Two – Immediate high-quality CPR

* Step Three – Rapid defibrillation

* Step Four – Basic and advanced emergency medical services

* Step Five – Advanced life support and post arrest care

The fourth step in the chain was covered with the EM Swami on SGEM#64. This was the classic OPALS trial done by Ian Stiell and his group in Ottawa, Canada. It demonstrated ACLS did not increase survival to hospital discharge over BLS for patients with OHCA.

In contrast, step two has been associated with a significant increase in survival. Bystander-initiated CPR improves chances of survival compared to those people who did not receive such help. A major barrier to improved survival of OHCA remains the low rates of bystander-initiated CPR.

There has been a dramatic increase in mobile phones over the last few years. These devices are becoming tools used in health care. One fascinating application has been automated text messaging to remind discharged emergency department patients of their follow-up appointments. This was a study published in AEM by Sanja Arora showed the NNT (number needed to text) was 10 (SGEM#102).

Clinical Question: Can using a mobile-phone positioning system to dispatch lay volunteers who were trained in CPR increase the rate of bystander-initiated CPR for patients with OHCA?

Reference: Ringh et al. Mobile-Phone dispatch of Laypersons for CPR in Out-of-Hospital Cardiac Arrest. NEJM June 2015 

* Population: Cases suspected by 911 dispatcher to be out-of-hospital cardiac arrest that occurred during daytime hours (6am-11pm) in Stockholm, Sweden and ended up getting treated by EMS.

* Excluded: Patients less than 8 years of age, hazardous environment, and cases of OHCA caused by drowning, trauma, intoxication, or suicide.

* Intervention: Volunteer within 500m radius called to scene of possible cardiac arrest, with the assumption that CPR should likely be performed.

* Comparison: Usual care.

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Date: January 5th, 2016

Guest Skeptics: Dr. Chris Carpenter is from Washington University, Deputy Editor of Academic Emergency Medicine and faculty member of Emergency Medical Abstracts.

Dr. Brian Rowe is a Professor, Department of Emergency Medicine, at the University of Alberta. He is a Canadian Research Chair in Evidence-Based Emergency Medicine and is also co-editor of the Cochrane Collaboration Airway Review Group.

Dr. Cristina Villa-Roel is a physician with a MSc in Clinical Epidemiology who is nearing the completion of her PhD at the School of Public Health at the University of Alberta. She is interested in improving the quality of life for patients with asthma by coordinating transitions in care between the emergency department and the primary care setting through the delivery of comprehensive and evidence-based care. Her research is supported by the Canadian Institutes for Health Research (CIHR) in partnership with the Knowledge Translation branch.

Case: A 21 year old with asthma since he was five years old and a prior intubation when he was eight presents to your emergency department with wheezing that is improved with two short (5 mg Albuterol) nebulizer treatments + Prednisone. He is eagerly awaiting discharge home when you note that he has had 15 visits to your emergency department for asthma exacerbations over the last 12 months.  You ask him if he is following up with his primary care provider and filling the asthma medication prescriptions that he receives at each emergency department visit. He notes that he has no primary care provider with whom to follow-up, no money to pay for prescriptions, and no transportation to get to either a doctor’s office or the pharmacy. You wonder if anything can be done from the emergency department to keep this patient at home with minimal asthma symptoms for a prolonged period while facing these social and financial barriers.

Background: Asthma is a common presentation to the emergency department. Listen to Dr. Brian Rowe discuss the following:

* Asthma’s impact on the health care system

* Asthma’s impact on the individual

* What happens to most emergency department patients who present with asthma

* What the guidelines say about post-emergency department discharge

* Patient education and teachable moments in the emergency department

Clinical Question: Can an educational intervention done in the emergency department prior to discharge improve follow-up with primary care providers in asthma patients?

Reference: Villa-Roel et al. Effectiveness of Educational Interventions to Increase Primary Care Follow-Up for Adults Seen in the Emergency Department for Acute Asthma: A Systematic Review and Meta-Analysis. AEM Dec 2016.

* Population: Original studies of adult patients discharged from the emergency department after treatment for asthma exacerbation.

* Intervention: Randomized controlled studies (or controlled studies) of any asthma-related educational intervention occurring within one week of the index emergency department visit for asthma. Interventions ranged from post-emergency department phone call reminding patients of follow-up appointment (or arranging follow-up appointment), 5-day course of steroids + transport voucher, fax from emergency department to primary care provider with tailored asthma care recommendations, and/or “asthma action plan” constructed in emergency department with patient prior to discharge.

* Comparison: All studies evaluated the effectiveness of educational interventions compared to usual care (discharge instructions + medication prescriptions at discretion of the treating emergency physician).

* Outcome:

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Date: December 17th, 2015

Guest Skeptics: Bob Edmonds is a 3rd year emergency medicine resident at the University of Missouri at Kansas City. Prior to medical school, he graduated from the US Air Force Academy, and when he completes his training will rejoin the Air Force for nine years as an Emergency Medicine physician. In his spare time he enjoys reading, finding random facts online, and hanging out with his wife and son.

This is a SGEM Xtra Holiday Edition. Last year we looked at paper by Chan et al (New Pun-land Journal of Medicine 2014) on Early Goal Directed Dating (SGEM#100). This was a review of an early goal directed dating protocol in the treatment of singledom and severe loneliness for physicians. The episode was in the spirit of the BMJ Holiday Edition that is put out every year at this time. One of the most famous papers in this series was the classic Parachute study (Smith and Pell BMJ 2003).

The SGEM has critically reviewed a couple of BMJ Holiday Edition articles over the years. The first one was SGEM#6 that reviewed the study called Orthopedic Surgeons: As Strong as an Ox and almost Twice as Clever? Multi-Centre Prospective Comparative Study (Subramanian et al. BMJ 2011). The other one we covered was SGEM#23 called Pain over Speed Bumps in Diagnosis of Acute Appendicitis: A Diagnostic Accuracy Study (Ashdown et al. BMJ 2012).

We hope you enjoy this SGEM Xtra Holiday edition on Spinach, Popeye, Iron and the Decimal Error Story (SPIDES).

Case: A 34-year-old former sailor presents to his primary care provider for a routine employment screening. He asks if he should consider eating lots of spinach to make him strong and healthy. He is noted to enjoy pipe smoking and to have disproportionately developed forearms.

Background: For many decades spinach has been promoted as a food with a super high iron content. It is also part of pop culture that Popeye the Sailor ate spinach for the iron to make him strong.

There has been a story about spinach, iron and Popeye that has been circulating for decades. It is referred to as the Spinach, Popeye, Iron and the Decimal Error Story (SPIDES). The story has been told by many academics and reproduced in many books. However, it turns out the story is complicated and not accurate.

I first heard of the story reading a book called the Half-life of Facts: Why Everything We Know Has an Expiration Date while on a cruise for my 20th wedding anniversary. Complexity scientist Samuel Arbesman wrote the book. He has been a fellow at Harvard and at the University of Colorado. He also writes for the New York Times and a few other magazines and newspapers.

In the Half-Life of Facts he tells the story about Popeye and the decimal error made in the calculation of the iron content of spinach. Apparently back in the 1870’s a German scientist named von Wolff was measuring the iron content of vegetables including spinach.This is where the infamous decimal point error was allegedly made changing the magnitude of iron in spinach to be ten fold greater.

This incorrect amount of iron per 100g serving would be ...