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    <title>The Skeptics Guide to Emergency Medicine</title>
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    <description>Meet ’em, greet ’em, treat ’em and street ’em</description>
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    <itunes:author>Dr. Ken Milne</itunes:author>
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      <title>SGEM Xtra: If I Could Turn Back Time – 14 Seasons of Skepticism, Kindness &amp; Evidence-Based EM</title>
      <link>https://podcast.show/thesgem/episode/155296025/</link>
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      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 05 Sep 2026 10:44:27 -0400</pubDate>
      <description><![CDATA[Date: September 4, 2026
This is an SGEM Xtra looking in the rearview mirror at 14 years of The SGEM and looking forward to Season#15. Season 15 is traditionally the crystal anniversary. Crystal is transparent; it can help us see things more clearly, and it can also shatter if you drop it. So, basically, a great metaphor for medical evidence.
Cue some 80s music. Because if I could turn back time. Unfortunately, I don’t have a DeLorean, a flux capacitor, or 1.21 gigawatts. What I do have is a microphone, a large collection of papers, and what may be an unhealthy willingness to discuss p-values and confidence intervals.




PICOT for this SGEM Xtra Episode:




 	Population: SGEMers
 	Intervention: 14 years of skeptical knowledge translation
 	Comparison: Practising emergency medicine before the SGEM
 	Outcome: Thinking better leading to better care
 	Type of Study: Not really a study, but more of an unblinded observation, heavily confounded by nostalgia, that has been funded primarily by enthusiasm and coffee.



When the SGEM began, the goal was straightforward but ambitious: to shorten the knowledge-translation window from more than 10 years to less than 1 year with the power of social media. We wanted to identify clinically relevant emergency medicine research, critically appraise it, and deliver that information to the front-line clinicians caring for patients. Medical education for anyone, anywhere, at any time. Very similar to the EM philosophy of seeing anyone, anytime, for anything. Listen to the podcast and turn your car into a classroom. That was the idea.
I am very thankful to my evidence-based medicine (EBM) mentor, Dr. Andrew Worster from McMaster University. He started the BEEM project and took a chance on me about 20 years ago. Andrew also taught me the EBM answer of “it all depends”. I pitched the idea to him in ~2011 about doing a podcast while riding a ski lift at the Silver Star ski resort in BC. He said…what’s a podcast? Andrew also suggested I attend the University of Oxford and take a mini-fellowship course from the Centre for Evidence-Based Medicine (CEBM) on how to teach EBM. My idea was to create a blog and podcast to encourage skepticism, critical thinking and demonstrate how to review a publication. That is how this whole thing got started.
There was no five-year strategic plan, no glossy prospectus and no venture-capital funding. There was a blog, a podcast, social media, a standardized critical-appraisal process adopted from the BEEM group, and a growing group of people who believed emergency clinicians deserved timely access to the best available evidence. It was fortunate that it happened at the same time as the Free Open Access to Medical Education (FOAMed) movement was launched in 2012.
Not the newest evidence simply because it was new. Not the loudest evidence because someone had a good marketing department. And not the most prestigious evidence merely because it appeared in a high-impact journal. As I like to say, the only thing you can conclude when something is published in the NEJM is that it was published in the NEJM. All your work to determine its validity is still in front of you.
The goal was to find and critically appraise the emergency medicine literature, interpret it in the context of clinical expertise and what matters to individual patients. Fourteen seasons later, the SGEM has more than 85,000 subscribers. It has been translated into five languages, and more than 100 SGEM critical appraisals have been published in peer-reviewed journals.
Those numbers are wonderful, and I am very proud of them. But numbers can only tell part of the story. I don’t want this to be an argument from popularity. A download does not tell you whether someone reconsidered an old habit. A subscriber count cannot capture the moment a clinician paused before ordering a low-value test, questioned an impressive relative risk rather than considering the absolute risk reduction, or had a better shared decision-making conversation with a patient.
The real outcome has always been what happens at the bedside. Did the episode help someone think more clearly? Did it help them recognize uncertainty? Did it help a patient receive better care? Those are the outcomes that matter. Especially the patient-oriented outcomes (POOs).
One of the major developments over the years was the SGEM Hot Off the Press, or SGEMHOP, series. This was created with my BFF, Chris Carpenter. Chris has been a friend, mentor, collaborator and occasional enthusiastic supplier of methodological questions that require three cups of coffee to understand. I’m thankful that the editor-in-chief of Academic Emergency Medicine (AEM), Jeffery Kline, saw the value in the SGEMHOP and supported the initiative.
The idea behind SGEMHOP was to take important new papers, appraise them while they were still hot off the press, speak directly with the authors, and have an open discussion with the wider emergency medicine community. Over the years, that series benefited from an outstanding group of co-hosts: Lauren Westafer, Chris Bond, Corey Heitz, Kirsty Challen, Justin Morgenstern, Neil Gupta &amp; Suchi Datta. Each brought a different perspective, a different area of expertise and, importantly, a willingness to disagree. That matters.
A panel in which everyone agrees may be comfortable, but it is not necessarily informative. The goal was never to build an echo chamber. It was to create a respectful space where methods could be challenged, conclusions could be examined, and uncertainty could be acknowledged.
We invited authors onto the SGEM knowing we were going to ask difficult questions, but critical appraisal was never meant to be a gotcha exercise. Research is difficult; I know I’ve been doing it for 42 years. It involves designing the study, conducting the research, submitting it for peer review, and facing post-peer-review criticism from potentially thousands of skeptical emergency clinicians who aren’t shy about telling you what they think. The focus was always on the paper, the evidence, the logical arguments and not the person.
Challenge the methods. Question the interpretation. Be curious about the choices that were made. Recognize the limitations. And be kind to the people who did the work.


Dr. Dennis Ren
Another terrific addition to the SGEM was Dr. Dennis Ren and the SGEMPeds episodes. He took over where PedsEM superhero Dr. Anthony Crocco (SketchyEBM) left off. Dennis brought expertise, enthusiasm and an important reminder that children are not simply small adults. He also shares my love of Batman.
Pediatric emergency medicine has its own evidence base, uncertainties, and challenges in communicating risk to families. Dennis helped us explore those questions while keeping the episodes practical for anyone who cares for children in an emergency setting.


Dr. Kirsty Challen
Then there is Dr. Kirsty Challen and her wonderful Paper in a Pic summaries. Every Thursday, Kirsty takes an entire critical appraisal and turns it into something clear, memorable and visually engaging. A picture may be worth a thousand words. Kirsty’s pictures are also worth a thousand likes and shares on social media.
Kirsty’s Paper in a Pic also allows SGEMers to revisit the clinical question, key results and bottom line in a format that can be understood quickly and shared easily. That is knowledge translation in its purest form: preserve the nuance but make the information accessible.
The SGEM has also expanded beyond traditional journal club episodes. The SGEM Xtras let us explore popular culture and ask a different kind of question: Can movies and television help make us better clinicians?
We looked at Star Trek, Buffy the Vampire Slayer, Batman, Ted Lasso, Top Gun, A League of Their Own, Mission: Impossible and others.


 	From Star Trek, we considered the balance between logic, leadership and humanity (Spock, Kirk and McCoy).
 	From Buffy, courage, teamwork and the family we choose.
 	Batman taught us the value of preparation (although billionaire vigilante medicine may have limited external validity).
 	Ted Lasso reminded us that kindness is not weakness, and we should be more curious and less judgmental
 	Top Gun gave us teamwork, communication and the importance of not letting confidence become overconfidence.
 	A League of Their Own reminded us that women have always belonged on the field, in the emergency department and in academic medicine.
 	Mission: Impossible? That one mostly prepared us for Monday mornings during respiratory-virus season, which is right around the corner.

The SGEM book reviews gave us another opportunity to slow down and think more deeply. We spoke with Timothy Caulfield about misinformation and celebrity culture, Brian Goldman about kindness, Steven Novella about skepticism, Darren McKee about AI superintelligence, and Mel Herbert about the extraordinary power of being average.
We were also fortunate to welcome some extraordinary guests. Noah Wyle joined us to talk about The Pitt, emergency medicine, and why his portrayal of an emergency physician felt so authentic to people who do the actual job. Terry O’Reilly from Under the Influence helped us think about communication, storytelling and making an idea memorable without overselling it.
Over the years, we have also worked to ensure that the SGEM reflects the full team caring for emergency patients. Emergency medicine is not practised by one profession in isolation. We should all be on Team Patient. Our patients are cared for by emergency physicians, other medical specialists, nurses, physician assistants, nurse practitioners, physiotherapists, pharmacists, paramedics, respiratory therapists and many others.
No profession has exclusive ownership of a good idea. And bias does not check your credentials before influencing your judgment. Bringing different clinicians into the conversation made the appraisals better,...]]></description>
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      <title>SGEM#519: Don’t Let Pediatric Pulmonary Embolism Leave You Breathless</title>
      <link>https://podcast.show/thesgem/episode/155175662/</link>
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      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 29 Aug 2026 08:30:43 -0400</pubDate>
      <description><![CDATA[Reference: Ellison AM, et al. PERC-Peds rule for bedside exclusion of pulmonary embolism without radiation in children in the USA (BEEPER): a multicentre, prospective, observational, diagnostic accuracy study. Lancet Respir Med. July 2026.

Date: August 13, 2026

Dr. Lauren Westafer

Guest Skeptic: Dr. Lauren Westafer is an Associate Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School, Baystate. She is the co-founder of FOAMcast and a researcher in pulmonary embolism and implementation science.  Dr. Westafer serves as the research methodology editor for Annals of Emergency Medicine.

Check out this FOAMcast episode on PERC-Peds as well!

Case: A 15-year-old previously healthy teenage girl presents to the emergency department (ED) with pleuritic chest pain and feeling short of breath after a recent viral illness. On your exam, she is comfortable, has a heart rate of 88 beats/min and oxygen saturation of 99% throughout the visit. She denies hemoptysis, unilateral leg swelling, recent surgery, estrogen exposure, or previous venous thromboembolism. You are working with a trainee who gives you a fantastic differential diagnosis for the chief complaint, which includes a pulmonary embolism. The trainee thinks pulmonary embolism is unlikely and asks, “I have heard of PERC and Wells in adults, but can we apply these to pediatric patients?”

 Background: Pulmonary embolism (PE) represents a broad spectrum of disease with clinical history and presenting features that overlap with many other disease processes. Historically, venous thromboembolism (VTE) has been thought to be quite uncommon in pediatric patients, absent malignancy or indwelling lines. The gold standard diagnostic modality for PE, CT pulmonary angiography (CTPA), carries additional risk to children due to ionizing radiation. In adult patients, the epidemiology of VTE, validated diagnostic algorithms, and D-dimer testing can safely exclude PE in many patients without the need for CTPA.

Previously, there were no prospectively validated bedside tools to identify children in whom we could feel comfortable safely stopping PE testing. Some clinicians extrapolated from adult Pulmonary Embolism Rule-Out Criteria (PERC). In adults, PERC can be used to exclude PE without need for additional blood work or imaging studies. The use and accuracy of D-dimer test to exclude PE in children is also unclear.

The new PERC-Peds rule is a modified version of PERC that was created using retrospective data. There are 8 criteria.



Many criteria are similar between the adult and pediatric PERC but there are some notable differences.

Obviously, for children, PERC-peds has no age100. Rather than relying only on unilateral leg swelling, PERC-Peds asks whether deep vein thrombosis (DVT) is clinically suspected.

There’s also a small change regarding the definition for surgery, which is a procedure requiring endotracheal intubation within the past 30 days.



Clinical Question: In children aged 4-17 years in whom pulmonary embolism is being tested for or strongly considered, can a negative PERC-Peds rule safely exclude PE or proximal DVT within 45 days without laboratory testing or pulmonary vascular imaging?



Reference: Ellison AM, et al. PERC-Peds rule for bedside exclusion of pulmonary embolism without radiation in children in the USA (BEEPER): a multicentre, prospective, observational, diagnostic accuracy study. Lancet Respir Med. July 2026.

 	Population: Children aged 4-17 years at 21 pediatric EDs in the United States who had PE testing ordered (included D-dimer, CTPA, ventilation perfusion scan, magnetic resonance angiography, or other pulmonary vascular imaging) or in whom the senior clinician strongly considered PE (this could be when a D-dimer or CTPA were ordered or cancelled or there was an open verbal discussion about the possibility of ordering one of those tests but decided against it).

 	Exclusion: Known pregnancy, current anticoagulation for VTE, intoxication, incarceration, inability to obtain consent/assent, and inability to complete 45-day contact


 	Intervention: PERC-Peds
 	Comparison: None
 	Outcome: Performance of the PERC-Peds rule

 	Primary: Safe exclusion of PE or proximal DVT, defined a priori as the upper bound of the 95% confidence interval for the false-negative rate not exceeding 1.5%.
 	Secondary: Sensitivity, specificity, predictive values, likelihood ratios, inter-rater reliability, D-dimer performance, and potential reduction in CTPA use


 	Trial: Multicentre, prospective, observational diagnostic accuracy study

Authors’ Conclusions: “In this multicentre, prospective, observational, diagnostic accuracy study of children with suspected pulmonary embolism in the emergency department, we found a 6·3% prevalence of pulmonary embolism or proximal DVT; in this population, the PERC-Peds negative rule can safely rule out pulmonary embolism. Use of PERC-Peds might reduce low-value diagnostic testing for pulmonary embolism in children and adolescents.”
Quality Checklist for A Diagnostic Study:

 	The clinical problem is well defined. Yes
 	The study population represents the target population that would normally be tested for the condition (ie no spectrum bias). Yes
 	The study population included or focused on those in the ED. Yes
 	The study patients were recruited consecutively (ie no selection bias). Unsure
 	The diagnostic evaluation was sufficiently comprehensive and applied equally to all patients (ie no evidence of verification bias). No
 	All diagnostic criteria were explicit, valid and reproducible (ie no incorporation bias). Yes
 	The reference standard was appropriate (id no imperfect gold-standard bias). Yes
 	All undiagnosed patients underwent sufficiently long and comprehensive follow-up (ie no double gold-standard bias) Yes
 	The likelihood ratio(s) of the test(s) in question is presented or can be calculated from the information provided. Yes
 	The precision of the measure of diagnostic performance is satisfactory. Yes
 	Who funded the trial? National Institutes of Health.
 	Did the authors declare conflicts of interest? At least one author, T Charles Casper, reported payments to his institution.

Results: From July 2020 through September 2024, 4,039 children were enrolled. The median age was 15 years (IQR 13-16), 64% were female, and 17% were younger than 12 years. A final VTE outcome was adjudicated for 4,011, and 3,988 had complete PERC-Peds data for the diagnostic accuracy analysis.

Among the adjudicated cohort, 254 children (6%) met the criterion standard:

 	

 	122 had PE only
 	56 had PE plus DVT
 	76 had isolated proximal DVT.





The false negative rate was 0.1% (95% CI 0.0-0.8). Below the threshold of 1.5% they had set at the beginning of the trial.

PERC-Peds was negative in 734 of 3,988 children (18.4%). But there was one false negative.

One child with a negative rule was adjudicated as having PE. This was a 16-year-old female with cough, recent positive SARS-CoV-2 test, chest pain, dyspnea. But she also had normal vital signs and a normal D-dimer test. She had a CTPA ordered that had a filling defect in a peripheral pulmonary arterial branch of the left lower lobe.



 Key Results: The PERC-Peds rule had high sensitivity and a very low false-negative rate, but low specificity. Apply it carefully as indiscriminate use could increase downstream testing and potentially unnecessary imaging.





Verification Bias: 

This is sometimes called work-up bias and can occur when only some participants receive the definitive reference-standard test (often those who appear higher risk) while the remainder are classified using a less intensive method. This can make a diagnostic test appear more accurate because disease is more likely to be detected in test-positive or clinically concerning patients, while disease in lower-risk, untested patients may be missed.

In this study, pulmonary vascular imaging was performed in only around a third (36.6%) of participants, and all diagnostic testing was left to the treating clinician. Children with concerning symptoms, abnormal vital signs, or other risk factors were more likely to undergo imaging, whereas lower-risk or PERC-Peds-negative children were considered disease-free based on medical-record review and 45-day follow-up rather than direct imaging. An occult PE that caused no return visit or diagnosis during follow-up could therefore have been missed, potentially inflating sensitivity and lowering the observed false-negative rate.

The authors did take meaningful steps to reduce this bias. The PERC-Peds variables were collected prospectively but were not used as a mandated clinical management pathway, all adjudicated participants had complete 45-day follow-up, and an independent committee reviewed imaging, follow-up responses, and outside records. This makes the study stronger than one in which un-imaged patients simply were assumed not to have PE, but follow-up is still not equivalent to applying the same definitive imaging reference standard to everyone. Given the harms of imaging thousands of children solely for research, this was a pragmatic and ethically reasonable compromise, but some residual partial verification bias remains.

PE and Proximal DVT: 

The study’s criterion standard was broader than pulmonary embolism alone. A patient was considered positive if they developed either imaging-confirmed PE or proximal DVT within 45 days. Of the 254 patients classified as having venous thromboembolism, 76 (~30%) had proximal DVT without a verified PE. Among those 76, 42 had a negative CTPA and 33 never underwent pulmonary vascular imaging.

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      <title>SGEM#518: What Have You Done for Me Lately – Oseltamivir for Hospitalized Patients?</title>
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      <guid>https://thesgem.com/?p=18819</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 22 Aug 2026 10:58:44 -0400</pubDate>
      <description><![CDATA[Date: August 23, 2026
Guest Skeptic: Dr. Roya Caloia is a former EM program director, longtime faculty at Henry Ford Genesys and current interim Associate Medical Director. She is also the Chairperson of the National Clinical Governance Board for US Acute Care Solutions
Case: A 62-year-old woman with diabetes and chronic lung disease presents to the emergency department (ED) with five days of fever, cough, myalgias and progressively worsening dyspnea. Her respiratory rate is 34 breaths per minute, oxygen saturation is 82% on room air, and chest imaging shows bilateral air-space disease. Molecular testing is positive for influenza A.
Despite supplemental oxygen, she requires high-flow nasal oxygen at 50 L/min with an FiO₂ of 0.60. Following initial fluids, her blood pressure remains low, and norepinephrine is started. She has received no more than one dose of oseltamivir before arrival. The ICU team is contacted, and the question is whether she should receive enteral oseltamivir for five days, ten days, or no influenza antiviral.
Background: Influenza season has a way of turning the ED waiting room into a coughing convention. Most patients feel miserable but recover with time and supportive care. The concern is the smaller group at higher risk of complications, or those already sick enough to require hospital admission. That is usually when someone asks the annual question: Should we give Tamiflu? 
Centers for Disease Control and Prevention (CDC) says:


 	“For hospitalized patients with suspected or confirmed influenza, initiation of antiviral treatment with oral or enterically administered oseltamivir is recommended as soon as possible. Antiviral treatment might be effective in reducing morbidity and mortality in hospitalized influenza patients, especially adults, even if treatment is started more than 48 hours after onset of illness.”

For those outside the United States, the World Health Organization (WHO) guideline specifically addresses severely ill and critically ill patients. The WHO guideline recommends oseltamivir for patients with severe influenza and even suggests considering extending treatment from 5 to 10 days in critically ill patients.
Oseltamivir, better known by the brand name Tamiflu, is an oral neuraminidase inhibitor active against influenza A and B. It blocks an enzyme the virus uses to release newly formed viral particles from infected cells and spread to other cells. Put another way, oseltamivir tries to stop the flu from going viral (dad joke). The usual adult treatment is 75 mg twice daily for five days, with dose adjustment for renal impairment. The regulatory indication focuses on acute, uncomplicated influenza when treatment starts within 48 hours, but clinical guidelines recommend starting it as soon as possible in hospitalized patients, even when they present later in the illness.
The challenge is that a biologically plausible mechanism does not automatically produce a patient-oriented outcome (POO). In otherwise uncomplicated influenza, oseltamivir appears to shorten symptoms by about 17 hours on average. That could mean feeling better Tuesday evening instead of Wednesday morning. It has not convincingly reduced hospital admission in outpatient trials, and it does increase nausea and vomiting. Headache and neuropsychiatric events have also been part of the safety discussion, although the causal relationship for the latter remains uncertain.
Tamiflu has also been at the centre of one of medicine’s biggest data-transparency battles [1,2].  Much of the phase III evidence supporting oseltamivir had not been published, and independent Cochrane reviewers spent years trying to obtain the full clinical study reports from Roche, the manufacturer. The BMJ’s Open Data campaign helped keep the pressure on until the reports were eventually released. When the Cochrane team examined the more complete record, the benefits appeared smaller and the harms more apparent [3]. This became a cautionary tale about publication bias and why evidence-based medicine requires access to all the evidence, not just the parts selected for publication.
This is not SGEM’s first rodeo when it comes to talking about oseltamivir. SGEM#98: Don’t Stand So Close to Me reviewed neuraminidase inhibitors and concluded that the small reduction in symptom duration needed to be weighed against adverse effects. SGEM#312: Oseltamivir is like Bad Medicine looked at primary-care patients with influenza-like illness and remained unconvinced that routine treatment offered a favourable benefit-to-harm ratio. SGEM#397: Give a Little Bit…of Oseltamivir examined hospitalized children and highlighted how much uncertainty remained because the evidence was observational. Finally, SGEM#409: Same as It Ever Was found no good evidence that routine oseltamivir prevented hospitalization among influenza-positive outpatients.
For emergency physicians, the more interesting question is not whether an otherwise healthy outpatient gets off the couch 17 hours earlier. It is whether oseltamivir changes outcomes that matter once influenza becomes severe. Much of the rationale for treating hospitalized patients has historically come from observational evidence, while clinical guidelines have continued to recommend early treatment. That is exactly the kind of gap where guideline momentum, biological plausibility, and patient-oriented evidence need to meet under the SGEM skeptical microscope.




Clinical Question: In critically ill patients aged 12 years or older with laboratory-confirmed influenza who require respiratory or cardiovascular organ support, does treatment with oseltamivir improve 90-day survival?


Reference: Murthy et al. Oseltamivir for Critically Ill Patients with Influenza: A Randomised Trial. SSRN: https://ssrn.com/abstract=7172531 or http://dx.doi.org/10.2139/ssrn.7172531


 	Population: Hospitalized patients aged 12 years or older with laboratory-confirmed influenza who were critically ill and receiving at least one of the following: High-flow nasal oxygen at ≥30 L/min and FiO₂ ≥0.40, non-invasive ventilation, invasive mechanical ventilation, or vasopressor or inotrope support

 	Exclusions: Patients who were expected to die within 24 hours and for whom there was no commitment to full support, had received sustained organ support for more than 48 hours, had already received more than one dose of oseltamivir, were planned to receive another influenza antiviral or were considered by the treating clinician not to be suitable for participation.


 	Intervention: Oseltamivir 75 mg enterally twice daily (with renal dose adjustment) assigned for either 5 or 10 days.
 	Comparison: No influenza antiviral treatment. However, some sites did not offer the no-antiviral option because of a lack of local clinical equipoise. Five-day oseltamivir had to remain an available option.
 	Outcome: 

 	Primary Outcome: All-cause mortality at 90 days.
 	Secondary Outcomes: Survival time to 90 days, hospital and intensive care unit (ICU) length of stay (LOS), cardiovascular- and overall organ-support-free days, progression to invasive ventilation, ECMO or death, and serious adverse events.


 	Type of Study: A multicentre, international, open-label, multifactorial, Bayesian, response-adaptive platform randomized controlled trial.


Authors’ Conclusions: “Treatment with oseltamivir is ineffective and highly likely to increase 90-day mortality in critically ill patients with influenza.”

Quality Checklist for Randomized Clinical Trials: (Yes, No or Unsure)


 	The study population included or focused on those in the emergency department. No
 	The patients were adequately randomized. Yes
 	The randomization process was concealed. Yes
 	The patients were analyzed in the groups to which they were randomized. Yes
 	The study patients were recruited consecutively (i.e. no selection bias). Unsure
 	The patients in both groups were similar with respect to prognostic factors. No 
 	All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No
 	All groups were treated equally except for the intervention. Unsure
 	Follow-up was complete (i.e. at least 80% for both groups). Yes
 	All patient-important outcomes were considered. Yes
 	The treatment effect was large enough and precise enough to be clinically significant. The point estimate is clinically important, but the magnitude is imprecise. 
 	Who funded the trial. The platform had numerous predominantly governmental, academic and philanthropic funders. No oseltamivir manufacturer was named as a funder. The investigators stated that funders had no role in study design, analysis or reporting.
 	Did the authors declare conflicts of interest? We could not find the documents online

Results: The analysis included 442 participants: 162 assigned to five days of oseltamivir, 156 to ten days and 124 to no antiviral. They were recruited at 139 sites across 18 countries; only 79 sites offered the no-antiviral option. The Median age was 60 years in each oseltamivir group and 63 years in the no-antiviral group. Approximately 38% to 45% were female, and the median symptom duration before randomization was five days. Approximately 89% had influenza A. At randomization, 33% were receiving high-flow nasal oxygen, 15% non-invasive ventilation and 47% invasive ventilation. Almost half were receiving vasopressors in at least one treatment group. A total of 42% had received one dose of oseltamivir before randomization.




Key Result: In critically ill patients with laboratory-confirmed influenza requiring organ support, neither five nor ten days of oseltamivir improved survival compared with no antiviral treatment, and both treatment strategies raised a concerning signal of increased mortality.




 	Primary Outcome: Mortality by 90 days

 	Control 14%, Five-day 20%, and Ten-day 19%
 	Five days: OR 2....]]></description>
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      <title>SGEM Xtra: Carl Heneghan – Legend of Evidence-Based Medicine</title>
      <link>https://podcast.show/thesgem/episode/155021545/</link>
      <rawvoice:pid>155021545</rawvoice:pid>
      <guid>https://thesgem.com/?p=18805</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 15 Aug 2026 06:38:34 -0400</pubDate>
      <description><![CDATA[Date: March 4, 2026

Guest Skeptic: Prof Carl Heneghan is a General Practitioner, Professor of Evidence-Based Medicine at the University of Oxford and current Director of the Centre for Evidence-Based Medicine (CEBM).

Today, we’re launching a brand-new SGEM series: Legends of Evidence-Based Medicine (EBM). In the past, I’ve interviewed legends of Emergency Medicine: Dr. Diane Birnbaumer, Dr. Ian Stiell, Dr. Jerome Hoffman, Dr. Joe Lex, Dr. Richard Bukata, Dr. Andrew Worster and Dr. Judith Tintinalli. But today, we pivot to the people who shaped how we think about evidence itself.

I first met Carl back in 2012 when I took the Teaching Evidence-Based Practice course at Oxford. That experience directly inspired the SGEM as a knowledge translation project. So, in many ways, the SGEM is Carl's fault. 

Before we start the formal part of the podcast, Carl and I discussed what it is like to be recording this SGEM episode on location at the University of Oxford. The place with cobblestone streets, spires, Latin inscriptions, and the occasional person in academic robes- basically, it’s Hogwarts.



Five Questions for Professor Heneghan



Professor Heneghan

1) The Superhero Origin Story

 	What got you interested in evidence-based medicine?
 	How did your training as a GP influence your thinking?
 	Was there tension at the time between traditional authority and emerging EBM?
 	What was Oxford like during the early years of the EBM movement (late 1990s)?

2) Contribution to EBM

 	When you look back on your career, what do you think you’ve contributed to the evolution of EBM?
 	What are you trying to change as the director of the CEBM?
 	Why is transparency such a foundational issue?
 	Do you think we’ve improved trial reporting meaningfully over the last 20-30 years?

One of the things I’ve always admired about Carl's work is that he doesn't just “use” evidence; he questions whether the evidence itself is trustworthy. This is something he talks about on his Substack: Trust the Evidence. It is described as a couple of old geezers writing about the evidence. 

3) The Critics (Haters Gonna Hate)

EBM hasn’t been without controversy. Some of the criticisms have involved being cookbook medicine, having too much pharma influence (hijacked), being overly reductionist, using a hierarchy of evidence (pyramid) while dismissing mechanistic evidence, being too focused on randomized controlled trials (gold-standard), being dismissive of clinical expertise and ignoring patients’ values/preferences. Some have suggested we need to go to EBM+. 

 	Has EBM ever drifted away from its original intent, promoted by Dr. Sackett and Dr. Guyatt?
 	Are we sometimes confusing guidelines with GODlines?
 	One of my mentors, Dr. Jerry Hoffman pushed back about EBM and said…Do we need an RCT for everything, like looking both ways before crossing the street?
 	Do we sometimes forget patient values in the process?

EBM was never meant to replace clinical expertise; it was meant to make it more disciplined.

4) The Future of EBM

 	Let’s fast-forward 30 years: what does evidence-based medicine look like in 2056?
 	My DPhil is looking at how artificial intelligence can be used ethically and responsibly to improve EBM. What are your thoughts on AI &amp; do you think it strengthens EBM or undermines it?
 	Will systematic reviews become living, real-time documents?

5) Future EBM Leaders 

 	Who are the future leaders of EBM?
 	What qualities do you think matter most in the next generation of EBM practitioners?
 	What advice would you give a trainee who wants to shape the future of evidence?

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



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



Previous PubCast in Oxford with Melanie Golob]]></description>
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      <title>SGEM#517 : I Will Try to Fix You. Surgery or Not for Pediatric Displaced Medial Epicondyle Elbow Fractures</title>
      <link>https://podcast.show/thesgem/episode/154952426/</link>
      <rawvoice:pid>154952426</rawvoice:pid>
      <guid>https://thesgem.com/?p=18720</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 08 Aug 2026 08:30:05 -0400</pubDate>
      <description><![CDATA[Reference:  Perry DC, et al. Surgical fixation versus non-surgical care for children with a displaced medial epicondyle fracture of the elbow (the SCIENCE study): a multicentre, randomised controlled, superiority trial and economic evaluation. The Lancet 2026

Date: July 14, 2026

Guest Skeptics: Dr. Megan Terle is an orthopedic surgeon and Assistant Professor for Pediatrics and Trauma services at UC Davis Health. She completed her orthopedics residency at the University of Washington and completed two fellowships, one in pediatrics at the University of Washington and one in trauma at UC Davis.

Dr. Megan Terle

Dr. Holly Leshikar is also an orthopedic surgeon and Associate Professor for Pediatrics and Trauma services at UC Davis Health. She completed orthopedics residency at UC Davis and a pediatric orthopedic surgery fellowship at Vanderbilt Children’s Hospital in Nashville.

Case: An 11-year-old gymnast comes to the emergency department (ED) after a fall from the bars. She felt a “pop” in the elbow and now refuses to move the arm. The elbow is swollen and tender on your examination. You perform a careful neurovascular exam and note intact distal perfusion and no neurological deficits. You temporarily immobilize the arm and order radiographs.

X-ray shows a displaced medial epicondyle fracture. Her parent asks you: “Does she need surgery to put the bone back where it belongs?”

Dr. Holly Leshikar

Background: Medial epicondyle fractures are pediatric elbow injuries involving the bony prominence on the inside of the distal humerus. In children, this area is a secondary growth center. The typical mechanism is an avulsion injury from valgus stress at the elbow, often after a fall onto an outstretched hand or a sports-related injury. These fractures are extra-articular in most cases, but they can be associated with elbow dislocation and, occasionally, the fragment can become trapped inside the joint.

Key early priorities are pain control, neurovascular assessment, recognition and reduction of any elbow dislocation, and post-reduction imaging to ensure the medial epicondyle fragment is not incarcerated in the joint.

Management has traditionally varied widely. Minimally displaced fractures are usually treated non-operatively with immobilization, often in an above-elbow backslab or cast with the elbow flexed around 900. Surgery, usually open reduction and internal fixation (ORIF) with a screw or wires, has generally been reserved for clearer indications such as an incarcerated fragment, open fracture, ulnar nerve entrapment, gross elbow instability, or selected high-demand upper extremity athletes.

The real controversy has been the isolated displaced fracture. Supporters of ORIF argue that surgery restores anatomy, improves the reliability of healing, improves stability, and speeds return to activity. Observational studies have supported both approaches, driving uncertainty. Pediatric orthopedics has historically had few clinical trials, leaving decisions shaped by tradition, expert opinion, and retrospective data. Much of the older literature on the medial epicondyle has methodological limitations (e.g., follow-up issues, selection bias, limited patient-reported outcomes).

One smaller RCT from Finland (n=72) suggested non-operative care was non-inferior at 1 year, but a single small trial still left uncertainty.



Clinical Question:  In children (age 7 to 15 years) with a displaced medial epicondyle fracture, does surgical fixation improve patient-important outcomes compared with non-surgical immobilization, and is it cost-effective?



Reference:  Perry DC, et al. Surgical fixation versus non-surgical care for children with a displaced medial epicondyle fracture of the elbow (the SCIENCE study): a multicentre, randomised controlled, superiority trial and economic evaluation. The Lancet 2026

 This was the same lead author as the FORCE trial covered in SGEM #372 that taught us it is reasonable to treat a buckle fracture of the forearm with a soft bandage and the CRAFFT trial covered in SGEM #510 that taught us a cast-first strategy for young children with displaced distal radius fractures can be a reasonable approach.

 	Population: Children 7 to 15 years of age with a displaced medial epicondyle fracture (across 59 hospitals in the UK/Australia/NZ)

 	Exclusion: Injury &gt;2 weeks old; incarcerated fragment in joint; complex intra-articular elbow fracture; additional fractures outside the elbow.


 	Intervention: Surgical fixation under general anaesthesia and fixation with screws/wires. A cast, splint, or bandage was applied afterward, and the duration was at the surgeon's discretion.
 	Comparison: Non-surgical care which was immobilization of the elbow elbow ~90° flexion with cast/splint/sling. Duration was at the discretion of the surgeon. They were also allowed mobilization under clinical supervision and as tolerated base don pain. Casting &gt;4 weeks was discouraged.
 	Outcome: 

 	Primary Outcome: Functional recovery assessed by the Patient Report Outcomes Measurement System (PROMIS) Upper Extremity Score for Children Computer Adaptive Test (CAT) at 12 months. A higher score means better limb function.
 	Secondary Outcomes: Sports and performing arts participation assessed with the Disability of the Arm Shoulder, and Hand (DASH), pain assessment with the Wong-Baker Faces Pain Scale, health-related quality of life assessed with EQ-5D-Y, complications, health-care utilization, parental leave, days of purchased childcare, school absence


 	Trial: multicentre, randomised controlled superiority trial

Authors’ Conclusions: “The SCIENCE trial demonstrates that surgical fixation offers no clinical benefit and is not cost-effective compared with non-surgical care, while exposing children to avoidable surgical risks. These findings suggest that non-surgical care should be adopted as the default management strategy for these injuries, regardless of initial elbow dislocation status.”
Quality Checklist for Randomized Clinical Trials:

 	The study population included or focused on those in the emergency department. No
 	The patients were adequately randomized. Yes
 	The randomization process was concealed. Yes
 	The patients were analyzed in the groups to which they were randomized. Yes
 	The study patients were recruited consecutively (i.e. no selection bias). Unsure
 	The patients in both groups were similar with respect to prognostic factors. Yes
 	All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No
 	All groups were treated equally except for the intervention. Unsure
 	Follow-up was complete (i.e. at least 80% for both groups). Yes
 	All patient-important outcomes were considered. Yes
 	The treatment effect was large enough and precise enough to be clinically significant. No
 	Trial Funding. Funded by the National Institute for Health and Care Research Health Technology Assessment programme, with additional NIHR Academy, Oxford NIHR Biomedical Research Centre, and Starship Foundation support.
 	Financial conflicts of interest. Declared NIHR grant support; DCP and MLC had NIHR HTA roles; KW reported Zimmer Biomet and Medartis fellowship support; JGW reported other grants and consultancy fees.

Results: A total of 647 patients were assessed for eligibility, with 335 being randomized, and 334 were included in the ITT analysis. There were 166 children assigned to non-surgical care and 168 assigned to surgical fixation. Mean age was 11.7 years, 51% were female, 58% of injuries were sports-related, and 24% presented with elbow dislocation. The dominant arm was injured in 51% of participants.

Primary Outcome: (PROMIS UE at 12 months)

 	The non-surgical group had a score of 53.1 (SD 7.8), while the surgical group had a score of 54.3 (SD 5.7).
 	This was a mean difference of 1.57 (95% CI –0.01 to 3.14), p=0.052
 	The pre-specified clinically important difference was 4 points, so the observed difference was not clinically meaningful.

There was a slight difference in the per-protocol analysis. Non-surgical group had a score of 53 (SD 7.9). The surgical group had a score of 54.5 (SD 5.6). There was a mean difference of 1.76 (95% CI 0.1 to 3.42), p=0.0372

There was not much difference in the PROMIS scores as they tracked the patients over time. There was improvement in the scores up until around 6 months and the scores started to plateau.

Secondary Outcomes: There were many secondary outcomes. We will highlight a few.

They used different tools like the DASH, Wong-Baker Faces Pain Scale, or the EQ-5D-Y to measure return to activity, pain, and quality of life between the two groups. There were no significant differences between the two groups.

There was less school absence in the non-surgical group (5 vs 3.1 days) with a mean difference of 2.2 days (95% CI 0.7-3.6), p=0.003. That’s important to me as a parent.

Among the 150 children who underwent surgical management, 14 (9%) had intraoperative complications that included ulnar nerve injuries, hardware issues, fragmentation of the bony fragment. Seven required more surgery afterwards for these complications, and another 17 required surgery for screw or wire removal.

There were 5 (2%) complications in the 184 children who underwent non-surgical management, with one having a complication related to the cast and 3 who had to undergo delayed fixation of the bone fragments.

The surgical treatment option was also more expensive with a mean additional cost of £2435 per patient (95% CI; £1812 to £3057).



We want to give a shout-out to the involvement of patients and the public in many aspects of the study. The authors report that patients and the public were involved in design, conduct, oversight and dissemination. They helped select the outcomes that mattered the most and defined what constituted a “meaningful” treatment effect....]]></description>
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      <title>SGEM#516: A Whole Lotta Blood – Whole Blood Transfusion in the Prehospital Setting</title>
      <link>https://podcast.show/thesgem/episode/154597519/</link>
      <rawvoice:pid>154597519</rawvoice:pid>
      <guid>https://thesgem.com/?p=18762</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 01 Aug 2026 08:07:11 -0400</pubDate>
      <description><![CDATA[Date: July 27, 2026 2026
Guest Skeptic: Dr. Howard (Howie) Mel is an emergency physician and FACEP. 
Reference: Smith JE et al. SWiFT Trial Group. Prehospital Whole Blood in Traumatic Hemorrhage - a Randomized Controlled Trial. NEJM 2026 March
Case: A 36-year-old man is brought to the emergency department (ED) by air ambulance after a high-speed motorcycle crash. Paramedics report blunt polytrauma, transient hypotension, tachycardia, pelvic instability, and concern for intra-abdominal bleeding. IV/IO access was obtained in the field, and prehospital blood was started. On arrival, he is pale, cool, and diaphoretic, with blood pressure (BP) 86/52 mm Hg, heart rate (HR) 128 bpm, Glasgow Coma Scale (GCS) score of 13, a pelvic binder in place, abdominal distension, and a positive FAST.
Background: Traumatic hemorrhage is one of the classic time-critical problems in emergency care. Patients do not die because their hemoglobin is low on tomorrow’s CBC; they die because they are bleeding now. This is one of the reasons the 11th edition of ATLS has formally prioritized external bleeding before airway management (SGEM Xtra). The new mnemonic is xABCDE, with the “x” standing for exsanguinating hemorrhage. This reinforces early tourniquet use, direct pressure, and hemostatic adjuncts as first-line priorities when appropriate.
For in-hospital-based trauma resuscitation, the PROPPR trial helped move the conversation toward balanced component therapy. In that 2015 RCT, they compared 1:1:1 plasma:platelets:red cells with 1:1:2. The authors showed better secondary outcomes (hemostasis and fewer deaths from exsanguination at 24 hours), even though the primary outcome (overall mortality) was not statistically different (SGEM#109).
The harder question is what should happen before the patient ever reaches the trauma bay. Prehospital transfusion sounds attractive because it shortens the time to blood-based resuscitation, but the evidence has been mixed.
The PAMPer study found lower 30-day mortality with prehospital plasma in patients at risk for hemorrhagic shock transported by air, while RePHILL did not show superiority for a prehospital blood-product strategy over saline (SGEM#369). A pooled post hoc analysis of PAMPer and COMBAT suggested that any benefit from prehospital plasma may be most apparent when transport times are longer, and resuscitation is started early enough to matter. 
For emergency clinicians, the real debate is not whether bleeding trauma patients need blood. They do. The more useful question is which product, for which patient, in which system, and over what transport interval. That is why prehospital transfusion research keeps circling back to logistics, case selection, transport time, and whether a prehospital strategy complements what happens after ED arrival rather than simply adding complexity.




Clinical Question: In trauma patients with life-threatening hemorrhage treated by participating air ambulance services, does prehospital transfusion with up to 2 units of leukocyte-depleted whole blood, compared with standard component therapy (up to 2 units of red cells and 2 units of plasma), reduce the composite of death or massive transfusion within 24 hours?


Reference: Smith JE et al. SWiFT Trial Group. Prehospital Whole Blood in Traumatic Hemorrhage - a Randomized Controlled Trial. NEJM 2026 March


 	Population: Patients of any age with traumatic injury, attended by a participating air ambulance service clinical team, who required prehospital blood transfusion for major traumatic hemorrhage. 

 	Exclusions: Patients were excluded if IV or IO access could not be established, if there was a known objection to blood transfusion, or if blood products had already been given before the participating air ambulance service arrived. For the main modified intention-to-treat analysis, nontraumatic hemorrhage and traumatic cardiac arrest on arrival of the air ambulance were excluded. 


 	Intervention: Up to 2 units of prehospital leukocyte-depleted whole blood. 
 	Comparison: Up to 2 units of red blood cells and 2 units of plasma (thawed fresh frozen plasma or lyophilized plasma, depending on service). 
 	Outcomes:

 	Primary Outcome: Composite of death from any cause or massive transfusion within 24 hours after randomization. Massive transfusion was defined as at least 10 units of blood components/products in adults, and at least 40 mL/kg in pediatric participants under 16 years weighing under 50 kg. 
 	Secondary outcomes: All-cause mortality at 6 hours, 24 hours, 30 days, and 90 days; massive transfusion; organ-failure–free days up to 30 days; days in critical care and acute care hospital; units of blood products received in 24 hours; cell salvage; additional hemostatic agents; coagulopathy; acid-base disturbance; thrombotic events; transfusion reactions/events; and planned cost-effectiveness and quality-of-life analyses. 


 	Type of Study: Pragmatic, multicenter, parallel-group, open-label (unblinded), superiority randomized controlled trial (RCT).


Authors’ Conclusions: “Among participants with life-threatening hemorrhage, prehospital transfusion of 2 units of whole blood was not superior to standard care in reducing the risk of death or massive transfusion within 24 hours.”

Quality Checklist for Randomized Clinical Trials:


 	Did the study population include or focus on those in the emergency department? No
 	Were the patients adequately randomized? Yes
 	Was the randomization process concealed? Yes
 	Were the patients analyzed in the groups to which they were randomized (i.e. intention-to-treat analysis)? No
 	Were the patients recruited consecutively (i.e. no selection bias)? Unsure
 	Were both groups similar with respect to prognostic factors? Yes
 	Were all participants (patients, clinicians, outcome assessors) unaware of group allocation (blinded/masked)? No
 	Were all groups treated equally except for the intervention? Unsure
 	Was the follow-up complete (i.e. at least 80% for both groups)? Yes
 	Were all patient-important outcomes considered? Unsure
 	Was the treatment effect large enough and precise enough to be clinically significant? No
 	Who funded the trial? NHS Blood and Transplant, participating Air Ambulance Charities, and the Ministry of Defence. The sponsor was NHS Blood and Transplant. 
 	Did the authors declare any conflicts of interest? Unsure from the main paper files alone, but the protocol states that at the time it was written, the chief investigators, principal investigators, and trial committees had no competing interests, with a plan for disclosure of any arising conflicts during the trial.

Results: A total of 942 patients were randomized overall. After exclusions and data removal, 641 participants comprised the modified intention-to-treat population (327 whole blood, 314 standard care). The primary outcome analysis used complete cases: 314 in the whole-blood group and 302 in the standard-care group. Most participants were male (76%), the majority had blunt trauma (71%), and the median age was 38 years in the whole-blood group and 35 years in the standard-care group. 




Key Result: Prehospital transfusion with up to 2 units of whole blood was not superior to standard component therapy for reducing 24-hour death or massive transfusion in patients with life-threatening traumatic hemorrhage.




 	Primary Outcome: Occurred in 153/314 (48.7%) in the whole-blood group and 144/302 (47.7%) in the standard-care group, for a relative risk of 1.02 (95% CI 0.80 to 1.31; P=0.84). 
 	Secondary Outcomes: Mortality at 6 hours, 24 hours, 30 days, and 90 days appeared similar between groups, as did the rate of massive transfusion and most other secondary outcomes. One notable difference was that prothrombin time above the normal range was more common in the whole-blood group (40.7% vs 30.5%; RR 1.31, 95% CI 1.10 to 1.56). Serious adverse events were slightly fewer with whole blood (31 vs 37), thrombotic events appeared similar, and two transfusion-related/SHOT-type events occurred in standard care with none reported in whole blood.

 
1. Modified ITT Analysis (mITT): In SWiFT, the main analysis was modified intention-to-treat, excluding nontraumatic hemorrhage, traumatic cardiac arrest on arrival, and patients whose data were withdrawn or deleted after a serious protocol breach. On top of that, the primary analysis was effectively a complete-case analysis within the modified ITT population. Some of these exclusions were clinically reasonable, but they still weaken the integrity of randomization and raise the possibility that excluded participants differed in important ways from included participants. 

Open Label

2. Open label: This was an unmasked trial once the box was opened. Death is a hard outcome, but “massive transfusion” is not purely biological; it is somewhat subjective and depends partly on clinician decisions, local transfusion behaviour, and downstream management. That makes the composite more vulnerable to performance bias than a purely objective endpoint, such as mortality alone. 

3. Contamination &amp; Protocol Slippage: A clean superiority trial needs meaningful separation between groups. In SWiFT, protocol deviations occurred in roughly 7% of both groups, randomization errors occurred in about 5%, and 7 participants in the standard-care arm received whole blood prehospital due to mispacked boxes or because only whole-blood boxes were available. There was also co-enrollment in other studies, including some deemed non-permissible. None of this invalidates the study outright, but it can dilute differences between groups and make a truly superior intervention harder to detect. 

4. Lack of Power: The trial was powered for the primary composite, not for most secondary outcomes. Meanwhile, missingness was modest for the primary outcome but substantial for some secondary and safety measures: 90-day vital]]></description>
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      <title>SGEM Xtra: Ferraris, Friends, and First Responders – Lessons Learned from Watching Magnum, P.I.</title>
      <link>https://podcast.show/thesgem/episode/154481109/</link>
      <rawvoice:pid>154481109</rawvoice:pid>
      <guid>https://thesgem.com/?p=18752</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 25 Jul 2026 08:27:31 -0400</pubDate>
      <description><![CDATA[Date: July 9, 2026

Guest Skeptic: Dr. Aaron Skolnik is an Assistant Professor of Emergency Medicine at the Mayo Clinic Alix School of Medicine and Vice Chair of Critical Care Medicine at Mayo Clinic Arizona. Aaron is a full-time multidisciplinary intensivist and is the medical student clerkship director for critical care. 

Today’s episode is a little different. We’re diving into a classic 80s TV show. Aaron and I were in Hawaii earlier this year at the Center for Continuing Medical Education Emergency Medicine and Acute Care Course. While walking down the beach, Aaron told me how much he loved Magnum PI. That made me think we should do an SGEM Xtra. 

We’ve done this before on the SGEM, using pop culture TV to reflect on medicine from Star Trek to Ted Lasso and, most recently, Buffy the Vampire Slayer. It turns out TV can be surprisingly educational. And today we’re going with Magnum, P.I. 

Magnum, P.I. aired from 1980 to 1988 and followed Thomas Magnum, a private investigator living in Hawaii. Alongside his Vietnam War friends, T.C. (helicopter pilot) and Rick (club owner). Magnum solves cases while constantly sparring with Higgins, the estate manager. But beneath the action and humour are themes that surprisingly resonate with emergency medicine.





Five Lessons from Magnum, P.I. for Emergency Medicine



1. Teamwork is Everything

Magnum never works alone. His success depends on his team. T.C. provides logistics, transport, and perspective. Rick is communication, connections and social intelligence. Higgins offers structure (even if annoying).

 	EM Parallel:

 	Emergency medicine is a team sport: Nurses, RTs, techs, EMS, and consultants are all critical
 	High-performing teams outperform individual brilliance
 	We should all be on Team Patient



Takeaway: No matter how skilled you are, patient outcomes depend on the team.
2. The Hidden Burden: Post-Traumatic Stress Disorder and Mental Health

Magnum and his friends carry emotional scars from Vietnam, which are often subtly portrayed but always present.

 	EM Parallel: Exposure to trauma, moral injury and burnout, and high rates of PTSD among emergency clinicians

Takeaway: Recognize it. Talk about it. Support each other. Mental health is not optional in EM.
3. We Love Our Toys and Should Use Them Wisely

Magnum has a Ferrari 308 GTS, helicopter access and high-tech (for the time) surveillance equipment. 

 	EM Equivalent: Point-of-care ultrasound, video laryngoscopy, REBOA, and ECMO

Takeaway: Technology is powerful, but tools don’t replace clinical reasoning. Use them appropriately, not reflexively.
4. Navigating “Higgins” (a.k.a. The Hospital Administrator)

Magnum constantly clashes with Higgins over rules vs. reality.

 	EM Parallel: Policies vs. patient care. Throughput pressures vs. quality. Documentation vs. bedside time.

Takeaway: You must learn to work within the system, and occasionally around it, while advocating for patients.
5. Controlled Chaos: Comfort with Uncertainty

Magnum thrives in unpredictable, evolving situations. He needs to act on incomplete information and changing circumstances, and make rapid decisions.

 	EM Parallel: We have undifferentiated patients with diagnostic uncertainty and need to make time-sensitive decisions. 

Takeaway: Emergency medicine is about making the best possible decision with imperfect information, not waiting for certainty.


SGEM Xtra Magnum P.I. Summary:

 	Teamwork is greater than individual heroics
 	Mental health matters
 	Technology is a tool, not a crutch
 	Systems navigation is part of the job
 	Comfort with uncertainty is a core EM skill

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



Remember to be skeptical of anything you learn, even if you learned it on the Skeptics’ Guide to Emergency Medicine.]]></description>
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      <title>SGEM#515: Now the Azithromycin Don’t Work for Preschool Wheeze</title>
      <link>https://podcast.show/thesgem/episode/154363473/</link>
      <rawvoice:pid>154363473</rawvoice:pid>
      <guid>https://thesgem.com/?p=18715</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 18 Jul 2026 08:30:45 -0400</pubDate>
      <description><![CDATA[Reference:  Denninghoff KR et al. Azithromycin for Preschoolers with Wheezing in the Emergency Department. New England Journal of Medicine. May 2026

Date: July 14, 2026

Dr. Zara Ibrahim

Guest Skeptic: Dr. Zara Ibrahim is a pediatric emergency medicine fellow at Children’s National Hospital in Washington DC where she also completed medical school, pediatric residency. Her research interests include AI applications in medicine and health equity. In her time off, Zara likes to read books, travel, go on long walks to explore DC's excellent bakery scene, and do HIIT workouts to balance out the pastries.

Case: A 3-year-old with a history of recurrent wheezing presents to the pediatric emergency department (ED) with cough, rhinorrhea, increased work of breathing, and expiratory wheeze. His Pediatric Respiratory Assessment Measure (PRAM) score is 6. He receives albuterol, ipratropium, and dexamethasone with some improvement. His parents ask: “Last time he was sick, someone gave him antibiotics, I think it was ‘Zith something. Would antibiotics help him get better faster?”

Background: Preschool wheeze is best viewed as a heterogeneous clinical syndrome rather than a single diagnosis. Some of these children wheeze mainly during viral illnesses, some may be manifesting an early asthma phenotype, and a smaller number have alternative causes such as bronchiolitis, foreign-body aspiration, anatomic airway abnormalities, etc. Wheezing and asthma exacerbations are frequent reasons for ED care and hospitalization in children. In U.S. data from 2012 to 2020, asthma hospitalization rates were consistently highest among children aged 0 to 4 years and decreased across successive pediatric age groups.

During an acute asthma-like episode, airway inflammation, mucosal edema, mucus hypersecretion, and bronchial smooth-muscle constriction further narrow the airways.  This can produce expiratory wheeze, prolonged expiration, tachypnea, retractions, reduced air entry, and, in more severe episodes, hypoxemia. Viral respiratory infections are the most common triggers of acute wheezing and asthma exacerbations in young children, with rhinovirus and respiratory syncytial virus among the frequently identified pathogens. Because preschool children can’t typically perform reproducible spirometry, emergency clinicians rely on clinical examination, pulse oximetry, and validated bedside severity scores such as the Pediatric Respiratory Assessment Measure, or PRAM. The PRAM is a bedside score from 0 to 12 based on oxygen saturation, suprasternal retractions, scalene-muscle contraction, air entry, and wheezing; higher scores indicate greater severity.

The immediate ED goal is to rapidly assess exacerbation severity, identify impending respiratory failure, and reassess the child’s response to treatment, rather than assign a permanent diagnostic label during a single acute visit. Standard management includes inhaled short-acting beta₂-agonists, early systemic glucocorticoids for moderate-to-severe exacerbations when appropriate, supplemental oxygen for hypoxemia, and repeated clinical assessment. Antibiotics are not routinely recommended for an asthma-like exacerbation unless there is a separate bacterial indication.

Two biologically plausible arguments have been advanced in support of azithromycin.

First, Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae are often detected in the upper airways of young children, and observational studies have associated colonization or microbiome profiles dominated by these organisms with more severe lower respiratory illness and later recurrent wheeze or asthma. These associations raised the hypothesis that bacteria may contribute to some episodes, but nasopharyngeal detection can represent colonization and, by itself, does not establish lower-airway bacterial infection or causation.

Second, macrolides have immunomodulatory and anti-inflammatory actions distinct from their antibacterial activity. Earlier outpatient randomized trials in selected children suggested that azithromycin, particularly when started very early in a respiratory illness before substantial airway obstruction developed, might shorten episodes or reduce progression to severe lower respiratory illness. In contrast, an earlier ED-based placebo-controlled trial found no reduction in symptom duration, short-acting beta₂-agonist use, or time to the next exacerbation. These mixed findings raised an important timing-and-severity question: might azithromycin have a pre-emptive effect early in an illness but little or no effect once moderate-to-severe wheezing is established?



Clinical Question: In preschool children presenting to the ED with moderate-to-severe wheezing, does a 5-day course of azithromycin reduce wheezing-related symptom severity compared with placebo?




 	Population: Children 18 to 59 months old presenting to one of eight PECARN-affiliated pediatric EDs with moderate-to-severe expiratory wheezing, defined as PRAM score ≥4

 	Excluded: Children with antibiotics in the prior two weeks, acute infection requiring systemic antibiotics, recent systemic glucocorticoids for wheezing, suspected foreign-body aspiration, prematurity, systemic illness other than allergies, azithromycin allergy, or active COVID-19.


 	Intervention: Azithromycin 12 mg/kg orally once daily for 5 days.
 	Comparison: Matching placebo for 5 days
 	Outcome: 

 	Primary Outcome: Sum of Asthma Flare-up Diary for Young Children scores over 5 days. Scores ranged from 5 to 35, with higher scores indicating worse symptoms.
 	Secondary Outcomes: ED length of stay, hospital length of stay, return ED visits or hospitalization within 72 hours, bacterial clearance, antimicrobial resistance, and adverse events.


 	Type of Study: A multicentre, parallel-group, masked, placebo-controlled superiority randomized controlled trial.

Authors’ Conclusions: “Azithromycin did not lead to a greater reduction in the severity of wheezing-related symptoms than placebo in preschool-age children who presented to the emergency department with moderate-to-severe acute wheezing.”
 Quality Checklist for Randomized Clinical Trials:

 	The study population included or focused on those in the emergency department. Yes
 	The patients were adequately randomized? Yes
 	The randomization process was concealed. Yes
 	The patients were analyzed in the groups to which they were randomized. Yes
 	The study patients were recruited consecutively (i.e. no selection bias). No
 	The patients in both groups were similar with respect to prognostic factors. Yes
 	All participants (patients, clinicians, outcome assessors) were unaware of group allocation. Yes
 	All groups were treated equally except for the intervention. Unsure
 	Follow-up was complete (i.e. at least 80% for both groups). Yes 
 	All patient-important outcomes were considered. Yes
 	The treatment effect was large enough and precise enough to be clinically significant. No
 	Financial conflicts of interest. The study was funded by NHLBI/NIH and PECARN, and the funders reportedly had no role in design, analysis, interpretation, manuscript writing, or publication decisions.

Results: A total of 840 children were randomized. Of these, 521 (62%) tested positive for at least one of the three pathogenic bacteria, and 312 tested negative. Around half of the patients were hospitalized. The trial was stopped early for futility after an interim analysis



Key Results: Adding five days of azithromycin to standard ED treatment did not reduce wheezing-related symptom severity compared with placebo.



Primary Outcome: ADYC Symptoms Score



There was no significant improvement in wheezing-related symptom severity with azithromycin, whether children had the prespecified bacteria detected or not.

Secondary Outcomes: No meaningful differences were seen in ED length of stay, hospital length of stay, or 72-hour return ED visits/hospitalizations.

 	Bacterial Clearance: Among bacteria-positive children with follow-up testing, azithromycin cleared the prespecified bacteria more often than placebo: 58.7% vs 11.4%.
 	Adverse Events and Resistance: Adverse events were similar between groups, and no deaths occurred. Antimicrobial resistance at follow-up was similar among those who returned for follow-up testing, but the bacterial follow-up sample was incomplete



Negative Study:

This was a negative study. This is important because we know there is publication bias, where studies with positive or exciting findings are more likely to be submitted, accepted, published, promoted, and remembered. Negative trials can quietly disappear, leaving clinicians with an inflated sense that an intervention works.

A well-done negative trial can be just as valuable as a positive one because it helps us stop doing things that do not help patients.

Selection Bias/Generalizability: 

The flow diagram in Figure 1 provides food for thought. More than 2,600 children were eligible, but only 840 underwent randomization. Among families approached, about 64% declined to consent. In addition, some eligible families were never approached because of staffing, guardian availability, language, or administrative issues. This also included a small group where the provider had a clinical preference.

This introduces selection bias.

The children enrolled in the trial may not perfectly represent all preschoolers with wheezing who show up to the ED. For example, we do not know whether families who declined had strong feelings about antibiotics. Did some parents want azithromycin and not want to risk placebo? Did some parents want to avoid antibiotics and not want to risk receiving azithromycin? Were some families too stressed, too busy, or too overwhelmed to consider research participation? We do not know.

The same question applies to clinicians....]]></description>
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      <title>SGEM#514: Every Time You Go Away (and survive alive for 90 days) – Is It Due To A Restricted Fluid Strategy with Early Vasopressors?</title>
      <link>https://podcast.show/thesgem/episode/154321315/</link>
      <rawvoice:pid>154321315</rawvoice:pid>
      <guid>https://thesgem.com/?p=18708</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 11 Jul 2026 11:36:27 -0400</pubDate>
      <description><![CDATA[Date: July 9, 2026
Reference: The ARISE FLUIDS Investigators. Vasopressors or Fluids in Early Septic Shock. NEJM June 2026. 
Guest Skeptic: Dr. Aaron Skolnik is an Assistant Professor of Emergency Medicine at the Mayo Clinic Alix School of Medicine and Vice Chair of Critical Care Medicine at Mayo Clinic Arizona.  He is board-certified in Emergency Medicine, Medical Toxicology, Addiction Medicine, Internal Medicine-Critical Care, and Neurocritical Care.  Aaron is a full-time multidisciplinary intensivist and enjoys serving as the medical student clerkship director for critical care.
Case: A 69-year-old man presents by EMS to the emergency department (ED) with fever, productive cough, confusion, and weakness. He has hypertension, type 2 diabetes, and mild chronic kidney disease. His initial vitals are Temperature 38.8°C, heart rate 118 bpm, blood pressure 82/48 mmHg, respiratory rate 28 bpm, SpO₂ 90% on room air, and Glasgow Coma Scale (GCS) score of 14. He looks mottled, has delayed capillary refill, crackles at the right base, and dry mucous membranes.
A chest x-ray suggests right lower-lobe pneumonia. Labs show white blood cell count (WBC) 17,000, creatinine 1.8 mg/dL, and lactate 3.4 mmol/L. Blood cultures are drawn, broad-spectrum antibiotics are started, and he receives 1 litre of balanced crystalloid. Thirty minutes later, his mean arterial pressure (MAP) remains around 60 mmHg. The resident asks: “Should we give more fluid to get to 30 mL/kg, or start norepinephrine now?”
Background: Sepsis remains one of the highest-stakes and humbling diagnoses in emergency medicine. It is not as simple as infection plus abnormal vitals. Sepsis-3 reframed sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, moving away from the older SIRS-based definition and retiring the term severe sepsis. Septic shock is now generally understood as sepsis with persistent hypotension requiring vasopressors to maintain a MAP of at least 65 mmHg, with lactate greater than 2 mmol/L despite adequate volume resuscitation.
For emergency physicians, the challenge is that sepsis is still largely a clinical diagnosis without a gold standard test. Systemic Inflammatory Response Syndrome (SIRS) is sensitive (true-positive) but not specific (true-negative). qSOFA may predict mortality, but it is not sensitive enough to rule out sepsis in the ED. Lactate is useful for risk stratification, but it's not a magic wand, and procalcitonin is not accurate enough to rule in or rule out bacterial infection. The SGEM has repeatedly emphasized that sepsis screening tools, biomarkers, and bundles should be used with healthy skepticism rather than blind obedience.    
Treatment in the ED usually starts with the basics: recognize the patient may be septic, obtain cultures when appropriate without delaying care, give early appropriate antimicrobials, seek source control, and support perfusion. The resuscitation controversy has evolved over two decades. Early goal-directed therapy (EGDT) gave way to usual-care trials that challenged protocolized central venous pressure and ScvO₂ targets. Fixed fluid mandates have been questioned, and many clinicians now worry about both under-resuscitation and fluid overload. As SGEM has argued, whether rigid bundles based on low-certainty evidence improve patient-oriented outcomes (POO).    
That leaves a very practical bedside question: after an initial litre or two, should we keep pouring in crystalloid, or should we start vasopressors earlier? Fluids can improve preload and perfusion, but excessive fluid administration may worsen pulmonary edema, tissue edema, and organ dysfunction. Vasopressors can restore vascular tone and perfusion pressure, but raise concerns about ischemia, monitoring, IV access, and intensive care unit (ICU) resource use. This is exactly the kind of EM question that deserves a patient-oriented answer. As we say on the SGEM, they are called guidelines, not GODlines.




Clinical Question: In adult ED patients with early septic shock, does a strategy of restricted fluids and early vasopressors, compared with more liberal fluids and later vasopressors, increase days alive and out of hospital at 90 days?


Reference: The ARISE FLUIDS Investigators. Vasopressors or Fluids in Early Septic Shock. NEJM June 2026. 


 	Population: Adults presenting to the ED with clinically suspected infection, systolic blood pressure (SBP) 2000 mL IV fluids before enrollment, &gt;6 hours since ED presentation, care limitations, immediate surgery, and clinician-determined unsuitability.


 	Intervention: Restricted fluid strategy with early vasopressors. IV resuscitation fluids were stopped after randomization; vasopressors were started, with 250 mL boluses permitted for specified signs of persistent hypoperfusion.  
 	Comparison: Greater fluid volume with later vasopressors. Patients received up to 1000 mL initially, then 500 mL boluses for persistent hypotension or hypoperfusion; 30 mL/kg within 3 hours was recommended unless contraindicated.  
 	Outcome: 

 	Primary Outcome: Days alive and out of hospital from randomization to day 90.
 	Secondary Outcomes: Mortality at 28 and 90 days, survival time to day 90, days alive and at home at day 90, days alive and free from organ support at day 28; tertiary and safety outcomes included discharge timing, in-hospital mortality, organ support, pulmonary edema, ischemia, and peripheral vasopressor complications.


 	Type of Study: Investigator-initiated, multicenter, open-label, parallel-group randomized controlled trial.


Authors’ Conclusions: “Among adult patients who presented to the emergency department with septic shock, an approach that involved restricted fluid volume and early vasopressors did not result in a greater number of days alive and out of the hospital at day 90 than an approach involving greater fluid volume and later administration of vasopressors.”

Quality Checklist for Randomized Clinical Trials (Yes, No or Unsure):


 	Did the study population include or focus on those in the emergency department? Yes
 	Were the patients adequately randomized? Yes
 	Was the randomization process concealed?. Yes
 	Were the patients analyzed in the groups to which they were randomized? Yes 
 	Were the patients recruited consecutively, with no selection bias? No
 	Were both groups similar with respect to prognostic factors? Yes
 	Were all participants, clinicians, and outcome assessors blinded to group allocation? No
 	Were all groups treated equally except for the intervention? Unsure
 	Was follow-up complete, meaning at least 80% for both groups? Yes
 	Were all patient-important outcomes considered? Yes
 	Was the treatment effect large enough and precise enough to be clinically significant? No
 	Who funded the trial? The trial was funded by the Australian National Health and Medical Research Future Fund and the New Zealand Health Research Council. The appendix states the funders had no role in design, conduct, analysis, interpretation, or reporting.
 	Did the authors declare any conflicts of interest? At least two authors had potentially relevant professional/industry disclosures. However, there were no obvious trial-specific commercial conflicts apparent.




Key Results: In adult ED patients with early septic shock, restricted fluids with early vasopressors did not improve days alive and out of hospital at 90 days compared with a more liberal fluid strategy and later vasopressors.




 	Primary Outcome: Median days alive and out of hospital at day 90 were 76 days in both groups: 76 days (IQR 55–83) vs 76 days (IQR 55–82), difference 0.0 days, 95% CI −2.7 to 2.7, P=1.00.


 	Secondary Outcomes: Mortality appeared similar: 28-day mortality 12.9% vs 10.0%, and 90-day mortality 16.4% vs 14.4%. Days alive and at home at day 90 were also similar. Invasive ventilation and renal replacement therapy were similar. Pulmonary edema was lower in the vasopressor group, 0.6% vs 5.0%, though the authors noted this could partly reflect reporting bias in an unblinded trial.

 
1. Modified Intention-To-Treat Analysis: The trial randomized 1000 patients, but 37 patients were excluded because informed consent or permission for data use was not obtained, leaving 963 patients in the analyzed population. This was balanced between groups and is unlikely to overturn the result, but it is not a pure intention-to-treat analysis (ITT). A strict ITT analysis preserves the prognostic balance created by randomization and avoids post-randomization exclusions.  

2. Selection Bias &amp; External Validity: This trial applies to a selected group of adult ED patients with early septic shock after at least 1 L but not more than 2 L of IV fluid, lactate &gt;2 mmol/L, antibiotics started, and randomization within a narrow ED time window. Many real-world septic shock patients were excluded, including those who had received &gt;2 L of fluid, presented late, required immediate surgery, had treatment limitations, had imminent death, had low likelihood of 90-day survival, or were judged by clinicians to be unsuitable for one or both treatment arms. This makes the trial highly relevant to early ED septic shock, but less applicable to patients who are already fluid overloaded, profoundly hypovolemic, perioperative, late-presenting, transferred, palliative, or outside systems where peripheral vasopressors and ICU-level monitoring are readily available.  

Open Label

3. Open-Label: Patients and treating clinicians were not masked to group assignment. This is understandable for a fluids-versus-vasopressors strategy trial, but it can influence clinician-mediated decisions such as additional fluid boluses, vasopressor initiation, corticosteroid use, ICU admission,...]]></description>
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      <title>SGEM#513: Everything is Awesome – Unless You Swallow A LEGO Head</title>
      <link>https://podcast.show/thesgem/episode/154157687/</link>
      <rawvoice:pid>154157687</rawvoice:pid>
      <guid>https://thesgem.com/?p=18684</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 27 Jun 2026 10:10:21 -0400</pubDate>
      <description><![CDATA[Date: June 23, 2026

Reference: Tagg A, et al. Everything is awesome: Don’t forget the Lego. J Paediatr Child Health. 2019



We recorded this SGEM episode live at the Don't Forget the Bubbles conference in Glasgow, Scotland. Dennis and I had just given an hour presentation on how to build better critical appraisal skills. It was a wonderful experience, and we would like to thank Dr. Tessa Davis, Dr. Andy Tagg, and the entire DFTB team for putting on an amazing event. 


Case: A 2-year-old boy is brought to the emergency department (ED) after swallowing a foreign body. His sister was playing with some of her plastic LEGO pieces. After cleaning up, she noticed one of the minifigures was missing its head. The boy’s mother thinks he may have swallowed one. On exam, he looks comfortable and is playful.  Vital signs are stable.  Abdominal exam is benign. An X-ray obtained does not demonstrate any radio-opaque foreign body. He drinks and eats a snack in the ED without any issues. As you get ready to send the family home, his parent asks, “Do you think he’s going to be ok? When do you think this thing is going to come out?”
Kids eat a lot of weird stuff. The world is an adventure that they like to explore, sometimes with their mouths. Sometimes kids also swallow non-nutritive items, such as glue, coins, or toy parts. Foreign body ingestion is very common in children aged 6 months to 3 years.
We get worried if it’s an object like a button battery or two magnets, as they can cause significant damage to the gastrointestinal (GI) tract. Button batteries stuck in the esophagus can burn through it. Magnets can pinch off the bowel and cause necrosis. Fortunately for the many swallowed foreign bodies I’ve encountered in the ED, the kids tend to do fine.




Clinical Question: How long does it take for an ingested LEGO figurine head to pass through the gastrointestinal tract in healthy adult volunteers, and are there any complications?


Reference: Tagg A, et al. Everything is awesome: Don’t forget the Lego. J Paediatr Child Health. 2019


 	Population: Six pediatric healthcare professionals were recruited.

 	Exclusion: Previous GI surgery, inability to swallow a foreign object, or, my favourite, aversion to searching through faecal matter.


 	Intervention/Exposure: Ingestion of a LEGO head. The authors also standardized pre-ingestion bowel habit using a 3-day stool diary and their Stool Hardness and Transit score, mercifully abbreviated SHAT.  
 	Comparison: I mean, I don’t think they tried to see who pooped it out first. The study included a within-person pre/post comparison of stool consistency using pre-SHAT and post-ingestion SHAT.
 	Outcome: Found and Retrieval Time, or FART score, defined as the time from ingestion until the Lego head was found in stool.  
 	Type of Study: Prospective, international, uncontrolled case series/self-experiment with a small within-subject before-and-after component for stool consistency.

Author’s Conclusion: “A toy object quickly passes through adult subjects with no complications. This will reassure parents, and the authors advocate that no parent should be expected to search through their child’s faeces to prove object retrieval.”
Quality Check List for Observational Studies:


 	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? No
 	Was the exposure accurately measured to minimize bias? Yes
 	Was the outcome accurately measured to minimize bias? Unsure
 	Have the authors identified all important confounding factors? No
 	Was the follow up of subjects long enough? Yes
 	
How precise are the results? Not very precise.
 	Do you believe the results? Yes
 	Can the results be applied to the local population? No
 	Do the results of this study fit with other available evidence? Yes
 	Who funded the trial? Not funded
 	Conflicts of Interest: None

Results: The study included six participants, half female, aged 27 to 45 years, with a mean age of 36 years. The participants were adult pediatric health-care professionals. 
Five of the six participants successfully found the LEGO head. One male participant searched through 13 stools over two weeks and never found it.




Key Result: A swallowed Lego head was recovered from the stool within around 2 days.




 	Outcome: FART Score

 	Among those who retrieved the Lego head, the average FART score was 1.71 days.
 	The range was about 1.14 to 3.04 days, or roughly 27 hours to 73 hours.



The authors also compared pre-ingestion and post-ingestion stool patterns using the Stool Hardness and Transit (SHAT) score and found no significant change in bowel consistency after swallowing the Lego head.
They also examined whether looser or more frequent stools predicted faster retrieval. No significant correlation was found.
No one had complications.

1. Selection Bias: This study was open to any healthcare professionals working in the field of paediatric hospital care, but only included six adult paediatric healthcare professionals. The authors do not mention exactly how many participants were eligible. It is unclear if these six participants had certain qualities that led to self-selection or if they are representative of the entire population.
2. Generalizability: The average age in this study was 36 years. This does not reflect the pediatric population. Bowel transit, behaviour, diet, history reliability, and risk tolerance differ substantially between adult volunteers and toddlers. In addition, the study participants only swallowed a LEGO head: small, smooth, plastic, and blunt. These results should not be generalized to button batteries, magnets, sharp or long objects, or anything else that may cause symptoms.

3. Imprecise: There were only six participants, and only five successfully retrieved the object, making the study underpowered. A zero-complication result in six adults does not exclude rare but important complications, and it cannot meaningfully inform high-stakes pediatric ED decisions. The study was not designed to estimate rare complications. If something bad happens 1 in 1,000 times, this study cannot detect that. It can provide a memorable point estimate of transit time, not a robust estimate of risk.  

4. Confounders: The authors also reported the number of stools to LEGO head retrieval. They did not account for the time each bowel movement took. In participants who may spend more time on the toilet, perhaps while using their mobile device, this may have falsely decreased the number of bowel movements required to retrieve the Lego head.
Also, we do not have data on whether participants chose to use laxatives or on their dietary practices, which may have also affected the results. To their credit, they tried to standardize some of this using the SHAT score, but we were unable to find a study that validated that instrument.
5. Confirmation of Passage: The primary outcome depended on participants finding the Lego head in the stool. Participants knew the exposure and outcome and used individualized stool-searching techniques, which are vulnerable to detection bias. Also, one participant never found it despite extensive searching. That does not necessarily mean the object did not pass.
The participant self-reported the presence of a LEGO head without any additional outside confirmation. It is also possible that a participant mistakenly identified what they thought was a Lego head and confused it with something else small, like a yellow, undigested piece of corn. The authors acknowledged that the population could not be blinded and that SHAT was not a perfect surrogate for the underlying bowel pattern.




SGEM Bottom Line: For a witnessed ingestion of a small, blunt plastic toy part in an asymptomatic patient, “everything is probably awesome,” but this tiny adult case series should reassure, not replace, standard ED risk stratification.


Case Resolution: The 2-year-old remains well appearing. No drooling. No vomiting. No abdominal pain. No respiratory symptoms. You explain to the parents that this kind of object will usually pass on its own. You give return precautions and tell them they do not need to search every diaper unless there is a specific clinical reason to do so. The parents are relieved. The toddler immediately tries to eat the discharge paperwork. 
Clinical Application: This paper should not change how we manage dangerous ingestions. Button batteries, multiple magnets, sharp objects, or symptomatic children are different situations. But for the common ED scenario of a well-appearing child with a small, blunt, inert object ingestion, this study gives us a memorable way to reassure families. The most useful part of the paper may not be the exact FART score. It may be the permission it gives clinicians to say: “You do not have to search the poop.”
What Do I Tell the Patient? Based on what we know, small smooth plastic objects like this usually pass on their own, often within a few days. Your child looks well right now, which is reassuring. You do not need to check every stool to find it. Please come back right away if your child develops vomiting, belly pain, fever, trouble swallowing, drooling, coughing, breathing problems, blood in the stool, or starts acting very unwell.
Keener Kontest: Last week’s winner was Ryker Kiel from Wyoming. He knew an appendicolith is calcified stool in the appendix.
Other FOAMed:


 	NPR: 6 doctors swallowed Lego heads for science. Here's what came out
 	Science News: These researchers swallowed Legos for science
 	Smithsonian Magazine: It Takes 1.71 Days to Poop Out a Lego
 	Huffington Post: Researchers Swallow Lego To Reassure Parents It Will Come Out The Other End
 	The Guardian: Shit a brick - Doctors swallow Lego to allay parents' fears




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      <title>SGEM#512: When you go your way, and I Go Mine – Surgery or Antibiotics for Acute Appendicitis.</title>
      <link>https://podcast.show/thesgem/episode/154001562/</link>
      <rawvoice:pid>154001562</rawvoice:pid>
      <guid>https://thesgem.com/?p=18667</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 13 Jun 2026 10:08:56 -0400</pubDate>
      <description><![CDATA[Date: June 12, 2026

Guest Skeptic: Mr. Ross Fisher. Ross is a paediatric surgeon, presentation guru (P-Cubed), and long-time friend of the SGEM. 

Reference: Talan et al. Nonoperative Treatment of Appendicitis and Implications for Emergency Department Management: A Narrative Review. Ann Emerg Med. June 2026

Case: A 29-year-old healthy man presents to the emergency department (ED) with 18 hours of abdominal pain that began around the umbilicus and migrated to the right lower quadrant. He has anorexia, nausea, a temperature of 38.1°C, and focal right lower quadrant (RLQ) tenderness without diffuse peritonitis. The white blood cell (WBC) count is 13,500/µL. CT abdomen/pelvis shows an 8-mm inflamed appendix with periappendiceal fat stranding but no abscess, phlegmon, perforation, mass, or appendicolith. He is hemodynamically stable, not immunocompromised, has no history of inflammatory bowel disease (IBD), can return to the ED if worse, and asks whether he really needs surgery tonight.

Background: Appendicitis is one of those diagnoses we don’t want to miss. It’s common, it can be sneaky, and the classic textbook presentation only shows up around half the time. That means labs and scores can help, but they often can’t rule out appendicitis. In 2026, imaging (especially CT scans) is still doing much of the heavy lifting.

For more than a century, appendicitis was taught as a surgical emergency: diagnose it, call surgery, and remove the appendix before it ruptures. This new narrative review challenges that mental model. It argues that modern imaging can identify uncomplicated appendicitis, that perforated and nonperforated appendicitis may be biologically different entities, and that short delays to surgery in uncomplicated disease do not appear to increase perforation risk. This new narrative review notes that the American College of Surgeons (ACS) has endorsed antibiotics as a safe alternative for selected patients while continuing to endorse appendectomy.

The SGEM has followed this topic for years, and our interpretation of the literature has evolved as the evidence has changed (see list of other SGEM episodes at the end of this blog post). In 2015, the SGEM emphasized diagnostic uncertainty and concern that failed antibiotics could increase morbidity; in 2017, the pediatric conclusion was that NOTA was “not ready for prime time.” By 2019, we were more open to antibiotics in selected patients, using shared decision-making and acknowledging that nonoperative care may be better than we thought, though it may (or may not) come with a small absolute increase in complications.

So, the question is no longer whether to cut or not to cut. The ED question is: who is safe for an antibiotic-first pathway, who needs the surgeon now, and who can reliably come back if things go sideways? This is a classic preference-sensitive decision: surgery is highly definitive, while antibiotics may reduce pain, disability, and time away from school or work, but with a meaningful recurrence/appendectomy risk. This review by Talan et al explicitly places emergency physicians in the shared decision-making role for selected uncomplicated appendicitis patients.



Clinical Question: In ED patients with imaging-confirmed acute uncomplicated appendicitis, can initial nonoperative management with antibiotics and observation, with appendectomy reserved for worsening, nonresponse, or recurrence, be considered a safe and effective alternative to urgent appendectomy?



This matters because appendicitis sits right at the intersection of emergency medicine, surgery, radiology, antibiotics, patient values, and system capacity. Some patients want the most definitive treatment. Others want to avoid surgery if it's safe to do so. Our job is not to sell one option. Our job in the emergency department is to explain the trade-offs.

Reference: Talan et al. Nonoperative Treatment of Appendicitis and Implications for Emergency Department Management: A Narrative Review. Ann Emerg Med. June 2026

 	Population: Adults and children with clinically suspected, localized, imaging-confirmed acute, uncomplicated appendicitis. The included trials enrolled children as young as 5 years and adults older than 80 years. 

 	Exclusions: The major exclusions were diffuse peritonitis, severe systemic illness/sepsis, pregnancy, immunocompromise, renal failure, inflammatory bowel disease (IBD), prior antibiotic-treated appendicitis, and imaging evidence of major abscess, phlegmon, perforation, mass, or tumour. Some trials also excluded appendicolith, abnormal WBC thresholds, prolonged pain duration, or older age. 


 	Intervention: Nonoperative treatment: initial antibiotics plus observation, with appendectomy if the patient worsened, failed to improve, or later recurred. Antibiotic regimens varied but generally used parenteral antibiotics followed by oral antibiotics to complete a total therapy of 7–10 days. 
 	Comparison: Urgent appendectomy with perioperative antibiotics, usually laparoscopic in the more recent trials. 
 	Outcome

 	Primary Outcome: There was no single primary outcome in the review. Across the major trials, the most important outcomes were 1-year appendectomy/treatment failure rates for antibiotic-first care, and in CODA, 30-day EQ-5D health-status noninferiority. 
 	Secondary Outcomes: Complications/serious adverse events, pain resolution or pain medication use, disability days, recurrence, ED return visits, feasibility of ED discharge/outpatient treatment, cancer detection, cost-effectiveness, and appendicolith subgroup outcomes


 	Type of Study: Narrative review of the major comparative trials, not a true systematic review or meta-analysis.

Authors’ Conclusions: “Nonoperative treatment of uncomplicated appendicitis will be increasingly considered as experience and confidence grows among physicians and as awareness grows among patients in this new treatment option. Emergency physicians are being asked about nonoperative treatment of uncomplicated appendicitis and have an important role now to inform patients of their treatment options and expected associated outcomes, and an emerging role in expanding access to safe and cost-effective care for patients with appendicitis, including those who can be managed by nonoperative treatment of uncomplicated appendicitis as outpatients.”
Quality Checklist for Systematic Reviews: (Yes/No/Unsure)

 	Was the clinical question sensible and answerable? Yes
 	Was the search for studies detailed and exhaustive? No
 	Were the primary studies of high methodological quality? Unsure
 	Were the assessments of studies reproducible? No
 	Were the outcomes clinically relevant? Yes
 	Was there low statistical heterogeneity for the primary outcomes? N/A
 	Was the treatment effect large enough and precise enough to be clinically significant? Unsure
 	Who funded the review? The authors stated that no funding was received for this work.
 	Did the authors declare any conflicts of interest? The authors reported no conflicts of interest.

Results: The review focused on four major comparative trials: APPAC, CODA, MPSC, and APPY. Together, they included more than 2,000 adults and more than 2,000 children. The review did not provide a pooled table of sex, race, baseline pain duration, comorbidities, or socioeconomic demographics.



Key Result: In selected patients with uncomplicated appendicitis, antibiotics initially worked in about 90% and reduced pain/disability, but roughly one-third underwent appendectomy within 1 year, with higher appendectomy rates among patients with appendicolith.




 	Primary Outcome: 

 	APPAC reported a 1-year appendectomy rate of about 27% in adults treated with antibiotics. 
 	CODA found antibiotics noninferior to appendectomy for 30-day EQ-5D health status, but the 1-year appendectomy rate was 36% without appendicolith and 52% with appendicolith.
 	MPSC reported a 1-year appendectomy rate of about 33% in children
 	APPY reported about 34% treatment failure/appendectomy in the antibiotic group. The table on page 3 of the review summarizes these trial-specific results.


 	Secondary Outcomes: These generally favoured antibiotics for short-term recovery, but not always for adverse events. 

 	APPAC reported fewer 1-year complications with antibiotics than surgery, 2.8% vs 20.5%, with faster pain resolution and fewer disability days. 
 	CODA reported similar serious adverse event rates, 3% vs 3%, and fewer disability days with antibiotics. 
 	MPSC reported similar complicated appendicitis rates, 3.6% vs 3.3%, and fewer disability days with antibiotics. 
 	APPY reported no serious adverse events in either group, but more mild-to-moderate adverse events with antibiotics, largely GI distress; antibiotics reduced post-discharge pain medication use and disability days.





The ED discharge data came mainly from CODA. In a CODA sub-analysis, 335 of 726 antibiotic-treated adults, 46%, were discharged from the ED after longer-acting parenteral antibiotics, observation, oral tolerance, stable status, and pain control. Serious adverse events over 7 days were uncommon: 0.9 per 100 outpatients vs 1.3 per 100 inpatients. ED discharge was associated with fewer appendectomies and about one day less disability, without a significant increase in first-week ED return visits.

Summary of the Four RCTs:





1. Narrative Review: This was not a systematic review, and that matters. No PRISMA diagram, no duplicate screening, no formal risk-of-bias assessment, and no pooled estimate. That does not make it useless, and we should not judge it against a formal SRMA. It just means we should treat it for what it is, an expert narrative synthesis, not the final word.

Open Label

2. Open-Label: The included RCTs were not masked and vulnerable to performance, detection, and preference bias. You really can’t blind antibiotics vs surgery....]]></description>
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      <title>SGEM Xtra: Welcome to the Jungle of Disaster Medicine</title>
      <link>https://podcast.show/thesgem/episode/153917455/</link>
      <rawvoice:pid>153917455</rawvoice:pid>
      <guid>https://thesgem.com/?p=18616</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 30 May 2026 08:30:41 -0400</pubDate>
      <description><![CDATA[Date: April 21, 2026

Lauren Openshaw

Guest Skeptic: Lauren Openshaw is a medical student at the George Washington University School of Medicine &amp; Health Sciences, Class of 2027, where she is a part of the Disaster Medicine Scholarly Concentration. Her clinical interests include pediatrics, disaster medicine, critical care, and emergency preparedness, particularly as they relate to protecting vulnerable children during natural disasters and public health crises.

Background: 

Floods, fires, hurricanes, blizzards, cyberattacks, hospital surges, the list goes on. Disasters are no longer just movie events or rare abstractions. These are real-world events that disrupt and change how we care for patients and families.

We spend a lot of time in training learning how to manage sepsis, trauma, asthma, etc. But disaster medicine? For many learners and clinicians, that part of the curriculum is thin, fragmented, or missing entirely. 

Not every medical school has a disaster medicine concentration. There is typically very minimal formal teaching around disasters, if any, in the medical school curriculum.

Today, we’d like to introduce our audience to a new Free Open Access to Medical Education (FOAMed) resource, the Disaster Medicine Handbook, which we like to call the front door to disaster medicine.

Tune in to the podcast to hear Lauren's perspective on this resource and how she's used and contributed to it.



The Gap



Let’s start with the basic question: why create something like this at all?

Many trainees, nurses, Emergency Medical Services (EMS) clinicians, and even attending physicians may have heard of terms like surge capacity, incident command, crisis standards of care, evacuation, decontamination, and major incident triage. We know these things matter, and they affect children, families, hospitals, and communities. 

However, there's often no good starting point in disaster medicine for students, residents, or other learners.

That’s the space the Disaster Medicine Handbook is trying to fill. It was built for the person who is curious, motivated, maybe a little intimidated, and looking for a place to begin.

It depicts key topics in disaster medicine in a friendly, digestible format that also incorporates a pediatric lens. 

That idea of an entry point is really important. This is not trying to replace formal disaster training, advanced courses, or deeper reference material. It’s trying to do something else: help someone say, “Okay, now I finally understand the basics in words that make sense.” 



Plain Language



One of the things we like most about many existing FOAMed resources and what we’ve adopted for the Handbook is that it starts from a very simple premise: explain disaster medicine in normal words. 

Disaster medicine is full of technical language, acronyms, frameworks, and systems terminology. That can be useful once you’re in the field, but it can also become a barrier for people who are just trying to understand the fundamentals.

We love this quote attributed to Einstein, “Everything should be made as simple as possible, but not simpler.”



 That’s the balance we try to strike. We recognize that disaster medicine, with its various frameworks and systems, is complex. Our goal is to make it more understandable and accessible. 

We want it to pique interest and give people that “aha” moment that unlocks a complicated concept, leaving them curious to learn more. Which is why we have references and resources to further material. 



Bite-Size, Choose-Your-Own-Adventure



 These are bite-sized chapters. Short, focused, digestible pieces that you can read in one sitting. 

After a busy clinical day, it’s hard to sit down and read a giant textbook chapter or digest a dense academic article. We often try to learn between other tasks or during parts of our day, before a conference, on our commute, or during a quiet moment in the department. Maybe even in the ten minutes after seeing something pop up in the news, you realize, I should probably understand this better.

It’s built like a choose-your-own-adventure.

You don’t have to start at page one and go in order. You start with your question.

If you want to understand triage, start there. If you’re interested in surge, start there. If you want to know how to prepare children and families, start there.

That kind of navigation matters because curiosity is not linear.

Lauren has used and shared this resource a few times. Tune in to hear how she's used it. 



Peer-Reviewed and Living



The next piece is quality and evolution. FOAMed sometimes gets a bad rap because some people believe it’s not high-quality, even though it hasn’t undergone the traditional peer-review process. (There are potential issues around peer review which have been written about elsewhere.)

The Handbook is peer-reviewed by subject matter experts. In fact, the content and chapters are reviewed by many experts who provide comments and feedback before publication.

It is a living resource. It is not static. Our goal is for it to grow, change, and improve over time. Balancing the evolution and quality of the resource is important to us. On the one hand, it stays dynamic. On the other hand, it still has rigour.



Community



Maybe the most distinctive part is that this resource is built around community.

There’s a forum where learners and contributors can suggest revisions, flag areas that need clarification, propose new topics, and even contribute to writing future chapters. This was inspired by the community around Don’t Forget the Bubbles.

It changes the relationship between the audience and the resource. You’re not just passively consuming content. You can help shape what comes next.

Some of the early visible contributors are medical students and trainees. That sends a strong message that we value the learner perspective and that this field is open to you.

For our audience:

Go check out the Disaster Medicine Handbook.

Don’t worry about reading everything. Just pick one chapter that catches your eye. Read it. See if it helps something click.

And then join the forum.

Ask a question. Suggest a revision. Propose a topic. If you’re a learner and you’ve ever thought, "I wish someone would explain this better," this is a chance not only to learn but to help build the resource you wish you had.

Remember, the goal here is not to turn everyone into a disaster medicine expert overnight. It’s to create a clear and welcoming first step. A front door.

The SGEM will be back next episode, doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over 10 years to less than 1 year using the power of social media. So, patients 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.



Resources:

GW DM Scholar Concentration Resources page https://ospe.smhs.gwu.edu/disaster-medicine-resources]]></description>
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      <title>SGEM#511: I’d Like To Treat, DKA with the SQuID Protocol</title>
      <link>https://podcast.show/thesgem/episode/153903532/</link>
      <rawvoice:pid>153903532</rawvoice:pid>
      <guid>https://thesgem.com/?p=18631</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 23 May 2026 08:12:49 -0400</pubDate>
      <description><![CDATA[Date: May 20, 2026
Guest Skeptic: Dr. Matt McArthur is an ED Physician working primarily in Guelph and Kitchener with occasional rural locums in the small town of Walkerton, where he grew up. His clinical interests include POCUS, emergency cardiology, QI, knowledge translation, motivational interviewing, and vertigo. He is very active in medical education, including as a clinical skills and POCUS instructor, a Contributing Editor with the EMCases Podcast, and Regional Education Lead for Undergraduate Family Medicine at the Waterloo Regional Campus of McMaster University.
Reference: Qiang et al. Safety and Effectiveness of Subcutaneous Insulin for Management of Mild to Moderate Diabetic Ketoacidosis in Non-Pregnant Patients: A retrospective cohort study at a tertiary care centre. Canadian Journal of Diabetes. Oct 2025
Case: A 56-year-old woman with insulin-treated type 2 diabetes presents to the emergency department (ED) with 24 hours of nausea, vomiting, polyuria, and weakness after missing insulin doses during a viral illness. She is alert, mildly tachycardic, normotensive, breathing slightly fast, and appears dry but not toxic. Her labs show glucose 23 mmol/L, pH 7.26, bicarbonate 14 mmol/L, an anion gap of 22, and positive serum ketones. You diagnose her with diabetic ketoacidosis (DKA). After initial IV fluids, she has clinically improved and does not require any vasopressors or airway support. The practical question is whether she really needs an intravenous (IV) insulin drip and intensive care unit (ICU)-level care, or whether a structured subcutaneous (SC) insulin pathway would be safe and effective.
Background: DKA is one of the classic endocrine emergencies that lands squarely in the wheelhouse of emergency medicine. It is a state of insulin deficiency that leads to progressive dehydration, electrolyte deficits, and acidemia, which together can be fatal if untreated. Clinically, these patients show up with some combination of polyuria, polydipsia, nausea, vomiting, abdominal pain, tachypnea or Kussmaul respirations, dehydration, and sometimes altered mental status.
Since the discovery of insulin by Fredrick Banting in Toronto in 1921, the treatment of DKA has changed dramatically in the last 100 years. Prior to insulin, the mortality from DKA was thought to exceed 95%. In modern times, the mortality is less than 1%.
As a reminder, Sir Frederick Banting, Charles Best and James Collip, sold the patent for insulin to the University of Toronto for just $1 in January 1923. Banting famously stated, “Insulin does not belong to me, it belongs to the world”.
DKA treatment involves protocol-based care, including IV rehydration to address hypovolemia; insulin therapy to stop ketoacidosis and restore normal metabolism; electrolyte and dextrose replacement to correct deficits, with regular monitoring of glucose and electrolytes (especially potassium) during treatment.
Most hospitals have labour-intensive DKA protocols involving IV insulin infusion, which often require patients to be admitted to the ICU due to high nursing demands. However, with the introduction of rapid-acting subcutaneous (SC) insulin analogues in the late 1990s, such as insulin lispro and aspart, some clinicians have evaluated the use of rapid-acting SC insulin boluses as an alternative to IV infusion.
SGEM has already dipped a toe into these waters in SGEM#414, which covered the SQuID protocol. That episode asked whether adults with mild-to-moderate DKA could be treated with fast-acting subcutaneous insulin on a non-ICU floor, resulting in shorter ED length of stay. That study by Griffey et al in AEM highlighted the operational appeal of avoiding an insulin drip and an ICU bed for every uncomplicated DKA patient.
Between 2004 and 2016, six small randomized controlled trials found no difference in safety between SC insulin boluses and IV infusions in adults. Given the safety evidence and out of a desire to provide more efficient DKA care and avoid unnecessary ICU admissions, some hospitals have designed and implemented SC insulin-based treatment protocols as a first-line option for uncomplicated DKA patients and have published their outcomes in the medical literature.
In the last five years, several observational studies have been published reporting patient and operational outcomes after implementation of a hospital-wide SC DKA protocol. That includes SQuID I by Griffey et al (SGEM#414), as well as SQuID II, which provided a further report on outcomes in the same hospital in St Louis.
Additionally, we have seen Rao's 2022 report on their protocol introduced at Kaiser Permanente San Jose, Stuhr et al. in 2023 from Utah, and Ibarra et al. in Fresno in 2026. There were also Diabetes Consensus Guidelines published in 2024 that endorse the use of SC insulin in DKA.




Clinical Question: In nonpregnant adults with mild to moderate DKA, is SC insulin a safe and effective alternative to IV insulin for DKA management?


Reference: Qiang et al. Safety and Effectiveness of Subcutaneous Insulin for Management of Mild to Moderate Diabetic Ketoacidosis in Non-Pregnant Patients: A retrospective cohort study at a tertiary care centre. Canadian Journal of Diabetes. Oct 2025


 	Population: Nonpregnant adults aged 18 years or older admitted with mild or moderate DKA defined as an elevated urinary or serum ketones plus at least two of: pH 12 mmol/L, or glucose &gt;14 mmol/L; euglycemic DKA could have relatively normal glucose. 

 	Excluded: Severe DKA or unknown DKA severity, insufficient data, incomplete treatment, patients treated with both IV and SC insulin, insulin pump cases, pregnancy, reduced consciousness (GCS 160 kg. Patients not eligible for the SC protocol also included those with these higher-acuity features. 


 	Intervention/Exposure: SC insulin protocol: glargine 0.3 U/kg (or home dose) plus aspart 0.2 U/kg every 4 hours unless glucose fell below 14 mmol/L, with glucose checks every 2–4 hours and electrolytes/blood gas every 4 hours; fluids and replacement per treating physician. 
 	Comparison: Standard IV insulin treatment. 
 	Outcome:

 	Primary Outcome: Co-primary outcomes were time to anion-gap closure and hospital length of stay (LOS).
 	Secondary Outcomes: Hypoglycemia, hypokalemia, and anion-gap acidosis requiring intervention within 24 hours. 


 	Type of Study: Retrospective cohort study.


Authors’ Conclusions: “These results suggest SC insulin is safe. Although it may take 8.4 hours longer to close the AG with SC insulin, there is less hypoglycemia and hypokalemia and no difference in LOS in hospital.” 

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? Yes
 	Was the cohort recruited in an acceptable way? Yes
 	Was the exposure accurately measured to minimize bias? Yes
 	Was the outcome accurately measured to minimize bias? Unsure
 	Have the authors identified all-important confounding factors? No
 	Was the follow-up of subjects complete enough? Yes
 	How precise are the results? Unsure
 	Do you believe the results? Yes
 	Can the results be applied to the local population? Unsure
 	Do the results of this study fit with other available evidence? Yes
 	Funding of the Study? It was supported by a Quality Improvement Grant from Banting and Best Diabetes Centre Innovative Diabetes.
 	Did the authors declare any conflicts of interest? None were declared.

Results: The final cohort included 153 unique admissions: 92 treated with IV insulin and 61 with SC insulin. The mean age was about 57 years in both groups. Women made up 53% of the IV group and 54% of the SC group. Type 2 diabetes predominated (65% IV, 69% SC), with type 1 diabetes making up about one-third (33% IV, 31% SC). Euglycemic DKA was present in 24% of IV-treated patients and 16% of SC-treated patients. The IV group appeared sicker at baseline, with more moderate DKA (37% vs 11%), more renal dysfunction (33% vs 13%), and more neurologic dysfunction (17% vs 3%). About 30% of the cohort was taking an SGLT2 inhibitor. 




Key Result: IV insulin closed the anion gap more quickly, but SC insulin caused less hypoglycemia and hypokalemia, with no meaningful difference in hospital length of stay or in anion-gap reopening requiring intervention.




 	Primary Outcomes:

 	IV insulin was faster to close the anion gap: adjusted median 15.6 hours versus 24.0 hours for SC, with an adjusted hazard ratio of 0.65 (95% CI 0.45 to 0.92; p=0.02)
 	There was no statistically significant difference in hospital LOS: adjusted relative risk 0.83 (95% CI 0.61 to 1.13; p=0.24). 


 	Secondary Outcomes:



1a. Confounding by Indication: Treatment was not randomized; the treating physician chose IV or SC insulin. In a cohort study, the exposed and comparison groups should have the same prognosis if we want a minimally biased estimate of the effect. Here, the IV group was clearly sicker at baseline, with more moderate DKA, more renal dysfunction, and more neurologic dysfunction. Multivariable adjustment helps, but no regression model can fully remove bias from unmeasured or poorly measured prognostic differences in a retrospective cohort study.

1b. Critical Appraisal of a Hospital Implementation/Quality Improvement (QI) Study: This is an observational study in which the authors retrospectively report on outcomes in their hospital after they introduced a new treatment protocol. So, we must appraise it for what it is, and not read it like an RCT.
Observational studies, particularly QI/implementation studies like this one, generally aim to determine whether a given intervention in a specific healthcare setting was feasible and effective. QI studies are highly specific to the site where they took place.
...]]></description>
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      <title>SGEM#510: Take this Broken Radius and just Cast It.</title>
      <link>https://podcast.show/thesgem/episode/153885734/</link>
      <rawvoice:pid>153885734</rawvoice:pid>
      <guid>https://thesgem.com/?p=18609</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 16 May 2026 08:30:01 -0400</pubDate>
      <description><![CDATA[Reference:  Perry DC, et al. Non-surgical casting versus surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study): a multicentre, randomised, controlled non-inferiority trial and economic evaluation. Lancet April 2026.

Date: May 8, 2026

Dr. Andrew Tagg

Guest Skeptic:  Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder and website lead of Don’t Forget the Bubbles.

Case: A healthy 7-year-old boy presents to the emergency department (ED) with obvious deformity of the wrist after a fall from playground equipment. X-rays show a severely displaced distal radius fracture, with an associated ulnar fracture. The child is neurovascularly intact. But the wrist looks dramatic. It’s quite bent. The child gazes at his arm, a mix of fear and intrigue. You consult the friendly orthopedics specialist who greets the family and recommends reduction under sedation because “it looks too crooked to leave alone.” You recall that in younger children, some fractures can remodel quite well on their own. The child’s father asks you whether you think the boy really needs a procedure to re-align the bones, or if he can just be placed in a cast.

 Background: 

Distal radius fractures are among the most common fractures in childhood, and severely displaced injuries create one of those classic tensions between what looks bad on an X-ray and what matters to patients over time.

Traditional teaching has favored reduction, often under sedation or general anesthesia, to restore anatomy and avoid concerns about deformity, loss of motion, or unhappy families. But pediatric bone is not adult bone. Younger children have substantial remodeling potential, especially near active growth plates, and prior observational studies suggested that even very displaced distal radial fractures can straighten out over time with good function.

Many clinicians still feel uneasy leaving these fractures unreduced. The visual deformity can be alarming. Families may equate straight bones with proper healing. Procedural reduction also comes with costs and potential harms: anesthesia, sedation, procedural pain, wound complications, etc.



Clinical Question: In children aged 4 to 10 years with severely displaced distal radial fractures, is non-surgical casting non-inferior to surgical reduction for functional recovery?



Reference:  Perry DC, et al. Non-surgical casting versus surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study): a multicentre, randomised, controlled non-inferiority trial and economic evaluation. Lancet April 2026.

 	Population: Children aged 4 to 10 years from 49 UK hospitals with severely displaced distal radial fractures, either metaphyseal or Salter-Harris II, with or without an associated ulnar fracture.

 	Exclusion: Injury &gt;7 days, complex wrist fractures that were open or extending into the joint, additional fractured bones elsewhere, inability to adhere to trial procedures or follow up.


 	Intervention: Non-surgical casting without purposeful manipulation, without sedation or general anesthesia.
 	Comparison: Surgical reduction under general anesthesia or conscious sedation, with fixation permitted at the surgeon's discretion.
 	Outcome: 

 	Primary Outcome: Patient Report Outcomes Measurement System (PROMIS) Upper Extremity Score for Children at 3 months.
 	Secondary Outcomes: Pain, health-related quality of life, cosmesis, complications, refracture, unplanned surgery, school absence, parental satisfaction, and cost-effectiveness.


 	Trial: Pragmatic, multicenter, randomized, controlled non-inferiority trial with economic evaluation

Authors’ Conclusions: “The CRAFFT trial did not demonstrate non-inferiority of non-surgical casting at 3 months against a conservative margin; however, the observed difference in favour of surgical reduction was small, below thresholds that families considered meaningful, and did not persist beyond early recovery. Surgical reduction was associated with higher costs, early procedural complications, and only a modest improvement in cosmetic appearance, supporting consideration of a cast-first strategy for most children.”

Quality Checklist for Randomized Clinical Trials:

 	The study population included or focused on those in the emergency department. Yes
 	The patients were adequately randomized. Yes
 	The randomization process was concealed. Yes
 	The patients were analyzed in the groups to which they were randomized. Yes
 	The study patients were recruited consecutively (i.e. no selection bias). Unsure
 	The patients in both groups were similar with respect to prognostic factors. Yes
 	All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No
 	All groups were treated equally except for the intervention. Unsure
 	Follow-up was complete (i.e. at least 80% for both groups). Yes
 	All patient-important outcomes were considered. Yes
 	The treatment effect was large enough and precise enough to be clinically significant. Yes,
 	Who funded the study? Funded by the National Institute for Health and Care Research Health Technology Assessment programme and supported by the NIHR Oxford Biomedical Research Centre.
 	Financial conflicts of interest. One author declared paid lectures for Smith &amp; Nephew and Arthrex; all other authors declared no competing interests.

Results: The trial enrolled 750 children, with 375 randomized to non-surgical casting and 375 to surgical reduction. The median age was 7.9 (IQR 6.5-9.5) years, with 456 (61%) being male. 44% had completely off-ended or displaced fractures.



Key Results: In children aged 4 to 10 with severely displaced distal radius fractures, surgery provided a small early functional advantage, but the difference was not clinically meaningful and disappeared in later months. Non-surgical casting was less expensive and had fewer early complications.



Primary Outcome: PROMIS Upper Extremity score was:

 	44.9 in the non-surgical group vs 46.6 in the surgical group
 	Adjusted mean difference was minus 1.64 points [95% CI -2.84 to -0.44], favouring surgery.



This confidence interval crossed the prespecified conservative non-inferiority margin of 2.5. Non-surgical casting did not meet formal non-inferiority for the full cohort.

Secondary Outcomes: 

There are several secondary outcomes from this study (check out the paper for more detail). Secondary outcomes mostly told a small early advantage, little long-term difference story.

First, in the pre-specified subgroup with completely off-ended fractures, non-surgical casting was non-inferiority. Keep in mind this threshold was a bit wider with a margin of minus 5 points.

When they looked at PROMIS scores over time, there was really no functional difference between groups by 6 and 12 months.



Surgical patients had more early complications, including pressure injury, wound infection, scarring, and nerve irritation.

Cosmesis slightly favored surgery early on, but the gap narrowed over time

Non-surgical casting saved about £1665 per patient and had a 100% probability of being cost-effective at standard UK willingness-to-pay thresholds.



Statistical vs Clinical Significance

This was a non-inferiority trial, but whether something is ‘non-inferior’ depends entirely on where you draw the line. The margin was –2.5 PROMIS points, and the result was minus 1.64 with the 95% confidence interval barely crossing the prespecified margin at -2.84. So technically, it failed non-inferiority.

It’s important to keep in mind that, because they had incorporated patient and public involvement across many aspects of the trial, they knew that families said a 5-point difference mattered. They chose a bit more conservative margin of -2.5.

This is one of those trials where the statistics say, ‘maybe not’… but the patients say, ‘we don’t care.’

And we care about the POOs, those patient-oriented outcomes, more.

Lack of Masking (and why it matters here)

One thing worth pausing on is the lack of masking. In this trial, neither clinicians nor families were masked to the treatment, and the primary outcome was a parent-reported function measure using PROMIS. That combination matters because it opens the door to expectation bias, which is a form of observer bias.

If your child has gone to theatre, had an anaesthetic, and the bone has been “put back in place,” it’s very natural to feel that something definitive has been done. It feels like proper treatment. On the other hand, if the arm has been put in a cast and left looking a bit bent, that can feel like something has been left unfinished even if it’s entirely appropriate.

When we see a small early functional advantage for surgery, it’s worth asking how much of that is true benefit, and how much might be shaped by perception. Because if you’ve just watched your child go through a procedure, you might understandably feel like they’re doing better, regardless of what’s happening at the level of bone healing.

There’s a lot of additional information in the supplemental section, but one part includes parental satisfaction scores, and there were really no big differences between the two groups.

Selection Bias / Equipoise Problem

Another interesting aspect is who made it into the trial. Of the 1,227 children who were eligible, only 750 were randomized. Many families declined to participate, and a notable proportion of clinicians felt there wasn’t enough equipoise to even offer enrollment.

Some of these exclusions based on clinician equipoise seem warranted like concern for neurovascular compromise. When it came to the families who declined consent, most of them declined because they had a preferred treatment…which more preferring surgical reduction.

...]]></description>
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    <item>
      <title>SGEM#509: I love the Java Jive &amp; It Loves Me – Preventing Dementia with Coffee and Tea</title>
      <link>https://podcast.show/thesgem/episode/153836185/</link>
      <rawvoice:pid>153836185</rawvoice:pid>
      <guid>https://thesgem.com/?p=18581</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 25 Apr 2026 08:12:20 -0400</pubDate>
      <description><![CDATA[Date: April 23, 2026 
Guest Skeptic: Dr. Manrique Umaña McDermott is an attending physician specializing in Emergency Medicine based in San José, Costa Rica. He has a passion for medical education, is a renowned international speaker and serves as a faculty member in undergraduate Internal Medicine at UCIMED and postgraduate training programs in Emergency Medicine and Family and Community Medicine at the University of Costa Rica (UCR). You can follow him on X and Instagram at @umanamd. 
Reference: Zhang et al. Coffee and Tea Intake, Dementia Risk, and Cognitive Function. JAMA 2026 March
Case: A 47-year-old emergency physician presents to their primary care physician for a rare act of preventive care between a run of night shifts. She drinks 3 large coffees most workdays, switches to tea on post-nights when her hands are vibrating fast enough to start an IV at 20 paces and asks whether her caffeine habit is frying her brain or secretly protecting it. She has heard that coffee is either a miracle, a menace, or both, depending on which headline got posted in the group chat that week.
Background: Coffee’s origin story reads like a case report from the annals of caffeinated discovery. Legend traces it back to Ethiopia, where a goat herder observed his animals behaving like over-caffeinated residents after nibbling on certain berries. From there, coffee spread through the Arabian Peninsula, where it was first cultivated and consumed in Yemen, eventually fueling the rise of coffeehouses. By the 17th century, coffee had reached Europe, where it was alternately praised as a miracle tonic and condemned as a suspicious stimulant. Over time, coffee became embedded in global culture, transitioning from a mystical brew to an industrial-scale commodity, and ultimately, a critical adjunct in emergency medicine workflow optimization.
Costa Rica takes coffee seriously, arguably more seriously than most emergency departments (EDs) take shift coffee orders. Introduced in the late 18th century, coffee quickly became a cornerstone of the country’s economy and identity. The government actively promoted coffee cultivation, even offering farmers free land to grow it, resulting in a thriving industry based on small family farms rather than large plantations. Costa Rican coffee is renowned for its high quality, thanks to ideal growing conditions: volcanic soil, high altitude, and just enough rain to keep things interesting. The country even banned the production of low-quality coffee. Today, Costa Rica is a leader in sustainable coffee production. So, the next time you’re powering through a night shift, there’s a good chance your cognitive performance is being supported by carefully cultivated beans from a hillside in Central America.
Emergency physicians do not need a pathophysiology lecture on caffeine; they need a fresh cup. Coffee is practically a staffing model, while tea is the civilized cousin, and both have long been part of the informal pharmacopeia of night shift survival. The real question is whether our specialty’s favourite legal liquid stimulant does anything beyond keeping our differential diagnoses alive until sunrise.
Biologically, the hypothesis is plausible. Coffee and tea contain caffeine and other bioactive compounds, including polyphenols, that may influence oxidative stress, neuroinflammation, vascular function, and insulin sensitivity. These are all pathways that could plausibly matter for cognitive decline and dementia. But human studies have been inconsistent, and many older studies did not clearly distinguish between caffeinated and decaffeinated coffee. 




Clinical Question: Is long-term intake of caffeinated coffee, decaffeinated coffee, or tea associated with incident dementia and cognitive outcomes?



Reference: Zhang et al. Coffee and Tea Intake, Dementia Risk, and Cognitive Function. JAMA 2026 March

 	Population: Adults from the Nurses’ Health Study (NHS) and Health Professionals Follow-up Study (HPFS).

 	Excluded: People with cancer, Parkinson’s disease, or dementia at baseline; those with implausible total energy intake; and those missing caffeinated beverage intake data. 


 	Exposure: Long-term intake of caffeinated coffee, decaffeinated coffee, and tea, assessed every 2 to 4 years with validated food frequency questionnaires (FFQs). 
 	Comparison: Lower intake categories, especially the lowest quartile or tertile of consumption, depending on the beverage. 
 	Outcomes:

 	Primary Outcome: Incident dementia, identified via death records and physician diagnoses. 
 	Secondary outcomes: Subjective cognitive decline and objective cognitive function; objective testing was assessed only in the NHS cohort, including a telephone interview for cognitive status (TICS) and composite cognitive measures. 


 	Type of Study: Prospective observational cohort study.


Authors’ Conclusions: “Greater consumption of caffeinated coffee and tea was associated with lower risk of dementia and modestly better cognitive function.” 

Quality Checklist for Observational Studies:


 	Did the study address a clearly focused issue? Yes
 	Did the authors use an appropriate method to answer their question? Yes 
 	Was the cohort recruited in an acceptable way? Yes
 	Was the exposure accurately measured to minimize bias? Yes
 	Was the outcome accurately measured to minimize bias? Unsure
 	Have the authors identified all-important confounding factors? Unsure
 	Was the follow-up of subjects complete enough? Yes
 	How precise are the results? Reasonably for the primary outcome.
 	Do you believe the results? Yes
 	Can the results be applied to the local population? Yes
 	Do the results of this study fit with other available evidence? Yes
 	Who funded the study? Multiple National Institutes of Health grants. 
 	Did the authors declare any conflicts of interest? Yes. Dr. Hu reported receiving research support from the Analysis Group; no other disclosures were reported.

Result: The study included 131,821 middle-aged US health professionals from 2 cohorts: female nurses in the NHS and male health professionals in the HPFS. The mean age at baseline was 46.2 years in NHS and 53.8 years in HPFS, and 66% of the pooled sample was female. Follow-up was extraordinarily long, up to 43 years, with a median of 37 years. Higher coffee consumers tended to be younger, drink more alcohol, smoke more, and consume more total energy. 




Key Result:  Higher caffeinated coffee intake was associated with lower dementia risk.




 	Primary Outcome: Incidence of dementia HR 0.82 (95% CI 0.76 to 0.89)
 	Secondary Outcomes? Higher caffeinated coffee intake was associated with lower prevalence of cognitive decline, 7.8% versus 9.5% in the highest versus the lowest quartile, prevalence ratio 0.85. In the NHS objective testing subgroup, higher caffeinated coffee intake was associated with a small increase in the telephone interview for cognitive status (TICS) score (mean difference 0.11), whereas the global cognition result (mean difference 0.02) did not reach conventional statistical significance. Tea showed similar patterns; decaf did not. 




1. Residual Confounders: This is the biggest threat. Observational cohort studies are appropriate for exposure questions but inherently vulnerable to bias from prognostic differences between the exposed and the unexposed groups. Even after multivariable adjustment, coffee and tea drinkers may differ from lower-intake participants in ways that matter for cognition. These include sleep habits, education, work patterns, health-seeking behaviour, medication use, diet quality, and unmeasured social factors. The authors acknowledge residual confounding, including neuroactive drugs that were not fully captured across follow-up. 
2. Reverse Causation: Even in a prospective cohort, early cognitive decline could influence beverage habits or the reliability of dietary self-report before formal dementia diagnosis. Someone drifting into cognitive decline may reduce coffee intake due to sleep disturbance, jitters, gastrointestinal symptoms, or a caregiver’s influence, making coffee appear protective when declining cognition changes the exposure. The authors conducted sensitivity analyses but still acknowledge that reverse causation cannot be fully excluded. 

3. Imperfect Exposure Measurement: Repeated validated food frequency questionnaires (FFQs) are better than a single baseline diet snapshot, yet they cannot fully capture brew strength, cup size, preparation method, shifts between caffeinated and decaf products, or additives like sugar and cream. Mismeasurement of exposure can distort observed associations, and nutrition studies are especially vulnerable because the dose is harder to standardize than a prescription drug. 

4. Outcome Ascertainment: The primary outcome relied on death records and self-reported physician diagnoses, with medical-record confirmation when available. That is pragmatic and probably better in health professionals than in the general population, but it still leaves room for missed cases and misclassification. The authors also could not isolate Alzheimer's disease specifically, which matters because all-cause dementia may lump together biologically distinct conditions with different relationships to caffeine. 

5. Time-Varying Confounding &amp; Imperfect Capture of Exposure Over Time: This combines nerdy point #1 and #3. Although the authors used repeated FFQs, beverage consumption is likely to change meaningfully over a 30- to 40-year follow-up. Participants may switch between caffeinated and decaffeinated coffee, change dose, or modify intake due to early (subclinical) cognitive decline, sleep issues, comorbidities, or physician advice. Even with cumulative averaging, this introduces time-varying confounding and exposure misclassification, which represents a major threat in longitudinal observational studies.]]></description>
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      <title>SGEM #508: How Low Can You Go? Rethinking Lumbar Punctures in Well-Appearing Febrile Infants</title>
      <link>https://podcast.show/thesgem/episode/153812919/</link>
      <rawvoice:pid>153812919</rawvoice:pid>
      <guid>https://thesgem.com/?p=18545</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 18 Apr 2026 08:30:28 -0400</pubDate>
      <description><![CDATA[Reference: Burstein B, et al. Prediction of Bacteremia and Bacterial Meningitis Among Febrile Infants Aged 28 Days or Younger. JAMA. Published online December 08, 2025.

Date: April 3, 2026

Dr. Margarita Ramos

Guest Skeptic: Dr. Margarita Ramos is a pediatric hospitalist at Children’s National Hospital in Washington, D.C., and Assistant Professor of Pediatrics at the George Washington University School of Medicine and Health Sciences where completed the Master Teacher Leadership Development Program in 2024. Her scholarly interests include equity in medical education and health services research.

Case: A 12-day-old boy is brought to the emergency department (ED) by his parents for fever. At home, he felt a little warm, so they took his temperature and found it was 38.3°C. The family called the boy’s pediatrician, who told them to bring him to the ED immediately. The baby has been feeding well. He has had a normal number of wet diapers and stools. He has no other medical history and was born full-term. On your exam, the baby looks good. There is no obvious source for his fever.

His parents say to you: “Our pediatrician told us that fevers at this age are worrisome, and our baby may need a lot of testing, including something called a lumbar puncture. We looked it up, and it sounds really scary. Do we have to do all that?”

Background: 

We’re back on the topic of well-appearing febrile infants, and things have changed! Specifically, the “limbo” bar of age for which of the infants requiring a lumbar puncture (LP) has dropped quite a bit. Some may recall practicing at a time when any febrile babies ≤3-months-old were getting an LP. Later, that bar had dropped down to febrile babies ≤28 days getting an LP.

Along the way, we’ve had various tools to help guide us in identifying babies at low risk for what was once termed a serious bacterial infection (SBI), including urinary tract infection, bacteremia, and bacterial meningitis. These included tools like the Philadelphia, Rochester, and Boston criteria that risk-stratified based on pre-determined thresholds for temperature, lab tests, urine studies and more.



In 2019, the Pediatric Emergency Care Applied Research Network (PECARN) derived and validated a clinical decision rule for identifying low-risk febrile infants based on urine, absolute neutrophil count (ANC) and procalcitonin. We covered this study in SGEM#296.

The rounded PECARN Rule is:

 	Negative urinalysis
 	Absolute Neutrophil Count (ANC) ≤4,000/µL
 	Serum procalcitonin ≤0.5 ng/ml

In 2021, we saw the limbo bar drop again with new guidance from the American Academy of Pediatrics (AAP) covered on SGEM#341. The age for LP moved down to 22 days. Based on this guideline, the decision to perform LP on infants from 22 to 28 days could be guided by inflammatory markers.

There was also another shift. Instead of focusing on SBIs, which included UTIs, one of the most common sources of infection, researchers started to focus on bacteremia and bacterial meningitis, termed invasive bacterial infections (IBIs), which have very bad consequences if missed.

Right now, the bar sits around 21–22 days because that’s where the data feels comfortable. And to be fair, newborns are different from older infants. Their immune systems are immature, their symptoms are subtle, and the consequences of missing meningitis are enormous. So naturally, we are cautious.



Clinical Question: How accurately can the PECARN rule identify febrile infants 28 days or younger at low risk for invasive bacterial infections?



Dr. Brett Burstein

Reference: Burstein B, et al. Prediction of Bacteremia and Bacterial Meningitis Among Febrile Infants Aged 28 Days or Younger. JAMA. Published online December 08, 2025.

 	Population: well-appearing febrile infants ≤ 28 days, temperature ≥38°C, from four prospective cohort studies across six countries within the global Pediatric Emergency Research Network (PERN) who underwent testing with PECARN rule components (procalcitonin, ANC, UA/urine dipstick).

 	Excluded: Criteria differed across the included studies. Some exclusion criteria included prematurity, pre-existing medical conditions, and being critically ill. Other studies excluded infants with viral signs.


 	Intervention: PECARN clinical decision rule
 	Comparison: None
 	Outcome: Diagnostic accuracy of the PECARN rule to identify infants with IBI (bacteremia or bacterial meningitis)
 	Type of Study: A pooled analysis of 5 published prospective cohort studies that was analyzed using meta-analytic methods to assess diagnostic accuracy

Guest Authors:

Dr. Nathan Kuppermann

Dr. Brett Burstein is a paediatric emergency medicine physician at Montreal Children’s Hospital and Associate Professor in the Department of Pediatrics at McGill University. His research focuses on the care of febrile young infants, emphasizing parental preferences, shared decision-making, and family-centered outcomes. 

Dr. Nathan Kuppermann is executive vice president, chief academic officer of Children’s National Hospital and director of the Children’s National Research Institute. He also serves as chair of the Department of Pediatrics and associate dean of Pediatric Academic Affairs at the George Washington University School of Medicine and Health Sciences. Dr. Kuppermann is a pediatric emergency medicine physician, clinical epidemiologist and leader in emergency medical services for children.

 
Authors’ Conclusions: “The updated PECARN rule had higher sensitivity but lower specificity for identifying febrile infants 28 days or younger with invasive bacterial infections, with no missed cases of bacterial meningitis. These results may support shared decision-making regarding selective vs routine use of lumbar puncture among infants classified as low risk.”
Quality Checklist for Systematic Review Diagnostic Studies

 	The diagnostic question is clinically relevant with an established criterion standard. Yes
 	The search for studies was detailed and exhaustive. No
 	The methodological quality of primary studies were assessed for common forms of diagnostic research bias. Yes and No.
 	The assessment of studies was reproducible. Yes
 	There was low heterogeneity for estimates of sensitivity or specificity. No 
 	The summary diagnostic accuracy is sufficiently precise to improve upon existing clinical decision-making models. Yes
 	Funding of the Study: No industry funding was reported
 	Conflicts of Interest: No major conflicts of interest were reported

Results: They included 1537 infants in the primary analysis, of whom 69 (4.5%) had IBI. The majority were male (~59%) and presented within 12 hours of fever onset. Not surprisingly, most (86.15%) were hospitalized. Approximately 41% of infants met PECARN low-risk criteria.

Of those infants who had invasive bacterial infections:

 	58 with bacteremia
 	11 with bacterial meningitis (0.7%)

The prevalence of IBI ranged from 2.5% to 7.3% between studies.



Key Results: The PECARN clinical prediction rule for identifying febrile infants ≤28 days at low risk for invasive bacterial infection has good sensitivity but low specificity. It did not miss any infants with bacterial meningitis.



The rule had a sensitivity of 94.2%, specificity of 41.6%, negative predictive value of 99.4%, and negative likelihood ratio of 0.14.

They also conducted a secondary analysis across all six cohorts (n=2531) that included the PECARN cohorts. The accuracy was quite similar.



All six cohorts together had 96 (3.8%) cases of IBI with 22 (0.9%) cases of bacterial meningitis.

The PECARN rule did misclassify 5 infants as low risk. Three infants had bacteremia with S. aureus, H. influenzae, and E. coli. The other two infants had positive urine cultures with E. coli, one of whom had concurrent E. coli bacteremia while the other had S. aureus bacteremia.



Tune into the podcast to hear Brett and Nate answer our questions!

Measurement of Temperature: 

Here in the United States, we are more accustomed to measuring core temperature, especially in this very young population, rectally. It is mentioned that rectal temperature is used in three of the included cohort studies. But one study included temperatures measured by any method. There is differing evidence regarding the accuracy of temperature measurement by different methods.

How do you think the inclusion of that patient population may have affected your results?

Biases: 

Some of the exclusion criteria may introduce selection bias. For example, in two of these study cohorts, patients were excluded because they had “viral signs present.” The AAP febrile infant guideline excludes infants with clinical bronchiolitis but states that infants with respiratory symptoms or positive viral test results may still be included.

What do you think about excluding babies with viral symptoms from the workup? How does the exclusion of those babies with viral signs in the two cohorts mentioned affect your results?

Here are some other examples of potential biases:

Not all infants in the pooled cohorts underwent a complete reference standard evaluation, particularly lumbar puncture for meningitis. This is appropriate given we try to limit invasive testing like LPs if possible. However, when only a subset of patients receives the gold-standard test, the accuracy of the diagnostic rule can be distorted. This is known as partial verification bias, where patients with higher clinical suspicion are more likely to undergo confirmatory testing. If infants classified as low risk were less likely to receive an LP, it is possible that some cases of meningitis could have been missed, artificially inflating the rule's sensitivity (true positive) estimates.

The authors followed the STARD guidelines for diagnostic accuracy studies,]]></description>
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      <title>SGEM#507: Till Everybody Got Delirious – Geriatric Patients in the Emergency Department</title>
      <link>https://podcast.show/thesgem/episode/153802698/</link>
      <rawvoice:pid>153802698</rawvoice:pid>
      <guid>https://thesgem.com/?p=18550</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 11 Apr 2026 09:13:10 -0400</pubDate>
      <description><![CDATA[Date: April 2, 2026  
Reference: Lee et al. GRADE-Based Clinical Practice Guidelines for Emergency Department Delirium Risk Stratification, Screening, and Brain Imaging in Older Patients With Suspected Delirium. AEM Feb 2026
Guest Skeptic: Dr. Christina Shenvi is a board-certified emergency physician, educator, keynote speaker, coach, and academic leader. She is widely recognized for her work in geriatric emergency medicine, faculty development, and professional identity formation in EM. She brings deep clinical expertise along with thoughtful perspectives on systems-level change and guideline development.
Case: An 82-year-old woman with hearing impairment and mild baseline dementia is brought to the emergency department (ED) by her daughter because she became “not herself” over 24 hours. She is more sleepy, intermittently agitated, keeps losing the thread of conversation, and cannot say the months backward. She arrived by ambulance from home after nearly falling twice. Vitals show fever and mild tachycardia. The daughter reports foul-smelling urine and poor oral intake for two days. On examination, there is no head trauma and no focal neurologic deficit. The question in the ED is not simply “Is she confused?” but “Does she have delirium, how do we confirm it efficiently, and does she need a head CT as part of the workup?”
Background: Delirium is an acute brain dysfunction: a disturbance in attention and awareness that develops over hours to days, fluctuates, and is accompanied by additional cognitive disturbances such as memory, language, orientation, or perceptual changes. In older adults, it is common, dangerous, and often goes unnoticed. The latest GED Delirium Guidelines indicate that delirium occurs in about 6% to 38% of older ED patients, increases mortality, contributes to functional decline, and imposes a significant burden on health systems. ED-based geriatric screening tools also highlight that delirium is frequently under-recognized by emergency clinicians and that hypoactive delirium is most common, making bedside detection even more challenging. 
For emergency physicians, delirium matters because it is rarely the final diagnosis. Delirium is usually a clue that something else serious is also wrong. The practical ED task is to identify the syndrome, search for precipitants, and avoid worsening the situation. But one reason the new guideline is so useful is that it is honest about the evidence gap. Prior reviews found no consistent ED-based strategy to prevent incident delirium or to treat prevalent delirium, so this guideline appropriately focuses on the parts of care for which there is sufficient evidence to guide bedside decisions now. It addresses risk stratification, diagnosis, and brain imaging. 
This delirium guideline is also notable because it was built using the newer GED 2.0 model for subspecialty guideline development [1].  The Geriatric Emergency Department initiative moved beyond the older consensus-based 2014 framework and adopted a transparent GRADE process: multidisciplinary working groups, explicit PICO questions, systematic reviews and meta-analyses, Evidence-to-Decision frameworks, attention to feasibility, equity, and stakeholder values, plus external stakeholder review. This SGEM episode highlights the first EM subspecialty guideline effort to fully adopt GRADE, and this delirium guideline shows that process in action. 




Clinical Questions:




 	
Which older ED adults are at the highest risk on walking in, and who should then be further assessed for delirium? (or CLS addition, should have special prevention measures or expedited treatment or bed placement).

 	
Which tools should be used to identify ED delirium?

 	
Should acutely confused older ED patients undergo head CT as part of the delirium evaluation?




Reference: Lee et al. GRADE-Based Clinical Practice Guidelines for Emergency Department Delirium Risk Stratification, Screening, and Brain Imaging in Older Patients With Suspected Delirium. AEM Feb 2026


Authors’ Conclusions: “Rigorous ED-based research is needed to strengthen evidence and guide delirium care for older adults in geriatric emergency medicine.”

Quality Checklist for a Guideline:


 	The study population included or focused on those in the emergency department? Yes 
 	An explicit and sensible process was used to identify, select and combine evidence? Yes
 	The quality of the evidence was explicitly assessed using a validated instrument? Yes
 	An explicit and sensible process was used to value the relative importance of different outcomes? Yes
 	The guideline thoughtfully balances desirable and undesirable effects? Yes
 	The guideline accounts for important recent developments? Yes
 	Has the guideline been peer-reviewed and tested? Yes/No
 	Practical, actionable and clinically important recommendations are made? Yes
 	The guideline authors’ conflicts of interest are fully reported, transparent and unlikely to sway the recommendations? Unsure




Key Recommendations: They came up with six recommendations that are conditional and all rest on very low certainty of evidence.





 	Risk Stratification

 	A Delirium Risk Score may be used to identify low-risk older adults. Conditional FOR; very low certainty. The delirium risk score gives you a baseline risk of delirium before the patient comes into the ED. It’s based on work by Jin Han and friends from 2009. In a cross-sectional convenience sample of about 300 patients, they identified three factors were independently associated with presenting with delirium in the ED: dementia, Katz ADL= 75, dementia, hearing impairment, and psychotropic drugs. High risk is &gt;= 4. This could be used to identify patients at high risk.
 	For adults &gt;75 presenting to the ED, REDEEM threshold ≥11 may identify low- or high-risk patients, and a cutoff =11 would mean about 1/5th or 20% of the ED older adult population, so then if you only screened those patients for delirium, then it may reduce the work. But that means you’re screening everyone with REDEEM and then 20% of them with a delirium diagnostic tool. And the redeem questions are more complex (see paper). REDEEM stands for Recognizing Delirium in geriacric Emergency medicine and is based off of a paper from 2021. It was an observational study of patients age &gt;=75 coming to the ED who were screened for delirium and then regression analysis used to create a model with 10 variables – 7 from triage info and 3 obtained during early history. Some caveats here. Also scores from -3 to +66. This to me seems more complex than just screening everyone for delirium with a DTS and bCAM or the 4AT




 	Diagnostic Tools

 	4AT, bCAM, CAM-ICU, mCAM, AMT-4, or RASSmay be used to rule delirium in or out. Conditional FOR; very low certainty.
 	Delirium Triage Screen (DTS) may be used to rule out, but not rule in, delirium [4]. Conditional FOR; very low certainty.



The DTS and bCAM are frequently used in concert. Start with the DTS (2 components: RASS=/0 or ALOC and attention – spell LUNCH backwards). If normal, NOT delirious. If not normal, do the bCAM:


 	Acute change or fluctuating course – from family or pt
 	Inattention eg months of the year backwards
 	Altered level of consciousness or
 	Disorganized thinking eg will a stone float on water

If you have 1, 2, and 3 or 4, then you are delirious.
4AT is often used internationally for 4 items and a single step.


 	Alertness, normal/mild sleepiness/clearly abnormal
 	AMT4 (abbreviated mental test for orientation)

 	Age
 	Date of birth
 	Location
 	Year


 	Attention - months of the year backwards
 	Acute change or fluctuating course

Score 0 - normal, 1 to 3 possible cognitive impairment, &gt;=4 possible delirium or severe cog impairment


 	Brain Imaging

 	In the undifferentiated older ED patient with delirium or altered mental status (AMS), there are insufficient data to recommend for or against a head CT. Conditional EITHER; very low certainty.




1. Certainty: The biggest limitation is the certainty of the underlying evidence. The guideline authors are admirably transparent about the fact that every recommendation is conditional and based on very low-certainty evidence. In GRADE terms, this means the true effect may be substantially different from the estimate, especially when evidence is downgraded for risk of bias, indirectness, inconsistency, and imprecision. That matters because even a methodologically rigorous guideline can only be as trustworthy as the body of evidence beneath it. 
2. External Validity: A second threat is that much of the evidence base consists of single-center diagnostic or prognostic studies with limited external validation. The delirium paper explicitly notes that the risk-stratification tools were supported by single-center evidence and, in most cases, lacked separate validation research. From an evidence-based diagnosis perspective, this raises real concerns about spectrum effects and transportability: a tool that appears to work in one ED case mix may perform differently in another. 

3.]]></description>
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      <title>SGEM Xtra: You You You Oughta Know – GED 2.0 Guidelines</title>
      <link>https://podcast.show/thesgem/episode/153786290/</link>
      <rawvoice:pid>153786290</rawvoice:pid>
      <guid>https://thesgem.com/?p=18533</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 04 Apr 2026 09:42:38 -0400</pubDate>
      <description><![CDATA[Date: March 23, 2026


Dr. Christina Shenvi
Guest Skeptic: Dr. Christina Shenvi is a board-certified emergency physician, educator, keynote speaker, coach, and academic leader. She is widely recognized for her work in geriatric emergency medicine, faculty development, and professional identity formation in emergency medicine (EM). She brings deep clinical expertise along with thoughtful perspectives on systems-level change and guideline development.
This is another SGEM Xtra episode. Today’s show focuses on how to build high-quality subspecialty clinical practice guidelines, using the Geriatric Emergency Department Guidelines 2.0 (GED 2.0) as a model.
We’ve talked about Geriatric EM a lot on the SGEM over the years. And if we’re serious about evidence-based emergency medicine, we must be serious about geriatric EM. Here are some previous SGEM episodes: 


 	SGEM#89: Preventing Falling to Pieces
 	SGEM Xtra: Don’t Bring Me Down – Preventing Older Adult Falls from the ED
 	SGEM#261: Cristal Ball to Assess Older Patients in the ED
 	SGEM#280: This Old Heart of Mine and Troponin Testing
 	SGEM#424: Ooh Ooh I Can’t Wait to Be Admitted to Hospital

The original 2014 GED Guidelines were consensus-based and helped establish standards for geriatric emergency departments, including staffing, education, transitions of care, quality improvement, equipment, and protocols. Since then:


 	The evidence base in geriatric EM has expanded.
 	Expectations for clinical practice guideline development have evolved.
 	The GRADE framework has become the international standard for rating the quality of evidence and the strength of recommendations.

GED Guidelines 2.0 represent the first EM subspecialty effort to fully adopt the GRADE methodology and provide a transparent, reproducible model for future EM guideline development. 
This work involved a multidisciplinary collaboration, including experts affiliated with organizations such as the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM), as well as geriatricians, methodologists, and patient representatives. Started with an open call to the Geriatric Emergency Medicine community via SAEM, ACEP, AGS, EUSEM, and ENA. With funding via JAHF.
The GED Guideline 2.0 group is planning 14 Systematic Reviews/Meta-analyses, with 6 or 7 Clinical Practice Guidelines. They will all be available on the GEAR 2.0 website




Five Questions for Dr. Shenvi


I have five key questions to frame our discussion about the GED 2.0 Model for Subspecialty Clinical Practice Guidelines. As a reminder, they are called GUIDElines, not GODlines. This means they are meant to guide our care, not dictate care.
 
1) Why Update the Original GED Guidelines? 
The original 2014 GED Guidelines were enormously important because they gave the field its first shared framework for what high-quality emergency care for older adults should look like. But they were developed as consensus-based guidelines at a time when the evidence base in geriatric emergency medicine was much less mature than it is now. Since then, there has been major growth in research, especially through work from GEAR and GEAR 2.0, in areas like delirium, dementia, falls, medication safety, transitions of care, and elder abuse. The update was needed to ensure the guidelines reflected the newer evidence and remained clinically relevant.
A second reason is that expectations for guideline development have changed. The paper makes clear that the original guidelines did not include a formal assessment of the quality, quantity, reproducibility, or applicability of the evidence. In today’s environment, clinicians and health systems expect more transparency about how recommendations are made, how strong the evidence is, and how benefits, harms, feasibility, and equity are weighed. GED Guidelines 2.0 was designed to meet those newer standards.
A third issue was implementation. The original guidelines had a clear impact, especially through ACEP accreditation, but the paper notes that accredited GEDs still represent a minority of EDs, and many sites have struggled with barriers such as limited resources, competing priorities, and a lack of local champions. So, this update was not just about refreshing content. It was also about making the guidance more usable, transparent, and implementable in both accredited and non-accredited settings.
Bottom line, hospitals won’t do things unless there are clear clinical reasons, or financial reasons, or mandates, like CMS measures, which are financial.
2) Why Adopt the GRADE Framework?
GRADE stands for: Grades of Recommendation, Assessment, Development, and Evaluation. They provide a systematic, transparent framework for rating the quality of evidence and grading the strength of recommendations in healthcare. 
The group adopted GRADE because they wanted the updated guidelines to be more rigorous, more transparent, and more trustworthy. According to the paper, GED Guidelines 2.0 is the first emergency medicine subspecialty guideline effort to fully adopt GRADE. The attraction of GRADE is that it provides a structured framework for framing questions, assessing evidence, evaluating bias, and connecting the certainty of the evidence to the strength of the recommendations. That makes it easier for clinicians to understand not only what is being recommended but also why.
 GRADE also helps move the field beyond expert opinion alone. The new process is grounded in systematic reviews and meta-analyses, and it explicitly incorporates patient values and preferences, health equity, feasibility, and the balance of benefits and harms. That is especially important in geriatric emergency care, where decisions are often preference-sensitive and where the “right” intervention may depend on function, cognition, caregiver context, and resource availability.


 	What were the biggest challenges in implementing GRADE in a largely volunteer-driven initiative?

The biggest challenge was GRADE's resource intensity. The paper explicitly states that it requires trained methodologists, research librarian support, and the completion of systematic reviews and meta-analyses. On top of that, the working group was largely volunteer-driven, and there was variability in members’ familiarity with systematic-review methods and GRADE processes. So, the group had to invest in ongoing training, recalibration, and role adaptation over time.

3) What are the Seven Priority Domains?
The seven priority domains were delirium, dementia, falls, frailty, medication management, palliative care, and elder abuse. 

 	How were these selected, and were there important areas left out?

They were the result of 6 to 9 months of meetings, starting in 2019. They were selected through a gap analysis of the original guidelines, plus a review of where the evidence base had become strong enough to support a formal guideline. The paper also makes clear that not everything was revised. Some foundational operational elements were intentionally left unchanged because they remained current. So, the omission of some areas was not because they were unimportant, but because the group prioritized where new evidence-based guidance would add the most value.


 	How did patient and caregiver input shape the priorities?

Each guideline has involved a patient or a patient's care partner. Evidence for decision rule meetings when they vote on the level of evidence. The patient or advocate takes part in that meeting and process. For each of the 6 or 7 Clinical Practice Guidelines (CPGs).
4) What is Different about GED Guidelines 2.0? 


Dr. Chris Carpenter
Core leaders Dr. Chris Carpenter (expert in methodology and content), Dr. Shan Liu, and seven subgroups with leaders. Greater than 60 people from seven countries, not just physicians, nurses, allied health, methodologists, and patient representatives.
What is most different is that this was intentionally built as a broad, multidisciplinary, international, and methodologically rigorous process. The paper describes a collaboration involving more than 60 members from 23 US states and seven countries, including not only emergency physicians but also geriatricians, nurses, allied health professionals, methodologists, and patient caregivers. That is a broader coalition than many traditional emergency medicine guideline efforts, which are often more specialty-contained.
The second major difference is the method. Rather than relying primarily on expert consensus, this model uses formal GRADE methods, systematic reviews, meta-analyses, and structured PICO questions. The paper presents this as a transparent, replicable framework intended not only to generate better geriatric emergency guidelines but also to serve as a blueprint for future emergency medicine subspecialty guideline development.
A third difference is the emphasis on implementation from the beginning. The model was designed not just to write guidelines, but also to anticipate dissemination, adoption, feasibility, equity, and usability across different ED environments. In that sense, it is not just a content update. It is also a delivery model for creating and spreading subspecialty guidelines in a way more likely to reach frontline practice.


 	How does this process serve as a blueprint for other EM subspecialties?

It shows that an emergency medicine subspecialty can develop guidelines using the same formal architecture as other major guideline organizations: broad stakeholder engagement, PICO-based question framing, systematic review, evidence grading, and explicit attention to feasibility and equity. The authors explicitly present this as a replicable framework for other EM subspecialty groups.

 	What lessons can be generalized to areas like toxicology, critical care, or ultrasound?

The generalizable lessons are: start with a broad coalition,]]></description>
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      <title>SGEM Xtra: This One Goes to 11 – ATLS 11th Edition</title>
      <link>https://podcast.show/thesgem/episode/153769309/</link>
      <rawvoice:pid>153769309</rawvoice:pid>
      <guid>https://thesgem.com/?p=18519</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 28 Mar 2026 07:00:48 -0400</pubDate>
      <description><![CDATA[Date: March 26, 2026


Dr. Rob Leeper
Guest Skeptic: Dr. Robert Leeper is a trauma surgeon at the London Health Sciences Centre and an ATLS instructor who has helped train generations of physicians in trauma care. He has previously joined SGEM for:


 	SGEM #200 – Bloodletting and Alexander Hamilton
 	SGEM #256 – RLQ Pain and Appendectomy
 	SGEM #345 – Non-operative Management of Appendicitis

It’s SGEM Xtra time, where we go beyond a single paper and dive into broader topics that impact our daily practice. Now, some of you may remember that back in 2018, we did a Top 10 list for ATLS 10th Edition. Yes, we cranked it up to 10.




ATLS 10th Edition: Top 10 Changes




But today… We’re not stopping at 10. Because this SGEM episode goes to 11. If you don’t get that reference, go watch This Is Spinal Tap. It’s a mockumentary about a fictional rock band whose amplifiers go to 11 instead of 10. And when asked why they didn’t just make 10 louder, the guitarist replies: “These go to 11.” And that brings us to ATLS, now officially in its 11th edition. 
For those who don’t know the history of ATLS, here is the brief back story. ATLS was born out of tragedy. In 1976, orthopedic surgeon Dr. James Styner crashed his small plane in rural Nebraska. His wife died at the scene. He and his children survived but were severely injured. When they arrived at a small hospital, the trauma care they received was, by his account, disorganized and inadequate.
Styner later said: “When I can provide better care in the field with limited resources than my children and I received at the primary care facility, there is something wrong with the system.” That moment led to the development of a structured approach to trauma, one that could be taught, replicated, and standardized.
The first ATLS course was introduced by the American College of Surgeons (ACS) in 1980. It emphasized something radical at the time: a systematic, prioritized assessment of trauma patients, beginning with Airway, Breathing, Circulation, Disability, Exposure (ABCDE).
In EM, our alphabet is A-B-CT, send them to the donut of truth. But back to the 1980s, the systematic ABCDE approach wasn’t about memorizing injuries. It was about preventing death from the first thing that kills. Over the decades, ATLS became one of the most widely adopted trauma education programs in the world. It has trained hundreds of thousands of clinicians in over 80 countries.
And like any long-running franchise (Star Wars, Mission Impossible, Star Trek and Batman), each new edition tries to improve on the original. So today, instead of a Top 10 list as we did for ATLS 10, we’re going with: The 5 important changes in ATLS 11. Because sometimes less is more. Even if the amplifier goes to 11.




Five Changes to the ATLS 11th Edition





1. xABCDE – Hemorrhage Now Comes Before Airway: The most noticeable clinical change in ATLS 11 is the addition of the “x” to ABCDE, making it xABCDE, with the “x” standing for exsanguinating hemorrhage. Massive external bleeding is now formally prioritized before airway management in select patients. While many trauma teams have already internalized the “bleeding kills first” principle, especially after a decade of military-to-civilian trauma translation, ATLS has now codified it. In practical terms, this reinforces early tourniquet use, direct pressure, and hemostatic adjuncts as first-line priorities when appropriate. It’s less of a revolution and more of an official acknowledgment that the trauma world has already turned the volume up on hemorrhage control. But formalizing it in the primary survey does matter, because what gets taught gets practiced.

2. Hemodynamic Optimization Before Intubation: Another subtle but important evolution in the 11th edition is the greater emphasis on resuscitating shock before proceeding with rapid sequence intubation (RSI). ATLS 11 highlights the risk of peri-intubation hypotension and arrest in unstable trauma patients, encouraging clinicians to correct hemodynamics before pushing paralytics. This aligns with growing emergency medicine literature around the dangers of precipitous airway management in the shocked patient. It’s a welcome shift toward physiologic thinking rather than purely procedural thinking. In other words, it reminds us that the airway isn’t just anatomy, it’s physiology.

3. Major Structural Reorganization and Systems Focus: The changes to ATLS 11 aren’t just clinical. This edition reorganizes the manual into three major sections: resuscitation, trauma systems/context, and specific injury patterns. More notably, it introduces full chapters on Trauma Systems, Injury Prevention, Trauma-Informed Care, and Communicating Serious News. This reflects a broader view of trauma care that extends beyond the primary survey. ATLS is no longer just about what happens in the first 15 minutes. It is also about the system in which those 15 minutes occur. For instructors, this may feel like an expansion into public health. Whether that’s evolution or mission creep may depend on your worldview. But it’s clear ATLS is trying to move from protocol to platform.

4. Dedicated Penetrating Trauma Chapter: Penetrating trauma now has its own standalone chapter in the 11th edition. This shows recognition that penetrating injury has unique management considerations compared to blunt trauma. The new edition emphasizes mechanism-driven evaluation, selective non-operative management, and updated surgical decision-making paradigms. For the USA trauma systems, this is particularly relevant given the epidemiology of violence-related injury (acute lead poisoning…Gun Shot Wounds [GSWs]). GSWs are the leading cause of death in the US for children aged 1 to 17 years. The key question, from an SGEM lens, is whether the content fully reflects contemporary evidence, especially regarding selective non-operative approaches. But structurally, this is a meaningful shift that gives penetrating trauma its own intellectual real estate.

Dr. Andrew Worster

5. “Standardized Flexibility” – A Global Adaptation Philosophy: Perhaps the most philosophically important change in ATLS 11 is the formal adoption of “standardized flexibility.” The manual explicitly acknowledges global variability in trauma resources. Some places have CT availability, blood products, and access to specialist care, while others do not. ATLS now encourages adapting principles to the setting, rather than assuming Level I trauma center capabilities everywhere. This is a recognition that trauma education must be globally applicable. It moves ATLS from a rigid protocol toward a framework. It reminds me of the Evidence-Based Medicine (EBM) answer I learned from my mentor, Dr. Andrew Worster, “It all depends”. Traumas occur in a context (urban/rural/remote, academic/community, low-resource/high-resource, etc.). How ATLS is applied in your clinical situation will depend on many factors and requires flexibility.
Other changes we wanted to mention:


 	Head and spine combined into “disability.”
 	Expanded section on geriatric trauma (now “Trauma in the Older Adult”)
 	Enhanced team communication emphasis
 	Hybrid learning and required pre-course videos
 	Updated transfer mnemonic: S-xABCDE-BAR


S: Situation (Who/Where/Why): Your name &amp; role, location, patient demographics, mechanism of injury and reason for transfer.
 xABCDE: Primary Survey Summary


 	x – Exsanguinating Hemorrhage: Tourniquet? Pelvic binder? Massive Transfusion Protocol activated?Ongoing bleeding?
 	A – Airway: Patent? Intubated? Endotracheal tube size? C-spine protected?
 	B – Breathing O₂ saturation? Chest tube? Vent settings? Tension pneumothorax addressed?
 	C – Circulation: Blood Pressure/Heart Rate? Intravenous/Intraosseous access? Blood products given?TXA given?
 	D – Disability: Glasgow Coma Scale? Pupils? Lateralizing deficits?
 	E – Exposure: Other injuries? Temperature? Hypothermia prevention?

BAR:


 	(B) Background: Past Medical History. Medications (Anticoagulants?). Allergies. Baseline function.
 	(A) Assessment: Confirmed injuries. Working diagnosis. Clinical concerns.
 	(R) Recommendations: Immediate needs? Operating Room? Intensive Care Unit? Imaging? Surgical team activation?




SGEM Bottom Line: ATLS 11th Edition doesn’t radically reinvent trauma care. However, it formalizes hemorrhage-first thinking, expands systems-based trauma care, modernizes structure and teaching and recognizes global variation.


The SGEM will be back next episode with a structured critical appraisal of a recent publication. Our goal is to shorten the knowledge translation (KT) window from over 10 years to less than 1 year by leveraging the power of social media. So, patients 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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      <title>SGEM#506: Aww I’m Itchy…and I need a Second Generation Antihistamine</title>
      <link>https://podcast.show/thesgem/episode/153434006/</link>
      <rawvoice:pid>153434006</rawvoice:pid>
      <guid>https://thesgem.com/?p=18493</guid>
      <dc:creator>Dr. Ken Milne</dc:creator>
      <pubDate>Sat, 21 Mar 2026 08:30:56 -0400</pubDate>
      <description><![CDATA[Reference: Wong KH, et al. Improving Use of Oral Antihistamines in a Children’s Hospital. Pediatrics. Feb 2026;

Date: March 15, 2026

Dr. Stephanie Kubala

Guest Skeptic: Dr. Stephanie Kubala is an attending physician in the Division of Allergy and Immunology at Children’s Hospital of Philadelphia. She is double board-certified in both pediatrics and allergy and immunology.

Case: A 5-year-old girl is brought in by her parents for an itchy rash. Her symptoms started last night. The parent reports an itchy, raised red rash on her trunk and extremities. She has not had any fever. She does not have any difficulty breathing, wheezing, vomiting, or diarrhea. On your exam, you note hives on her body but no lip or tongue swelling. Her lungs are clear to auscultation. She intermittently scratches at the rash. Her parents tell you, “We gave her a dose of diphenhydramine last night, and it may have helped a little, but it seems to have worn off. Can you help?”

Background: 

In a lot of emergency departments, “hives = diphenhydramine” is practically muscle memory. It’s familiar, it’s been around forever, and families often expect it because it’s what they already have at home. As with many medical interventions, we must weigh potential harms against potential benefits.

The problem is that diphenhydramine and other first-generation antihistamines like hydroxyzine come with a bunch of potential side effects, such as sedation, anticholinergic side effects, and unpredictable behavior changes in some kids. It doesn’t always last very long, which can lead to repeat dosing and frustrated families when symptoms come back a few hours later.

On the other hand, second-generation antihistamines like cetirizine target the same H1 receptor for itch and urticaria but tend to be longer-acting and better tolerated, which is why many guidelines and expert groups prefer them for routine allergic symptoms. And there’s a bigger safety angle here, too: first-generation agents show up in dosing errors and misuse/overdose cases.

The real issue isn’t whether second-generation antihistamines like cetirizine work. They do. We need to start asking why our systems still nudge clinicians toward the older first-generation antihistamines as a default.

The issue is well-suited to a quality improvement (QI) study. Before we dive into the details of the study itself, let’s talk about some basics around QI.

QI helps close the gap between best practice and day-to-day care. It starts with a clear, measurable aim (what you want to improve, by how much, by when). This is followed by a simple measurement plan: an outcome measure (the main result you’re trying to change), process measures (the steps that should drive that result), and balancing measures (what might worsen unintentionally).

Teams then map the current workflow, identify barriers, and build a key driver diagram that links the aim to the handful of system levers most likely to move the needle.

The work is tested and refined using Plan–Do–Study–Act (PDSA) cycles. [2] These are iterative rather than a single big rollout. Data is tracked over time with run/control charts to show whether changes are real and sustained.



Clinical Question: Can a bundled QI approach meaningfully reduce first generation antihistamine use and increase cetirizine use among pediatric patients receiving oral antihistamines in the ED and inpatient settings?





Reference: Wong KH, et al. Improving Use of Oral Antihistamines in a Children’s Hospital. Pediatrics. Feb 2026;

 	Population: Patients 6 months to 21 years in the pediatric ED and inpatient units at a tertiary academic children’s hospital

 	Excluded: Patients in NICU, PICU, or hematology-oncology units


 	Intervention: There were 3 main drivers: education/awareness, cetirizine availability, and standardization through clinical pathways.
 	Comparison: Pre-intervention baseline prescribing practices
 	Outcome:

 	Primary Outcomes: There are two primary outcomes: The proportion receiving oral FGA and the proportion receiving cetirizine
 	Secondary Outcomes: PED revisits within 48 hours, median LOS, clinicians’ knowledge, frequency of clinical pathway use and monthly antihistamine cost.


 	Type of Study: Quality improvement initiative

Authors’ Conclusions: “Using the Model for Improvement, we reduced FGA use and increased cetirizine use in the PED and inpatient setting.”
Quality Checklist for Ql Study (adapted from QI-MQCS):


 	Do they clearly state the problem and why it mattered? Yes
 	Do they explain why the intervention should improve the outcome? Yes
 	Are the specific changes described in enough detail that another site could reproduce them? Unsure 
 	Do they describe the setting the intervention took place (type of hospital/clinic, size, population)? Yes 
 	Do they describe the approach to designing and introducing the program? Yes
 	Is the evaluation approach explicit? Yes
 	Do they describe what they are comparing against? Yes
 	Are data sources clear and is the primary outcome operationally defined? Yes
 	Is the timeline clear? Yes
 	Do they measure whether the intervention was actually delivered/used as intended? Yes 
 	Do they include patient health outcomes? No 
 	Do they describe organizational barriers/facilitators that affect readiness? Yes
 	Do they report who/what was eligible vs who/what actually participated? Yes
 	Do they describe the maintenance and sustainability of their interventions over time? Yes
 	Do they address whether the intervention could be replicated elsewhere? Yes
 	Do they discuss limitations? Yes
 	Funding of the Study. No funding for this study. No declared conflicts of interest.

Results: The study included 1235 pediatric ED patients and 737 inpatients. They undertook a total of 5 PDSA cycles, including the ED and inpatient units.



Key Results: FGA use decreased and cetirizine use increased after implementation of QI initiatives.



The use of FGA decreased from 74% to 28% in the pediatric ED and 54% to 36% in the inpatient units.

The use of cetirizine went from 31% to 75% in the pediatric ED and 54% to 74% un the inpatient units.

The changes were sustained for 8.5 months in the pediatric ED and 9 months in the inpatient units.

Secondary Outcomes

 	Knowledge assessment improved (among 31 surveyed participants): Median 50% to 100%.
 	Clinical pathway usage increased: Median 36 to 44 clinicians/month.
 	Balancing measures: ED revisit within 48 hours and median inpatient LOS remained stable.
 	Cost: Monthly median antihistamine costs increased (PED $53 to $177; inpatient $57 to $104), with discussion of unit cost drivers for cetirizine formulation.



A crucial part of any QI process is the identification of key stakeholders. This study included representation from the pediatric ED, a pediatric resident (a great inclusion given that residents rotate through so many units in the hospital), allergy and immunology, and pharmacy.

These stakeholders helped the group identify the key drivers that included education and awareness, availability of cetirizine, and standardization of preferred medication. Individuals from each group of stakeholders also acted as champions to help push the QI initiative.

Uncontrolled Before-After Design 

QI studies do not necessarily need to include control groups. However, without a concurrent control group/unit, improvements can reflect background practice drift, staffing changes, guideline diffusion, seasonal case-mix shifts, or other QI initiatives rather than the intervention itself. are a classic threat in time-based comparisons.

In addition, when clinicians are aware a practice is being measured (or receive peer-to-peer feedback), behavior can shift independent of the intrinsic effectiveness of the intervention. This is well described as the Hawthorne effect and the related sentinel effect [3].

 Intervention Bundle

Because they implemented multiple components (education, stocking, reminders, pathway updates, audit/feedback), the observed effect can’t be confidently attributed to any single change. This is a common challenge with complex interventions, where fidelity and mechanism can vary across units and time.

 Education and Awareness

Reliance on purely educational interventions for QI will likely only have a limited effect.

For this study, the authors did a 30-minute lecture during a staff meeting and emailed the lecture materials to absent staff. They also put up flyers in work areas. This intervention in the first PDSA cycle did not result in a consistent reduction in first-generation antihistamine use. Based on feedback from a PDSA flyer, they also shortened the educational sessions for the inpatient implementation phase, recognizing that attention wanes after 15-20 minutes.

Cetirizine Availability

The group worked with the pharmacy in the hospital to ensure the cetirizine solution and tablets were available in the medication dispensing machines. They emailed the pediatric ED staff to let them know. It is important to recognize that some children may either be too young or unable to swallow tablets or pills. This seems like a basic step, but if we want people to start using something new or different, we should try to make it accessible to them.

Standardizing Preferred Antihistamines

Now that the alternative second-generation antihistamine is available, there’s another step this group took to help with adopting the change. They looked at the existing clinical pathways for anaphylaxis and penicillin allergy delabeling and changed the primary antihistamine recommendation from diphenhydramine to cetirizine. This is a nice way of making it easy for people to adopt the change. For those already accustomed to using the clinical pathway and order set, this does not really change workflow at all.

Indications for Antihistamines]]></description>
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