The Skeptics Guide to Emergency Medicine

Reference: Cashen K, Reeder RW, Ahmed T, et al. Sodium bicarbonate use during pediatric cardiopulmonary resuscitation: a secondary analysis of the icu-resuscitation project trial. Pediatric Crit Care Med. 2022 Date: February 15, 2023 Guest Skeptic: Dr. Carlie Myers is Pediatric Critical Care Attending at Cincinnati Children’s Hospital Medical Center. Dr. Carlie Myers Case: A 6-month-old boy presents to the emergency department (ED) with three days of worsening cough, cold symptoms, and fever. Parents note that he has been progressively more tired and difficult to arouse. He is found to be in hypoxic respiratory failure and septic shock. Intravenous (IV) access is obtained. He is quickly intubated. Despite multiple fluid boluses, he remains hypotensive and is started on vasoactive support. His blood gas reveals a mixed respiratory and metabolic acidosis with a lactate of 5.0. Despite your best efforts, he has an episode of agitation leading to hypoxia and subsequent cardiac arrest. Your team begins high quality cardiopulmonary resuscitation (CPR). An arterial blood gas is obtained demonstrates a pH of 7.0, PaCO2 of 70, PaO2 of 28, HCO3- of 7, Base Deficit of -10, and Lactate 10.0. A team member asks if you want to administer some sodium bicarbonate (1mEq/kg). Background: We often manage patients in cardiac arrest in the ED or the intensive care unit (ICU). Apart from high-quality CPR and early defibrillation, many other interventions we try lack a strong evidence base. But that does not stop us from trying to save the patient’s life and may represent some intervention bias.[1] The SGEM has covered the use of epinephrine, vasopressin, methylprednisolone, and calcium for cardiac arrest in SGEM#238, SGEM#350, and SGEM#353. Today we are focusing on sodium bicarbonate. Sodium bicarbonate has historically been used during CPR with the goal of alkalizing blood pH and treating metabolic acidosis. There are a few key assumptions about the use of sodium bicarbonate.  Low pH decreases cardiac function and responsiveness to catecholamines. Sodium bicarbonate administration will increase the pH. The increase in pH will lead to improved responsiveness to catecholamines and cardiac function. But it’s not that straightforward. Many of the studies supporting these claims were conducted on animal models or in vitro. [2] It is unclear if we see the same effects of acidosis and sodium bicarbonate in vivo. HCO3- + H+ ↔ H2O + CO2 Rapid bicarbonate infusion can cause an imbalance in CO2 across the cell membrane. HCO3- + H+ converts to H2CO3 and then to CO2 +H20. Extracellular CO2 rises rapidly, it diffuses across cell membranes and the reverse reaction occurs H2O + CO2→ HCO3- + H+; therefore, creating intracellular acidosis. There was a lack of evidence about the benefits and potential harm from using sodium bicarbonate in cardiac arrest [3], so it was removed from the American Heart Association’s (AHA) guidelines. The latest guidelines from the AHA in 2020 state, “clinical trials and observational studies since the 2010 guidelines have yielded no new evidence that routine administration of sodium bicarbonate improves outcomes from undifferentiated cardiac arrest and evidence suggests that it may worsen survival and neurological recovery.” [4] This association seems to hold true in the pediatric literature as well. [5-6] Clinical Question: What is the association between sodium bicarbonate use and pediatric in-hospital cardiac arrest mortality and morbidity? Reference: Cashen K, Reeder RW, Ahmed T, et al. Sodium bicarbonate use during pediatric cardiopulmonary resuscitation: a secondary analysis of the icu-resuscitation project trial. Pediatric Crit Care Med. 2022 Population: Pediatric patients 37 weeks to 18 years of age who received chest compressions across 18 pediatric intensive care units (PICU) or pediatric cardiac intensive care units (PCICU) from Oct 2016 to March 2021. Excluded: Children were excluded if prior to the arrest, they had terminal disease and were not expected to survive, documented lack of commitment to aggressive ICU therapies, brain death, and out of hospital cardiac arrests. Additionally, in the secondary analysis patients on extracorporeal membrane oxygenation (ECMO) at the time of CPR were excluded. Intervention: Sodium Bicarbonate administration during CPR Comparison: No sodium Bicarbonate administered during CPR Outcome: Primary Outcome: Survival to hospital discharge Secondary Outcomes: Return of spontaneous circulation (ROSC), survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category [PCPC] of 1), functional status at the time of discharge using the Functional Status Scale (FSS), and presence of a new morbidity defined as worsening from baseline FSS by 3 or more points. Authors’ Conclusions: “Sodium bicarbonate use was common and associated with lower rates of survival to hospital discharge.” 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? Unsure. Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure. Was the follow up of subjects complete enough? Yes How precise are the results? 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 Financial Conflicts of Interest: No Results: 1,100 CPR events were included in the study. Approximately half (48%) received sodium bicarbonate. The median age was 0.63 years (IQR 0.19-3.81 years) and 53.5% were male. The most common pre-existing medical condition was respiratory insufficiency. Key Result: Sodium bicarbonate use had no association with ROSC and was associated with lower survival to hospital discharge and lower survival to hospital discharge with favorable neurologic outcomes. Primary Outcome: Survival to hospital discharge was 42.2% in patients who received sodium bicarbonate vs 73.3% (aOR 0.7, 95% CI; 0.54-0.92) Secondary Outcomes: ROSC: Sodium bicarbonate use had no association Survival to hospital discharge favorable neurologic outcomes and new morbidity 1)Patient Population: There are a few things to say about the cohort included in this study. One issue was excluding patients who were terminal and not expected to survive the hospitalization. It can be difficult at times to predict when patients will die. This subjective exclusion criteria could have introduced some selection bias. Another issue is a large portion of the patients included in this analysis had underlying are medical or surgical cardiac disease (58%) that included congestive heart failure, pulmonary hypertension, congenital heart disease, and single ventricle heart disease. Sodium bicarbonate was used more commonly in PCICU compared to those in the PICU.  These were in-hospital cardiac arrests. If outcomes with bicarb were this poor in the hospital (a better place to experience cardiac arrest than out of hospital), this doesn’t bode well for sodium bicarbonate use for out of hospital cardiac arrests. 2) Time Dependent Propensity Matching: The time dependent propensity matching of bicarbonate administration was not available in original database. The patients in this study may have received bicarbonate at different times. In the presence of time-varying treatment or exposure (HCO3), the conventional method (propensity scoring is traditionally time fixed) may cause bias because subjects with early and late exposure are treated as the same. Any patient receiving HCO3 was treated the same, regardless of the time frame the HCO3 was administered. After time-dependent propensity matching, the matched cohort can be analyzed with conventional Cox regression model or conditional logistic regression. For more information on propensity score matching, you can read Peter Austin’s introductory article on the topic. [7] 3) Confounding Factors: This was an observational study with only measured confounding factors that could be controlled for with adjustments. It means we can only conclude associations from this data not causation. Sodium bicarbonate use was associated with prolonged resuscitation time and additional pharmacologic interventions during CPR (epi, atropine, calcium, vasopressin, amiodarone, lidocaine, and fluid boluses). Sodium bicarbonate was also used more often in children with higher (Pediatric Risk Mortality Score) PRISM and VIS (Vasoactive Inotropic Score)– both markers of severity of illness. Were outcomes worse in the group receiving sodium bicarbonate because of the sodium bicarbonate or because the length of resuscitation was longer, the patients were sicker, and what about all the other medications or interventions? 4) Futility: When it comes to using sodium bicarbonate in cardiac arrest, we’ve heard some clinicians say, “well what’s the harm? The patient is dead already.” We want to caution against this mindset. This is an extremely vulnerable patient population, and our interventions should be deliberate and targeted to maximize potential benefit and reduce potential harm. Additionally, spending time performing interventions that don’t help can take away time and energy spent on performing more meaningful interventions. 5) Racial Demographics: While this study did not particularly look at variable outcomes based on race or gender of the patient, race and ethnicity are worthy demographics to report for 1) Generalizability of study findings and 2) Further examination of results in the context of equitable care.

Date: February 17, 2023 Reference: Gettel et al. Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019. AEM Feb 2023 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and Assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: You are an administrator responsible for staffing emergency departments (EDs) in a health care system comprising both urban and rural locales. The hiring pool includes emergency medicine trained physicians, non-emergency trained physicians, and advanced practice providers (physician assistants and nurse practitioners). Prior to your hiring search, you wonder how many patient encounters are being seen by each type of physician or advanced practice provider. You also wonder the breakdown of visit acuity being seen by the different provider types. Background: Advanced practice providers (APPs), primarily physician assistants (PAs) and nurse practitioners (NPs), make up more of the emergency medicine (EM) workforce each year (1-4). While APPs have traditionally focused on low-acuity patient encounters, as ED visit volumes and physician shortages increase, APPs are seeing more complex, high-acuity patients (5-6). In the United States, policies have been implemented to permit more independent APP practice, with or without direct physician support. This increase in independent service provision by APPs and change in practice pattern to more high-acuity patients has not been formally assessed (7-8). There is concern regarding the expanding practice pattern of APPs, and a March 2022 Guideline by the American College of Emergency Physicians (ACEP) stated that PAs and NPs should not perform independent, unsupervised care in the ED setting (9). Given current workforce limitations, it is not feasible to continue current 24/7 staffing models in certain EDs and communities without APPs (1,3). Similarly, many rural Canadian emergency departments have reduced their open hours or closed over recent years due to inadequate staffing (MacLean's Magazine - Dr. Alan Drummond) There are both NPs and PAs working in Canadian EDs currently and we could see their role increase in the future should staffing shortages increase. The SGEM has done two previous podcasts on APPs in the ED. These focused on productivity, safety and diagnostic testing differences between emergency physicians and APPs (SGEM#308 and SGEM#316). Clinical Question: How has the role of APPs in the provision of emergency care changed in recent years? Reference: Gettel et al. Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019. AEM Feb 2023 Population: Emergency care providers including emergency physicians, non-EM physicians and APPs (Physician assistants, nurse practitioners, certified nurse midwives, certified registered nurse anesthetists) who provided fee-for-service Medicare in the United States emergency departments from 2013 to 2019. Exclusion Criteria: Providers who received less than 50 total reimbursements within a study year for evaluation services reflecting typical emergency critical care codes. Exposure: Patient encounters by APPs Comparison: Patient encounters by Physicians Outcome: Primary Outcome: Proportion of high acuity encounters independently billed by different emergency clinician types over time. Secondary Outcomes: Variation in clinicians seeing high acuity encounters based on geography (urban vs. rural). Proportion of Evaluation Management services provided by each clinician that were high, moderate or low acuity in comparison to the total number of cases seen. Type of Study: Observational study using a repeated cross-sectional analysis of emergency clinicians using the Centers for Medicare & Medicaid Services (CMS) Provider Utilization and Payment Data Practitioners Public Use File (PUF), Dr. Cameron Gettel This is an SGEMHOP and we are pleased to have the lead author on the show. Dr. Cameron Gettel is an Assistant Professor in the Department of Emergency Medicine and a Clinical Investigator at the Yale Center for Outcomes Research and Evaluation. In these roles, he primarily conducts geriatric-related and health services research Authors’ Conclusions: “In 2019, APPs billed independent services for approximately 1 in 6 high acuity EDencounters in rural geographies and 1 in 11 high acuity ED encounters in urban geographies, and well over one-third of the average APPs’ encounters were for high acuity E/M services. Given differences in training and reimbursement between clinician types, these estimates suggest further work is needed evaluating emergency care staffing decision-making.” 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? Yes Have the authors identified all-important confounding factors? No Was the follow up of subjects complete enough? Yes How precise are the results? N/A 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 – Institutional funding from a variety of sources including SAEM, ABEM, National academy of Medicine and others. Results: They identified 84,477 unique clinicians provided at least 50 emergency department services during one of the 2013 to 2019 study years. There were 47,323 EM Physicians, 10,555 Non-EM Physicians and 26,599 APPs. Key Results: APP independent billing for all encounter types increased over time and close to double in rural areas compared to urban practices. Primary Outcome: Proportion of high acuity encounters independently billed APPs increased from 5.1% to 9.7% Secondary Outcomes: APPs billed more high acuity independently in rural geographies, increasing from 7.3% in 2013 to 16.4% in 2019. APPs also billed more high acuity encounters in urban areas, increasing from 4.8% in 2013 to 8.8% in 2019. Conversely, EM physicians billed more rural high acuity encounters in 2013 (74.5%) compared to 2019 (66.6%). EM physicians also billed more high acuity urban encounters in 2013 (88.5%) than in 2019 (85.5%). There was a much larger relative difference in the number of encounters billed as high acuity between 2013 and 2019 by APPs as compared with EM physicians. Critical care encounters were increasingly billed independently by APPs from 2013 to 2019, increasing from 1.1% to 2.9% Listen to the SGEM podcast to hear Cameron respond to our five nerdy questions. 1. Billing: How do we prove that people are getting sicker rather than we are billing more “aggressively”? 2. Critical Care: What about the interpretation of what is critical care, can this vary by provider type (eg. an APP may consider a pneumonia critical care, while an EM physician at a major trauma centre considers it a comprehensive visit or equivalent) 3. Non-EM Physicians: Why are there ophthalmologists, psychiatrists, family medicine and other specialties included in this study? Psychiatrist, Ophthalmologist and Family Physician 4. Database Accuracy: This study only looked at Medicare fee-for-service beneficiaries. In addition, you could not separate out split/shared billing between the APP and physician. How do you think that may have impacted the results? 5. External Validity: This was a large US based study. How do you think the results would apply to other health care systems around the world like in Canada? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusions. SGEM Bottom Line: APPs are becoming an increasing part of the emergency department workforce in the United States and billing for more high acuity patient encounters. Case Resolution: You determine that your hiring strategy will include APPs as well as physicians. APPs will be providing critical care and be seeing high acuity patients. You use this information to balance hiring of APPs and EM physicians in your urban and rural sites. Dr. Chris Bond What Do I Tell the Staff? We are looking how to safely staff our urban and rural emergency departments. This will be a difficult process and adapt over time. We need to ensure that patients get the right care, by the right clinician. Their safety is a top priority, and we are all on “Team Patient”. A variety of metrics will be followed to monitor this implementation and ensure we get the right balance of APPs and physicians. Keener Kontest: Last weeks’ winner was Albert Homs. He knew Wilt Chamberlain held the title for most double-doubles in NBA history. Listen to the SGEM podcast this week to hear the keener question. If you know the answer, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize. SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on APPs? Tweet your comments using #SGEMHOP.  What questions do you have for Cameron and his team, ask them on the SGEM blog? The best social media feedback will be published in AEM. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. References: Gettel CJ, Courtney DM, Janke AT, et al. The 2013 to 2019 emer- gency medicine workforce: clinician entry and attrition across the US geography. Ann Emerg Med. 2022;80(3):260-271. Nelson SC, Hooker RS.

Dr. Sean Moore, an emergency physician and Chief of Staff at Lake of the Woods District Hospital, shares insights into tackling refractory ventricular fibrillation during cardiac arrests. He discusses a case involving a health professional who suffered an out-of-hospital cardiac arrest and the innovative defibrillation techniques being tested, including double-sequential defibrillation. The conversation also delves into the complexities of research in emergency medicine, particularly in rural settings, and emphasizes the importance of adaptability in critical care practices.

Date: February 1, 2023 Reference: Wolfrum et al. Temperature Control After In-Hospital Cardiac Arrest: A Randomized Clinical Trial. Circulation. September 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: You are working an overnight shift at a small rural hospital. You are tidying your things in anticipation of the arrival of the dayshift when a code blue is called. A 50-year-old man who was admitted to the hospital with a non-ST elevated myocardial infarction (NSTEMI) overnight was found unconscious and without a pulse. The nurses started CPR immediately and place pads before you even arrived. The patient is in ventricular fibrillation, and you achieve return of spontaneous circulation (ROSC) on the second shock. The patient is still unconscious. A post-arrest ECG doesn’t show any signs of STEMI. At this point, the dayshift doc walks into the room and asks, “I can’t keep up with all the evidence. Are we supposed to be starting hypothermia?” Background: “Therapeutic” hypothermia took the critical care world by storm in 2002, with the simultaneous publication of two randomized control trials (RCTs) in the same issue of the New England Journal of Medicine – the Hypothermia after Cardiac Arrest (HACA) study and the Bernard study. As a very brief recap, the HACA study randomized 275 comatose adult patients with ROSC after a witnessed cardiac arrest with a shockable rhythm, a presumed cardiac origin of arrest, and a short downtime. The hypothermia group was cooled using an external device to a target temperature between 32 and 34 degrees Celsius and maintained there for 24 hours. The primary outcome was a good neurologic outcome within six months and occurred in 55% of the hypothermia group and 39% of the normothermia group (p=0.009, RR 1.40, 95% CI 1.08-1.81). This translated into an impressive NNT of 6. The six-month mortality was also improved in the hypothermia group (41% vs 55%, p=0.02) NNT 7. Key issues with this study were possible selection bias, early stopping without a clear endpoint, and a subjective outcome in a trial that was only partially blinded. The Bernard study included 77 patients with an initial cardiac rhythm of ventricular fibrillation who had achieved ROSC but were persistently comatose. It was not randomized to individual patients, but rather based on the day of the week. It was also not blinded. The primary outcome, patients with neurologic function good enough to be sent home or to a rehabilitation facility, occurred in 49% of the hypothermia group and 26% of the normothermia group (p=0.046, although when you plug the numbers into a fragility index calculator, you get a fragility index of 0 and a p value of 0.06). This give a very impressive NNT of 4. There was an NNT of 6 for mortality (51% vs 68%, p=0.16) but it was not statistically significant. For more information on the fragility index (FI) click on this LINK. Therefore, therapeutic hypothermia was introduced into clinical practice based on two small trials with multiple sources of bias. Since 2002, we have seen several larger trials that have raised questions about the value of hypothermia. We have covered the issue of cooling patients post OHCA sever times on the SGEM including the original Targeted Temperature Management (TTM) trial (SGEM#82). TTM was a multicentre RCT from 36 intensive care units (ICUs) in Europe and Australia, which enrolled 950 comatose adult patients on arrival to hospital after out of hospital cardiac arrest, regardless of the presenting rhythm. Patients all had their temperatures controlled, but they were randomized to a target of either 33 or 36 degrees Celsius. There were no statistical differences between the groups in mortality, Cerebral Performance Category (CPC), modified Rankin Score (mRS) or mortality at 180 days. The TTM2 trial was covered on SGEM#336. It was another multicenter RCT, and that time hypothermia was compared to normothermia (a goal of keeping temperatures less than 37.5). Once again, there was no statistical difference in outcomes between the two groups in all-cause mortality or neurologic function at six months. On the other hand, the HYPERION trial, which was covered in SGEM#275, was an RCT which include both OHCAs (73%) and IHCAs (27%). The trial comparing hypothermia (33 degrees) to normothermia. In that trial, there was a statistically significant improvement in their primary outcome of neurologically intact survival (10.2% TTM vs. 5.7% usual Care (absolute difference 4.5%), p=0.047 which gives an NNT of 22). The fragility index was 1 and the trial was unblinded, leaving us with significant uncertainty. Therapeutic hypothermia has also been trialed in the prehospital environment and not been found to be superior to usual care (SGEM#21 and SGEM#54). Therefore, there remains significant uncertainty about the value of therapeutic hypothermia after cardiac arrest, especially in the inpatient environment, where patients generally have better outcomes than the OHCAs we usually see in the emergency department. Clinical Question: Does hypothermia improve all-cause mortality in adult patients who remain comatose after inpatient cardiac arrest? Reference: Wolfrum et al. Temperature Control After In-Hospital Cardiac Arrest: A Randomized Clinical Trial. Circulation. September 2022 Population: Adult patients who remained unconscious (GCS <9) more than 45 minutes after inpatient cardiac arrest. Patients were eligible irrespective of cardiac rhythm or etiology of arrest. Exclusions: These can only be found in the supplemental appendix and include the following: active bleeding, suspected intracranial bleeding, immunodeficiency, severe heart rhythm disorders, known severe cognitive deficit, pregnancy, any condition that makes 6-month survival unlikely, major hemodynamic instability. Intervention: Temperature control with a target between 32 and 34 degrees Celsius for 24 hours, followed by slow rewarming. Comparison: Temperature control with a target of normothermia. No specific protocol was followed; it was just strongly recommended to avoid temperatures greater than 37.5 Celsius. Outcome: Primary Outcome: All-cause mortality at 180 days Secondary Outcomes:In-hospital mortality and favorable functional outcome after 180 days using the Cerebral Performance Categories (CPC) score <3 Type of Study: Multicentred, open-label, blinded-outcome-assessor, randomized controlled trial Authors’ Conclusions: “Hypothermic temperature control as compared with normothermia did not improve survival nor functional outcome at day 180 in patients presenting with coma after IHCA. The HACA-IHCA (Hypothermia After In-Hospital Cardiac Arrest) trial was underpowered and may have failed to detect clinically important differences between hypothermic temperature control and normothermia.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the ED. 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. No Financial Conflicts of Interest. Several authors declared fCOIs Results: Of 1,055 patients assessed for eligibility, 249 were randomized, and 238 are included in the final analysis. The mean age was 73 years, 64% were male, 54% were on the medical ward, and 73% were witnessed arrests. Key Result: No statistical difference in all-cause mortality at six months. Primary Outcome: All-cause mortality at 180 days. 72.5% with hypothermia and 71.2% with normothermia, RR 1.03, 95% CI 0.79-1.40, p=0.89. Secondary Outcomes: No statistical difference for in-hospital mortality and favourable functional outcome after 180 days. In-hospital mortality, ICU length of stay, and hospital length of stay were all also statistically insignificant. Lack of Blinding: Although blinding a trial of hypothermia would be incredibly difficult, the lack of blinding could have a significant impact on the results. In a modern ICU, decisions about life and death are contingent on the choices of physicians, and the way we present prognosis to patients. Clinicians beliefs about the efficacy of hypothermia might have shaped their clinical decisions or how they counselled patients, and that could have biased even a seemingly objective outcome like all cause mortality. Small Study Stopped Early: This trial was supposed to include 440 patients based upon their sample size, but they only enrolled 249. The trial was stopped early for futility, but there were no predetermined criteria for this decision. The result is a study less than half the size that they calculated was required to identify a 16% absolute decrease in all-cause mortality. Even without stopping early, this study was probably under-powered. A 16% absolute decrease in all cause mortality is a completely unheard-of benefit in modern critical care, so designing a trial with that goal seems overly optimistic. (To be fair to the researchers, that was the benefit supposedly seen in the original HACA trial.) Imbalanced Groups: Perhaps because it was stopped early, the groups are not balanced at baseline.

Date: January 22, 2022 Reference: Samuels-Kalow M et al. Post-Roe Emergency Medicine: Policy, clinical, training, and individual implications for emergency clinicians. AEM Dec 2022 Guest Skeptic: Dr. Michelle Lin is an emergency physician and health services researcher whose goal is to transform acute care delivery to best meet the needs of those who experience the greatest barriers to accessing health care. This is an SGEM Xtra episode. The ruling of the US Supreme Court on June 24, 2022 in Dobbs v Jackson Women’s Health Organization overturned Roe v Wade and allowed individual US states to determine their own restrictions on abortion. There was a recent tweet about allyship and advocacy by an orthopaedic surgeon, Dr. Simon Fleming. He encouraged people to shut up and listen. To amplify other voices and transfer your privilege. I interpreted that to mean, at times, men should talk less and listen more. Dr. Kirsty Challen This is one of those times. Therefore, Dr. Kirsty Challen will be hosting this SGEM Xtra episode. Academic Emergency Medicine published a special contribution in December 2022 exploring the implications of this for providers of emergency healthcare. This episode was recorded one day after the 50th Anniversary of the Roe v Wade on January 22, 1973.  Although the SGEM is based in Canada and Dr. Challen is British we felt this was an issue of such importance that we wanted to invite the authors to discuss it further with us. TRIGGER WARNING: AS A WARNING TO THOSE LISTENING TO THE PODCAST OR READING THE BLOG POST, THERE MAY BE SOME THINGS DISCUSSED ABOUT ABORTION THAT COULD BE UPSETTING. THE SGEM IS FREE AND OPEN ACCESS TRYING TO CUT THE KNOWLEDGE TRANSLATION DOWN TO LESS THAN ONE YEAR. IT IS INTENDED FOR CLINICIANS PROVIDING CARE TO EMERGENCY PATIENTS, SO THEY GET THE BEST CARE, BASED ON THE BEST EVIDENCE. SOME OF THE ABORTION MATERIAL WE ARE GOING TO BE TALKING ABOUT ON THE SHOW COULD TRIGGER SOME STRONG EMOTIONS. IF YOU ARE FEELING UPSET BY THE CONTENT, THEN PLEASE STOP LISTENING OR READING. THERE WILL BE RESOURCES LISTED AT THE END OF THE BLOG FOR THOSE LOOKING FOR ASSISTANCE. QUESTIONS FOR DR. MICHELLE LIN Dr. Michelle Lin was asked several questions about the implications of the Dobbs v Jackson Women’s Health Organization decision. Please listen to the SGEM Xtra podcast on iTunes to hear her answers and for more details. Dr. Michelle Lin Why does Emergency Medicine need to know? After all, we aren’t abortion providers, or even Obstetrician/Gynaecologists. The paper talks about the unequal implications of this decision – surely the law is the law everywhere? Can you tell us more? What are the legal implications for Emergency Physicians caring for patients who may be miscarrying spontaneously, have an ectopic pregnancy, or present with the complications of an abortion which is illegal in that state? You said something specifically about documentation as well? And what about the pregnant or potentially pregnant Emergency Physician? Is this going to impact on us as a workforce too? You’ve mentioned that one of the policy actions for emergency physicians could be to use EMTALA to pre-empt state restrictions. Can you explain how that would work practically for those of us outside the US who don’t have an EMTALA-like system? Is there anything else you would like to say about this issue? 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 ten years to less than one year using the power of social media. So, patients get the best care, based upon the best evidence. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE. Additional Resources: College of Family Physicians of Canada (CFPC) Abortion National Health Services (NHS) Abortions Center for Reproductive Rights Planned Parenthood

Dr. Jennifer Harmon, a board-certified pediatric neurologist completing a genetics fellowship at Children’s National Hospital, discusses the complexities of diagnosing and treating Bell palsy in children. She highlights a case involving a nine-year-old girl with facial paralysis, addressing parental concerns about recovery. The conversation tackles the efficacy of prednisolone based on recent clinical trials, critiques on study exclusion criteria, and emphasizes shared decision-making with families during treatment.

Date: January 13, 2023 Reference: Razi et al. Dexamethasone and ketorolac compare with ketorolac alone in acute renal colic: A randomized clinical trial. AJEM 2022 Dr. Kevan Sternberg Guest Skeptic: Dr. Kevan Sternberg is a urologist/endourologist. His focus is on the medical and surgical management of kidney stone disease. Dr. Sternberg did his medical school and residency training at the University of Buffalo (SUNY) and endourology fellowship at the University of Pittsburgh Medical Center. Kevan was on the SGEM Xtra episode three years ago that brought together Emergency Medicine, Radiologists and Urologists to discuss ultrasound vs CT scans for suspected renal colic. You can listen to the SGEM podcast to hear what he thinks the impact of this initiative has been. Case: A 38-year-old female presents to the emergency department (ED) with a five-hour history of acute onset left flank pain.  The pain comes in waves, radiates into her left groin and is associated with nausea and vomiting.  She noticed darkening of her urine, but does not have dysuria, fever, or vaginal discharge. Background: We have looked at many different therapies to treat renal colic on the SGEM. That has included things like fluid bolus or diuretics (SGEM#32), tamsulosin (SGEM#4, #71, #154, #230), acupuncture (SGEM#220) and lidocaine (SGEM#202). The SGEM bottom line to these different treatment options: You don’t need to push fluids (oral/IV) or use diuretics to pass kidney stones. Medical expulsive therapy with tamsulosin is unnecessary for stones < 5mm. If a benefit does exist for Tamsulosin it's with distal ureteral stones > 5 mm. Acupuncture is not superior to morphine for renal colic. The evidence doesn’t support the use of lidocaine for renal colic. Glucocorticoids (steroids) act as anti-inflammatories, immunosuppressants, antiproliferative drugs, and have vasoconstrictive effects. It has been hypothesized that adding a long-acting glucocorticoid like dexamethasone may help with pain and vomiting associated with passing a kidney stone and decrease opioid use. Clinical Question: Should we be adding a dexamethasone to NSAIDs for the management of suspected acute renal colic? Reference: Razi et al. Dexamethasone and ketorolac compare with ketorolac alone in acute renal colic: A randomized clinical trial. AJEM 2022 Population: Patients presenting to the ED with flank pain and presumed renal colic Exclusions: Pregnancy (confirmed or possible), analgesic therapy during six hours before admitted to the emergency unit, near history of hemorrhagic diathesis, addiction or recent methadone use, use of warfarin and other anticoagulants, acute abdomen, fever, BP ≥ 180/100 mmHg; any contra- indication for ketorolac including hypersensitivity to aspirin or other NSAIDs, active or history of peptic ulcer disease, a recent history of GI bleeding or perforation or suspected or confirmed cerebrovascular bleeding, advanced hepatic or renal disease, patients at risk for renal failure, hyperkalemia, and uncontrolled severe heart failure; and any contraindications for the use of dexamethasone Intervention: Ketorolac 30mg IV plus dexamethasone 8mg IV Comparison: Ketorolac 30mg IV Outcome: Primary Outcome: Change in pain on a 10-cm visual analog scale (VAS) at 30 minutes and 60 minutes Secondary Outcomes: Grade of vomiting and the need for antiemetics and need for opioids Type of Trial: Single-centered, triple-blind, randomized clinical trial from Iran Authors’ Conclusions: “In comparison with the patients who just received ketorolac, adding dexamethasone provided improved pain control after 30 min of therapy”. 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). Yes The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. Unsure 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. No The treatment effect was large enough and precise enough to be clinically significant. No Financial conflicts of interest. No Results: They recruited 120 participants (60 in each group), the mean age was 37.6 years of age, 70% were male and 42% reported some vomiting. Key Result: Dexamethasone plus ketorolac was statistically superior to ketorolac alone for pain control at 30 minutes but not at 60 minutes in adults with suspected acute renal colic. Primary Outcome: Change in pain from baseline using VAS 30 Minutes: -5 intervention vs -3 control, p=0.014 60 Minutes: -7 intervention vs -5 control, p=0.07 Secondary Outcomes:  Grade of Vomiting: No statistical difference Need for Antiemetic: 12% vs 28%, p=0.02 Need for Opioids: 35% vs 58%, p=0.01 Did they Even Have Stones? The diagnosis was based upon cell blood count, urinary assay, US, or CT scan. I would need a CT diagnosis or an US with hydronephrosis correlated clinical to know whether these are actual stone related events. Did everyone get imaging? What was the incidence of hydronephrosis? How big were these stones? Where were these stones (proximal, mid or near the ureterovesical junction)? Flank pain can have many reasons and while the goal of this study is to address the pain, it may not be accurate to title the study using acute renal colic. Two Primary Outcomes? We know that there can be only one primary outcome. Why did they have two primary outcomes at 30 and 60 minutes?  Why would the results change after another 30 minutes? Is this clinically relevant anyway? Visual Analog Scale? Is the VAS score the most appropriate primary outcome clinically? It is a subjective outcome measure. A potentially and more important outcomes may be to see those who needed intervention due to poorly controlled pain or those who need opioids for the same. Secondary Outcome? In the trial registry they only had one secondary outcome (grade of vomiting). The publication had an additional two (need for antiemetic and need for opioids). It is unclear when these were added and if they were done post-hoc. In addition, there was no information on adverse events. We do not know if adding dexamethasone to ketorolac causes an increase, same or decrease number of adverse events. Without knowing the potential harms, it is difficult to put any potential benefits into proper context. Adjunct Medication? No information was provided if any adjunct medication was provided. Specifically, alpha-blockers like tamsulosin are still often used in many practice settings. While the goal of alpha blockers is for stone passage (and this is very controversial), they may also play a role in the management of renal colic as we see evidence of pain improvement in the setting of ureteral stents. It is unclear if patients were treated equally except for the addition of dexamethasone to the standard dose of ketorolac. Comment on Authors’ Conclusion Compared to SGEM Conclusion: We think the authors are over-interpreting their evidence. Without additional information on how accurate the diagnosis, stone size and location, rate of adverse events and use of adjunct medication we should consider this preliminary data hypothesis generating. SGEM Bottom Line: We cannot recommend the addition of dexamethasone to ketorolac in the treatment of adult patients with suspected renal colic. Case Resolution: The patient is provided with 15mg IV ketorolac and her pain improves. The CT scan shows a 4mm stone at the ureterovesical junction without any hydronephrosis. She is discharged home with a prescription for ketorolac, strainer for urine, instructions on when to return and referred to urology for an outpatient consult. Clinical Application: I will not be suggesting dexamethasone for patients presenting with suspected acute renal colic. I fully support ketorolac or NSAIDs in general as first line and this is certainly supported in the literature. I do applaud the consistency of this approach in this group. What Do I Tell the Patient?  You have a small kidney stone. Most people will be able to pass this size of stone. We are going to give you a prescription for some pain medicine. If your pain gets worse, you can’t keep anything down, develop a fever or are worried please return to the ED. A referral has been sent to the urologist on-call and their office will contact you about an appointment. Keener Kontest: Last weeks’ winner was Tim Kolosionek. He knew Inge Edler and Hellmuth Hertz are credited for publishing the first description of M-mode echocardiography in 1953. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Date: January 4th, 2023 Reference: Hasbrouck et al. Acute management of atrial fibrillation in congestive heart failure with reduced ejection fraction in the emergency department. AJEM 2022 Guest Skeptics: Dr. Timlin Glaser currently a fourth-year resident in emergency medicine at Lehigh Valley Health Network and future medical toxicology fellow at the University of Arizona College of Medicine - Phoenix. Dr. Matt Murphy is currently a third-year resident in emergency medicine at Lehigh Valley Health Network.  He has interests in FOAMEd and is currently following the EBM track in his residency. Welcome to the SGEM Matt. This episode is recorded live as an SGEM journal club. There are five rules to journal club 1) You Must Talk/Tweet about SGEM-JC: The SGEM is a knowledge translation project. We know that it can take over ten years for high-quality, clinically relevant information to reach the patient. As Sir Mark Walport famously said: “science is not finished until it’s communicated.” 2) The EBM Answer Is "It All Depends": This rule was learned this from my EBM mentor Dr. Andrew Worster. There are lots of nuances to the application of the literature. It requires critical appraisal skills, clinical judgment and asking the patient about their values and preferences. 3) Don’t Panic – Even Your Faculty Is Not Sure of Some of the Answers: It is hard to stay up on all the relevant medical literature. There is a tsunami of new information being published every day. It can be overwhelming at times. Don’t panic. As Professor Feynman said…It’s ok to say: “I don’t know”. 4) It’s All About the Methods: The method section is the most important section of the paper. We just said there is so much research being published every day. It can be like drinking from a fire hose making it difficult to find the signal in all the noise. As Professor Altman said in the BMJ back in 1994; “we need less research, better research and research done for the right reasons.” This means we need to be asking the right questions that have patient-oriented outcomes and use proper high-quality methods to answer those questions. 5) Be Skeptical of Anything you Learn, Even If You Heard It On the SGEM Journal Club: Skepticism is such an important concept to understand the medical literature and navigate through life. Aristotle advocated for this thousands of years ago and encouraged people to “be a free thinker and don’t accept everything you hear as truth. Be critical and evaluate what you believe in.” Case: A 62-year-old male with a past medical history of heart failure with reduced ejection fraction presents to your emergency department (ED) via ambulance for palpitations and shortness of breath that started earlier that day. He arrives with an irregular heart rate of 142 beats per minute (bpm). The remainder of his vital signs are unremarkable. On physical exam, you notice three plus pitting edema of both lower extremities and bibasilar rales when auscultating his lungs. He takes multiple medications at home, including a beta-blocker, an angiotensin converting enzyme inhibitor (ACEi), and a loop diuretic.  You order an ECG and confirm the patient has atrial fibrillation (AF) with rapid ventricular response (RVR).  The patient is very symptomatic, and you need to decide which pharmacologic agent you will use to treat his current condition. Background: Atrial fibrillation is a common dysrhythmia seen on a regular basis by emergency physicians. We have covered this topic several times on the SGEM including: SGEM#88: Shock Through the Heart (Ottawa Aggressive Atrial Fibrillation Protocol) SGEM#133: Just Beat It (Atrial Fibrillation) with Diltiazem or Metoprolol? SGEM#222: Rhythm is Gonna Get You – Into an Atrial Fibrillation Pathway SGEM#260: Quit Playing Games with My Heart – Early or Delayed Cardioversion for Recent Onset Atrial Fibrillation? SGEM#267: AFib of the Night – Chemical vs. Electrical First Cardioversion As discussed in SGEM#133, clinicians routinely employ beta blockers or calcium channel blockers (CCBs) for rate control in patients with AF. Multiple studies have demonstrated that both agents are effective in decreasing ventricular rate to an acceptable range, and current AHA guidelines approve their use in uncomplicated AF. However, the use of beta blockers and non-dihydropyridine calcium channel blockers for rate control in patients with AF with RVR and concurrent decompensated heart failure with reduced ejection fraction (HFrEF) remains controversial. Current guidelines specifically recommend against the use of CCBs (1) despite limited evidence (Level C).  For the ED clinician, such a scenario poses a conundrum, as both the disease process and the intervention can worsen heart failure and contribute to cardiogenic shock. Clinical Question: In patients with HFrEF presenting to the ED in AF with RVR, are there significant differences in adverse outcomes for patients treated with IV diltiazem vs IV metoprolol? Reference: Hasbrouck et al. Acute management of atrial fibrillation in congestive heart failure with reduced ejection fraction in the emergency department. AJEM 2022 Population: Adult patients 18 years of age or older who presented to the ED with Atrial Fibrillation with Rapid Ventricular Response and had a formal echo with an EF less than or equal to 40% during the same encounter Excluded: Did not receive rate control agent in the ED within 12 hours, pregnant, incarcerated Intervention: Intravenous Diltiazem Comparison: Intravenous Metoprolol Outcome: Primary Outcome: Adverse events – hypotension (systolic BP<90 mmHg requiring fluid bolus or vasopressor administration), bradycardia (HR <60 bpm), worsening heart failure (increase in oxygen requirements by at least two liters within four hours or the need for inotrope within 48hrs) Secondary Outcomes: Incidence of rate control failure, admission level of care, ED length of stay, hospital length of stay, in-hospital mortality Type of Study: A single-center, retrospective study Authors’ Conclusions: “There was no difference in total adverse effects between HFrEF patients treated with diltiazem vs metoprolol for acute AF. However, patients with diltiazem had higher incidence of worsening CHF symptoms defined as increased oxygen requirement within four hours or initiation of inotropic support within 48 h.” 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? Unsure Was the exposure accurately measured to minimize bias? Unsure 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? 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? No conflicts of interest noted Results: They screened 169 patients and included 125 (57 receiving diltiazem and 68 receiving metoprolol). The mean age was 62 years, 76% were male and the average ejection fracture was 16%. The mean initial dose was 16mg for diltiazem and 5mg for metoprolol. Key Result: No statistical difference in adverse effects due to the interventions Primary Outcome: Composite outcome of adverse effects due to the interventions (32% vs 21%, P = 0.217) No statistical difference in any of the components of the composite outcome except for worsening CHF symptoms (33% vs. 15%, P = 0.019). Worsening CHF was driven by increased oxygen requirement within four hours Secondary Outcomes: No statistical difference in any of the secondary outcomes. Admission level of care was 33% vs 32% general, 51% vs 44% step-down and 16% vs 24% ICU. The most obvious nerdy point limiting this study is the observational design. That means that unmeasured confounders cannot be controlled and could bias the results. Unbalanced Groups – Patients who received diltiazem were younger with higher baseline blood pressures (BP), so they may have been less likely to become hypotensive, which was defined primarily as systolic BP < 90 mmHg, rather than a measured drop in BP. Small Sample Size – There was an 11% absolute difference between the two drugs and incidence of adverse effects. This difference was not statistically significant. It is possible that a larger sample size would have reported a difference that was statistically significant. However, the observational nature of the study would only provide low-level evidence. Observer-Expectancy Effect – Discussion of the article mentions guidelines recommending against the use of diltiazem in patients with AF + RVR with HFrEF as it may worsen HF, despite minimal confirmatory evidence. Outcomes measured by increased oxygen requirement and inotrope administration can be subjective, and it is possible a greater number of patients in this cohort received interventions based on provider expectations. Lack of Comparator Group – It may have been useful to include a cohort of patients with AF + RVR without heart failure and examine whether their adverse effects would have been similar. Parametric and Non-parametric Data Analysis – Parametric data analysis is typically performed when data is normally distributed, and non-parametric data is best analyzed when data is not normally distributed. Common tests for parametric data analysis are the chi-square test, student t-test, ANOVA by sum of squares, among others; tests non-parametric data analysis are Fisher exact test, Wilcoxon signed rank test, Mann-whitney U test, ANOVA by rank, and Spearman rank coefficient.

Date: Dec 15, 2022 Reference: Mahajan et al. Serious bacterial infections in young febrile infants with positive urinalysis results. Pediatrics. October 2022 Dr. Brian Lee Guest Skeptic: Dr. Brian Lee is a pediatric emergency medicine attending at the Children’s Hospital of Philadelphia and Assistant Professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. Guest Authors: Dr. Prashant Mahajan Dr. Prashant Mahajan is a Professor of Emergency Medicine and Pediatrics at the University of Michigan Department of Emergency Medicine in Ann Arbor, Michigan. He is the Vice-Chair for the Department of Emergency medicine and Section chief for Pediatric Emergency Medicine in CS Mott Children’s Hospital. Currently, he is the founding chair of Emergency Medicine Education and Research by Global Experts (EMERGE), a global emergency research network across 17 countries and 23 emergency departments. Dr. Nathan Kuppermann is a Distinguished Professor of Emergency Medicine and Pediatrics, and the Bo Tomas Brofeldt Endowed Chair of the Department of Emergency Medicine at UC Davis and Associate Dean for Global Health at UC Davis Health. He chaired the first US research network in Pediatric Emergency Medicine (the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics) then became founding chair of the Pediatric Emergency Care Applied Research Network (PECARN). He also recently completed a term as Chair of the Executive Committee of the global Pediatric Emergency Research Network (PERN). Dr. Nathan Kuppermann Both of our guests have received federal funding for their research and played huge roles in establishing multicenter research networks dedicated to improving the care of children across the world. Case: A 6-week-old girl is brought into the emergency department (ED) for fever of 38.5°C that started four hours prior to presentation. Her parents noted that she has been fussier today and has had feeding a little less than normal, but she’s had no other symptoms. She is otherwise healthy, full-term female who had no pre- or postnatal complications. On exam she is well-appearing, and there are no focal signs of infection. You decide to start by obtaining blood and catheterized urine for testing. The urinalysis shows 15 WBCs, 2+ leukocyte esterase and positive nitrites. While waiting for the results of the blood tests, you tell the family the news that their child likely has a urinary tract infection. The family asks you, “does this mean we found the source of her fever? Our son also had a fever when he was very young, and he had to get a lumbar puncture? Do we need to do a lumbar puncture for her today?” Background: Febrile infants ≤ 60 days are at higher risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. While UTIs tend to be the most common, we really do not want to miss those infants with bacteremia and meningitis, termed invasive bacterial infections (IBI). Multiple groups have worked to risk stratify these infants and have listed positive urinalysis as a risk factor for IBI. The SGEM covered the Step-by-Step Approach on SGEM #171 and PECARN Clinical Prediction Rule for Low Risk Febrile Infants on SGEM #296. Recently, the American Academy of Pediatrics (AAP) published guidelines for the management of febrile infants 8-60 days old covered in SGEM #241. In infants 22 days and older, the AAP guidelines state that lumbar puncture may be performed (rather than should) in those with positive urinalysis but normal inflammatory markers. There is wide practice variability in evaluation febrile infants [1-2]. Prior studies have demonstrated low prevalence of meningitis in infants with positive urinalysis [3,4].  Infants between 29-60 days of age are at a comparatively lower risk, with studies estimating their risk to be 0.2% in those with a positive urinalysis [5-6]. These studies, and others, have also highlighted risks to indiscriminate lumbar puncture, stemming from the relatively high rates of sterile pleocytosis in these infants, occurring in 18-24% of these infants [7,8]. Not surprisingly, these infants undergo longer hospitalizations with more IV antibiotics. Clinical Question: In a febrile infant ≤60 days with an abnormal urinalysis suggesting a UTI, do they really need a lumbar puncture or blood work? Reference: Mahajan et al. Serious bacterial infections in young febrile infants with positive urinalysis results. Pediatrics. October 2022 Population: Infants ≤ 60 days of age presenting to 26 emergency departments in the PECARN network between March 2011 and April 2019 with temperature ≥38°C who had urine, blood, and cerebrospinal fluid (CSF) testing at the time of visit Excluded: Prematurity (<37 weeks), significant comorbidities, antibiotic use in the preceding 48 hours, and those critically ill (requiring intubation or vasoactive infusions), UA was nor obtained, CSF not obtained and unable to contact parents at 7-day phone follow up. Intervention: Evaluation of invasive bacterial infections in blood and cerebrospinal fluid (CSF) Comparison: None Outcome: Primary Outcome: Prevalence of bacteremia or bacterial meningitis in infants with a positive urinalysis (growth of a pathogen in the urine or CSF culture) Secondary Outcomes: none Type of Study: Secondary analysis of prospective observational study Authors’ Conclusions: Among noncritical febrile infants ≤ 60 days of age with positive UA results, there were no cases of bacterial meningitis in those aged 29 to 60 days and no cases of bacteremia and/or bacterial meningitis in any low-risk infants based on low-risk blood thresholds in both months of life. These findings can guide lumbar puncture use and other clinical decision making. 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? Yes Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes (excluded if unable to contact at 7 days) 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 Conflicts of Interest: No Results: 7,180 infants were included in the analysis. 1090 (15.2%) had positive urinalysis results. Of those with a positive urinalysis, 541 (50.2%) had UTI. For those with a negative urinalysis, only 45 (0.8%) had a UTI. E. Coli was the most common cause of both UTI and bacteremia. Key Results: Risk of IBI was higher in infants with positive UA, largely driven the prevalence in bacteremia. No infants >28 days with positive UA had bacterial meningitis. Primary Outcome: Bacteremia Overall, 6% of infants with positive UA had bacteremia while only 1% of infants with negative UA had bacteremia. Bacterial Meningitis For infants in first month of life, rates of bacterial meningitis did not differ with positive or negative UA. For infants in second month of life, there were no cases of meningitis even with positive UA. No cases of meningitis in any infants with positive UA results and normal inflammatory markers based on PECARN febrile infant SBI prediction rule, ANC <4,000 cells/mm3 and procalcitonin <0.5 ng/mL. Listen to the SGEM Podcast for to hear Drs. Mahajan and Kuppermann respond to our 5 nerdy questions. 1) Urinalysis and UTI - We mentioned earlier that only around 50% of those with positive UA truly had a UTI. Why do you think there was such a pronounced discrepancy [9]? Bacterial Meningitis in those UTI 2) Community Setting: If I am working in a setting where I do not have access to procalcitonin, what laboratory or clinical criteria would you recommend to help risk stratify these infants [10-11]? 3) Quaternary Care Setting: If I am working in a setting where I have access to it all (procalcitonin, CRP, temperature, ANC), is there any benefit in using all of it to risk stratify? 4) Low Prevalence of Bacterial Meningitis and Bacteremia- How do you think the low rates of bacteremia and bacterial meningitis impact the power of your conclusions? Any thoughts on how we can overcome this barrier in future studies? 5) Generalizability- How can we leverage global research networks to help us solve the riddle of the febrile infant? Do you think we will ever get to a point where we find a clinical prediction rule that can be applied everywhere or are there too many shifting variables to consider [12]? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusions. SGEM Bottom Line: In well-appearing infants ≤60 days with positive UA, continue to perform blood work and blood culture. However, infants with positive UA in the second month of life may not routinely need a lumbar puncture. Case Resolution: Blood test results demonstrate that procalcitonin is <0.5 ng/dL and the ANC is <4000. You have a conversation with the parents and tell them the results of both the blood and urine testing. You review the risks and benefits of performing a lumbar puncture versus empirically treating with antibiotics. Ultimately, the parents opt to forgo the lumbar puncture and receive empiric antibiotics with the plan to follow up closely with their pediatrician the next day. Clinical Application: In well-appearing febrile infants >28 days with positive UA and meeting low-risk laboratory criteria, it may not be necessary to perform a lumbar puncture.

Date: December 11th, 2022 Dr. Dennis Ren Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine physician at Children’s National in Washington, DC. You may also know him as the host of this season’s SGEM Peds. This is an SGEM Xtra for the holidays. We have done previous shows on what we have learned from Star Trek and Top Gun. It is hard to believe that we have not done an SGEM Xtra about what Batman has taught us about medicine and life. The release of Season#9 of the SGEM as a PDF book seemed like an excellent opportunity to discuss Batman. This is because the book has a DC comic theme.  Some people might find that a bit dark. However, this edition arrives at a time of uncertainty. We have been navigating our way through a pandemic, understaffing, emergency department closures, boarding crises, astronomical wait times sometimes barely keep our heads above water and struggling to do everything we can to care for the patients who depend on us. Despite the challenges we face, I hope the SGEM has been a beacon in the darkness, a bat signal, to remind us that the application of the principles of evidence-based medicine is more important than ever. We discussed this early in the pandemic with Dr. Simon Carley from St. Emlyn’s. Before we start talking nerdy about Batman, I think it is important we give a shout out to Dr. Tayler Young. She is a first year Family Medicine resident at Queen’s University. Her interests are quality improvement and Free Open Access to Medical Education (FOAMed). Tayler did Season#8 book with an Avengers theme. SGEM Season#9 contains the an introduction by Dr. Chris Carpenter. He takes us back to 1934 and the start of DC comics. Batman first appears in 1939. The first page for each chapter has the clinical question, the SGEM bottom line and introduces the guest skeptic. Next comes the case presentation and some background material. This is followed by the PICO with each letter looking like the superman symbol. Each episode has the authors’ conclusions and the appropriate quality checklist to probe the study for its validity. The key results are listed. The Talk Nerdy To Me section has a Green Lantern theme. This is followed by the clinical application, what do I tell the patients and a case resolution section. Each chapter ends with any other FOAMed resources, twitter poll results and the Paper in a Picture infographic by  Kirsty Challen You can listen to the SGEM podcast and hear Tayler discuss the layout of SGEM Season#9.  You can also download all the previous SGEM books clicking on this LINK. Batman and How it Relates to Medicine and Life We discuss eleven ways that Batman relates to emergency medicine and life. You can listen to the entire discussion on the SGEM podcast available on iTunes. 1. Emergency Medicine is Batman If I were to pick one superhero that embodies the practice of emergency medicine, it must be Batman. He is a detective, a tactician, strategist. He is truly a jack of all trades. He has knowledge of criminal justice, psychology, forensics, chemistry, just to name a few. Sounds very similar to emergency medicine where we act as primary care providers, pediatricians, intensivists, cardiologists, neurologists, psychiatrists, often during one shift. Batman also has a lot of cool gadgets just like we have many tools in our arsenal when practicing emergency medicine. I think some of us might even carry a fanny pack (utility belt) on shift. 2. Vulnerability One of the things that sets Batman apart from other superheroes is that ultimately, he is human. He can get fatigued. He can be hurt. This quality makes me appreciate him more. Dr. Tim Graham shared his powerful story of burnout on SGEM Xtra: Everybody Hurts, Sometimes. We have witnessed people working in emergency medicine perform heroic acts every day, but it’s important take a moment to check in on each other. The pressure and stress can build up and it is ok not to be ok, to be vulnerable. I am fortunate to work at an institution where colleagues commonly check on one another after a difficult patient encounter or bad outcome. I have also had colleagues and friends check on me when I have been going through difficult personal circumstances. This supportive community does not only have to be at your own institution but can extend through social media. Let’s normalize looking out for one another. 3. Batman Won’t Give Up “Maybe that’s what Batman is about. Not winning, but failing, and getting back up. Knowing he’ll fail, fail a thousand times, but still won’t give up.” (Batman-Zero Year) I don’t know about you, but I can’t imagine shouldering the responsibility and burden of being Batman. He is doing his day job of running Wayne Enterprises and no matter how great or poorly his day or how much he got hurt or injured in the previous night, Batman always suits up and goes out on patrol. You just must admire that discipline and tenacity. Our emergency medicine colleagues also exhibit this “won’t give up” attitude. They keep showing up despite the craziness of the past shift, past week, or even the past few years. 4. Turning Failures to Triumph Is it surprising that this theme has popped up again? Chris Carpenter and I spoke about this on the SGEM Top Gun episode. Sometimes despite our efforts, we can still “fail”. If you define failing as patients having bad outcomes or dying. It sort of reminds me of Star Trek the Next Generation and Captain Jean-Luc Picard. He said “it is possible to commit no mistakes and still lose. That is not a weakness. That is life.” That is also emergency medicine. It is possible to do everything right and a patient can still have an adverse event or even die. This “failure” can be turned into opportunities for us to learn and get even better at what we do. Constantly striving to improve what we do. Ultimately everyone will die but what do we learn and how can we grow from these situations? 5. Hard Work, No Complacency Because Batman has no innate superhero abilities, he is constantly training to maintain his skills just like we are in emergency medicine. The SGEM encourages everyone to keep reading, keep thinking critically, keep questioning, and keep adapting so patients get the best care based on the best evidence. 6. The Bat Family I think some people mistake Batman for being a strong, silent, brooding loner type. Some of that is true, but he is not alone. He has the support of the entire Bat family with Alfred, Robin, Jim Gordon. But he also has the entire Justice League to help him when it comes to saving the world. We want to acknowledge all the people we get to work with in the emergency department (nurses, cleaning staff, respiratory therapists, PAs, NPs, switchboard operators, consultants, lab technologists, diagnostic imaging, etc). It is truly wonderful when everyone comes together as part of Team Patient. We also want to acknowledge all the family and loved ones that accompanied us and supported us through medical training and our careers. We appreciate your patience and understanding when we’ve disappeared for months on end while studying for a certification exam or missed important life events. Without you all, we would not be able to do what we do. 7. We are Defined by Our Actions What has defined emergency medicine is to be the one specialty that is for anyone, for anything at any time. We are the light in the house of medicine that never goes out. Like a light house we offer safe harbour in stormy weather. It is these actions of being available for patients in their time of need that defines who we are in emergency medicine. 8. One Person Can Make a Difference Batman always reminds me that one person can make a difference. There are many things for which we do not have much control over. But we can always choose to be kind and take a moment to recognize that everyone has a story. How we choose to approach a challenging situation or patient may leave a lasting impression. I learned about this from my kindness mentor Dr. Brian Goldman. Kindness Mentor Dr. Goldman with BatDoc 9. Everyone is Batman A hero truly can be anyone. The best part about Batman is that we can all strive to be Batman, or BatPerson or BatDoc. 10. Batman as a Symbol “As a man; I am flesh and blood; I can be ignored, I can be destroyed. But as a symbol, I can be incorruptible. I can be everlasting.” I want to take a moment and acknowledge all the amazing work that Ken has done with the SGEM. I am incredibly grateful for his mentorship. To me, Ken represents the importance of skepticism and critical thinking in applying the principles of evidence-based medicine to provide the best care for patients. More importantly, I think Ken embodies a kindness of spirit that I hope to emulate. I am sure I am not the only one that feels this way. So, thank you, Ken, and the SGEM for being that symbol for us. 11. Hope For our last point, we want to again acknowledge that things are tough in healthcare right now. However, one of the greatest things that has come out of these times is the wonderful #FOAMed community that has developed around SGEM. We want to thank you for tuning in every week to listen, learn, and share your stories and expertise. 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 ten years to less than one year using the power of social media. So, patients get the best care, based upon the best evidence. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. Kevin Conroy 1955-2022