SMART EM

Heart attack: it is the never-miss diagnosis. Accordingly, we virtually never miss. Is the victory Pyrrhic? This month, with an eye on how we got here, and what matters most (hint: it's not the doctor), we seek coronary absolution.  

Pseudioaxioms—false medical truths—surround us. Here's one about blistering ear infections, and an update on recent public health and stroke literature. One might title the update "When Editorial Boards Fail...."

Do statins save lives in healthy people? To a raging debate, here's an answer.

This month we're going back to basics with a literature update, something new we plan on doing regularly. We'll tackle a few of the latest and greatest studies, get you comfy with the data, and show you what they really say. Join us on the cutting edge.

It's baack. The greatest controversy in acute care rages on, and a new guideline is making headlines. Behind the guideline, into the data. And, a bonus: the Courtroom of Science tries its first case.

Johnny fell down and his ankle is tender, but the film is normal. Now what? This classic teaching goes back to 1895, the advent of x-rays. So we went back farther... time travel is revealing.

Coronary computed tomographic angiography: seeing the arteries is, apparently, believing. Here it is, an update on the two hottest trials in EM—and the editorial that could change everything. 

This week The Lancet published the largest ever randomized trial of thrombolytics for acute stroke. Hands are wringing, teeth are gnashing, and department heads are fighting. It is the biggest, baddest controversy in our field: Do clot-busters benefit stroke patients? Let's do this.

In medicine we love us a good diagnostic test; we're always looking for the next one. It is strange, then, that we should be so aloof to the basics of diagnostic testing. This month's audio is a primer on testing—and it changes everything. We're going back to basics: if you learn the four axioms of diagnostic testing you'll know more about how to choose and how to interpret diagnostic tests than just about everyone. Weird thing is that it turns out you knew it all already... you just needed a reminder. 

This is a month for reflection, so we're reflecting on some of our previous podcasts. In fact we're updating earlier material based on the latest literature. Previous podcasts like Chest Pain Risk, Stress Testing, and Subarachnoid Hemorrhage are getting a fresh new coat. The updates are brief but they're dense, so be prepared for some practice-changers. Much to discuss. Tolstoy once said "Everyone thinks of changing the world, but no one thinks of changing himself." Perhaps it is time.

The 'stress test' is a part of our cultural lexicon, whether it's for banks or the human heart, and the concept is elegant: take a machine to its limits, and when you find the cracks shore them up. read more

Cirrhotics bleed and they get infected. It is, apparently, a law of nature. Question is, when they're bleeding is it worthwhile to treat them prophylactically with antibiotics? This review is more of a snorkel than a deep dive, since the literature is both thick and thin: Thick enough to review, but thin enough to make a deep dive unnecessary. Join us for both a brief review, and a gloating rant.

In July we scoured the data on PPIs for ulcer bleeding. This month we tackle the other, often scarier cause of upper GI bleeding, esophageal varices. We dived deep (deeper than ever) to find the best and most relevant data on the commonly used pharmacologic agents for variceal bleeding: somatostatin analogues, like octreotide. This one was a twisted road, and there were a whole lot of pigs on the road. They were mostly wearing lipstick. Come with us to the zoo....

Deep inside most medical providers there is a war of the psyche; a battle between art and science. We are ambassadors for ‘science’, true believers. Yet we are baffled and unsettled every day by events and conditions that defy the scientific precepts on which we stand. read more

Upper GI bleeds are common, and they’re messy. We wanted to know how good the data are for the pharmacological interventions that have become standard fare for upper GI bleeds. Turns out the data are messy too. In fact, because no one else would, we did our own little meta-analysis. Good news is we have a concrete answer on PPIs for upper GI bleeding. Bad news is that the news is not good. And not at all what we expected.

Threatened abortion is among the most common conditions in outpatient settings. The explosive growth of ultrasound imaging, and increasingly limited access to specialty care have combined to make first trimester bleeding a disease for emergency and primary care docs. Thing is, there is no therapeutic intervention that can alter the course of ‘Threatened Ab’. Which means that knowledge is our only power—the power to guide and inform. read more

We do it every day. Editorials and experts everywhere are asking us to do it more, and more completely. But no one ever showed us the numbers. So here it is, a reasonable, data driven set of risks that we can tell our patients who are considering undergoing CT scan. Risk of the dye, risk of the radiation, and risk of false positives. It’s all here, adults and kids alike. Deep dive in, this data is flat out fun.

Risk stratification is the emergency physician’s best friend. We stratify, it’s what we do. So how likely is it that a 56 y/o gentleman with mild exertional chest pain, a non-diagnostic EKG, and a negative troponin is going to have an MI or die in the next 30 days? Covered. How about the 38 y/o with a good story? Done. What about the 47 year old diabetic with a decent story? Solved. This month we’ve got your rapid fire, quickie lecture on chest pain risk. It’s what we do.  

Antibiotics for Otitis Media: Feel Better? Otitis media is the primary reason that children in western developed nations spend 6-7 weeks per year taking antibiotics before their 2nd birthday. Seriously. Is it worth it? What’s in it for them? What’s in it for moms and dads? Who are we helping and who are we hurting? Come on a deep dive through the swamps of the AAP guidelines, the strange world of antibiotic recommendations, and the clinical evidence for the treatment of ear infections. There’s a few surprises in the swamp.

UTI’s are the ‘in thing’. Particularly with the heptavalent pneumococcal vaccine in play, and bacteremia increasingly a part of our past, UTI’s have become the number one concern in febrile children over 2 months of age. So if you’re wondering about how and why fevers matter in kids, and what to do about them, we’ve got your answer. Come with us on a dive where you’ll learn about why UTI’s matter, how they got top billing, and what to do about them. It’s not pretty. read more