So rarely is a study published that directly and effortlessly translates into clinical practice. Very few of these studies examine the nuances of everyday practice in the fast paced milieu of the Emergency Department. Given the infrequency of such studies, I am continually amazed by the work put forth by Brian Driver and colleagues at […]
EMNerd
The Nihilistic Ramblings of Rory Spiegel, MD
EM Nerd-The Case of the Temporal Fallacy
Inadvertent catastrophes are often hidden just beneath good intentions. Such is the case with the most recent iteration of the Surviving Sepsis Campaign’s treatment bundle. Published in Intensive Care Medicine by Levy et al, this special editorial includes the Surviving Sepsis Campaign’s most recent recommendations for the early and aggressive treatment of sepsis (1). Most […]
EM Nerd-Behind the Veil of Science
On March 26th 2018, the New York Times published an article by Gina Kolata, For Many Strokes, There’s an Effective Treatment. Why Aren’t Some Doctors Offering It?, examining the efficacy of tPA in acute ischemic stroke. The article was dismissive and misleading. In response, I sent a letter to the editor which I fear […]
CC Nerd-The Case of the Unbalanced Solution
The use of 0.9% saline has undergone a degree of scrutiny in recent years. Detractors claim high chloride content, leads to acidosis and kidney injury. But clinical evidence supporting the clinically deleterious effects is lacking. The SPLIT Trial published in JAMA in 2015 by Young et (1) al failed to find any difference in outcomes […]
EM Nerd-The Case of the Diagnostic Absurdity
Is it just me or have we lost our collective minds? A recent trial published in JAMA, by Freund et al (1), illustrates just how far our diagnostic psychosis has progressed. The authors conducted a crossover cluster–randomized non-inferiority trial examining a strategy utilizing the pulmonary embolism rule out criteria (PERC) rule to rule out pulmonary […]
CC Nerd-The Case of the Inverted Premise
No mode of ventilation is burdened with more emotional baggage than airway pressure release ventilation (APRV). The mere suggestion of its use is met with either the delight of recognizing an old friend whom you are meeting for the first time, or the type of disgust typically reserved for the likes of snake oil salesmen. […]
CC Nerd-The Case of the Relative Insufficiency
When it comes to the efficacy of glucocorticoid therapy for the treatment of septic shock, we have existed in a state of ambiguity, torn between the results of two contradictory RCTs. The first, the Annane et al trial published in JAMA in 2002, suggested a mortality benefit in favor of the corticosteroid group in the […]
EM Nerd-The Case of the Aimless Convoy Continues
Evidence has consistently demonstrated the lack of clinical utility provided by natriuretic peptides. Further studies documenting their incompetencies are no longer necessary, but it is rather enjoyable to highlight their dependable failures. The most recent illustration of natriuretic peptides clinical ineptitude was published this week in CIRCULATION by Stienen et al (1). The authors randomized […]
EM Nerd-The Case of the Tardy Delegate Continues
In 2000 Fazzini et al published a paper comparing the use of ionization vs photoelectric smoke alarms in rural Alaskan homes (1). The authors noted that at the time of the article’s publication. the fire fatality rate for native Alaskans was 9.6 times the national rate and 3.5 times higher than the general rate in […]
EM Nerd-The Case of Corporeal Clock
How exactly do trialists proceed when deciding upon the appropriate acronyms for their soon-to-be blockbuster trial? Is the proper etiquette to follow a traditional prospective process, utilizing the first letter of each word in a trial’s longer title? Or is the selection of an acronym based on its ability to inspire and only then, retrospectively […]
EM Nerd-The Case of the Inert Remedy
In 1959 Cobb et al published a trial of 17 patients investigating the efficacy of internal mammary artery ligation for the treatment of symptomatic angina. The authors randomized 17 patients “seriously limited by angina” to either bilateral internal mammary artery ligation or a blinded sham procedure (1). At 6-months follow up the authors reported the […]
The Case of an Ugly Truth
The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact. […]
EM Nerd-The Case of the Divisive Tincture
The guiding physiological principles of resuscitation have for so long been based off the restoration of normal macroscopic hemodynamics in the hopes that the reversal of such circulatory perturbations will correct the underlying cellular injustices. And yet time after time such strategies have failed to show definitive benefits when empirically tested. The simple practice […]
EM Nerd-The Case of the Liberated Radicals
A recent publication in the NEJM by Hofmann et al (1) serves as a nice reminder that so many of our therapeutic staples while based on sound physiological reasoning fail to translate into clinically important realities when empirically tested. This mammoth undertaking, entitled the DETO2X trial, randomized 6629 adult patients (>30 years old) presenting to […]
The Case of the Aimless Convoy
Never has a biomarker with so much evidence demonstrating its disutility, enjoyed such a long reign of prosperity as BNP and its natriuretic analogs. And while evidence discrediting BNP’s use for the diagnosis and inpatient management of acute exacerbations of heart failure (HF) is well documented, its utility to guide outpatient therapy in patients […]
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