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 will never see the light of day. What follows … [Read more...]
EMNerd
The Nihilistic Ramblings of Rory Spiegel, MD
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 for patients who received crystalloid … [Read more...]
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 embolism (PE). The … [Read more...]
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. This divide, is rarely crossed, and typically only … [Read more...]
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 subset of patients who were found to have relative adrenal … [Read more...]
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