In the era before the ubiquitous use of bedside ultrasound, BNP and its derivative natriuretic peptides were, at best, a mediocre test that added little to clinical judgment. In today’s world of sonographic abundance, they simply add noise to our already deafening workflow. Despite a wealth of evidence demonstrating natriuretic peptides’ lack of clinical utility, […]
EMNerd
The Nihilistic Ramblings of Rory Spiegel, MD
You Don’t Understand the Osm Gap – Guest Post by Rory Spiegel
Think you understand the Osm Gap–you don’t
The Adventure of the Impassable Stone
As medical skeptics we have a tendency to revel in the negative study. We bemoan the p-value’s tendency to underestimate the risk of type I error and cite Frequentist statistics’ history of getting it wrong almost as often as it gets it right. Despite these nihilistic inclinations it is important that we are equally vigilant […]
The Case of the Non-inferior Inferiority
The practice of Frequentist statistics is often a study in extremes. Based on an arbitrary threshold of significance, we are asked to interpret data as either positive or negative when in reality it merely shifts our probability of certainty. Even more important, because of the singular nature of Frequentist statistics, our interpretation of data is […]
The Case of the Irregular Irregularity
We have proven ourselves highly capable of managing atrial fibrillation in the Emergency Department. In recent years, a number of prospective cohorts have demonstrated that with the use of IV anti-arrhythmic medication and electrical cardioversion, patients presenting to the Emergency Department with new onset atrial fibrillation can be successfully discharged in sinus rhythm consistently and […]
The Problem of Thor Bridge
Disclosure: This post is unusually full of hearsay and conjecture. Like a secondary endpoint that flirts with statistical significance it should be viewed purely as hypothesis generating. For a more reasoned and experienced view of the following data please read Josh Farkas’s wonderful post on pulmcrit.org. Damage control ventilation is not a novel concept. It functions […]
The Third Annotation of a Case of Identity
So often in modern medicine we mistake science for truth. In doing so we have become enamored with the p-value and view it as the major determinant of relevance in scientific inquiry. An almost arbitrary selected value of 0.05 is independently responsible for defining what is considered beneficial, and what will be discarded as medical […]
A Truncated Summation of the Adventure of the Cardboard Box
One gets the sense when reading the literature on endovascular therapy for acute ischemic stroke that they are on a small seafaring vessel attempting to map the shoreline through a dense fog. There are moments when the fog lifts and you catch a glimpse of the topographic details of the shore, and then the […]
The Case of the Anatomic Heart Part 2
The PROMISE Trial, like any aptly named study chose an acronym meant to inspire. In this case, the hope for a better tomorrow. And though the authors of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain trial were not clear on the specific details their promise entailed, I fear the results of this […]
The Case of Dubious Squire
I often get the sense that the makers of many biomarkers envision us as helpless damsels in distress drowning in an icy pond or trapped in a monumental tower with no obvious means of descent. I imagine they think in our desperate grasps for aid, we will cling to whatever assistance they may offer, independent […]
The Adventure of the Second Stain Continues
The CT-LP (lumbar puncture) diagnostic pathway has been a permanent fixture in the arsenal of the Emergency Physician for what seems like an eternity. Steadfast in its dependability, for many generations, the LP was a necessity for Emergency Physicians to safely exclude the diagnosis of subarachnoid hemorrhage (SAH). And yet, rarely a moment has passed over […]
The Adventure of the Cardboard Box Continues
For those whose beliefs are already firmly in favor of endovascular therapy for acute ischemic stroke, the publication of the MR CLEAN trial earlier this year and more recently the EXTEND-IA and ESCAPE trials only serve as a big fat, “I TOLD YOU SO!” For the perpetual disbelievers, each of these trials possesses enough flaws […]
The Adventure of the Blanched Soldier
So often in the management of the critically ill we are forced to choose between the lesser of two evils. The transfusion of blood products in the face of hemorrhagic shock is in some ways the best compromise of less than ideal choices. Every drop of resuscitative fluid given that does not mimic the […]
The Case of the Balanced Solution
Saline-based resuscitation strategies were first proposed as far back as 1831 during the Cholera Epidemic. In an article published in the Lancet in 1831, Dr. O’Shaughnessy suggests the use of injected salts into the venous system as a means of combating the dramatic dehydration seen in patients afflicted with this bacterial infection(1). Saline’s potential harms […]
A Secondary Examination of The Adventure of the Cardboard Box-Addendum
Published in the NEJM on December 17th 2014, ushered in with the inflated fanfare only the medical industry capable of, MR CLEAN marks the first successful trial of interventional therapy for acute ischemic stroke. In direct contrast to IMS-3, SYNTHESIS and MR RESCUE, MR CLEAN is a significantly positive trial. The authors demonstrated success in […]
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