Our standards for acceptable benefit of antiplatelet agents in the management of ACS have become deplorably low. When ISIS-2 was first published we defined success only by aspirin’s ability to affect mortality. The number commonly cited, 2.4%, only describes aspirin’s absolute benefit to decrease death (1). In the one trial that examined its properties to […]
EMNerd
The Nihilistic Ramblings of Rory Spiegel, MD
A Secondary Examination of The Adventure of the Cardboard Box
In November of 1995 stroke care as we know it drastically and permanently changed. With the publication of NINDS-2 the NEJM ushered in the interventional era of acute ischemic stroke (1). No longer were we powerless in our management of these patients. Finally we could offer them more than an aspirin to chew on, a […]
The Science (Fiction) of FOAM
If you want to know how we practiced medicine 5 years ago, read a textbook. If you want to know how we practiced medicine 2 years ago, read a journal. If you want to know how we practiced medicine last year, go to a (good) conference. If you want to know how we practice medicine now and in […]
The Case of the Anatomic Heart
Our obsession with diagnostic certainty has led us down many false paths and blind alleyways in the history of medicine. This statement has never been more true than when spoken in regards to cardiovascular health. The small successes that we have obtained when treating the highest acuity patients have been enthusiastically and incorrectly applied across […]
“The Adventure of the Sussex Vampire”
A brief forethought. This post we will stray from the usual whimsical rants regarding recent literature in Emergency Medicine. Instead we will focus on the far more practical topic of the insertion of the Midline catheter. Of note, I am overwhelmingly biased in favor of these devices and have taken such a fanciful liking to […]
A Case of Shadows
In medicine we frequently propagate half-truths and unsubstantiated certainties. Thus, truth is a relative experience, dependent primarily on how we choose to define it rather than any concrete state of reality. Increasingly we have favored a technological definition of truth over that of the clinical perspective. As such we are driven to act in disease […]
A Secondary Analysis of the Adventure of the Crooked Man
Removing a cervical collar in the early aftermath of a traumatic injury is becoming an increasingly difficult task. With ever more sensitive imaging modalities we have progressively devalued the traditional methods used to evaluate the integrity of the spinal column in favor of more technologically advanced ones. Despite decades of success in treating this pathology, […]
“The Adventure of the Red-Headed League”
A peasant traveling home at dusk sees a bright light traveling along ahead of him. Looking closer, he sees that the light is a lantern held by a ‘dusky little figure’, which he follows for several miles. All of a sudden he finds himself standing on the edge of a vast chasm with a roaring […]
“The Adventure of the Golden Standard”
We have all been told ghost stories and fairy tales. Campfire fables intended to frighten the gullible populace into behaving in a manner deemed appropriate. Even in Emergency Medicine we have our fair share of ghost stories. Most notably we are taught from an early age to fear and respect the clinically occult pulmonary embolism. […]
“The Adventure of the Dancing Men”
The illustrious Cardinal Commendoni suffered sixty epileptic paroxysms in the space of 24 hours, under which nature being debilitated and oppress’d he at leangth sank, and died. His skull being immediately taken off, I found his brain affected with a disorder of the hydrocephalous kind. -Gavassetti, 1586 The […]
“A Timely Reexamination of the Case of the Thirteen Watches”
-Doing the same thing over and over again and expecting different results Albert Einstein on Insanity- For a near decade now our mad dash to the cath lab has been based off flawed data and an illogical certainty that every moment of delay is detrimental to our patients. As such we were completely flabbergasted […]
“The Adventure of the Greek Interpreter Revisited”
If our affair with thrombolytics had not started off with the success it did, we may not still be trying to nostalgically relive our yesteryears of throbolytic glory. Whether it was streptokinase, alteplase or tenectoplase (TNK), thrombolytics have consistently demonstrated a mortality benefit when used in patients experiencing an ST-elevation infarction (1). If it […]
“The Case of the Dying Detective Continues…”
Survivors of the Armageddon in any of its many forms, zombie, alien, or otherwise, are often left in a state of emotional turmoil. They face an uncertain future, the loss of loved ones, and the constant stress of imminent danger. Underneath the obvious anguish lies a deeper more subtle but equally distressing sentiment, uncertainty. Now […]
“The Adventure in the Valley of Fear”
In the biomedical industry’s relentless war against clinical reasoning, a multitude of biomarkers have been developed that promise assistance in the diagnosis and management of sepsis. In this ocean of mediocrity, procalcitonin has risen to the top. Since its predictive value is only slightly better than chance alone, it behooves those promoting its value to […]
“The Case of the Uncertain Principle”
Atoms or elementary particles themselves are not real; they form a world of potentialities or possibilities rather than one of things or facts. -Werner Heisenberg The uncertainty principle states, there is a limit to the precision with which the position and momentum of any subatomic particle can be measured. Their location and velocity can only […]
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