REBEL EM – Emergency Medicine Blog

REBEL MIND – Growth vs Fixed Mindset in Medicine

Mark Ramzy — Wed, 01 Apr 2026 11:00:39 +0000

🔑Key Points

🌱 Growth mindset transforms learning – Residents and students who believe skills can be developed are more open to feedback, more resilient after failure, and more engaged in practice.
🧠 Language matters in feedback – Simple reframes such as “You’re developing procedural skills” instead of “You’re not strong at procedures” encourage persistence and normalize the learning curve.
🤝 Mindset shapes team culture – Growth mindset leaders foster psychological safety, invite input, and create collaborative teams. Fixed mindset hierarchies, on the other hand, silence voices and can compromise patient care.
🔥 Growth mindset protects against burnout – By reframing mistakes as part of the process, clinicians reduce perfectionism and shame, bolstering resilience and wellness.
🔍 Practical steps start with self-talk – Add the word “yet” to limiting beliefs (“I’m not good at X…yet”) and shift feedback questions toward improvement (“What’s one thing I can do better next time?”).
🛠️ Embracing mistakes with a growth mindset – Leads to more effective feedback loops and improvement do this by building a culture of psychological safety is crucial for growth and reducing medical errors.

Click here for Direct Download of the Podcast.

👀Previously Covered and Related Content:

- REBEL EM: The EM Mindset
- REBEL EM: Titles Dont Make Leaders
- REBEL EM: Mind of the Resuscitationist with Scott Weingart
- EM Crit: Making Things Happen with Cliff Reid

📝 Introduction

Welcome to this episode of REBEL MIND, where MIND stands for Mastering Internal Negativity during Difficulty. Here we sharpen the person behind the practitioner by focusing on things that improve our performance, optimizing team dynamics and the human behavior that embodies the hidden curriculum of medicine.

Mindset shapes everything we do in medicine—from how we teach and learn to how we show up for patients at the bedside. Drawing from Carol Dweck’s influential book Mindset, this episode of REBEL MIND explores the critical difference between a fixed mindset (believing abilities are innate and static) and a growth mindset (seeing skills as things that can be developed through effort and feedback).

We sat down with Dr. Kim Bambach, an emergency medicine physician and medical educator, and Dr. Frank Lodeserto, a dual-trained intensivist and internal medicine program director, to unpack how mindset influences medical education, bedside performance, and physician wellness. In this episode, we delve into how the mindset of clinicians can profoundly influence their performance, professional growth, and ultimately patient care

Cognitive Question

How does adopting a growth versus a fixed mindset influence clinical performance, medical education and patient outcomes?

🌱What is Growth vs Fixed Mindset?

- In Carol Dweck’s research, two primary mindsets are highlighted:
  - Fixed mindset: Which sees intelligence and skills as static
    - In the medical field, adopting a fixed mindset might lead a clinician to avoid complex cases due to fear of failure.
    - Growth mindset: Which views abilities as improvable through dedication and effort.
      - In contrast, a growth mindset encourages embracing challenges as opportunities for learning and development.

🏥How This Applies to the Emergency Department or ICU?

- In high-stakes environments like the ICU or the ED, the mindset adopted by healthcare providers can distinctly shape patient care and team dynamics.
- A fixed mindset might lead to defensive behaviors and a reluctance to engage in challenging cases, potentially stunting personal and professional growth.
- Conversely, a growth mindset not only fosters resilience and adaptability but also enhances team collaboration and patient outcomes by encouraging open communication, continuous learning, and acceptance of constructive feedback.

⏩Immediate Action Steps for Your Next Shift

**Monitor Self-Talk**: Notice your internal narrative when faced with challenges. Replace negative, fixed-mindset thoughts with growth-oriented ones like “Not yet” or “What can I learn from this?”
**Promote a Culture of Inquiry**: Challenge yourself and your team to engage in constructive questioning and explore alternative diagnoses or treatment plans to encourage a growth-centered environment.
**Model Vulnerability**: Share personal learning experiences and mistakes with colleagues to normalize the growth process and reduce the stigma of imperfection.
**Reframe Feedback**: Instead of broadly asking, “How did I do?” inquire, “What’s one thing I can improve on next time?” This shift helps maintain focus on growth rather than performance validation

- - - - Feedback is a whole another topic that we plan to have dedicated episodes and blog posts. This is an area where sometimes faculty struggle and often learners are asking for more/improved feedback.

💬Conclusion

Cultivating a growth mindset in medicine isn’t merely about staying positive; it’s about embracing continuous learning in the face of challenges. It involves creating supportive environments that encourage vulnerability, experimentation, and resilience. By adopting these practices, clinicians can improve not just personal competencies but also enhance patient care quality and safety.

🚨 Clinical Bottom Line

Clinicians who embrace a growth mindset not only enhance their skills but also contribute to a more dynamic, adaptive, and error-resilient healthcare environment. Remember, the best clinicians are those who never stop learning, not the ones who never make mistakes.

Episode Audio Edited By: Kim Bambach, MD and Mark Ramzy, DO (Twitter/X/IG: @MRamzyDO)
Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_Propersi)

Meet the Authors

Mark Ramzy, DO

Co-Editor-in-Chief

Cardiothoracic Intensivist and EM Attending RWJBH / Rutgers Health, Newark, NJ

Kimberly Bambach, MD

Assistant Professor of Emergency Medicine

The Ohio State University Wexner Medical Center, Columbus, OH

Frank Lodeserto, MD

Internal Medicine Residency Program Director

Cape Fear Valley Medical Center, Fayetteville, NC

The post REBEL MIND – Growth vs Fixed Mindset in Medicine appeared first on REBEL EM - Emergency Medicine Blog.

MDCalc Wars: HAT vs SEDAN — Hemorrhage Risk After Stroke Thrombolysis

Eric Steinberg DO, MEHP — Mon, 30 Mar 2026 11:00:38 +0000

🗝️ Key Points

🧠 HAT and SEDAN help estimate symptomatic intracranial hemorrhage risk after stroke thrombolysis and can support real-time bedside counseling.
⚡ HAT is faster and simpler, making it useful when you need a quick estimate with basic clinical and CT data.
🖥️ SEDAN adds more imaging detail, which may provide a more refined risk estimate when CT findings are well characterized.
⚠️ These scores are adjuncts, not gatekeepers and should not be used alone to deny thrombolytics to otherwise appropriate patients.
🗣️ Best use case: inform shared decision-making, set expectations with families, and guide post-treatment monitoring.

🤕 Case

A 68-year-old man presents with right-sided weakness and slurred speech (NIHSS 12), with a negative CT, making him a clear thrombolytic candidate. As you review the risks and benefits, she seems to be on board, but asks, “What’s his chance of bleeding? Do you think it’s worth it?” You step out briefly, pull up MDCalc to better individualize the risk.

🔗 Scoring Tools

- ➡️ HAT (Hemorrhage After Thrombolysis) Score for Predicting Post-tPA Hemorrhage
- ➡️ SEDAN Score for Post-tPA Hemorrhage

🎯 Quick Hits

💬 Case Resolution

You review his hemorrhage risk using HAT and, given detailed CT findings are available, apply SEDAN for a more refined estimate. After a brief discussion, she agrees to proceed, and thrombolytics are administered without delay.

🚨 Clinical Bottom Line

Use the HAT or SEDAN score to quickly estimate the risk of symptomatic intracranial hemorrhage after stroke thrombolysis and to support bedside counseling, shared decision-making, and post-treatment monitoring. These tools help frame risk, but they should not be used in isolation to withhold thrombolytics from otherwise appropriate patients.

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_Propersi), and Mark Ramzy, DO (X: @MRamzyDO)

FAQ

When should I use HAT or SEDAN?
Use these scores when considering thrombolytics for acute ischemic stroke and you want to estimate symptomatic intracranial hemorrhage risk to support bedside counseling and monitoring.
How do HAT and SEDAN differ?
HAT is faster and simpler, using core clinical data and basic CT findings. SEDAN is more detailed and incorporates additional CT features for a more imaging-informed estimate.
Should these scores determine whether a patient gets thrombolytics?
No. They are decision-support tools meant to inform discussion and monitoring, not to withhold treatment from otherwise appropriate patients.
What are the main limitations of these scores?
Both rely on CT interpretation, which can be subjective, and their performance may vary across patient populations. They also use different definitions of symptomatic intracranial hemorrhage.
How should I use the result in practice?
Use the score to frame the risk-benefit discussion with patients and families, individualize counseling, and guide post-thrombolytic monitoring.

🧭 Prep Sheets

HAT (Hemorrhage After Thrombolysis) Score for Predicting Post-tPA Hemorrhage

SEDAN Score for Post-tPA Hemorrhage

👤 Author

Eric Steinberg

DO, MEHP

Content Director, MDCalc, Residency Director, Emergency Medicine St. Joseph's University Medical Center, Paterson, NJ

Meet The Team

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The post MDCalc Wars: HAT vs SEDAN — Hemorrhage Risk After Stroke Thrombolysis appeared first on REBEL EM - Emergency Medicine Blog.

The Queen of Hearts Returns: AI vs Physicians in STEMI-Equivalent and STEMI-Mimic ECGs

Joseph Bove, DO; Anika Suri, MD — Mon, 23 Mar 2026 11:00:26 +0000

📌 Key Points

️ Queen of Hearts AI outperformed both emergency physicians and cardiologists when interpreting challenging STEMI-equivalent and STEMI-mimic ECGs.
⚡ These are some of the hardest ECGs to interpret, where missed OMIs can delay reperfusion and false positives can trigger unnecessary cath lab activation.
🫀 Physicians missed 41% of true OMIs, while the Queen of Hearts AI missed only 11%, suggesting meaningful improvement in detection.
🎯 The AI also reduced overcalling of non-OMI ECGs, which could help decrease unnecessary catheterization laboratory activations.

📝 Introduction

Rapid identification of occlusive myocardial infarction (OMI) is essential to ensure timely catheterization laboratory activation (CLA). [1,2] Traditional STEMI criteria rely on measurement-based ST-segment elevation thresholds, but many acute coronary occlusions occur without classic ST elevation. [3,4] These presentations, often referred to as STEMI-equivalents, are among the most challenging ECGs to interpret, and failure to recognize them can delay reperfusion therapy and worsen patient outcomes. [4]

Conversely, several ECG findings can mimic STEMI despite the absence of true coronary occlusion, resulting in false-positive catheterization laboratory activations in 9% to 23% of cases. [5,6] These STEMI-mimics may demonstrate ST-segment elevation meeting traditional millimeter-based criteria but are caused by conditions such as left ventricular hypertrophy, early repolarization, bundle branch blocks, old myocardial infarction, or Brugada pattern. [4,7] In addition, conditions that cause myocardial injury without coronary occlusion, including takotsubo cardiomyopathy, myocarditis, and post-cardiac arrest changes, can create further diagnostic uncertainty. [7] Misinterpretation of these patterns may lead to unnecessary catheterization, exposing patients to contrast and radiation, increasing costs, and delaying diagnosis and treatment of the actual underlying condition.

Artificial intelligence tools for ECG interpretation have recently been developed to assist clinicians in identifying patterns associated with acute coronary occlusion. The Queen of Hearts (QoH) AI system, a deep neural network trained on millions of ECGs, analyzes 12-lead ECG tracings to identify patterns consistent with OMI, including cases that may not meet traditional STEMI criteria, while also helping differentiate true occlusion from common STEMI mimics.

This study evaluated whether the QoH AI algorithm could outperform emergency physicians and cardiologists in interpreting some of the most challenging ECGs in acute coronary care—STEMI-equivalents and STEMI-mimics—to determine whether cath lab activation was warranted.

🧾 Paper

Shroyer S, Mehta S, Thukral N, Smiley K, Mercaldo N, Meyers HP, Smith SW. Accuracy of cath lab activation decisions for STEMI-equivalent and mimic ECGs: physicians vs AI (Queen of Hearts by PMcardio). Am J Emerg Med.2025;97:193-199. PMID: 40763602

️ What They Did

CLINICAL QUESTION

What is the diagnostic accuracy of clinically-experienced emergency physicians and cardiologists in interpreting STEMI-equivalents and STEMI-mimics on ECG compared to the AI-based “Queen of Hearts” ECG interpretation system for cath lab activation?

STUDY DESIGN

A cross-sectional online survey study
Participants were recruited from a hospital system in San Antonio, Texas consisting of two community hospitalsand four standalone emergency departments, managing approximately 108,000 ED visits and 239 cath lab activations annually
53 ED physicians and 42 cardiologists were presented with 18 pre-selected 12-lead ECG tracings
Participants were asked a binary question: Would you activate the cath lab based on this ECG?
The QoH AI ECG interpretation software was tasked with independently evaluating the same set of ECGs to determine the presence or absence of OMI
Diagnostic performance was compared and analyzed between the physician group and QoH AI
Participants were blinded to patient outcomes and OMI prevalence during completion of the survey
Respondents received no clinical context other than concern for coronary artery occlusion, except in case #8 (Transient STEMI), where minimal EMS history was provided only to physicians—not AI: “We have ST elevation, estimated time to ED arrival—five minutes.”

Definitions

STEMI-equivalents: OMI without classic ST elevation

deWinter T-waves, hyperacute T-wave OMI, transient STEMI, LBBB with positive modified Sgarbossa criteria, posterior wall OMI, Wellens syndrome, aVR ST-elevation, RBBB with left anterior fascicular block and OMI

STEMI-mimics: Patterns exhibiting ST elevation without coronary occlusion

LVH, benign early repolarization, LV aneurysm, Brugada pattern, hyperkalemia, pulmonary embolism, RBBB fascicular block without OMI, LBBB with negative modified Sgarbossa criteria

ECG SETS

The investigators selected 18 ECGs from adult patients:

9 STEMI-equivalent ECGs associated with true OMI
9 STEMI-mimic ECGs without acute coronary occlusion

COMPARISON GROUPS

95 residency-trained physicians
- 53 emergency physicians
- 42 cardiologists
Queen of Hearts (QoH) AI model

OUTCOMES

Primary outcome: Diagnostic accuracy in distinguishing true STEMI-equivalent OMIs from STEMI mimics
Secondary outcomes: Miss rate for OMI and overcall rate for non-OMI ECGs

📈 Results

OUTCOMES

DEMOGRAPHICS

OUTCOMES

Metric	Emergency Physicians	Cardiologists	Queen of Hearts AI
True Positive	282	194	8
False Positive	133	77	1
False Negative	195	184	1
True Negative	344	301	8
Total ECG Interpretations	954	756	18
Sensitivity	59% (95% CI 36–79)	51% (95% CI 31–71)	89% (95% CI 76–95)
Specificity	72% (95% CI 57–83)	80% (95% CI 67–88)	89% (95% CI 78–95)
Accuracy	65.6% (95% CI 51–78)	65.5% (95% CI 51–77)	88.9% (95% CI 82–93)
Potential Unnecessary CLA	32% of caths	28% of caths	11% of caths
Potential Missed OMIs	41% of OMIs	49% of OMIs	11% of OMIs

DEMOGRAPHICS

💥 Critical Results

QoH AI had higher overall accuracy than physicians (89% vs 66%; p < 0.001).
Emergency physicians and cardiologists performed similarly (65.6% [95% CI 51–78] vs 65.5% [95% CI 51–77]; p = 0.97).
QoH AI outperformed both groups in sensitivity and specificity, achieving 88.9% sensitivity and 88.9% specificity.
Emergency physicians identified 59% of OMIs with 72% specificity, while cardiologists identified 51% of OMIswith 80% specificity.
For difficult ECG subtypes, hyperacute T-wave OMI was more often recognized by EPs than cardiologists (57% vs 24%; p = 0.002), whereas RBBB with fascicular block was more often recognized by cardiologists (64% vs 42%; p = 0.030).
QoH AI correctly classified 3 of 4 ECG patterns that more than half of physicians misclassified, though it missed mSgarbossa-positive LBBB and LV aneurysm.

💪 Strengths

Blinding: Physicians and AI were blinded to outcomes and OMI prevalence and interpreted ECGs without clinical context, ensuring decisions were based solely on ECG interpretation.
Reference Standard: Diagnostic accuracy was compared against a reference standard incorporating angiography, troponins, echocardiography, and clinical follow-up.
Focus on High-Risk ECGs: Evaluation of complex STEMI-equivalent and STEMI-mimic patterns prone to diagnostic error
Inter-Specialty Comparison: head-to-head comparison of performance between emergency physicians and cardiologists
Experienced Participants: Participants were residency-trained physicians with substantial experience (median 7 years for emergency physicians and 15 years for cardiologists), increasing clinical relevance.

⚠️ Limitations

Case Selection Bias: ECGs were a small set of hand-selected examples of STEMI-equivalents and STEMI-mimics rather than randomly sampled cases, likely exaggerating diagnostic difficulty.
Artificial Study Environment: The controlled survey environment does not reflect real-world ED conditions such as time pressure, interruptions, and competing clinical priorities. In practice, these pressures could further worsen physician performance, potentially widening the gap between physician and AI accuracy.
Spectrum Bias: The study used a simulated 50% OMI prevalence, which differs from real-world ED chest pain populations where OMI prevalence is much lower.
Misclassification: One ECG was mischaracterized as modified Sgarbossa-positive LBBB, although sensitivity analysis showed minimal impact on overall study conclusions.
Undefined Troponin Threshold: “Significantly elevated troponin” was not defined for cases with TIMI 3 flow, which could introduce some misclassification of OMI status. However, this limitation is likely minor since all participants interpreted the same ECG set

🗣️ Discussion

Not All Occlusions Meet STEMI Criteria

The traditional STEMI vs NSTEMI framework is increasingly being challenged by the OMI vs NOMI paradigm, which focuses on identifying acute coronary occlusion rather than relying solely on ST-segment elevation thresholds. Multiple studies have demonstrated that approximately one-third of patients classified as NSTEMI have a completely occluded coronary artery at angiography, and these patients may experience mortality rates comparable to those with classic STEMI. [8-10] This suggests there is a substantial subset of patients who could benefit from earlier cath lab activation despite not meeting traditional STEMI criteria. Recognizing these subtle ECG patterns requires careful scrutiny and expertise, and the findings of this study suggest that AI-assisted ECG interpretation may help clinicians identify these occlusion patterns that are frequently missed by physicians alone.

Different Specialties, Different Priorities

One interesting finding from this study is that emergency physicians and cardiologists performed almost identically overall, with diagnostic accuracy of roughly 66% for both groups. However, their error patterns differed in ways that reflect their clinical roles. Emergency physicians demonstrated higher sensitivity for identifying STEMI-equivalent ECGs, whereas cardiologists demonstrated higher specificity for STEMI mimics. This likely reflects differing priorities: emergency physicians are generally more focused on not missing an occlusion, while cardiologists are more focused on avoiding unnecessary cath lab activations. The high rate of cath lab activation for the Wellens case by both groups further illustrates evolving clinical thinking, with most physicians recognizing Wellens syndrome as a STEMI-equivalent that warrants urgent intervention rather than delayed evaluation.

ECG Patterns That Still Challenge Experienced Clinicians

The study also highlights specific ECG patterns that remain challenging even for experienced clinicians. Hyperacute T-wave OMI and RBBB with fascicular block generated the greatest disagreement between emergency physicians and cardiologists, suggesting these patterns are particularly prone to diagnostic uncertainty and inter-specialty debate. Importantly, this was not a group of novice interpreters—participants were experienced physicians with a median of 7 years of practice among emergency physicians and 15 years among cardiologists—making the diagnostic difficulty of these ECG patterns even more notable. Interestingly, physicians performed well in identifying several classic STEMI mimics such as LVH and benign early repolarization, but accuracy dropped substantially when bundle branch blockswere present. These findings suggest that conduction abnormalities combined with ischemic patterns may represent one of the important ongoing educational gaps in ECG interpretation.

Potential Clinical Role for AI

Perhaps the most striking finding was the magnitude of difference between physicians and the AI model. Physicians missed 41% of true OMIs and overcalled 32% of non-OMIs, whereas the Queen of Hearts AI missed only 11% and overcalled 11%. While this study was conducted in a controlled environment with a small number of selected ECGs, the results suggest a potential clinical impact if these findings hold in real-world practice. Improved detection of subtle OMI patterns could reduce missed occlusions while simultaneously decreasing unnecessary cath lab activations. In theory, this could translate to better patient outcomes and more efficient use of cardiology resources. Rather than replacing physician interpretation, tools like QoH may ultimately function best as decision support systems, helping clinicians recognize complex ECG patterns that are difficult even for experienced physicians to consistently identify.

State of the Evidence

The Queen of Hearts AI model has now been evaluated in at least six recent peer-reviewed studies, including large international validation cohorts, real-world cath lab activation registries, and physician–AI comparison studies.

Study (Year)	Design	Dataset / Patients (n)	Study Groups / Comparison	Primary Outcome	Key Findings
Herman et al. (2023)	Multicenter international validation	~18,000 ECGs	QoH AI vs STEMI criteria vs ECG experts	AI accuracy 90.9%, sensitivity 80.6%, specificity 93.7% for OMI detection	AI significantly improved detection of occlusion MI compared to use of STEMI criteria
Cooper et al. (2025)	Retrospective STEMI activation cohort	304 STEMI pathway activations	QoH AI vs STEMI criteria	Sensitivity 89.2% vs 68.3%; specificity 72.9% vs 51.7%; accuracy 82.9% vs 61.8%	AI correctly identified 86/118 (73%) of false-positive cath lab activations
Karim et al. (2025)	Retrospective case series	42 OMI patients (78 ECGs)	QoH AI vs conventional ECG algorithms	AI detected OMI in 72% of first ECGs labeled “normal” by computer interpretation	Demonstrates ability of AI to identify occlusions missed by conventional ECG algorithms as “normal”
Shroyer et al. (2025)	Cross-sectional physician vs AI study	95 physicians interpreting 18 ECGs	Emergency physicians vs cardiologists vs QoH AI	AI accuracy 88.9% vs physicians 65.6% (p<0.001)	Missed OMI 11% vs 41%; unnecessary cath activations 11% vs 32%
Meyers et al. (2025)	Retrospective substudy of DOMI-ARIGATO cohort	808 patients with ACS; 53 acute LAD TIMI-0 occlusions analyzed	QoH AI vs STEMI criteria vs expert interpretation	STEMI criteria missed 38% of acute LAD occlusions on the first ECG	Both AI and expert ECG interpretation detected 100% of LAD occlusions on the first ECG in cases missed by STEMI criteria (20 cases)
Herman et al. (2026)	Multicenter registry validation study	Multicenter cohort of 1032 emergent CCL activations	Retrospective QoH AI analysis applied to real-world STEMI activation casesa	Sensitivity 92% vs 71% for detecting true STEMI/OMI	AI markedly reduced false-positive STEMI activations by reclassifying 277 of 306 (91%) biomarker-negative FPAs correctly.

📘 Author's Conclusion

“QoH AI significantly outperformed physicians, suggesting a potential to inform cath lab activation processes that improve patient care and cardiology resource utilization.”

💬 Our Conclusion

In this study, the QoH AI system demonstrated higher diagnostic accuracy than both emergency physicians and cardiologists when interpreting challenging STEMI-equivalent and STEMI-mimic ECG patterns. This is not the first study demonstrating robust performance of this AI model, and taken together the available evidence suggests that AI-assisted ECG interpretation may be ready for use as an adjunct to physician interpretation, helping clinicians recognize subtle occlusion patterns that are frequently difficult to detect.

🚨 Clinical Bottom Line

Once FDA approved, the Queen of Hearts will be ready for clinical use as tool to support physicians in ECG interpretation.

👉 FAQ

What is the Queen of Hearts AI ECG model?
The Queen of Hearts (QoH) is an AI ECG interpretation tool designed to identify patterns consistent with occlusive myocardial infarction (OMI), including cases that may not meet traditional STEMI criteria.
Can AI outperform physicians on STEMI-equivalent and STEMI-mimic ECGs?
In this study, the QoH AI model demonstrated higher overall diagnostic accuracy than both emergency physicians and cardiologists when interpreting challenging STEMI-equivalent and STEMI-mimic ECGs.
What are common STEMI-equivalent ECG patterns?
Common STEMI-equivalent patterns include posterior MI, de Winter T waves, hyperacute T waves, modified Sgarbossa-positive left bundle branch block or paced rhythm, and other subtle findings that suggest acute coronary occlusion despite the absence of classic STEMI criteria.
What are common causes of STEMI-mimic ECG patterns?
Common STEMI mimics include left ventricular hypertrophy, early repolarization, bundle branch blocks, old myocardial infarction with persistent ST elevation, and Brugada pattern. Other conditions such as takotsubo cardiomyopathy and myocarditis can also create similar ECG appearances.
Can AI improve cath lab activation decisions?
AI may help clinicians better recognize subtle occlusion patterns and distinguish true OMI from mimics, which could reduce both missed OMIs and unnecessary cath lab activations when used as an adjunct to physician interpretation.

📚 References

Bhatt DL, Lopes RD, Harrington RA. Diagnosis and Treatment of Acute Coronary Syndromes: A Review. JAMA. 2022;327(7):662–675.
Rao SV, O’Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2025;85(22):2135-2237.
Writing Committee, Kontos MC, de Lemos JA, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022;80(20):1925-1960.
Kola M, Shuka N, Meyers HP, Zaimi Petrela E, Smith SW. OMI/NOMI: Time for a New Classification of Acute Myocardial Infarction. J Clin Med. 2024;13(17):5201. Published 2024 Sep 2.
Agrawal A, Lu M, Kanjanahattakij N, et al. ECG clues for false ST-segment elevation myocardial infarction activations. Coron Artery Dis. 2019;30(6):406-412.
Larson DM, Menssen KM, Sharkey SW, et al. “False-Positive” Cardiac Catheterization Laboratory Activation Among Patients With Suspected ST-Segment Elevation Myocardial Infarction. JAMA. 2007;298(23):2754–2760.
Herman R, Mumma BE, Hoyne JD, et al. AI-Enabled ECG Analysis Improves Diagnostic Accuracy and Reduces False STEMI Activations: A Multicenter U.S. Registry. JACC Cardiovasc Interv. 2026;19(2):145-156.
Ricci F, Martini C, Scordo DM, et al. ECG Patterns of Occlusion Myocardial Infarction: A Narrative Review. Ann Emerg Med. 2025;85(4):330-340.
Hung CS, Chen YH, Huang CC, et al. Prevalence and outcome of patients with non-ST segment elevation myocardial infarction with occluded “culprit” artery – a systemic review and meta-analysis. Crit Care. 2018;22(1):34. Published 2018 Feb 9.
Khan AR, Golwala H, Tripathi A, et al. Impact of total occlusion of culprit artery in acute non-ST elevation myocardial infarction: a systematic review and meta-analysis. Eur Heart J. 2017;38(41):3082-3089.

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter/X: @EMSwami), Propersi, DO (X:@Marco_propersi)

👤 Guest Authors

Joseph Bove, DO FAAEM

Associate Director Emergency Medicine, Co-Director of the Emergency Medicine Residency Clerkship

St. Joseph’s University Medical Center Paterson, New Jersey

Anika Suri, MD

PGY 3 Emergency Medicine Resident

Saint Joseph’s University Medical Center Paterson, New Jersey

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The post The Queen of Hearts Returns: AI vs Physicians in STEMI-Equivalent and STEMI-Mimic ECGs appeared first on REBEL EM - Emergency Medicine Blog.

Clinical Conundrum: Is Acetaminophen Safe in Pregnancy?

Anand Swaminathan — Wed, 18 Mar 2026 11:00:57 +0000

👉 Bottom Line Up Top

Acetaminophen is the safest choice for the treatment of pain and/or fever in pregnancy. There is no clear evidence of a relationship between acetaminophen use in any trimester of pregnancy and fetal developmental issues.

🤕 Case

A 25 year old G1P0 woman at 27 weeks gestation presents with 2 days of fever, cough and nasal congestion. Vital signs are significant for a temperature of 101.2 °F and the patient’s exam is otherwise unremarkable. You diagnose her with a viral syndrome and recommend rest, fluids and acetaminophen for fever. However, the patient expresses reluctance in taking acetaminophen due to reported links with the development of autism for her fetus.

🗣️ What Your Gut Says

Acetaminophen is fine in pregnancy, right?

📝 Introduction

In the first trimester, fever is associated with increased risk of birth defects such as cleft lip and palate, as well as serious neural-tube defects such as spina bifida and anencephaly. In late pregnancy, fevers can boost the risk of miscarriage, stillbirth, and preterm birth (Antoun 2021). Acetaminophen is the most commonly used antipyretic/analgesic medications with up to 62% of women using it during pregnancy (Bandli 2020). The drug does cross the placenta making it important to research fetal effects, particularly neurodevelopmental disorders (NDDs) including autism, ADHD and intellectual disability. For decades, the American College of Obstetrics and Gynecology (ACOG) has recommended acetaminophen as the safest antipyretic/analgesic during pregnancy (ACOG 2021).

📈 What The Evidence Says

Unfortunately, the majority of data available on the topic is of low to moderate quality. Because it would be unethical to perform a randomized controlled trial, we are left with observational cohort studies. Regardless of how well designed these studies are, they cannot show a causal link.

Pearl #1: There is NO data showing a causal relationship between acetaminophen exposure and the development of NDDs.

A recent publication combining data from observational studies touted a consistent association between acetaminophen exposure and NDDs. However, this publication contains a number of methodological flaws that bias the results (The SGEM).

The best data available comes from a Swedish national database (Ahlqvist 2024). The study looked at over 185,000 children who were exposed to acetaminophen during pregnancy and found a small increase in NDDs in that group. However, after comparing exposed patients to siblings (sibling control analysis) the association disappeared. Additionally, the researchers did not find any association between increasing doses of acetaminophen exposure and NDDs. The authors conclude,

“Acetaminophen use during pregnancy was not associated with children’s risk of autism, ADHD, or intellectual disability in sibling control analysis. This suggests that associations observed in other models may have been attributable to familial confounding.”

A large Japanese birth cohort study (> 217,000 children) echoes these findings noting that small differences in NDDs are likely attributable to confounding and misclassification (Okubo 2025).

Based on this data, ACOG continues to recommend acetaminophen in pregnancy as the safest treatment for pain and fever (ACOG 2025).

💬 Our Conclusion

The best available data shows no association between acetaminophen exposure in pregnancy and neurodevelopmental disorders including autism.

🚨 Clinical Bottom Line

Clinicians should continue to feel safe in treating pregnant patients with acetaminophen and pregnant patients should feel safe taking acetaminophen for pain or fever during any phase of pregnancy.

📚 References

Antoun S et al. Fever during pregnancy as a risk factor for neurodevelopmental disorders: results from a systematic review and meta-analysis. Mol Autism 2021; 12(1): 60. PMID: 34537069
Bandoli G, Palmsten K, Chambers C. Acetaminophen use in pregnancy: Examining prevalence, timing, and indication of use in a prospective birth cohort. Paediatr Perinat Epidemiol. 2020; 34(3):237-246. PMID: 31696962
Prada D et al. Evaluation of the evidence on acetaminophen use and neurodevelopmental disorders using the Navigation Guide methodology. Environ Health 2025; 24(1); 56. PMID: 40804730
Ahlqvist VH et al. Acetaminophen Use During Pregnancy and Children’s Risk Of Autism, ADHD, And Intellectual Disability. JAMA 2024; 331 (14): 1205-14. PMID: 38592388
Okubo Y et al. Maternal Acetaminophen Use and Offspring’s Neurodevelopmental Outcome: A Nationwide Birth Cohort Study. Pediatr perinat epidemiol 2025. PMID: 40898607

Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Marco Propersi, DO (X: @Marco_Propersi)

👤 Associate Editor

Anand Swaminathan

MD, MPH

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The post Clinical Conundrum: Is Acetaminophen Safe in Pregnancy? appeared first on REBEL EM - Emergency Medicine Blog.

Diastology: Use E/e’ to Estimate Left Atrial Pressure

Neha Kumrah DO, Joseph Felice MD — Mon, 09 Mar 2026 11:00:24 +0000

📌 Key Points

🎯 POCUS diastology answers one ED question: Is left atrial pressure (LAP) elevated right now? (not “diagnose diastolic dysfunction”)
📈 E/e’ estimates LAP using mitral inflow E (PW Doppler) and annular e’ (TDI) from an apical 4-chamber view
Interpretation: E/e’ ≥ 14 → likely elevated LAP (supports cardiogenic pulmonary edema); ≤ 8 → LAP likely normal; 8–14 → indeterminate
⚡ Fast + actionable: With a decent apical view, E and e’ can be captured in ~60 seconds to guide diuresis/afterload reduction vs non-cardiac pathways
⚠️ Use context: E/e’ performs best in reduced EF and can be confounded by MR/MS, tachycardia, and BiPAP/PEEP

📝 Introduction

A formal echocardiographic diagnosis of diastolic dysfunction is multivariable, nuanced, and not an ED priority in most acute dyspnea cases.

In the emergency setting, the bedside question that changes management is simpler:

Is left atrial pressure (LAP) elevated right now?

Elevated LAP is the physiologic substrate for cardiogenic pulmonary edema and the target for therapies like diuresis and afterload reduction. “POCUS diastology” is a focused ultrasound approach that helps you answer that question quickly—often faster than CXR, BNP, or a “CHF vs pneumonia” radiology impression.

POCUS diastology ≠ chronic diagnosis. It’s a real-time estimate of filling pressure to guide acute resuscitation.

🩺 Case: Acute dyspnea with an unclear story

A 72-year-old obese woman presents with severe dyspnea. EMS placed her on BiPAP for hypoxia. She’s uncomfortable, with bibasilar crackles and faint wheezing.

Vitals: BP 166/98, HR 110, RR 22, SpO₂ 86%.

Your differential is broad:

Pneumonia?
COPD exacerbation?
Flash pulmonary edema?

CXR: “Atypical pneumonia vs pulmonary edema” (not helpful)

Labs: WBC 14.1, pBNP 320 (still not helpful)

Your bedside ultrasound:

The IVC is dilated → tempting to anchor on CHF
But you pause: COPD on BiPAP can also dilate the IVC via increased intrathoracic pressure and RV loading.

You obtain a cardiac view:

EF looks normal → but that doesn’t rule out elevated filling pressures (hello HFpEF physiology)

Does this settle it? Can we give this patient bronchodilators, steroids and antibiotics?

🎯 The goal of POCUS diastology

You’re not trying to label the patient with “diastolic dysfunction.”

You’re asking one resuscitation question:

Is LAP elevated in this moment?

If yes → cardiogenic pulmonary edema becomes much more likely and diuresis/afterload reduction moves up the priority list.

If no → search hard for non-cardiogenic causes (COPD, pneumonia, PE, ARDS, etc.).

🧬 Pathophysiology Refresher

Diastolic filling depends on:

Intrinsic: LV relaxation, LV compliance, atrial contraction
Extrinsic: pericardial pressure, RV function, intrathoracic pressure (BiPAP), volume status

When the LV is stiff/noncompliant, blood backs up into the LA → LAP rises → pressure transmits to the pulmonary vasculature → pulmonary edema.

This can happen even with normal EF.

🛰️ The POCUS method: E/e’ to estimate LAP

To estimate LAP, you measure:

E wave: early diastolic mitral inflow velocity (PW Doppler)
e’ wave: early diastolic mitral annular tissue velocity (TDI)

Then calculate:

E/e’ = Mitral inflow (E) ÷ Mitral annular velocity (e’)

This ratio is used as a noninvasive estimate of LV filling pressures and correlates with formal echocardiography-derived estimates.

Example formula cited in echo literature:

LAP ≈ (1.24 × E/e’) + 1.9

Important nuance (keep your wording tight):

E/e’ can be used in both preserved and reduced EF, but performance is generally stronger in reduced EF. In normal EF, treat E/e’ as a high-value clue rather than a standalone verdict—especially in the intermediate zone.

😅 Spectral Doppler feels intimidating (so let’s make it practical)

A lot of POCUS users avoid Doppler because it feels “advanced.”

Here’s the reality:

If you can obtain a decent apical 4-chamber, you can obtain E and e’.

Once the view is good, capturing waveforms is straightforward.

🛠️ Step-by-step: How to get E and e’ in under 60 seconds

Mitral inflow E wave (PW Doppler)

1. Obtain an apical 4-chamber view

Best view: interventricular septum appears vertical

2. Place the sample gate at the mitral leaflet tips

If view isn’t perfectly parallel with flow of blood, consider using Doppler angle correction.

3. Activate Pulse Wave Doppler

4. Freeze the tracing & Identify:

E = early filling wave
A = atrial contraction wave

5. Measure peak E velocity

Take the average of 3 measurements to be more precise.

Mitral e’ wave (Tissue Doppler)

1. From the same apical 4-chamber view, switch to TDI & place the gate at the septal mitral annulus

2. Identify e’ (early diastolic annular motion)

To accommodate the inflow of blood, the annulus moves basally and away from the probe.
The waveforms will always be negatively deflected

3. Measure peak e’ velocity

Take the average of 3 measurements to be more precise.

🧾 Interpreting E/e’ (cutoffs)

🚑 Resus scenario: back to the bedside

You obtain your images:

E wave = 110 cm/s
e’ = 5 cm/s
E/e’ = 22

That strongly supports elevated LAP and therefore cardiogenic pulmonary edema physiology.

Action: You prioritize IV diuresis (and consider afterload reduction as appropriate), while avoiding reflexive bronchodilators/steroids/antibiotics as your default path.

Result: The patient’s breathing improves within 30 minutes—less diagnostic drift, fewer unnecessary meds, and potentially fewer intubations.

👉 FAQ

What is E/e’ on ultrasound?
E/e’ is the ratio of mitral inflow (E wave) to mitral annular tissue velocity (e’). It’s used to estimate LV filling pressures and left atrial pressure.
What E/e’ value suggests elevated filling pressure?
An E/e’ ≥ 14 supports elevated LAP; ≤ 8 suggests normal LAP; 8–14 is indeterminate and should be integrated with other findings.
Can E/e’ be used with preserved EF (HFpEF)?
Yes, but it’s generally less reliable than in reduced EF. In HFpEF, treat E/e’ as a strong clue—especially when very high—while integrating the full clinical picture.
Why not just use BNP or CXR?
BNP and CXR can be nonspecific or delayed. E/e’ targets physiology (filling pressure) at the bedside when it matters most.
Why aren’t we talking about the E/A ratio?
The E/A ratio can be misleading because of the phenomenon of pseudonormalization. In grade 2 diastolic dysfunction the E/A ratio reverts from abnormal to normal; this can be a clinical trap.

🚨 Bottom Line

POCUS diastology doesn’t diagnose chronic diastolic dysfunction—it estimates real-time LAP
E/e’ ≥ 14 supports elevated LAP and cardiogenic pulmonary edema physiology
E/e’ ≤ 8 makes elevated LAP less likely—pursue alternative causes of dyspnea
With a decent apical view, E and e’ are obtainable fast
The right call can be diuretics instead of antibiotics, and a better trajectory for your patient

🏁 Clinical Bottom Line

When you suspect pulmonary edema, don’t stop at lung ultrasound or BNP. Reach for your apical view, capture E and e’, and ask the real question:

Is the left atrial pressure elevated enough to flood the lungs?

With POCUS diastology, you’ll have the answer in under 60 seconds.

📚 References

Greenstein YY, Mayo PH. Evaluation of Left Ventricular Diastolic Function by the Intensivist. Chest. 2018;153(3):723-732. PMID: 29113815
Del Rios et al. Emergency physicians used average e’ (<9 cm/s) alone to assess for diastolic dysfunction. Compared to cardiology standard, agreement was 85.4% (κ = 0.74). Shows the feasibility of streamlined approaches in real ED practice. J Ultrasound Med. 2018 May;37(5):1237-1243
ASE/EACVI 2025 Guidelines – The most recent comprehensive guidance on echocardiographic assessment of diastolic function, re-emphasizing the centrality of E/e’ in estimating LAP. J Am Soc Echocardiogr. 2025 Apr;38(4):278-317

Post Peer Reviewed By: Marco Propersi, DO (X: @Marco_propersi), Mark Ramzy, DO (X/IG: @MRamzyDO), Jailyn Avilla, MD (Insta: @jailyn_avi)

👤 Guest Authors

Joseph Felice MD FPD-AEMUS

APD, Ultrasound Division

Vassar Brothers Hospital Poughkeepsie, New York

Neha Kumrah, DO

PGY 1 Emergency Medicine Resident

Vassar Brothers Hospital Poughkeepsie, New York

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The post Diastology: Use E/e’ to Estimate Left Atrial Pressure appeared first on REBEL EM - Emergency Medicine Blog.

REBEL MIND – How to Sleep When the World Says You Can’t

Mark Ramzy — Wed, 04 Mar 2026 12:00:21 +0000

🔑Key Points

Try the coffee nap! Where you combine caffeine and a 30-minute nap to then have that boost energy and alertness by the time it kicks in.

💤 Sleep isn’t optional—it’s crucial for memory, mood regulation, and physical recovery. It is fundamentally different from rest

❌ Replacing sleep with caffeine isn’t effective and can have negative health impacts. Make getting enough sleep a priority

🌞 Sunlight exposure is important for maintaining circadian rhythms and sleep quality. This applies even if you work as a nocturnist

💡 Creating a personalized sleep system enhances quality and consistency. It gives you back control of a schedule that you may feel like is out of your hands.

🧩 If you’ve tried these strategies and you’re still struggling, consider true sleep pathology (insomnia, shift work disorder, sleep apnea) and get help—this is not a “be tougher” problem.

🩺 Better sleep isn’t just about feeling good; it’s directly tied to error reduction, patient safety, and longevity in EM/ICU careers.

Click here for Direct Download of the Podcast.

👀Previously Covered and Related Content:

- REBEL Core Cast: Sleep Hygiene
- REBEL MIND: Rest Is Not Sleep: The Seven Dimensions of True Recovery
- Rebellion in EM: Care For Yourself – Sleep Hygiene
- First10EM: Some Evidence For Working Night Shifts
- REBEL MIND: Dunning Kruger Effect

📝 Introduction

Today we are exploring the imperative topic of rest and why it’s not just about sleeping. The second of a two part series, hosted by Dr. Mark Ramzy with guests Dr. Maureen Aiad and Dr. Amil Badoolah, continue our discussion but this time on the multifaceted nature of sleep, how it serves as medicine and how we can use our tools deliberately to get more of it!

Cognitive Question

How would your clinical performance, patience with families, and long-term career sustainability change if you treated sleep as a non-negotiable clinical intervention rather than a flexible “nice-to-have”?

💤How is Sleep Different From Rest?

1. Rest reduces load; sleep repairs systems

- We previously talked about the 7 types of rest and you can check that out here
- Examples of physical rest include: pausing tasks, stepping away from the monitor, taking a walk, stretching, breathing, journaling, connecting with a colleague. This lightens your cognitive/emotional burden.
- Sleep is fundamentally different in that it’s an active biologic process that helps:
  - - Consolidates memory and learning (yes, including the tough cases from last night).
    - Regulates mood, impulse control, and emotional reactivity.
    - Supports immunity, metabolic health, and cardiovascular function.
    - Repairs tissue, replenishes neurotransmitters, and fine-tunes neural networks.
- You can have “rested but underslept” days (you took breaks but got 4 hours in bed), and “slept but unrested” days (you got hours, but all junk sleep). Both matter, but they are not interchangeable.

2. Sleep architecture vs. “knocking out”

- True restorative sleep cycles through NREM and REM in predictable patterns.
- Alcohol, late caffeine, and fragmented nights may help you fall asleep faster but:
  - Suppress REM.
  - Shorten deep sleep.
  - Increase awakenings and light sleep.
- The result: you technically slept, but your brain didn’t get the “software updates” it needed.

Biology isn’t built for your schedule

- Circadian rhythms were designed for light-day / dark-night cycles, not:
  - 10 pm–7 am ED shifts.
  - 24-hour calls.
  - 6 nights in a row followed by days.
- Your body can adapt partially, but not instantly and not perfectly. That’s why:
  - You can feel “jet-lagged” even when you haven’t traveled.
  - Sleep before and after nights feels odd and fragile.
Recognizing that “this is biologically unnatural” is key: you’re not weak; you’re fighting physiology.

🏥How This Applies to the Emergency Department or ICU?

Performance & safety
- Sleep deprivation:
  - Slows reaction time and increases error rate.
  - Impairs risk assessment and complex decision-making.
  - Drops your frustration tolerance with consultants, families, and staff.
- In both emergency medicine and critical care, that translates into:
  - Anchoring on the wrong diagnosis.
  - Missing subtle clinical changes.
  - Snapping at a tech, nurse or resident and damaging team culture.
Chronic health for chronic shift work
Long-term sleep disruption is associated with:
- Hypertension, diabetes, obesity.
- Depression, anxiety, burnout.
- Arrhythmias (e.g., AFib) and increased stroke risk.
- Possibly increased all-cause mortality.
You’re already in a high-stress, high-exposure specialty. Chronically poor sleep amplifies that risk profile and can end a career early—or make you miserable while you’re still in it.
Culture of “heroics” vs. health
- Skipping sleep to pick up extra shifts, late meetings, or “just one more note” is often praised.
- We rarely celebrate:
  - The attending who says “no” to a 2 pm meeting post-nights.
  - The resident who defends their blackout-curtains-and-earplugs routine.

🛏️Different Ways to Improve Your Sleep

- Clarify your “sleep non-negotiables”
  - Decide how many hours you realistically need to function (e.g., 7–9 on off days, realistic blocks on nights).
  - Treat those hours as you would a procedure time—blocked, protected, and respected.
  Use caffeine like a drug, not a reflex
  - Aim for ≤ 2 cups equivalent on most days.
  - Avoid caffeine within 4–6 hours of your planned sleep time (remember: it can hang around up to 12 hours).
  - Consider scheduling caffeine for:
    - Early in the shift for alertness.
    - Strategic “coffee naps” (see below), not late-night chugging.
  Respect alcohol’s impact on sleep
  - Recognize that even small to moderate doses degrade sleep architecture.
  - Avoid using alcohol as a “sleep aid”—you’ll fall asleep faster but sleep worse.
  - If you do drink, separate it from bedtime and keep it modest.
  Optimize food and fluid timing
  - Hydrate consistently on shift, but taper fluids ~4 hours before bed to reduce nocturnal bathroom trips.
  - Avoid heavy, spicy, or large meals within 2–3 hours of sleep to decrease reflux and discomfort.
  - Plan a light, balanced “pre-sleep” snack if going to bed hungry keeps you awake.
  Move your body (but not right before bed)
  - Regular exercise improves sleep depth and latency.
  - Try to avoid intense workouts within 2 hours of bedtime.
  - On shift: micro-movement (stairs, brisk walks between pods, quick stretch sessions) can help alertness without wrecking sleep later.
  Control light exposure
  - Maximize sunlight or bright light after waking (even if that’s 3–4 pm after a night).
  - Minimize bright light and screens before sleep:
    - Dim lights.
    - Use night mode/blue-light filters if you must scroll.
  - For daytime sleep:
    - Use blackout curtains, tinfoil, cardboard, or sleep masks.
      - Yes seriously use tinfoil if you have to, we talk about it on the podcast episode!
    - Aim for “I might be blind” darkness—so dark you can’t see your hand in front of your face.
  Dial in your sleep environment
  - Cool room temperature (fan or AC if possible).
  - White noise or sound machine to mask household/traffic noise.
  - Earplugs and eye masks as needed.
  - Bed used primarily for sleep (and sex)—not for charting, doom scrolling, or email.
  Strategic power naps
  - Keep naps ≤ 20–30 minutes to avoid sleep inertia.
  - Prefer early-afternoon or pre-night-shift naps.
  - Coffee nap strategy:
    - Drink a small coffee.
    - Immediately lie down for a 20–30 min nap.
    - Wake up as the caffeine kicks in, combining nap benefit + stimulant.
  Thoughtful melatonin use
  - Remember melatonin is a hormone, not a vitamin gummy.
  - Lower doses often work as well as (or better than) large OTC doses.
  - Use it intentionally and intermittently, not as a crutch every night.
  - Over-reliance may reduce your own natural production and its effectiveness over time.
  Build pre-sleep rituals
  - Repeated, calming habits signal your body it’s time to downshift:
    - Warm shower, gentle stretching, or yoga.
    - Guided breathing or body scan.
    - Brief journaling or “brain dump” of tasks to get them out of your head and onto paper.
  Protect from pathologic patterns
  - If despite consistent effort you:
    - Snore heavily, stop breathing, or gasp in sleep.
    - Feel excessively sleepy driving home or at work.
    - Cannot fall asleep or stay asleep for weeks to months.
  Consider evaluation for sleep apnea, insomnia, or shift-work sleep disorder with your physician or sleep specialist.

⏩Immediate Action Steps for Before/During/After Your Next Shift

1. **Before the Shift**:

- Plan a 20–90 minute nap before your first night shift (many clinicians find 3–5 hours earlier in the day is ideal).
  - I treat ED and ICU shifts very differently. I always sleep 3-5 hours before my night shifts aiming for the full 5 (sometimes 6 or more) hours for my ED shifts because you always have to be “on”. Depending on the ICU I’m working in, I may have a bit more downtime so 3 to 5 hours is plenty.
- Set a caffeine plan: decide in advance when your last dose will be (e.g., none after 2–3 am if sleeping at 8–9 am).
- Tell your household, “This is my sleep block” and agree on a plan for kids, pets, deliveries, etc.
On my calendar, I completely block off time called “Pre-call sleep” so no meetings can be scheduled and then put my phone in airplane mode

2. **During the Shift**

- Hydrate early; taper fluids in the last 3–4 hours of your shift
- Eat something light but adequate; avoid “last-minute” heavy meals right before sign-out.
- Build in micro-breaks and movement: one or two short walks, a few stretches, even a quick stair run if safe.
- Get outside or near a window for a few minutes of light exposure if possible.

3. **After the Shift**

- On the way home:
  - Use sunglasses to reduce bright morning light if you’re aiming for sleep soon.
  - Avoid “just checking” email or messages; shift into wind-down mode.
- At home:
  - Do a brief, calming decompression (shower, light snack, 10–15 minutes of low-stimulation TV or reading).
  - Make your room cold, quiet, and dark (blackout curtains, tinfoil/cardboard, white noise, fan).
  - Put your phone on Do Not Disturb and physically place it away from the bed.
    - On my calendar, I completely block off time called “Post-call sleep” so again no meetings can be scheduled and then I personally don’t just put my phone on Do Not Disturb but rather in airplane mode and WIFI OFF
- If you can’t sleep after ~20–30 minutes:
  - Get out of bed, do something calming in dim light (breathing, gentle stretching, journaling).
  - Return to bed when sleepy—this trains your brain to associate bed with sleep, not frustration.

Conclusion

Rest and sleep are both critical—but they’re not interchangeable. Rest helps you step out of the constant “on” of our jobs, while sleep is the biological intervention that restores your ability to show up safely and sustainably. Rest ≠ sleep. Rest reduces load; sleep repairs your brain and body. You need both, on purpose.

As EM and ICU clinicians, we’re trying to perform formula-one-level medicine with engines that often only see half their maintenance. You won’t fix shift work. You can build a sleep system that respects your biology, your schedule, and your life at home.

That system starts with valuing sleep, then prioritizing it, personalizing it, trusting the process when it’s imperfect, and actively protecting both your routine and your mindset.

🚨 Clinical Bottom Line

Sleep is medicine. Shift work is biologically unnatural. Struggling does not mean you’re weak; it means you’re human fighting physiology. Use your tools deliberately. Caffeine, naps, light, food, movement, melatonin, and environment can be leveraged—or can quietly sabotage you. Build and defend a personalized sleep routine. Communicate it, normalize it, and protect it from casual encroachment. You can’t control every trauma, code, or admission—but you can control how seriously you take your own recovery. Your patients, your team, and your future self all benefit when you do.

Meet the Authors

Mark Ramzy, DO

Co-Editor-in-Chief

Cardiothoracic Intensivist and EM Attending RWJBH / Rutgers Health, Newark, NJ

Maureen Aiad, DO

Assistant Professor of Emergency Medicine

NYU Grossman Long Island School of Medicine, New York

Amil Badoolah, DO

Assistant Professor of Emergency Medicine

NYU Grossman Long Island School of Medicine, New York

REBEL Core Cast 119.0 – Sleep Hygiene

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The post REBEL MIND – How to Sleep When the World Says You Can’t appeared first on REBEL EM - Emergency Medicine Blog.

The PEERLESS Trial: Large-Bore Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis in Intermediate-Risk PE

Meghan Dillan MD, Maren Leibowitz MD — Mon, 02 Mar 2026 12:00:40 +0000

🗝️ Key Points

🫁️ In intermediate-risk PE patients already selected for catheter-based therapy, LBMT (FlowTriever) beat CDT on the 5-component win ratio (driven largely by ICU utilization).
🧮🏥 When ICU admission/ICU LOS were removed (4-component win ratio), the difference was no longer statistically significant, suggesting the primary result is heavily influenced by system-level practices.
🩸🧠⚰️ Mortality, intracranial hemorrhage, and major bleeding were not statistically different between LBMT and CDT.

📝 Introduction

The optimal treatment strategy for intermediate-risk (submassive) pulmonary embolism (PE) remains controversial. These patients are not in shock, but they have right ventricular (RV) dysfunction and myocardial injury, which are associated with higher risk for clinical decompensation and adverse outcomes.^1-3

The standard of care for intermediate-risk PE is therapeutic anticoagulation, though select patients may be considered for escalation to thrombolysis or catheter-based therapies.⁴Systemic fibrinolysis can reduce hemodynamic decompensation but carries substantial bleeding risk. In PEITHO, fibrinolysis reduced decompensation but increased major hemorrhage and stroke.1 The MOPETT trial explored “safe-dose” systemic thrombolysis and demonstrated improvements in pulmonary pressures without a clear mortality benefit.⁵

Catheter-based approaches aim to improve RV strain and clot burden while potentially reducing bleeding compared with systemic lysis. CDT has demonstrated physiologic improvements and low intracranial hemorrhage rates in selected populations (e.g., SEATTLE II).⁶ Ongoing trials (HI-PEITHO and PE-TRACT) will further define whether catheter-based strategies improve outcomes compared with anticoagulation alone.^7,8

Before PEERLESS, there were no high-quality randomized trials directly comparing CDT to large-bore mechanical thrombectomy (LBMT) in intermediate-risk PE.

🧾 Paper

Jaber, Wissam A et al. “Large-Bore Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis in the Management of Intermediate-Risk Pulmonary Embolism: Primary Results of the PEERLESS Randomized Controlled Trial.” Circulation vol. 151,5 (2025): 260-273. PMID: 39470698

️ What They Did

CLINICAL QUESTION

In adult patients with intermediate-risk PE selected for catheter-based intervention, does LBMT compared with CDT improve a prioritized in-hospital composite outcome and reduce adverse clinical events?

STUDY DESIGN

Design: Prospective, international, multicenter, open-label randomized controlled device trial (NCT05111613)
Randomization: 1:1 LBMT vs CDT, stratified by VTE-BLEED score (≥2 vs <2)
Sites: 60 international sites across multiple specialties and practice environments
Follow-up: 24 hours (±8), hospital discharge, and 30 days (with a +15-day visit window)

POPULATION

Inclusion Criteria:

Age ≥18 years
Intermediate-risk PE per European Society of Cardiology (ESC) criteria10
RV dilation/dysfunction on CTPA or echocardiography
Proximal filling defect in ≥1 main or lobar pulmonary artery
Symptom duration ≤14 days
Intervention planned ≤72 hours from diagnosis (or from transfer arrival)
At least one of the following:
- Elevated troponin
- History of heart failure
- History of chronic lung disease
- HR ≥110 bpm
- SBP <100 mmHg
- RR ≥30 breaths/min
- O2 saturation <90%
- Syncope related to PE
- Elevated lactate

Exclusion Criteria:

Unable to receive anticoagulation
Right-sided heart thrombus-in-transit
Life expectancy <30 days
Intraprocedural systolic pulmonary artery pressure ≥70 mmHg before catheter insertion

INTERVENTION & CONTROL

Intervention:

- LBMT performed using the FlowTriever System

Control:

Catheter-directed thrombolysis performed per local standard for device selection and thrombolytic dosing

OUTCOMES

Primary Outcome

Secondary Outcome

Win ratio composite at evaluation prior to discharge or at 7 days after procedure including:
- All-cause mortality
- ICH
- Major bleeding per International Society for Thrombosis and Haemostasis definition11
- Clinical deterioration or escalation to bail out therapy
- Post procedural ICU admission and LOS

Win ratio composite including the first four outcomes listed above
Each of the outcomes listed individually
Clinically relevant nonmajor bleeding events (not classified as major bleeding as above)
Change in RV:LV ratio from baseline to 24-hour visit
Modified Research Council dyspnea scores at 24-hour and 30-day visits
Pulmonary Embolism Quality of Life and EuroQol 5-Dimension 5-Level scores at the 30-day visit
Device- and drug-related serious adverse events through the 30-day visit
PE-related readmissions, all-cause readmissions, and all-cause mortality within 30 days
Total and postprocedural hospital length of stay

📈 Results

PATIENTS

💥 Critical Results

Primary endpoint: 5-component hierarchical win ratio favored LBMT vs CDT: 5.01 (95% CI 3.68–6.97; P<0.001).
Only 2 of 5 primary components differed (drivers of the win):
- Clinical deterioration/bailout therapy: 1.8% (LBMT) vs 5.4% (CDT); P=0.04
- ICU admission: 41.6% vs 98.6%
  - ICU stay >24h: 19.3% vs 64.5%
  - Post-procedural ICU utilization (major driver): P<0.001
Hard safety outcomes were similar:
- All-cause mortality (in-hospital): 0.0% vs 0.4%; P=1.00
- Intracranial hemorrhage (ICH): 0.7% vs 0.4%; P=0.62
- Major bleeding: 6.9% vs 6.9%; P=1.00
Key interpretive result: the 4-component win ratio (excluding ICU outcomes) was not significant: 1.34 (95% CI 0.78–2.35; P=0.30.

💪🏽 Strengths

Design & execution

Prospective, multicenter randomized controlled trial
Automated randomization with stratification by VTE-BLEED score, reducing selection bias
Intention-to-treat analysis preserved the benefits of randomization
External statistical oversight (BAIM Institute) strengthens credibility for an industry-sponsored trial

Generalizability

Broad mix of specialties and practice settings across 60 international sites, improving external validity

Outcome rigor

Several key endpoints were objective and less bias-prone (death, ICH, major bleeding, ICU admission)
Imaging (echo/CTPA) reviewed by a single independent, blinded physician
Independent clinical events committee adjudicated safety outcomes
Included patient-centered outcomes (dyspnea and quality-of-life measures)

Baseline balance

While the CDT arm appeared modestly higher risk (VTE-BLEED/sPESI, troponin, clot burden, dyspnea), between-group differences were not large

⚠️ Limitations

Comparators & applicability

Does not compare either strategy to anticoagulation alone (current standard of care for most intermediate-risk PE)
Patients enrolled only after being deemed “appropriate for intervention,” introducing indication/spectrum bias
Manuscript does not report how many intermediate-risk PE patients were screened but not enrolled (limits assessment of selection bias)

Bias & confounding risk

Open-label design increases risk of performance/ascertainment bias, especially for:
Clinical deterioration/escalation to bailout therapy
ICU admission and ICU LOS
Readmissions
ICU outcomes are particularly vulnerable to protocol confounding, since many centers routinely admit CDT patients to ICU for monitoring
Baseline differences suggest CDT patients may have been slightly sicker, which could influence deterioration/escalation outcomes

Intervention heterogeneity

CDT was delivered per local practice (variable catheters and thrombolytic dosing), which may:
Dilute real differences between CDT strategies
Increase between-site variability not fully captured

Endpoint construction & follow-up

Primary endpoint assessed at discharge or 7 days, which may reflect institutional practice patterns (especially ICU use)
Composite includes non-equivalent components (e.g., ICU admission/LOS vs death)
“30-day” follow-up allowed up to +15 days, increasing outcome window variability
30 days may be insufficient to detect longer-term differences

Post-randomization exclusions & transparency

49 patients excluded post-randomization due to intraprocedural systolic PA pressure ≥70 mmHg, introducing potential post-randomization bias
Trial sponsor (Inari Medical) helped design the study (conflict risk)
Data not shared for external verification, limiting reproducibility

🗣️ Discussion

In Summary

PEERLESS is the first large, international randomized trial to directly compare large-bore mechanical thrombectomy (LBMT) using the FlowTriever system versus catheter-directed thrombolysis (CDT) in intermediate-risk pulmonary embolism (PE) patients who were already deemed appropriate for catheter-based intervention. The trial’s headline result favored LBMT on the 5-component win ratio composite. Importantly, the 4-component win ratio (excluding ICU outcomes) was not significant, suggesting the primary result may be driven by ICU practice patterns.

Understanding the Win Ratio

The win ratio is a prioritized composite endpoint that compares paired patients across treatment arms, starting with the most important outcome (e.g., death). If there is a tie, the comparison moves down the hierarchy (e.g., ICH, major bleeding, then clinical deterioration, then ICU metrics). The advantage of this approach is that it can increase statistical power and reflect clinical priorities better than an unweighted composite. The tradeoff is that results can become heavily influenced when large between-group differences occur in lower-tier, protocol-sensitive outcomes—particularly in an open-label trial.

Inside the Numbers

One major limitation includes that while the LBMT arm was standardized with use of the FlowTrevier System, the CDT arm was not standardized, with variations between local standards when selecting device and thrombolytic dosing. Many institutions require ICU-level care for post-procedure monitoring of CDT, causing potential confounding bias when comparing ICU utilization. This may have ultimately influenced the win ratio when assessing the primary endpoint. Additionally, ICU admission and length of stay are not patient-oriented outcomes.

Clinical deterioration could have been influenced by small differences in patient group differences. Patients in the CDT group may have been overall sicker compared to the LBMT group, with higher VTE-BLEED and sPESI scores, more elevated troponin levels, more saddle embolus and main artery PE, higher heart rate and dyspnea scores. This may have led to higher rates of clinical deterioration in the CDT group and influence of the win ratio.

What This Does and Does Not Answer

PEERLESS compares outcomes for two interventions in patients in which further intervention beyond anticoagulation was considered to be clinically indicated. However, it does not compare either intervention to anticoagulation, which is the current standard of care. Further, it does not assist in the decision to initiate further intervention in patients with intermediate-risk PE. Additional research is needed to establish optimal practice patterns for patients with intermediate-risk PE.

📘 Author's Conclusion

“PEERLESS met its primary end point in favor of LBMT compared with CDT in treatment of intermediate-risk pulmonary embolism. LBMT had lower rates of clinical deterioration and/or bailout and postprocedural intensive care unit use compared with CDT, with no difference in mortality or bleeding.”

💬 Our Conclusion

The PEERLESS trial is the first randomized study to compare LBMT with CDT in intermediate-risk PE patients already judged to need intervention beyond anticoagulation. Although the composite primary endpoint favored LBMT, that advantage appears largely driven by clinician- and system-sensitive outcomes—clinical deterioration/escalation, ICU utilization, and readmissions—which are particularly vulnerable to bias in an open-label design. Importantly, there was no statistically significant difference in all-cause mortality between LBMT and CDT. Additional randomized trials are needed to determine whether these findings justify broad adoption of LBMT for intermediate-risk PE and to clarify how either strategy compares with anticoagulation alone.

FAQ

What is the PEERLESS trial?
A randomized trial comparing LBMT (FlowTriever) vs CDT in intermediate-risk PE patients selected for catheter intervention.
Did PEERLESS show a mortality benefit?
No—mortality was low and not statistically different between groups.
What drove the primary endpoint?
Differences in ICU admission/ICU LOS and clinical deterioration/bailout.
What is the “4-component win ratio” and why does it matter?
It excludes ICU outcomes; it was not significant, suggesting ICU practice patterns may drive the primary result.
Does this prove intervention is better than anticoagulation alone?
No—PEERLESS compares two interventions and does not include an anticoagulation-only arm.

🚨 Clinical Bottom Line

This study is the first RCT to compare interventional techniques for intermediate-risk PE, though does not clearly demonstrate superiority of LBMT compared to CDT due to concern for bias as the major driver of statistical differences in the primary outcome. It remains to be seen if intervention is superior to anticoagulation alone.

📚 References

Bouvaist H, Brenner B, Couturaud F, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370:1402-1411. PMID: 24716681
Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JSR, Huisman MV, Humbert M, Kucher N, et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)Endorsed by the European Respiratory Society (ERS). European Heart Journal. 2014;35:3033-3080. PMID: 25173341
Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123:1788-1830 PMID: 21422387
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e419S-e496S. PMID: 22315268
Sharifi M, Bay C, Skrocki L, Rahimi F, Mehdipour M, Investigators M. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” Trial). Am J Cardiol. 2013;111:273-277. PMID: 23102885
Piazza G, Hohlfelder B, Jaff MR, Ouriel K, Engelhardt TC, Sterling KM, Jones NJ, Gurley JC, Bhatheja R, Kennedy RJ, et al. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study. JACC Cardiovasc Interv. 2015;8:1382-1392. PMID: 26315743
Klok FA, Piazza G, Sharp ASP, Ní Ainle F, Jaff MR, Chauhan N, Patel B, Barco S, Goldhaber SZ, Kucher N, et al. Ultrasound-facilitated, catheter-directed thrombolysis vs anticoagulation alone for acute intermediate-high-risk pulmonary embolism: Rationale and design of the HI-PEITHO study. Am Heart J. 2022;251:43-53. PMID: 35588898
Sista AK, Troxel AB, Tarpey T, Parpia S, Goldhaber SZ, Stringer WW, Magnuson EA, Cohen DJ, Kahn SR, Rao SV, et al. Rationale and design of the PE-TRACT trial: A multicenter randomized trial to evaluate catheter-directed therapy for the treatment of intermediate-risk pulmonary embolism. Am Heart J. 2025;281:112-122. PMID: 39638275
Silver MJ, Gibson CM, Giri J, Khandhar S, Jaber W, Toma C, Mina B, Bowers T, Greenspon L, Kado H, et al. Outcomes in High-Risk Pulmonary Embolism Patients Undergoing FlowTriever Mechanical Thrombectomy or Other Contemporary Therapies: Results From the FLAME Study. Circ Cardiovasc Interv. 2023;16:e013406. PMID: 37847768
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41:543-603. PMID: 31504429
Kaatz S, Ahmad D, Spyropoulos AC, Schulman S, Anticoagulation SoCo. Definition of clinically relevant non-major bleeding in studies of anticoagulants in atrial fibrillation and venous thromboembolic disease in non-surgical patients: communication from the SSC of the ISTH. J Thromb Haemost. 2015;13:2119-2126. PMID: 26764429

Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Marco Propersi, DO (X: @Marco_Propersi)

👤 Guest Authors

Maren Leibowitz MD

Clinical Instructor

Northwestern University Department of Emergency Medicine Department of Pulmonary and Critical Care Medicine

Meghan Dillan, MD

PGY 1

Northwestern University Department of Emergency Medicine

The post The PEERLESS Trial: Large-Bore Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis in Intermediate-Risk PE appeared first on REBEL EM - Emergency Medicine Blog.

MDCalc Wars: GCS Alternatives in the ED: SMS and FOUR Score

Eric Steinberg DO, MEHP — Mon, 23 Feb 2026 12:00:40 +0000

🗝️ Key Points

- ⚡ Use SMS: When you need a fast, reliable severity snapshot and a full GCS is impractical.
- 🫁🧠 Use FOUR: When the patient is intubated or you need brainstem reflexes + breathing pattern to trend severity.
- 🗣️👀💪 Use GCS: When verbal is obtainable and you want the most familiar “common language” score.

🤕 Case

A 35 yo male patient arrives after a high-speed MVC with obvious head trauma. He’s confused, intermittently combative, and requires rapid sedation for imaging. After CT, the team attempts to calculate a Glasgow Coma Scale (GCS)—but sedation, intubation, and a changing neuro exam make the score hard to interpret. The question becomes practical, not academic:

If GCS isn’t feasible, what should we use to document and trend neurologic status right now?

🔗 Scoring Tools

- ➡️ Glasgow Coma Scale (GCS)
- ➡️ Simplified Motor Score (SMS)
- ➡️ FOUR (Full Outline of UnResponsiveness) Score

🎯 Quick Hits

💬 Case Resolution

Following CT, the patient remains intubated and sedated, making the verbal GCS unreliable. The team documents neurologic status using the FOUR score, which allows assessment of motor response, brainstem reflexes, and respiratory pattern despite intubation. Serial FOUR scores provide a clearer neurologic trend for ICU handoff and neurosurgical consultation.

FAQ

What is the Simplified Motor Scale (SMS) used for?
A rapid motor-only coma scale for quick severity assessment when a full GCS is impractical.
Why doesn’t GCS work well in intubated or delirious/sedated patients?
The verbal component becomes unusable, and sedation can depress eye/motor responses—making the total score misleading.
When should I use FOUR instead of GCS?
When the patient is intubated, or when you need to trend brainstem reflexes and breathing pattern.
How often should SMS/FOUR be reassessed in severe neurologic illness?
With any clinical change, after key interventions (sedation changes, procedures), and at scheduled neuro-check intervals per local protocol.
Can non-neurologic factors distort these scores?
Yes—sedatives, paralysis, intoxication, hypoxia, and shock can confound results. Document confounders with the score.
Does SMS replace GCS for mild floor-level patients?
Usually no—GCS remains the common language when feasible; SMS is best as a fallback when GCS is impractical.

🚨 Clinical Bottom Line

GCS: Still the standard—but can mislead in sedated, intubated, or nonverbal patients (verbal is unusable; meds can depress eye/motor).
Simplified Motor Scale (SMS): Fast, motor-only option when you just need a quick severity snapshot.
FOUR Score: Best when brainstem function or ventilatory status matters—especially in intubated patients.

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_Propersi), and Mark Ramzy, DO (X: @MRamzyDO)

🧭 Prep Sheets

Glasgow Coma Scale (GCS)

Simplified Motor Score (SMS)

FOUR (Full Outline of Unresponsiveness) Score

👤 Author

Eric Steinberg

DO, MEHP

Content Director, MDCalc, Residency Director, Emergency Medicine St. Joseph's University Medical Center, Paterson, NJ

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The post MDCalc Wars: GCS Alternatives in the ED: SMS and FOUR Score appeared first on REBEL EM - Emergency Medicine Blog.

Clinical Conundrum: Is Tamsulosin Effective in Increasing Spontaneous Passage Rate of Ureteral Stones?

Anand Swaminathan MD, MPH & Akash Bhatnagar, MD — Wed, 18 Feb 2026 12:00:44 +0000

👉 Bottom Line Up Top

In large ureteral calculi 5mm or greater, Tamsulosin is recommended for facilitating stone expulsion and decreasing associated pain.

🤕 Case

A 47-year-old woman presents with 10/10 sharp left-sided back pain radiating to her groin with associated nausea that started about 20 minutes prior to presentation. Vital signs are unremarkable. The patient’s pain is improved with 15 mg IV ketorolac and 10 mg IV metoclopramide. A non-contrast CT scan shows a 3.5 mm stone at the left ureterovesical junction and the urinalysis shows blood with no other abnormalities. The patient’s pain is well controlled and her nausea is resolved. You are preparing to discharge the patient and you contact your friendly neighborhood urologist to arrange a follow-up. The urologist requests that you start the patient on Tamsulosin prior to discharge home, but you are unsure about the utility of that intervention.

🗣️ What Your Gut Says

Urology feels pretty strongly about the utility of tamsulosin for stone passage. May as well just start it.

📈 What The Evidence Says

Spontaneous stone passage depends on many factors, the most important being stone size. A 2021 retrospective cohort study demonstrated spontaneous passage in 68% of stones ≤ 5 mm (95% CI: 46–85%), and 47% of stones 5-10mm (95% CI: 36–59%). In the group of patients with stones < 5 mm, rates may be as high as 95% depending on exact size. Urology often advises the use of alpha-blockers such as tamsulosin as part of medical expulsive therapy (MET) to facilitate stone passage in all patients regardless of stone size. Despite the routine recommendation to prescribe alpha-blockers to patients with stones of any size, the published data is less clear.

The SUSPEND trial, a large multicenter RCT, compared four-week spontaneous stone passage in 1,167 patients given either Tamsulosin, Nifedipine, or a placebo and demonstrated nearly identical passage rates (Placebo 80%, Tamsulosin 81%, Nifedipine 80% OR for MET vs placebo = 1.04; 95% CI: 0.77–1.43). Secondary outcomes (pain scores, analgesic use, time to passage, quality of life) also showed no differences between groups (Pickard 2015).

Smaller, more targeted studies published around the same time have challenged this discussion, showing that the benefit of Tamsulosin is directly correlated to stone size. A multicenter RCT in 2015 found a significant difference in spontaneous stone passage with the addition of tamsulosin in patients with stones 5-10 mm in size, but no significant difference in spontaneous passage in patients with smaller stones <5 mm (Furyk 2015).

To address these differences, larger studies were conducted, including a metaanalysis that supported higher passage rates for larger stones and little to no benefit in passage rates for smaller stones <5mm (Ye 2018), (Wang 2015). The data are consistent in finding a benefit for larger, distal ureteral stones, which raises a critical point: to identify the patient group that would benefit from the treatment, a CT scan would be necessary. While many patients presenting with ureteral colic symptoms will require a CT scan, not all patients will. A multispecialty consensus statement (endorsed by ACEP, The American Urology Association and The American College of Radiology) lays out a number of patient groups that don’t require advanced imaging in their evaluation (Moore 2019). Obtaining a CT scan when the diagnosis is clear for the purpose of determining stone size and location is not endorsed by any of the sponsoring groups.

Current guidelines recommend use of MET with tamsulosin 0.4mg daily for up to four weeks in patients with ureteral calculi measuring 5-10 mm, but not in smaller stones measuring < 5 mm (Wang 2015)

🚨 Clinical Bottom Line

The published data is clear that distal ureteral stones > 5 mm in diameter benefit from MET with tamsulosin but both smaller and more proximal stones do not. If the patient requires a CT scan for their evaluation and is found to have a small stone in any location or a proximal stone, they are unlikely to benefit from tamsulosin

📚 References

Wang H et al.
Comparative efficacy of tamsulosin versus nifedipine for distal ureteral calculi: a meta-analysis.
Drug Des Devel Ther. 2016;
PMID: 27099471
Wang RC et al.
Effect of Tamsulosin on Stone Passage for Ureteral Stones: A Systematic Review and Meta-analysis.
Ann Emerg Med. 2017 Mar 6.
PMID: 27616037
Pickard R et al.
Use of drug therapy in the management of symptomatic ureteric stones in hospitalised adults: a multicentre, placebo-controlled, randomised controlled trial and cost-effectiveness analysis of a calcium channel blocker (nifedipine) and an alpha-blocker (tamsulosin) (the SUSPEND trial).
Health Technol Assess. 2015 Aug;19.
PMID: 26244520
Furyk JS et al.
Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial.
Ann Emerg Med. 2016 Jan
PMID: 26194935
Ye Z et al.
Efficacy and Safety of Tamsulosin in Medical Expulsive Therapy for Distal Ureteral Stones with Renal Colic: A Multicenter, Randomized, Double-blind, Placebo-controlled Trial.
Eur Urol. 2018 Mar.
PMID: 29137830
Moore CL et al.
Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus.
Ann Emerg Med. 2019 Sep
PMID: 31402153

Post Peer Reviewed By: Anand Swaminathan, MD (X: @EMSwami) and Mark Ramzy, DO (X: @MRamzyDO)

Guest Post

Akash Bhatnagar, MD

Medical Education Fellow

Staten Island University Hospital Northwell Health

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🔎 Your Deep-Dive Starts Here

Clinical Conundrum: Is Tamsulosin Effective in Increasing Spontaneous Passage Rate of Ureteral Stones?

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Medical Expulsion Therapy in Ureteral Colic: An Update

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The post Clinical Conundrum: Is Tamsulosin Effective in Increasing Spontaneous Passage Rate of Ureteral Stones? appeared first on REBEL EM - Emergency Medicine Blog.

REBEL MIND: Applying Performance Science In and Out of the Emergency Department

Mark Ramzy — Wed, 18 Feb 2026 12:00:14 +0000

📌 Key Points

🔍 Understanding the Why: The significance of understanding underlying causes, beyond initial diagnoses, in both sports and emergency medicine is explored.
⏱️ Recovery Focus: Emphasizing the importance of recovery time and small daily choices in optimizing performance for both athletes and emergency physicians.
📊 Data-Driven Insights: The Arena Labs approach uses personalized data, leveraging wearable technology and expert coaching to tackle burnout and enhance well-being.
🤝 Personalization and Partnership: Arena Labs’ collaboration with emergency clinicians sheds light on personalized performance solutions rooted in scientific evidence.

Click here for Direct Download of the Podcast.

📝 Introduction

Welcome back to REBEL MIND, where MIND stands for Mastering Internal Negativity during Difficulty. Here we sharpen the person behind the practitioner by focusing on things that improve our performance, optimizing team dynamics and the human behavior that embodies the hidden curriculum of medicine. In this episode, we’re excited to continue collaboration with Arena Labs, where host Dr. Mark Ramzy interviews Allyn Abadie, Arena Labs’ Principal Scientist on how we can apply performance science in and out of the emergency department. Arena Labs is helping us measure healthcare performance through innovative programs designed to combat burnout and enhance personal wellness using data-driven strategies.

🔙Previously Covered on REBEL MIND:

Performance Under Pressure – What Medicine Can Learn from Elite Teams

The Power of Performance Coaching in Medicine

Rest Is Not Sleep: The Seven Dimensions of True Recovery

🤔Cognitive Question

How can emergency department clinicians utilize techniques inspired by athletic performance to better manage stress, prevent burnout, and optimize recovery?

💭 Why This is Important

- Burnout among healthcare workers is a growing concern, especially in such high-pressure environments as emergency and intensive care units. The collaboration with Arena Labs brings forth a vital focus on using data and coaching to build resilience among medical professionals.

🏥How This Applies to the Emergency Department or ICU?

- Emergency medicine, akin to high-performance sports, demands intense energy and quick decision-making under pressure, often leading to stress and burnout. By applying principles from athletic recovery and personalized data tracking, clinicians can moderate their performance intensity, enhance their recovery even in short breaks, and prevent long-term burnout. This approach allows emergency physicians to maintain endurance and clarity, improving patient care and team dynamics.

⏩ Things You Can Do on Your Next Shift

- Measure and Reflect: Start tracking your vital health metrics like heart rate with wearable sensors. Reflect on how daily activities impact these measurements to identify stress patterns.
- Implement Quick Recovery Techniques: Use short, actionable exercises such as deep breathing or the de-stress breath method between patient encounters to moderate stress levels.
- Invest in Self-Care: Dedicate brief time slots for essential self-care activities like hydration or quick reflection journaling, aiming to enhance mental resilience throughout your shift.
- Utilize Coaching Tools: Engage with personalized coaching apps or resources that offer science-backed recovery strategies tailored to your personal and professional needs.

👀 Where to Learn More

Intrigued by the possibilities this partnership offers? You can explore more by visiting Arena Labs’ website here. Also, check out the comprehensive coaching program available, designed specifically for healthcare providers looking to enhance their well-being and performance.

🚨 Clinical Bottom Line

In an era where burnout is pervasive, our collaboration with Arena Labs offers a beacon of hope for healthcare workers. By leveraging cutting-edge data insights and practical coaching, this partnership aims to redefine healthcare wellness, fostering a sustainable, resilient workforce that’s equipped to navigate the pressures of modern medicine.

Join us in this journey towards enhanced well-being and workforce empowerment, ensuring that those who care for us are also cared for.

Meet the Authors

Mark Ramzy, DO

Co-Editor-in-Chief

RWJBH / Rutgers Health, Newark NJ

Allyn Abadie

Principal Scientist

Arena Labs

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The post REBEL MIND: Applying Performance Science In and Out of the Emergency Department appeared first on REBEL EM - Emergency Medicine Blog.

The Hope Trial: Alteplase 4.5–24 Hours After Stroke (CT Perfusion Selected)

Carlton Watson, MD MSc — Mon, 16 Feb 2026 12:00:37 +0000

📌 Key Points

🧠🕒 Late-window benefit: Alteplase improved outcomes in patients treated 4.5–24 hours after stroke onset when imaging shows salvageable tissue—supporting a “tissue over time” approach where imaging guides treatment, not the clock.
📈⚠️ Benefit–risk tradeoff: Alteplase increased functional independence (40% vs 26%) but also increased symptomatic intracranial hemorrhage; importantly, this did not increase mortality.
🔬🌍➡️ What’s next: More data are needed—tenecteplase comparisons, more diverse populations, and studies across different healthcare systems to confirm whether these results generalize broadly.

📝 Introduction

The cornerstone of acute ischemic stroke (AIS) management involves timely reperfusion of the ischemic brain tissue. Intravenous thrombolysis with alteplase has been the standard of care for AIS within 4.5 hours of symptom onset, based on pivotal trials such as NINDS and ECASS III, which demonstrated improved functional outcomes despite an increased risk of intracerebral hemorrhage.^1,2 However, many patients present outside this narrow therapeutic window, excluding many patients from the potential benefits of thrombolytics. For some, mechanical thrombectomy is an option if their stroke is the result of a medium or large vessel occlusion and is amenable to aspiration or stent retrieval. Recent advances in neuroimaging, particularly perfusion-based techniques, have allowed for the identification of salvageable brain tissue beyond traditional time limits.³ This imaging-guided approach has spurred clinical trials evaluating the safety and efficacy of thrombolysis in the extended and late time windows.

The EXTEND trial suggested a modest functional benefit of alteplase administered between 4.5 and 9 hours in carefully selected patients with perfusion mismatch, though the absolute treatment effect was small and accompanied by increased hemorrhagic risk.⁴ Similarly, the WAKE-UP trial demonstrated improved functional outcomes in patients with unknown onset times selected by MRI-based DWI–FLAIR mismatch, reinforcing a tissue-based approach but with no mortality benefit and a higher risk of intracranial hemorrhage.⁵ Subsequent late-window thrombolysis studies have yielded inconsistent results; trials evaluating tenecteplase such as TIMELESS and TEMPO-2 failed to demonstrate clear clinical benefit and raised concerns regarding futility and safety in certain populations.^6,7 In addition, TRACE-III, conducted exclusively in Chinese patients, may reflect population-specific stroke pathophysiology that limits generalizability.⁸ Against this uncertain and heterogeneous evidence base, the HOPE trial was designed to reassess whether alteplase could provide meaningful functional benefit in patients presenting 4.5 to 24 hours after stroke onset who demonstrate imaging evidence of viable brain tissue.

🧾 Paper

Zhou Y, He Y, Campbell BCV, et al. Alteplase for Acute Ischemic Stroke at 4.5 to 24 Hours: The HOPE Randomized Clinical Trial. JAMA. Published online August 07, 2025. PMID: 40773205

️ What They Did

CLINICAL QUESTION

In acute ischemic stroke patients presenting between 4.5 and 24 hours after symptom onset with evidence of salvageable brain tissue on perfusion imaging and no plan for endovascular mechanical thrombectomy, does the administration of intravenous alteplase compared to standard medical treatment result in improved functional outcomes?

STUDY DESIGN

Phase 3, multi-center, randomized, open-label, blinded endpoint trial across 26 stroke centers in China
Patients with AIS presenting 4.5 to 24 hours after onset (or midpoint if onset unknown)
Salvageable brain tissue
- Ischemic core volume ≤70mL
- A perfusion-core mismatch ratio >1.2
- A perfusion-core mismatch volume of at least 10mL
No initial plan for thrombectomy
The patients were randomized to a 1:1 allocation to alteplase (0.9 mg/kg, max 90 mg) vs standard medical treatment (e.g., antiplatelet therapy, supportive care)
372 patients randomized
- 186 = alteplase
- 186 = control; standard therapy

POPULATION

Inclusion Criteria:

Age ≥ 18 years of age
AIS with CT perfusion (CTP) imaging demonstrating salvageable tissue
Presenting 4.5 to 24 hours after stroke onset
NIHSS >4 and <26
Pre-stroke mRS 0 or 1

Exclusion Criteria:

NIHSS < 4 or > 26
Underwent MT
ICH on CT or prior history of ICH
Thrombolytic treatment at an external hospital
Did not meet the target mismatch profile on CTP
Hypodensity in more than 1/3 of the middle cerebral artery (MCA) territory on non-contrast head CT (NCHCT)
AIS or myocardial infarction within the previous 3 months
Unable to perform or uninterpretable CTP
Any form of coagulopathy
Blood glucose < 50 or >396 mg/dL

INTERVENTION & CONTROL

Intervention:

Intravenous alteplase (0.9 mg/kg; maximum dose, 90 mg) was administered to patients who presented between 4.5 and 24 hours after symptoms onset with no initial plan for endovascular thrombectomy.

Control:

Patients received standard medical therapy for acute ischemic stroke, which is not explicitly stated but includes aspirin, clopidogrel, blood pressure control, and statin administration.

OUTCOMES

Primary Outcome:

Modified Rankin Scale (mRS) score of 0 or 1 at 90 days

Secondary Outcomes:

Safety
- Symptomatic intracranial hemorrhage (sICH) within 36 hours after randomization
- 90-day all-cause mortality
Functional
- mRS 0 to 2 at 90 days
- mRS 0 to 3 at 90 days
- Distribution of mRS at 90 days
- Improvement of at least 8 points on the NIHSS at 24 hours and 7 days
- NIHSS less than 1 at 24 hours and 7 days

📈 Results

OUTCOMES

DEMOGRAPHICS

OUTCOMES

DEMOGRAPHICS

💥 Critical Results

Primary efficacy (mRS 0–1 at 90 days): 40.3% (75/186) with alteplase vs 26.3% (49/186) with standard therapy → RR 1.52 (95% CI 1.14–2.02); absolute difference +13.98%; p = 0.004.
Symptomatic ICH within 36 hours: 3.8% (7/185) vs 0.5% (1/182) → RR 7.34 (95% CI 1.54–34.84); absolute difference +3.23%; p = 0.01.
90-day mortality: 10.8% vs 10.8% (no difference).
Secondary functional outcome (mRS 0–2 at 90 days): 55.4% vs 45.7% → RR 1.20 (95% CI 1.00–1.45); absolute difference +9.68%; p = 0.052 (borderline).
Early neurologic improvement (NIHSS):
- Major neurologic improvement at 24h: 21.0% vs 12.9% → RR 1.66; p = 0.04.
- Major neurologic improvement at 7 days: 35.5% vs 27.2% → RR 1.30; p = 0.10.

💪 Strengths

Randomized controlled multi-center trial design ensures a high level of internal validity for comparing treatments.
Patient-centered outcomes by utilizing mRS 0-1 at 90 days as the primary efficacy outcome, as a longer follow-up increases the validity of the intervention’s benefit.
Investigators performed and intention to treat analysis.
Baseline demographics were equal across both groups, including between age and gender.
Baseline characteristics were well-matched between groups, reducing the risk of confounding.
Blinded mRS outcome assessment reduced bias despite the open-label nature of the trial
Meaningful clinical outcome focused on functional independence and is patient-centered.
Tissue-based selection using perfusion imaging to guide eligibility shifts the paradigm away from rigid time windows toward identifying salvageable brain tissue.
Comprehensive secondary outcomes provide additional insight into neurologic recovery and safety.
Real-world relevance was achieved through the use of perfusion imaging, which facilitated broad inclusion and increased generalizability.
Approximately 50% of patients had an NIHSS score >10, which is a moderate stroke burden

⚠️ Limitations

The open-label design introduces a potential performance bias, as the treating clinicians were not blinded to the therapy.
A single-country (China) setting reduces generalizability to non-Chinese populations and international practice settings.
Safety trade-off in that alteplase significantly increased the rate of symptomatic intracranial hemorrhage (3.8% vs 0.5%), raising concerns about disability from hemorrhage, even if overall mortality did not differ.
Short safety follow-up for sICH (within 36 hours) may miss later-occurring adverse events.
Exclusion of thrombectomy candidates eliminates a large subset of patients who may benefit from alteplase and recannulization.
Exclusion of very high stroke severity (NIHSS > 26) may reduce the relevance to patients with severe strokes.
Out of the total 372 patients, 180 patients were enrolled from a single site, minimizing external validity

🗣️ Discussion

What HOPE Adds

The HOPE trial randomized 372 perfusion-selected patients to IV alteplase (0.9 mg/kg) vs standard care 4.5–24 hours after onset and found improved mRS 0–1 at 90 days (40% vs 26%).
The trial used a tissue-based perfusion mismatch selection strategy rather than a strict time cutoff, consistent with the paradigm established by EXTEND and WAKE-UP.4,5
HOPE demonstrated a clinically meaningful absolute benefit (~14% risk difference) but also a higher rate of symptomatic intracranial hemorrhage (3.8% vs 0.5%).
Mortality was unchanged between arms, suggesting bleeding events increased morbidity more than mortality in this cohort.
EXTEND previously showed benefit up to 9 hours with perfusion selection; HOPE extends that concept to 24 hours in selected patients.4
Trials of tenecteplase in late windows (eg, TIMELESS/TNK trials) have had mixed results, and some late-window tenecteplase trials did not show consistent benefit, leaving uncertainty about the optimal agent.6,7

Inside The Numbers

Primary benefit (functional independence): mRS 0–1 at 90 days occurred in 40.3% of patients treated with alteplase (75/186) vs 26.3% with standard therapy (49/186) → Absolute risk difference: +13.98%; RR 1.52 (95% CI 1.14–2.02); p = 0.004.
Number needed to treat (NNT): ~8 patients treated to achieve 1 additional excellent functional outcome (mRS 0–1) at 90 days (NNT = 8).
Key harm (symptomatic ICH): sICH within 36 hours occurred in 3.8% of alteplase patients (7/185) vs 0.5% of controls (1/182) → Absolute risk difference: +3.23%; RR 7.34 (95% CI 1.54–34.84); p = 0.01.
Number needed to harm (NNH): ~31 patients treated to cause 1 additional symptomatic intracranial hemorrhage (NNH = 31).
Mortality: No difference in 90-day all-cause mortality (10.8% vs 10.8%).

State of the Evidence

The HOPE trial adds to the existing body of evidence evaluating IV alteplase in an extended time window for patients presenting with acute ischemic stroke. Although EXTEND and WAKE-UP demonstrated that tissue-guided thrombolysis with IV alteplase could be beneficial beyond the conventional 4.5-hour window (up to ~9 hours or in wake-up strokes) using perfusion or MRI-based mismatch selection, the HOPE trial pushes this boundary dramatically further, showing a significant increase in 90-day functional independence when alteplase is given as late as 24 hours after onset in perfusion-selected patients.

Future Direction

Current major guidelines (AHA/ASA) emphasize time- and tissue-based selection (and recommend thrombectomy for LVOs within guideline windows); HOPE may prompt guideline reappraisal for alteplase in imaging-selected late-window patients.
HOPE is highly relevant where thrombectomy access is limited, but extrapolation to thrombectomy-rich systems requires caution because many patients had LVOs, and the trial excluded those already planned for EVT.
Operational barriers remain: routine perfusion imaging and standardized mismatch thresholds are not universally available, and variability in CT perfusion processing could alter eligibility and outcomes.
Head-to-head late-window comparisons of alteplase vs tenecteplase, integration with early/bridging EVT strategies, and cost-effectiveness analyses are needed before widespread adoption.

📘 Author's Conclusion

“In patients with acute ischemic stroke with salvageable brain tissue identified by perfusion imaging who did not initially receive thrombectomy, intravenous alteplase administered 4.5 to 24 hours after onset provided functional benefit, despite an increase in symptomatic intracranial hemorrhage”

💬 Our Conclusion

The HOPE trial investigated the use of alteplase outside the current standard treatment window in patients with salvageable brain tissue on CTP imaging. The findings demonstrated a significant functional benefit with a respectable hemorrhage risk. These results support shifting the paradigm from “time is brain” to “tissue over time,” and the consideration of extending treatment windows for eligible patients. However, more evidence in large, diverse settings is needed before extending the window.

🚨 Clinical Bottom Line

Perfusion-selected AIS patients treated with IV alteplase 4.5–24 hours after onset had better 90-day functional outcomes, with higher sICH but no mortality difference.

📚 References

The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581-1587. PMID: 7477192
Hacke W, Kaste M, Bluhmki E, et al; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317-1329. PMID: 18815396
Campbell BCV, Mitchell PJ, Kleinig TJ, et al; EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009-1018. PMID: 25671797
Ma H, Campbell BCV, Parsons MW, et al; EXTEND Investigators. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke. N Engl J Med. 2019;380(19):1795-1803. PMID: 31067369
Thomalla G, Simonsen CZ, Boutitie F, et al; WAKE-UP Investigators. MRI-guided thrombolysis for stroke with unknown time of onset. N Engl J Med. 2018;379(7):611-622. PMID: 29766770
Albers GW, Jumaa M, Purdon B, Zaidi SF, Streib C, Shuaib A, Sangha N, Kim M, Froehler MT, Schwartz NE, Clark WM, Kircher CE, Yang M, Massaro L, Lu XY, Rippon GA, Broderick JP, Butcher K, Lansberg MG, Liebeskind DS, Nouh A, Schwamm LH, Campbell BCV; TIMELESS Investigators. Tenecteplase for Stroke at 4.5 to 24 Hours with Perfusion-Imaging Selection. N Engl J Med. 2024 Feb 22;390(8):701-711. PMID: 38329148
Coutts, Shelagh B Salluzzi, Marina et al.;Tenecteplase versus standard of care for minor ischemic stroke with proven occlusion (TEMPO-2): a randomized, open label, phase 3 superiority trial. The Lancet, Volume 403, Issue 10444, 2597-2605. PMID: 38768626
Yang P, Zhang Y, Zhang L, et al; TRACE-III Investigators. Endovascular thrombectomy with or without intravenous alteplase in acute stroke. N Engl J Med. 2023;388(19):1791-1803. PMID: 32374959
Albers GW, Campbell BC, Lansberg MG, Broderick J, Butcher K, Froehler MT, Schwamm LH, Nouh AM, Liebeskind DS, Toy F, Yang M, Massaro L, Schoeffler M, Purdon B. A Phase III, prospective, double-blind, randomized, placebo-controlled trial of thrombolysis in imaging-eligible, late-window patients to assess the efficacy and safety of tenecteplase (TIMELESS): Rationale and design. Int J Stroke. 2023 Feb;18(2):237-241. PMID: 35262424
Campbell BCV, Majoie CBLM, Albers GW, et al; TIMELESS Investigators. Tenecteplase for ischemic stroke at 4.5 to 24 hours without thrombectomy: the TIMELESS randomized clinical trial. JAMA. 2023;330(19):1887-1897.

Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Marco Propersi, DO (X: @Marco_Propersi)

👤 Guest Author

Carlton Watson

MD, MSc

Neurocritical Care Fellow North Shore University Hospital, Manhasset, NY

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The post The Hope Trial: Alteplase 4.5–24 Hours After Stroke (CT Perfusion Selected) appeared first on REBEL EM - Emergency Medicine Blog.

REBEL Core Cast 150.0: Emergency Medicine Consults: How to Call a Consult + Handle Pushback (With Scripts)

Anand Swaminathan — Thu, 12 Feb 2026 12:00:22 +0000

📌 Key Points

The 4 Steps of an ED Consult:

👋 Introduce yourself and your role
🎯 Lead with the outcome (the ask)
🧾 Give a focused case summary (why it’s theirs + what you’ve done)
🔁 Close the loop (timeline, next steps, contingencies)

Click here for Direct Download of the Podcast.

📝 Introduction

Today we’re tackling one of the most important (and most under-taught) skills in emergency medicine: how to call a consult in the ED and what to do when a consultant pushes back.

To call a consult in the ED, start with a brief introduction, lead with the outcome you need (“the ask”), give a focused decision-relevant summary, and close the loop with timeline and next steps. If the consultant resists, clarify the “why,” restate the ask, offer alternatives, and escalate when patient safety or disposition is at risk.

After two decades in emergency medicine and countless consult calls, here’s a simple framework—plus copy/paste scripts—to make your consults faster, clearer, and easier to say “yes” to.

🤔 Why Consult Skills Matter in Emergency Medicine

Consults aren’t a formality—they’re a patient-care intervention. Strong consult communication:
- Reduces delays in time-sensitive care
- Improves ED throughput and disposition
- Decreases conflict and miscommunication
- Clarifies ownership and next steps
- Protects the patient (and the team) when plans are unclear

🪜 The 4-Step ED Consult Framework (Introduction → Ask → Summary → Close the Loop)

Most consult friction comes from one of two problems: unclear expectations or excessive noise. This four-step structure solves both.

1) Introduce yourself and your role

A simple intro sets a professional tone and removes ambiguity.

Script:

“Hey, this is Swami, one of the ED attendings. I’m calling for an ortho consult.”

2) Lead with the outcome (the ask)

Don’t bury the lede. The consultant wants to know what you need—immediately.

Script:

“I’m calling about a patient with a suspected septic knee. I need you to evaluate for operative management.”

3) Give a focused, decision-relevant summary

Your summary should answer:

Why this is your service’s problem
What’s already been done
What I’m worried about / what decision is needed now

Script:

“43-year-old man with no major PMH, 3 days of knee pain and swelling. XR negative. Febrile. Aspiration yielded purulent fluid—cultures sent. We started antibiotics after the tap. He’s hemodynamically stable.”

High-yield pearl: Add quick “stability anchors” when relevant:

“Airway stable, pain controlled.”
“Neurovascularly intact.”
“No signs of compartment syndrome.”
“No hypotension or escalating oxygen requirement.”

4) Close the loop (timeline + next steps)

This prevents the consult from floating in limbo and protects patient flow.

Script:

“When do you expect to see the patient, and do you want anything done before you arrive—NPO, repeat labs, additional imaging?”

📝 ED Consult Script

General ED Consult Script

“Hi, this is Dr. ___ in the ED. I’m calling for a ___ consult. The reason is ___. Briefly: ___ year-old with ___. We’ve done ___ and started ___. I’m concerned about ___. Can you see them today, and what’s your preferred next step?”

Septic joint / Ortho Example

“Hi, this is Swami in the ED. I need an ortho consult for suspected septic arthritis. 43-year-old with 3 days of atraumatic knee swelling and fever. XR negative. Tap produced purulent fluid—cultures sent. Antibiotics started after aspiration. Can you evaluate for operative management, and when can you see the patient?”

Neurology example (time-sensitive)

“Hi, this is Dr. ___ in the ED. I need neurology for suspected acute stroke. Last known well ___. NIHSS ___. CT/CTA completed (or pending). I’m calling to discuss candidacy for thrombolysis/thrombectomy and next steps. When can you evaluate and what additional workup do you want now?”

⛓️‍💥 Common ED Consult Mistakes (and Fixes)

Mistake: Long story before the ask

Fix: Lead with the outcome in the first sentence

Mistake: Unfiltered data dump

Fix: Provide only decision-relevant details

Mistake: No timeline

Fix: Ask explicitly when they’ll see the patient and what they need first

Mistake: Implicit “ownership”

Fix: Clarify who is admitting, who is following, and what happens if the patient worsens

✋ What to Do When a Consultant Pushes Back

Even a perfect consult can meet resistance. Your job is to stay calm, keep it professional, and protect the patient.

1) Ask “why?”

Don’t argue first—diagnose the refusal.

Script:

“Help me understand your concern about seeing this patient.”

Many refusals are based on misunderstanding: wrong service, missing key detail, or incorrect assumption about stability.

2) Restate the consult in one sentence, then offer options

If the conversation starts spiraling, reset it.

Script:

“To be clear, I’m concerned this is septic arthritis and needs ortho evaluation. If you don’t feel you’re the right service, who should be—rheum, medicine, or another surgical team?”

This keeps you collaborative while preventing dead ends.

3) Humanize the decision (use sparingly)

This is a “high-voltage” tool. Use it when stakes are high and you’ve already clarified the medical facts.

Script:

“I’m worried we’re missing something time-sensitive. If this were your family member, what would you want us to do next?”

Use it to re-anchor to patient risk—not as a guilt tactic.

⚡️When and How to Escalate a Consult

Escalation isn’t personal—it’s a safety mechanism when there’s an impasse that threatens timely care.

When to escalate

Time-sensitive condition is delayed (e.g., septic joint, cord compression, testicular torsion, GI bleed with instability)
No clear disposition plan despite reasonable ED evaluation
Consultant refusal blocks needed specialty decision-making
Patient safety or deterioration risk is increasing in the ED

How to escalate (lowest to highest intensity)

Ask for the consultant’s attending (if speaking to a resident)
Call the on-call attending directly
Involve ED leadership/medical director
Escalate to service chief/department chair (rare, but real)
Hospital supervisor/admin escalation for immediate operational impasse

Script:

“We’re at an impasse and the patient needs a decision. I’m escalating to clarify ownership and ensure timely care.”

️ Documentation Tips for Consult Refusals

Documentation should be factual and patient-centered, not punitive.

Include:

Your clinical concern and why the consult is needed
Who you spoke with (name/role)
Their stated reason for refusal or delay
Alternatives discussed
Escalation steps taken and final plan

👉 FAQ: Emergency Medicine Consults

What is the best way to call a consult in the ED?

Introduce yourself, lead with the specific ask, summarize only decision-relevant details, and close the loop with a clear plan and timeline.

What should I say when a consultant refuses to see a patient?

Ask why, clarify misunderstandings, restate your concern and the ask, and request an alternative plan or appropriate service.

When should I escalate a consult?

Escalate when an impasse delays time-sensitive care, threatens patient safety, or prevents appropriate disposition.

How do I document a refused consult?

Document the clinical concern, who you spoke with, their stated reason, alternatives discussed, and escalation steps taken.

🏁 Conclusion

Mastering emergency medicine consults makes you faster, safer, and easier to work with. The goal isn’t to “win” a consult call—it’s to get the patient the right care, with clear ownership and a shared plan.

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)

👤 Associate Editor

Anand Swaminathan

MD, MPH

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Continuous Suctioning Doesn’t Hasten Hypoxemia

Anand Swaminathan — Mon, 09 Feb 2026 12:00:44 +0000

📌 Key Points

🙅🏽‍️Continuous suctioning during RSI did not cause more rapid deoxygenation when compared to a standard approach of “as needed suctioning.”
📉Limitations in the study size and design make these results inconclusive and larger studies are needed to further elucidate the issue.

📝 Introduction

Airway contamination with vomit, blood or secretions poses a serious threat to first pass intubation success and subsequent hypoxemia and hemodynamic collapse. The Suction Assisted Laryngoscopy for Airway Decontamination (SALAD) technique, created by Dr. Jim DuCanto, addresses the issue of airway decontamination (video link). This technique relies on application of continuous suctioning. Prior research has shown that deep tracheal suctioning can result in more rapid development of hypoxemia. It is unclear if continuous suctioning during intubation poses a similar risk.

🧾 Paper

Strayer RJ et al. The Impact of Suctioning on Oxygenation During Rapid Sequence Intubation in the Emergency Department: A Multi-Center Pilot Randomized Controlled Trial. J Emerg Med. 2025. PMID: 40533376

🔙Previously Covered and Related Content:

REBEL EM: The DuCanto Catheter: It Sucks!
REBEL EM: Core Cast 4.0 – RSI Cheat Codes

️ What They Did

CLINICAL QUESTION

Does the application of continuous suctioning during rapid sequence intubation (RSI) result in more rapid deoxygenation?

STUDY DESIGN

Multicenter, pilot randomized controlled trial at three tertiary academic emergency departments.
Investigators, patients and outcome assessors were non-blinded to intervention.
Beyond the specific intervention of suctioning, all clinical care was at the discretion of the clinical team.

POPULATION

Inclusion Criteria:

Patients ≥18 years of age
Need for emergent airway management
RSI and laryngoscopy as the planned approach

Exclusion Criteria:

Cardiac arrest
Known or predicted heavily soiled airway (defined as significant blood or emesis in mouth)
Unreliable pulse oximetry

INTERVENTION & COMPARATOR

Intervention:

Constant suctioning: the suction catheter was inserted at the start of laryngoscopy and left in the oropharynx until the ETT was delivered.

Comparator:

As needed suction: the suction catheter was applied as needed to clear secretions.

OUTCOMES

Primary Outcome:

Absolute decrease to final O2 saturation (defined as SpO2 at the time of ETT confirmation subtracted from SpO2 at the time of laryngoscope insertion

Secondary Outcomes:

Absolute decrease to lowest saturation (defined as the lowest SpO2 recorded during laryngoscopy subtracted from the SpO2 at the time of initiation of laryngoscopy)
Duration of laryngoscopy
Number of laryngoscopy attempts
Procedural complications

📈Results

💥 Critical Results

💪🏽 Strengths

The study asks a clinically important question that has not previously been researched.
Multicenter nature increases external validity
Exclusion criteria were limited increasing external validity
Randomization was performed using a computer-generated random number sequence
Data available on all patients randomized to the study

⚠️ Limitations

This is a small study and no power calculation was performed prior to enrollment
All of the departments within the study operate under one hospital system which decreases external validity.
This was a convenience sample of patients thus introducing sampling bias as all patients requiring intubation were not included.
There was no standardization of care beyond the suctioning approach which decreases internal validity.
Investigators and outcome assessors were not blinded to intervention.
Only 25% of intubations were performed with large bore suction catheters (eg DuCanto catheters).

🗣️ Discussion

The sickest subset of patients were not included in the study
- Patients requiring immediate intubation may have been intubated prior to availability of a research assistant
- This biases the study towards patients who are less likely to desaturate
Most patients were not suctioned using a large bore suction catheter
- In many departments, these have become ubiquitous
- It is unclear if widespread use of large bore suction catheters would have a greater effect on deoxygenation with constant suctioning
Would have been interesting to evaluate the impact on the duration of suctioning with use of either a small bore or large bore catheter on overall hypoxia and how this may or may not have played a role in first pass success

📘 Author's Conclusion

“The study found that constant suctioning during Emergency Department laryngoscopy facilitated by RSI does not cause more rapid desaturation compared to as needed suctioning. However, the reliability of these results is limited by the small sample size and convenience sampling which likely skewed the cohort to patients less likely to develop hypoxia. Further studies are needed to confirm these findings and their impli- cations for emergency airway management.”

💬 Our Conclusion

In this small, ED based randomized controlled trial, continuous suctioning was not found to result in a greater risk of hypoxemia during RSI.

🚨 Clinical Bottom Line

Continuous airway suctioning in order to relieve or prevent airway contamination is a reasonable approach to airway management in the ED based on the available limited data.

📚 References

Strayer RJ et al.
The Impact of Suctioning on Oxygenation During Rapid Sequence Intubation in the Emergency Department: A Multi-Center Pilot Randomized Controlled Trial. J Emerg Med. 2025.
PMID: 40533376

Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Anand Swaminathan (X: @EMSwam)

👤Associate Author

Anand Swaminathan

MD, MPH

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REBEL CAST – RENOVATE Trial: HFNC vs BPAP in Acute Respiratory Failure

Jonathan Bradshaw, DO — Thu, 05 Feb 2026 12:00:27 +0000

📌 Key Points

💨 HFNC met criteria for non-inferiority to BPAP for preventing intubation or death within 7 days in four of the five ARF subgroups.
🧪 Bayesian dynamic borrowing increased power across subgroups but created variable certainty, especially in smaller groups such as COPD.
🫁 The immunocompromised hypoxemia subgroup did not meet non-inferiority, leading to early trial stopping for futility.
️ Rescue BPAP use, subgroup-specific exclusion criteria, and non-standardized BPAP delivery are important contextual factors that influence how subgroup results should be interpreted.

Click here for Direct Download of the Podcast.

📝 Introduction

Bilevel Positive Airway Pressure (BPAP) has long been a foundational modality in the management of acute respiratory failure (ARF), particularly in COPD exacerbations and cardiogenic pulmonary edema, where it can rapidly reduce work of breathing and improve gas exchange. It remains a core tool in our respiratory support arsenal.
High-flow nasal cannula (HFNC), however, has expanded what we can offer patients by delivering many of the same physiologic benefits through a far more comfortable interface. With high flows, modest PEEP, and effective dead-space washout, HFNC can improve oxygenation and decrease work of breathing while preserving the ability to talk, cough, eat, and interact with staff and family. This combination of physiologic support and tolerability makes HFNC especially attractive in patients where comfort, anxiety, or cardiovascular stability are key considerations, and in settings where prolonged noninvasive support may be needed. Rather than competing with BPAP, HFNC broadens our options in ARF and allows us to better match the modality to the patient and their underlying disease process.
The RENOVATE trial set out to answer a high-impact question across five distinct etiologic groups: Is HFNC non-inferior to BPAP (NIV) for preventing intubation or death in acute respiratory failure?

🧾 Paper

Azoulay É, et al. High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients With Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial. JAMA. 2025 PMID: 39657981

🔙Previously Covered On REBEL:

️ What They Did

CLINICAL QUESTION

Is HFNC non-inferior to BPAP for rate of endotracheal intubation or death at 7 days in patients with acute respiratory failure due to a variety of causes?

STUDY DESIGN

Multicenter, randomized non-inferiority trial
33 Brazilian hospitals
Nov 2019 – Nov 2023
Adaptive Bayesian hierarchical modeling with dynamic borrowing
Open label, outcome adjudicators blinded
Patients were classified into 5 subgroups

SUBGROUPS

1. Non-immunocompromised hypoxemia

SpO₂ < 90% on room air or
PaO₂ < 60 mm Hg on room air plus
- Increased respiratory effort (accessory muscle use, paradoxical breathing, thoracoabdominal asynchrony) or
- Respiratory rate > 25 breaths/min

2. Immunocompromised hypoxemia

Defined as:

- Use of immunosuppressive drugs for >3 months
- OR high-dose steroids >0.5 mg/kg/day
- OR solid organ transplant
- OR solid tumors or hematologic malignancies (past 5 years)
- OR HIV with AIDS / primary immunodeficiency

3. COPD exacerbation with acidosis

High clinical suspicion of COPD as primary diagnosis
RR >25 with accessory muscle use, paradoxical breathing, and/or thoracoabdominal asynchrony
ABG: pH <7.35 AND PaCO₂ >45

4. Acute cardiogenic pulmonary edema (ACPE)

Sudden onset dyspnea and rales
± S3 heart sound
No evidence of aspiration, infection, or pulmonary fibrosis
CXR consistent with pulmonary edema

5. Hypoxemic COVID-19 (added June 2023)

Added due to deviations between expected and observed outcome proportions
Any patient across the other 4 groups with PCR-confirmed SARS-CoV-2 infection in any of the above groups

POPULATION

Inclusion Criteria:

≥18 yrs with ARF* in one of 5 pre-defined subgroups excluding COPD was defined by the following:
Hypoxemia with SpO₂ <90 or PaO₂ <60
Accessory muscle use, paradoxical breathing, and/or thoracoabdominal asynchrony
RR >25 BPM

Exclusion Criteria:

Need for emergency intubation
Prolonged apneic episodes
Cardiorespiratory arrest
GCS <12
HR <50 with decreased consciousness
ABG pH <7.15
Severe agitation requiring heavy sedation
Hemodynamic instability (MAP <65, SBP <90 despite fluids or requiring high-dose pressors)
Contraindications to BPAP (facial trauma, recent esophageal surgery, copious secretions, vomiting, aspiration risk)
Pneumothorax or large pleural effusion
Severe arrhythmia
Thoracic trauma as primary ARF cause
Asthma attack
Cardiogenic shock
ACS requiring urgent cath
ARF within 72h post-extubation
Post-surgical ARF within 72h
Hypercapnic ARF due to neuromuscular/chest wall disease
Palliative care or DNI
Chronic pulmonary disease other than COPD
6 hours BPAP prior to randomization (hypoxemic non-immunocompromised, immunocompromised, and COPD groups)
Prior BPAP use in ACPE

INTERVENTION & COMPARATOR

Intervention (HFNC Group):

Flow:
- COPD: Start 30 L/min
- All others: Start 45 L/min
- Titrated up to 60 L/min or highest tolerated
FiO₂:
- Start at 50% and titrate to maintain target SpO₂
SpO₂ Targets:
- COPD: 88–92%
- Others: 92–98%
Rescue Therapy (COPD & ACPE only):
- If failing maximal HFNC → 1 hour of rescue BPAP
- If failing BPAP → immediate intubation
Weaning
- Begin ≥24 hrs once RR <25 and no distress
- Gradual reductions in FiO₂/flow
- Considered weaned at:
  - FiO₂ <30% and Flow <25–30 L/min

Comparator (BPAP Group):

Via ICU ventilator or BiLevel device
Initial Settings:
- COPD: IPAP 12–16 / EPAP 4
- Others: IPAP 12–14 / EPAP 8
Max settings: IPAP 20 / EPAP 12
SpO₂ Targets:
- COPD: 88–92%
- Others: 92–98%
Titration: Not standardized
Sedation: Not standardized
Weaning:
- After 24 hrs
- At clinician discretion
- Considered weaned at FiO₂ 30% and EPAP/PS <6

OUTCOMES

Primary Outcome:

Endotracheal intubation or death within 7 days.

Secondary Outcomes:

28-day mortality
90-day mortality
Mechanical ventilation free days at 28 days
ICU-free days at 28 days

Tertiary Outcomes:

Hospital and ICU length of stay within 90 days
Vasopressor-free days within 28 days
New DNI orders within 7 days
Patient comfort

📈 Results:

💥 Critical Results

MOR: Median Odds Ratio
MHR: Median Hazard Ratio

💪 Strengths

Broad, multicenter design: Large multicenter randomized trial comparing HFNC vs BPAP across several etiologies of acute respiratory failure in ED and ICU settings.
Etiology-based and COVID-specific subgroups: Patients were stratified into prespecified clinical subgroups (COPD with acidosis, ACPE, immunocompromised hypoxemia, non-immunocompromised hypoxemia), and COVID-19 was later added and analyzed as a separate subgroup rather than being combined with the original ARF categories.
Bayesian hierarchical model with dynamic borrowing: The primary analysis used a Bayesian hierarchical framework that allowed information to be borrowed across subgroups when treatment effects were similar and reduced borrowing when subgroups differed.
Prespecified non-inferiority and futility rules: Each subgroup had predefined non-inferiority and futility boundaries, and enrollment in the immunocompromised subgroup was stopped early after crossing a futility threshold.
Standardized BPAP delivery system: BPAP was delivered using a single BPAP system/interface across participating centers.
Single healthcare system and population: All sites were within one national healthcare system, with broadly similar clinician training, practice patterns, and patient populations for that country.
Current practice relevance: The trial addresses a post-COVID era question in which HFNC is widely used, providing comparative HFNC vs BPAP data across multiple ARF etiologies in a pragmatic ED/ICU population.

⚠️ Limitations

Small subgroup sizes: The COPD (35 vs 42) and immunocompromised (28 vs 22) subgroups included relatively few patients compared with the other etiologic groups.
Dependence on borrowing for COPD estimates: COPD treatment-effect estimates in the primary model were heavily influenced by borrowing from other subgroups, and no-borrowing sensitivity analyses showed wider intervals.
Pre-randomization BPAP and exclusion criteria: COPD patients could receive up to 6 hours of BPAP before randomization, and ACPE patients judged to require immediate BPAP were excluded from enrollment.
Rescue BPAP in the HFNC arm: Patients assigned to HFNC could receive rescue BPAP; BPAP settings were not standardized, and detailed reporting of rescue BPAP management and outcomes (including number of episodes) was limited.
Non-standardized weaning strategies: Weaning protocols for HFNC and BPAP were not tightly protocolized or aligned, and HFNC weaning permitted flows down to 25–30 L/min.
Single-country setting: All participating centers were located in one country.

🛣️Side Tangent on Bayesian Adaptive Model

Prior to our deep dive into the discussion, lets first explain the importance of the statistical method used in the RENOVATE trial, the Bayesian Adaptive Model.
A Bayesian Adaptive Model is a trial design that keeps updating its understanding of which treatment works better as new data are collected, and it allows the trial to change course in real time based on those results.
Now imagine you’re comparing two pairs of running shoes. Your goal is to see which one helps runners finish faster, so you measure their race times. Runners try Shoe A or Shoe B, and as the results come in, you analyze the times.

- If runners wearing Shoe A and Shoe B are finishing within a few seconds of each other, you would conclude the shoes perform similarly, meaning they are non-inferior.
- If runners wearing one shoe are consistently finishing much faster, you can say that shoe is superior, and the trial may stop early because you’ve clearly found the better option.
- If one shoe repeatedly produces slower times compared to the standard, you may stop the trial for inferiority, because continuing would not benefit runners.
This approach allows the study to learn as it goes and make decisions based on accumulating evidence rather than waiting until the very end.
The Bayesian adaptive model also utilizes a statistical tool known as dynamic borrowing. Dynamic borrowing is a statistical method that allows data from related groups to be shared or pooled when their outcomes appear similar, but automatically reduces or stops that sharing when the groups differ, ensuring accuracy and preventing misleading conclusions.

For example, if Shoes A and B are producing similar race times (non-inferior), the coach can combine or “borrow” data from both groups and average their times, which increases statistical precision.
However, if one shoe becomes clearly superior or clearly inferior, dynamic borrowing stops, because the race times are no longer comparable and averaging them would distort the results.
In this running-shoe analogy, the RENOVATE trial was essentially comparing Shoe A (BPAP) and Shoe B (HFNC) to see which helped patients “run faster,” or achieve better clinical outcomes in 5 different pathologies.
In this running-shoe analogy, the RENOVATE trial was essentially comparing Shoe A (BPAP) and Shoe B (HFNC) to see which helped patients “run faster,” or achieve better clinical outcomes across five different respiratory pathologies. As results accumulated, the Bayesian adaptive model used dynamic borrowing and could combine results when both devices performed similarly, but stopped pooling data if one clearly helped patients more or less.

🗣️ Discussion

What RENOVATE asked and what it found: The RENOVATE trial is the first multicenter randomized study to directly evaluate whether HFNC is non-inferior to BPAP for preventing intubation or death across multiple etiologies of acute respiratory failure. Overall, HFNC met non-inferiority criteria in four of the five predefined subgroups, with much of the statistical strength coming from the Bayesian borrowing structure. However, several design and analytic choices limit how confident we can be in these findings across all groups.
Bayesian model, borrowing, and small numbers: The Bayesian hierarchical model improves precision by “sharing” information between subgroups when outcomes look similar, but this does not fully fix the problem of small sample sizes. In subgroups with low numbers, the model still has less power and more uncertainty, and the apparent stability of the estimates is heavily influenced by the borrowing framework rather than large, subgroup-specific datasets.
COPD and ACPE – who actually got randomized: In both COPD and ACPE, enrollment decisions likely removed many of the sickest patients from randomization. COPD patients could be stabilized for up to six hours on BPAP before being randomized, and ACPE patients who clearly required immediate BPAP were excluded altogether. Because the trial never reported how many patients were treated or excluded in the ACPE group, we do not have a clear picture of how sick the randomized patients really were.
Rescue BPAP in the HFNC arm: Rescue therapy adds another layer of ambiguity. Nearly a quarter of COPD patients in the HFNC arm required rescue BPAP, yet the study did not describe the BPAP pressure settings used, how many times rescue could be repeated, or whether these patients ultimately improved, failed, or required intubation. This is particularly important because the primary endpoint is intubation within seven days, and we do not know how much non-standardized BPAP rescue influenced that outcome in patients initially assigned to HFNC.
Different weaning strategies between HFNC and BPAP: Weaning practices also differed meaningfully between HFNC and BPAP. HFNC patients could be considered “weaned” while still receiving flows that are well above physiologic baseline (25–30 L/min), whereas BPAP weaning was left largely to clinician judgment without tightly aligned criteria. This lack of standardized weaning makes it difficult to directly compare the two modalities in terms of duration of support and when a treatment should be considered to have “failed.”
Value of multiple etiologic subgroups: Rather than asking a single global question of whether HFNC works for all causes of acute respiratory failure, the trial was designed with multiple etiologic subgroups. This allows us to compare HFNC and BPAP within distinct pathologies commonly seen in the ED and ICU. In practice, this design helps us look across each subgroup and think about which modality—HFNC or BPAP—may be most appropriate for a given underlying diagnosis.
Immunocompromised subgroup had early futility and inadequate support: In immunocompromised patients, HFNC clearly underperformed BPAP on early outcomes. Intubation rates were higher with HFNC (50.0% vs 31.8%), and early deaths were also higher (17.9% vs 13.6%), leading this subgroup to cross a prespecified futility boundary and stopping further enrollment. By 28 and 90 days, mortality was similar between HFNC and BPAP in this cohort, suggesting that HFNC alone did not provide enough up-front respiratory support for this high-risk group rather than causing a lasting difference in long-term outcomes.
Why COVID was separated from the original ARF subgroups: Early in the COVID-19 pandemic, clinicians were making treatment decisions in real time without established guidelines or a solid understanding of disease trajectory. Many COVID patients behaved clinically like an immunocompromised or atypical ARF cohort. If COVID patients had been left inside the original ARF subgroups, they could have distorted those results and biased the trial toward an apparent signal of HFNC futility. By separating COVID into its own subgroup, the investigators preserved the integrity of the non-COVID etiologic groups while still including COVID patients in the overall study population. This approach allowed for cleaner estimates within each subgroup and more appropriate borrowing across groups without letting a large, atypical population dominate the model.
Standardized BPAP delivery as a control: Using one BPAP delivery method for all patients created a built-in control on the BPAP side of the trial. The interface and mode were standardized, so the main difference between patients was their underlying disease and assignment to HFNC vs BPAP. This consistency across BPAP subgroups reduces “noise” in how BPAP was delivered and makes it easier to attribute differences in outcomes to the disease process and modality choice rather than variation in the BPAP setup itself.
Single-country setting and external validity: Running the entire study in one country means clinicians share similar training, practice patterns, and system-level resources, which helps keep management more consistent across subgroups and centers. The trade-off is external validity: what is considered “standard” care in this health system may look very different in other countries, particularly in resource-limited settings, so these findings may not translate perfectly to other practice environments.

📘 Author's Conclusion

“HFNC met criteria for noninferiority to NIV for the primary outcome in 4 of the 5 patient groups. Small sample sizes and sensitivity to the analysis model suggest further study is needed in COPD, immunocompromised patients, and ACPE.”

💬 Our Conclusion

HFNC appears to perform comparably to BPAP in non-immunocompromised hypoxemic and COVID-positive patients. However, the data in COPD, ACPE, and immunocompromised patients are limited and statistically fragile—heavily influenced by small numbers and modeling assumptions—so BPAP should remain the preferred modality when ventilatory support is clearly required and may offer more reliable benefit in these groups.

🚨 Clinical Bottom Line

HFNC is a great option for many patients with acute respiratory failure, but some patients clearly need BPAP up front. In patients with obvious BPAP-responsive physiology—such as COPD with acidosis, ACPE with increased work of breathing, or frank hypercapnia—or in those who are crashing at the door, BPAP remains the first-line choice. In more stable patients, especially those without a strong indication for BPAP, with limited hypercapnia, or where comfort and longer-term tolerance matter, HFNC is a reasonable first-line option for extra respiratory support while you closely watch their trajectory and stay ready to escalate.

📚 References

RENOVATE Investigators and BRICNet Authors.
High-flow nasal oxygen vs noninvasive ventilation in patients with acute respiratory failure: The RENOVATE randomized clinical trial. JAMA. 2025;333(10):875–890.
PMID: 39657981
Tempo G, Grieco DL.
Article review: The RENOVATE randomised clinical trial. European Society of Intensive Care Medicine (ESICM) Article Review. 2025.
Available here
Roca O, Messika J, Caralt B, et al.
Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: The utility of the ROX index. J Crit Care. 2016;35:200–205.
PMID: 27481760
Rochwerg B, Brochard L, Elliott MW, et al.
Official ERS/ATS clinical practice guidelines: Noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50(2):1602426.
PMID: 28860265

Post Peer Reviewed By: Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), Frank Lodeserto, MD and Anand Swaminathan, MD (X: @EMSwami)

👤 Guest Contributor

Jonathan Bradshaw, DO
Emergency Medicine Resident (PGY-3)
Cape Fear Valley Medical Center
Fayetteville, NC

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REBEL MIND – Rest Is Not Sleep: The Seven Dimensions of True Recovery

Mark Ramzy — Wed, 04 Feb 2026 12:00:56 +0000

🔑Key Points

🛌 Rest isn’t a luxury; it’s a necessity and differs significantly from sleep in terms of mental and physical recovery needs.

🧠 Uncovering the seven types of rest can highlight diverse needs: physical, mental, sensory, creative, emotional, social, and spiritual.

🏃‍️ Rest from high-stress environments such as the ED is crucial for reducing exhaustion, enhancing decision-making, and maintaining empathy.

🔄 The necessity for intentional rest: tailor your rest strategies to meet personal recharge needs effectively.

🧐 Rest should be deserved, not earned—it’s a vital component of overall health and wellness, on par with nutrition and hydration.

Click here for Direct Download of the Podcast.

👀Previously Covered and Related Content:

- REBEL Core Cast: Sleep Hygiene
- Rebellion in EM: Care For Yourself – Sleep Hygiene
- First10EM: Some Evidence For Working Night Shifts
- REBEL MIND: Dunning Kruger Effect

📝 Introduction

Today we are exploring the imperative topic of rest and why it’s not just about sleeping. The first of a two part series, hosted by Dr. Mark Ramzy with guests Dr. Maureen Aiad and Dr. Amil Badoolah, our discussion sheds light on the multifaceted nature of rest, especially in the demanding field of emergency medicine. If you’re a clinician striving to perform at your best under pressure, this episode offers valuable insights into achieving the rest you deserve.

Cognitive Question

How do healthcare professionals in high-stress environments distinguish between rest and sleep, and how can they effectively incorporate various types of rest into their routines to manage stress and improve performance?

💤How is Rest Different From Sleep?

- Sleep is biological. It’s essential—but it’s only one form of recovery.
- Rest, on the other hand, is intentional, multifaceted, and active.
- You can sleep for 8 hours and still feel depleted—because what you needed wasn’t sleep, it was rest—in a different dimension.

🏥How This Applies to the Emergency Department or ICU?

- In the fast-paced, high-pressure world of the ED or ICU, medical professionals often overlook the importance of rest, perceiving it as unproductive.
- Yet, rest is crucial for maintaining cognitive function and emotional resilience. The unique concept of rest outlined in the ‘seven types of rest’ can be particularly beneficial.
- Understanding and implementing these can help practitioners handle the rigors of patient care and decision-making more effectively.

7️⃣The Seven Types of Rest

- 1️⃣Physical Rest: Passive (like sleep) and active (like stretching, massage, gentle movement).
- 2️⃣Mental Rest: Reducing decision fatigue. Tools like brain dumping, meditation, or taking real breaks during work.
- 3️⃣Sensory Rest: This involves reducing the input from your senses, such as limiting screen time, turning off the lights, or enjoying quiet time.
- 4️⃣Creative Rest: Reconnecting with awe. Nature, art, music—things that refill your inspiration tank
- 5️⃣Emotional Rest: Being around people you don’t have to perform for. Saying “I’m not okay.” spaces and people where you can be your authentic self and be at peace
- 6️⃣Social Rest: Taking space from draining interactions; spending time with life-giving people.
- 7️⃣Spiritual Rest: Connection to a greater purpose—faith, community, reflection, meditation

⏩Immediate Action Steps for Your Next Shift

**Identify Your Rest Needs**: Reflect on what kind of fatigue you’re experiencing and tailor rest activities accordingly, whether it’s sensory detox or emotional unwinding.
**Practice Sensory Rest**: Take brief moments to close your eyes, or step outside for fresh air to manage overstimulation during shifts.
**Plan Intentional Breaks**: Schedule specific times for rest that focus on particular dimensions you identify as lacking.
**Engage in Active Rest**: Incorporate activities like stretching or meditation during your breaks to enhance mental clarity and reduce physical exhaustion.
**Connect with Supportive Colleagues**: Seek interactions with peers who offer emotional and social support, promoting a healthy work-life balance.

🛌🏽The Many Aspects of What Makes Up Rest

- Rest is multifaceted – it comes in more than one form
- Rest is productive – it improves performance, decision-making, empathy
- Rest is intentional – it requires thoughtful engagement, not autopilot. Make a real plan
- Rest is layered – especially sensory, which uses all 5 senses
- Rest is about input and detox – what you consume, and what you remove. Social rest is a good example
- Rest is personal – one person’s recharge is another’s stressor
- Rest is deserved, not earned – full stop.

Conclusion

Rest is a pivotal, multi-dimensional tool that extends beyond mere sleep. For healthcare professionals navigating the strenuous environment of an emergency setting, recognizing and implementing varied forms of rest can enhance overall well-being, decision-making, and patient care. Make rest a deliberate part of your routine, understand its different forms, and remember that it’s a necessity you deserve.

🚨 Clinical Bottom Line

Incorporating rest into your lifestyle aligns with the demands of your professional roles and personal health needs. By understanding and employing various types of rest, you not only support your individual wellness but also enhance your ability to care for patients effectively. Rest is vital; it is not a privilege earned but an essential right you deserve every day.

Meet the Authors

Mark Ramzy, DO

Co-Editor-in-Chief

Cardiothoracic Intensivist and EM Attending RWJBH / Rutgers Health, Newark, NJ

Maureen Aiad, DO

Assistant Professor of Emergency Medicine

NYU Grossman Long Island School of Medicine, New York

Amil Badoolah, DO

Assistant Professor of Emergency Medicine

NYU Grossman Long Island School of Medicine, New York

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The post REBEL MIND – Rest Is Not Sleep: The Seven Dimensions of True Recovery appeared first on REBEL EM - Emergency Medicine Blog.

REBEL Core Cast 149: Review of Corticosteroids in Community-Acquired Pneumonia

Frank J. Lodeserto MD, Eric Acker MD, Alex Chapa MD — Mon, 02 Feb 2026 13:00:43 +0000

🗝️ Key Points

💉 Hydrocortisone Saves Lives:
The 2023 Cape Cod Trial (NEJM) showed a clear mortality benefit and reduced need for intubation in severe CAP patients treated with hydrocortisone.
📊 Guidelines Are Catching Up:
The SCCM (2024) and ERS now recommend steroids for severe CAP, while ATS/IDSA updates are still pending.
🔥 Redefining “Severe”:
Patients requiring high FiO₂ (>50%), noninvasive or mechanical ventilation, or PSI >130 meet criteria for steroid therapy — even outside the ICU.
🍬 Main Risk = Hyperglycemia:
Elevated glucose was the most consistent adverse effect, but rates of GI bleed and secondary infection were not increased.
🧭 Early, Targeted Use Matters:
Start hydrocortisone within 24 hours of identifying severity — especially in patients with high CRP (>150) or strong inflammatory response.

Click here for Direct Download of the Podcast.

📝 Introduction

Corticosteroids have long sparked debate in the treatment of bacterial pneumonia — once viewed with skepticism, now increasingly supported by high-quality evidence. In this episode, Dr. Alex Chapa joins the REBEL Core Cast team to explore how the 2023 Cape Cod Trial (NEJM) reshaped practice and guideline recommendations for severe community-acquired pneumonia (CAP).

📖 Historical Context & Long-Standing Skepticism

For decades, the use of steroids in pneumonia was controversial.

- Early Use: Steroids entered practice in the 1940s and 50s for autoimmune inflammation, but there was immediate hesitation regarding secondary superinfections.
- Mixed Data: From the 1980s to the 2000s, small studies emerged on severe pneumonia and ARDS, but the data was inconsistent. Different trials used varying definitions of “severe” pneumonia and different C-reactive protein (CRP) cutoffs, making the data “spread” and easy to “cherry pick” to support or deny a benefit.
- Past Guidelines: This uncertainty was reflected in official guidelines:
  - 2007 (ATS/IDSA): The American Thoracic Society and the Infectious Diseases Society of America did not address the topic due to insufficient data.
  - 2019 (ATS/IDSA): Pre-COVID, the guidelines recommended against using corticosteroids in severe CAP. They acknowledged no benefit for non-severe pneumonia, but the data for severe pneumonia was considered too weak to endorse.
  - Pre-Trial Consensus: Prior to 2023, the consensus was to avoid steroids in non-severe pneumonia, while severe pneumonia remained a “gray area” with no treatment showing a clear mortality difference.

📜 The Landmark Cape Cod Trial (NEJM 2023)

The Cape Cod trial, published in the New England Journal of Medicine in 2023, reignited the discussion by providing robust, positive data.

Trial Design: Phase 3, multi-center, double-blind, randomized, controlled trial.
Intervention: 800 patients randomized to two groups, Hydrocortisone as a continuous infusion (200mg/day) versus a placebo infusion.
Taper: On day 4, clinicians would decide whether to continue the infusion or begin a taper based on clinical response.
Population: Patients with severe CAP, defined by meeting at least one of the following criteria:
- Pneumonia Severity Index (PSI) > 130.
- O2 by FiO2 ratio < 300.
- Need for mechanical or non-invasive ventilation (with PEEP ≥ 5).
- Need for high FiO2 (>50%) via non-rebreather or heated high flow.
Primary Outcomes: Death for any cause 6.2% (hydrocortisone) vs 11.9% (placebo)
Secondary outcomes:
- Death from any cause at 90 days 9.3% (hydrocortisone) vs 14.7% (placebo)
- Endotracheal intubation 18% (hydrocortisone) vs 29% (placebo)
- Hospital-acquired infections 9.8% (hydrocortisone) vs 11.1% (placebo)
- Gastrointestinal bleeding 2.3% (hydrocortisone) vs 3.3% (placebo)
- Vasopressor initiation by day 28 15.3% (hydrocortisone) vs 25.0% (placebo)
Key Findings: The trial demonstrated superiority for hydrocortisone

📋 Updated Guidelines & Current Practice

The Cape Cod trial, along with subsequent meta-analyses, has begun to change official recommendations.

Society of Critical Care Medicine (SCCM): In 2024, an SCCM expert panel, reviewing the Cape Cod trial and 18 others, strongly recommended corticosteroids for severe CAP. They concluded that steroids reduce mortality and the need for mechanical ventilation.
Meta-Analysis (Smit et al.): A 2024 meta-analysis in Lancet Respiratory confirmed the 30-day mortality benefit.
European Respiratory Society (ERS): The ERS has issued a recommendation to use steroids for severe pneumonia but still urges caution regarding side effects.
ATS/IDSA: As of the podcast recording, the ATS/IDSA had not yet updated their 2019 guidelines.

🛠️ Practical Application for Clinicians

Defining “Severe” CAP: The key is to identify patients who qualify as “severe”. This can be done using:

Scoring Tools: The PSI is the best validated tool for mortality but is cumbersome. Simpler tools like CURB-65 or SMART-COP are practical and acceptable for defining severity. 2023 meta-analysis from by Zaki et al showed both work well, but CURB-65 has better mortality prediction early on.
Cape Cod Criteria: Any patient meeting the trial’s inclusion criteria (e.g., high-flow O2, non-invasive ventilation) qualifies, regardless of location (ED, floor, or ICU).
Biomarkers: While not required, a CRP level was used in many studies. A CRP > 150 (Cape Cod) or > 204 (Smit meta-analysis) strongly indicates severe inflammation that would benefit from steroids.
Clinical Judgment: A patient who looks “sick,” has “soft” blood pressure, or has dense infiltrates and high oxygen needs (e.g., >50% FiO2 on high flow) is a candidate.

Adverse Effects:

Hyperglycemia: This was the most significant risk identified, with rates between 6-12%. This is a primary concern, especially in patient populations with high BMI.
GI Bleed & Secondary Infection: Fears of these side effects, which contributed to historical skepticism, were not borne out in the Cape Cod trial. The data does not support being overly concerned.
Other Side Effects: Mood changes, delirium, insomnia, and agitation in the elderly are known side effects of steroids that were not specifically addressed in the trial but remain clinical concerns.

🔄 Clinical Pathway for Steroids in Severe CAP

Unanswered Questions & Future Research

Possible remaining questions:

Biomarkers: Can we find a more precise CRP level to distinguish moderate from severe disease? Could other markers like ferritin or IL-6 be used?
Dosing & Tapering: How much immunomodulation is needed, and when is it truly safe to taper?
Gender Differences: Early data suggests females may respond better to steroids and experience fewer side effects. The question of female patients with severe CAP require less corticosteroids needs further exploration.

👉 Clinical Bottom Line

The current literature, spearheaded by the Cape Cod trial, now supports the use of corticosteroids in severe community-acquired pneumonia. The best evidence currently points to hydrocortisone, started early (within 24 hours) after severity is identified using a validated tool. While hyperglycemia is a risk, the previous fears of GI bleeding and secondary infections were not substantiated in recent, rigorous trials.

📚 References

Chapa-Rodriguez A, Abou-Elmagd T, O’Rear C, Narechania S.
Do patients with severe community-acquired bacterial pneumonia benefit from systemic corticosteroids?. Cleve Clin J Med. 2025;92(10):600-604.
PMID: 41033846
Dequin PF, Meziani F, Quenot JP, et al.
Hydrocortisone in Severe Community-Acquired Pneumonia. N Engl J Med. 2023;388(21):1931-1941.
PMID: 36942789
Chaudhuri D, Nei AM, Rochwerg B, et al.
2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia. Crit Care Med. 2024;52(5):e219-e233.
PMID: 38240492

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)

👤 Show Notes

Alex Chapa, MD

PGY 5 Pulmonary Critical Care Fellow

Cape Fear Valley Medical Center Fayetteville NC

🔎 Your Deep-Dive Starts Here

REBEL Core Cast 149: Review of Corticosteroids in Community-Acquired Pneumonia

Corticosteroids have long sparked debate in the treatment of bacterial ...

Thoracic and Respiratory

Corticosteroids in Severe Community Acquired Pneumonia: Could CAPE COD catalyze a change in critical care management?

Background: Community-acquired pneumonia (CAP) can lead to pulmonary and systemic ...

Short Course Antibiotics for Peds CAP: A Systematic Review and Meta-Analysis

Background: There is a shifting paradigm with persuasive evidence favoring ...

Infectious Disease

The SCOUT–CAP Trial: 5d Abx vs. 10d Abx in Pediatric CAP

Background: The standard approach to treating pediatric community-acquired pneumonia (CAP) is ...

Infectious Disease

LEAP 2: Lefamulin vs Moxifloxacin for CAP

Background: Recently there have been some observed trends in decreasing ...

Infectious Disease

Update in Community Acquired Pneumonia (CAP) Treatment: Macrolide Resistance

Background: Community acquired pneumonia (CAP), defined as lower bronchial tree infection ...

Infectious Disease

The post REBEL Core Cast 149: Review of Corticosteroids in Community-Acquired Pneumonia appeared first on REBEL EM - Emergency Medicine Blog.

REBEL CAST – IncrEMentuM26 Speaker Spotlight : Drs. Sara Crager and Ryan Ernst

Mark Ramzy — Thu, 29 Jan 2026 12:00:28 +0000

📝Introduction

Welcome to this special edition of the REBEL Cast, where we unravel key highlights and educational insights from the IncrEMentuM Conference in Spain. This event is a cornerstone for advancing emergency medicine education, drawing esteemed speakers and participants from around the globe. As emergency medicine gains traction in Spain, this conference has become an essential platform for knowledge exchange and professional growth. Today, host Dr. Mark Ramzy shines a spotlight on two phenomenal educators: Drs. Sara Crager and Ryan Ernst who shared their expertise and experiences at this transformative gathering last spring.

Click here for Direct Download of the Podcast.

🤔What's IncrEMentuM?

A new conference and a pivotal gathering for emergency medicine professionals worldwide, has become an essential platform for education, collaboration, and advocacy, especially in light of emergency medicine’s recent recognition as a specialty in Spain. The conference is praised for its outstanding production quality, engaging speakers, and its capacity to foster a global community of emergency care professionals.

️What's an Essential Question?

Essential questions are open-ended, thought-provoking, and intellectually engaging inquiries that inspire deeper exploration into topics. In the context of medical education, they challenge practitioners to think critically and reflect on their practice deeply. By focusing on essential questions, medical educators aim to inculcate a culture of continuous learning and curiosity, ensuring that medical professionals stay adaptable and insightful in their approach to patient care.

🎮Rapid Sequence (no not the intubating style...)

The Rapid Sequence game is an innovative tool that Sara and Ryan designed to enhance the learning experience for emergency medicine clinicians. It mimics real-life scenarios requiring rapid decision-making in high-pressure situations, such as those faced in emergency medical settings. This clinical case-based game aims to improve cognitive and procedural skills, allowing participants to hone their ability to respond effectively under pressure, thereby enhancing their real-world clinical performance.

You can try it out for free on their website here!

Their work was featured in the September 2025 edition of Annals of Emergency Medicine as a 2025 ACEP Abstract

🌳The Arboretum Teaching Collective

An arboretum is a space that cultivates a wide variety of diverse, unique, and symbiotic growth. Arboretum provides a creative space to decrease barriers, open opportunities, and support the development of extraordinary teachers. The Arboretum Teaching Collective is a non-profit organization dedicated to supporting emergency medicine education in countries where it is a new or evolving specialty. Their aim to facilitate the development of expert teachers by reducing barriers, providing opportunities, and curating talent. Their goal is to create a community of educators around the globe who share a vision of bringing excellent, innovative emergency medicine teaching to where it is most needed. Their approach is driven by curiosity, humility, and sustainability.

If you want to learn more and get involved, check out the Arboretum Teaching Collective Website Here

️ See you in Spain!

The upcoming conference aims to gather world-class educators once more and promises an enriching experience for all attendees. Drs. Sara Crager and Ryan Ernst, along with many others, will be there at the event. For more information on the IncrEMentuM Conference and to register, visit their website! See you there!

Sara Crager, MD

Associate Professor, Critical Care and Emergency Medicine

UCLA, Los Angeles, CA

Ryan Ernst, MD

Assistant Professor of Emergency Medicine, Section Chief of Global EM

University of Utah, Salt Lake City, UT

Mark Ramzy, DO

Co-Editor-in-Chief

Rutgers Health / RWJBH, Newark, NJ

🔎 Your Deep-Dive Starts Here

REBEL CAST – IncrEMentuM26 Speaker Spotlight : Drs. Sara Crager and Ryan Ernst

Host Dr. Mark Ramzy shines a spotlight on two phenomenal ...

Resuscitation

REBEL CAST – IncrEMentuM26 Speaker Spotlight : Drs. Tarlan Hedayati, Jess Mason and Simon Carley

Host Dr. Mark Ramzy shines a spotlight on three distinguished ...

Resuscitation

REBEL CAST – IncrEMentuM26 Speaker Spotlight : George Willis and Mark Ramzy

🧭 REBEL Rundown 📝Introduction In this exciting episode of REBEL ...

Endocrine, Metabolic, Fluid, and Electrolytes

Incrementum Conference 2026: Revolutionizing Emergency Medicine in Spain

In this special episode of Rebel Cast, we spotlight the ...

The post REBEL CAST – IncrEMentuM26 Speaker Spotlight : Drs. Sara Crager and Ryan Ernst appeared first on REBEL EM - Emergency Medicine Blog.

REBEL MIND: The Power of Performance Coaching in Medicine

Mark Ramzy — Wed, 28 Jan 2026 12:00:10 +0000

📌 Key Points

💪 Building Resilience: Rebel MIND, in partnership with Arena Labs, introduces a science-based performance coaching platform specifically tailored for healthcare professionals, focusing on stress management and burnout prevention.
🤝 Personal Insights: Jackie Penn shares her journey from exercise science to digital coaching, highlighting the importance of tailored coaching in high-pressure environments like healthcare.
🎯 Clinician-Centric Approach: Understanding unique challenges faced by ER doctors, the program provides practical tools for stress and transition management, improving both professional and personal life balance.
💻 Revolutionary Wearables: Utilizing wearables, the program offers objective feedback on recovery and health metrics, allowing personalization of strategies to enhance clinician well-being.

Click here for Direct Download of the Podcast.

📝 Introduction

Welcome back to REBEL MIND, where MIND stands for Mastering Internal Negativity during Difficulty. Here we sharpen the person behind the practitioner by focusing on things that improve our performance, optimizing team dynamics and the human behavior that embodies the hidden curriculum of medicine. In this episode, we’re excited to continue collaboration with Arena Labs, where host Dr. Marco Propersi interviews Jackie Pen, Heading of Performance Coaching at Arena Labs. Arena Labs is helping us measure healthcare performance through innovative programs designed to combat burnout and enhance personal wellness using data-driven strategies.

🔙Previously Covered on REBEL MIND:

Performance Under Pressure – What Medicine Can Learn from Elite Teams

🤔Cognitive Question

How do specific performance coaching strategies and tools assist healthcare professionals, particularly those in emergency medicine, in managing stress and preventing burnout effectively?

💭 Why This is Important

- Burnout among healthcare workers is a growing concern, especially in such high-pressure environments as emergency and intensive care units. The collaboration with Arena Labs brings forth a vital focus on using data and coaching to build resilience among medical professionals.

🏥How This Applies to the Emergency Department or ICU?

- In the chaotic and high-stakes environment of the ED/ICU, healthcare professionals are often required to make split-second decisions under pressure while managing emotional stress. This necessitates not just clinical acumen but also strong emotional resilience and stress management skills. Performance coaching provides the tools and frameworks to enhance these skills, offering strategies like the de-stress breath and transition protocols to help clinicians navigate between high-pressure situations efficiently. These tools are designed to not only improve their professional performance but also ensure they are emotionally present for their personal lives, ensuring a healthier work-life balance.

⏩ Things You Can Do on Your Next Shift

- Practice the De-stress Breath: Before moving from one critical case to another, take a moment to take two inhales through the nose followed by an extended exhale, helping to reset your nervous system by activating your parasympathetic nervous system.
- Implement a Transition Protocol: Choose a point in your journey home to mentally switch from clinician to family member, helping you to be more present outside of work.
- Optimize Your Nutrition and Rest: Even small changes during your shift, like meals that promote easy digestion or quick physical activities, can make a significant difference in your energy levels.
- Engage with Wearables: If possible, use wearables to monitor your physiological responses, helping tailor personalized strategies for your shifts

👀 Where to Learn More

🚨 Clinical Bottom Line

Join us in this journey towards enhanced well-being and workforce empowerment, ensuring that those who care for us are also cared for.

Meet the Authors

Marco Propersi

Co-Editor-in-Chief

Vassar Brothers Medical Center, Poughkeepsie, NY

Jackie Pen

Head of Performance Coaching

Arena Labs

The post REBEL MIND: The Power of Performance Coaching in Medicine appeared first on REBEL EM - Emergency Medicine Blog.

MDCalc Wars: Alcohol Withdrawal–When CIWA-Ar Breaks Down, mMINDS Score Still Works

Eric Steinberg DO, MEHP — Mon, 26 Jan 2026 12:00:15 +0000

🗝️ Key Points

🗣️ CIWA-Ar needs patient participation — it works best when the patient is awake, verbal, and reliable.
🏥 In severe/ICU withdrawal, CIWA-Ar breaks down — intubation, delirium, sedation, or critical illnessmake symptom reporting unreliable.
🎯 mMINDS is the ICU-ready alternative — it emphasizes objective findings (vitals + agitation/tremor/diaphoresis) and can be used when the patient can’t participate.
🔁 Trend the score, don’t one-and-done it — serial mMINDS reassessments help guide symptom-triggered escalation and monitor response.
⚠️ Watch for mimics — tachycardia/agitation may reflect pain, sepsis, hypoxia, intoxication, or delirium, so treat the patient, not just the number.

🤕 Case

Mark, a 52-year-old man with long-standing alcohol use disorder, presents to the ED 12 hours after his last drink with worsening tremors, agitation, nausea, and diaphoresis. Vitals show T 37.8 °C, HR 122, BP 178/94. He is visibly anxious, diaphoretic, tachycardic, and intermittently confused, with coarse hand tremors and pressured speech. He struggles to answer questions reliably and becomes increasingly restless despite initial benzodiazepine dosing. You turn to the reliable CIWA-Ar, but that depends on patient participation—so what do you use when that’s not possible?

🔗 Scoring Tools

➡️ CIWA-Ar for Alcohol Withdrawal

➡️ Modified Minnesota Detoxification Scale (mMINDS)

🎯 Quick Hits

💬 Case Resolution

Using the mMINDS score, the team objectively assessed withdrawal severity despite limited patient participation. They escalated treatment with symptom-triggered therapy. Guided by serial mMINDS reassessments, his agitation and autonomic instability steadily improved without progression to seizures or delirium tremens. He was safely admitted for monitored care and ultimately discharged with addiction medicine follow-up and a clear recovery plan.

FAQ: mMINDS vs CIWA-Ar

What is the mMINDS score used for?
mMINDS (modified Minnesota Detoxification Scale) is used to assess the severity of alcohol withdrawal when patient participation is limited, especially in critically ill/ICU patients. It leans on more objective findings (e.g., vitals, tremor, diaphoresis, agitation/sedation scales) rather than patient-reported symptoms.
Why doesn’t CIWA-Ar work in intubated or delirious patients?
CIWA-Ar includes multiple elements that require a patient to answer subjective questions (e.g., anxiety, nausea, hallucinations) and communicate reliably. In intubation, delirium, psychosis, or severe critical illness, those inputs become impossible or unreliable, so CIWA-Ar can’t be completed accurately and may mislead care.
When should I use mMINDS instead of CIWA-Ar?
Use mMINDS when the patient is ICU-level or can’t reliably participate—examples: intubated, delirious, nonverbal, heavily sedated, or otherwise unable to provide consistent symptom reporting. The ASAM guideline specifically recommends using a scale that relies more on objective signs when communication is difficult.
How often should mMINDS be reassessed in severe withdrawal?
Reassessment cadence is protocol-dependent, but in many hospital pathways it becomes more frequent as severity increases. Commonly used MINDS protocol checks scores q2h (mild), q1h (moderate), and q20min (severe) during active titration/escalation.
Can tachycardia or agitation inflate mMINDS if the cause isn’t withdrawal?
Yes. Autonomic signs and agitation are not specific to alcohol withdrawal and can reflect pain, hypoxia, sepsis, intoxication, medication effects, or primary delirium. Guidelines recommend assessing whether withdrawal scales may be confounded by other causes and interpreting scores cautiously when those risks exist.
Does mMINDS replace CIWA-Ar for mild floor-level withdrawal
Usually no. CIWA-Ar remains appropriate for stable, communicative patients and is widely used/validated in general inpatient settings, whereas mMINDS is mainly valuable when objectivity is needed and CIWA-Ar isn’t feasible (often ICU/non-communicative scenarios).

🚨 Clinical Bottom Line

CIWA-Ar: Use for stable, communicative patients.
mMINDs: Reach for it in severe or ICU-level withdrawal when objectivity is paramount.

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_Propersi), and Mark Ramzy, DO (X: @MRamzyDO)

🧭 Prep Sheets

CIWA-Ar for Alcohol Withdrawal

Modified Minnesota Detoxification Scale (mMINDS)

👤 Author

Eric Steinberg

DO, MEHP

Content Director, MDCalc, Residency Director, Emergency Medicine St. Joseph's University Medical Center, Paterson, NJ

Meet The Team

🔎 Your Deep-Dive Starts Here

Acute Pancreatitis

Acute Pancreatitis Background: Definition: Acute inflammatory process of the pancreas; ...

Abdominal and Gastrointestinal

The post MDCalc Wars: Alcohol Withdrawal–When CIWA-Ar Breaks Down, mMINDS Score Still Works appeared first on REBEL EM - Emergency Medicine Blog.

Seizing the Evidence: Should We Consider Ketamine’s Place in Seizure Protocols?

Brendan Freeman, DO & Katherine Zabinski, MD — Wed, 21 Jan 2026 12:00:53 +0000

👉 Bottom Line Up Top

Ketamine is a promising therapeutic agent for the treatment of status epilepticus; however, currently, there is insufficient evidence to support its use as a first-line agent.

🤕 Case

A 16-year-old boy presents to the ED with seizures. His mom states that the seizures started 15 minutes ago, stopped without any intervention, and then started again about 10 minutes later, prompting her to drive to the hospital. He has a history of seizures managed with levetiracetam. On arrival, the patient continues to have generalized tonic-clonic movements. Vitals cannot be obtained except for an O2 saturation of 99% on RA. As IV access is established, your team’s nurse asks what medication you would like to administer. Typically, you would request midazolam or lorazepam, but you remember there was a recent study investigating ketamine in addition to the use of midazolam in this situation.

🗣️ What Your Gut Says

Who doesn’t love ketamine? Let’s give a dose and see what happens.

📈 What The Evidence Says

Ketamine was first introduced for human use in 1965 and has been widely utilized as a general anesthetic with an excellent safety profile (Mion 2017, Dorandeu 2013). Ketamine works on several receptors, resulting in various actions such as anesthesia, analgesia, and antidepressant effects. While not widely studied, ketamine has been shown to have antiepileptic properties. In seizures, the excessive release of glutamate leads to the overactivation of N-methyl-D-aspartate (NMDA) receptors, thereby causing neuronal hyperexcitability and seizure-like activity. Ketamine works by regulating neuronal excitability and reducing excessive, synchronized neural activity through non-competitive inhibition of glutamatergic transmission, primarily via NMDA receptor antagonism. More specifically, blocking the NMDA receptor with ketamine decreases neuronal depolarization and excitotoxicity, potentially halting seizure propagation (Tan 2024).

Animal models have shown that NMDA antagonism exerts a synergistic action with benzodiazepines, making it a potentially promising adjunct treatment for status epilepticus as a possible first-line treatment (Naylor 2005). Human data evaluating the role of ketamine in status epilepticus is sparse and primarily evaluates its utility as a rescue medication (Scheppke 2024).

The recent Ket-Mid trial investigated whether adding ketamine to midazolam as first-line therapy improves the rate of seizure cessation in pediatric status epilepticus compared with placebo plus midazolam (Othman 2025). A total of 144 pediatric patients were randomized to receive either ketamine plus midazolam or placebo plus midazolam as initial therapy for status epilepticus. At the 5-minute mark, seizure activity had ceased in 76% of those given ketamine-midazolam compared with 21% in the placebo-midazolam group (RR 3.7; 95% CI, 2.3–5.9). Higher rates of seizure cessation in the ketamine group were maintained at 15, 35, and 55 minutes. This group also required fewer additional doses of midazolam. Endotracheal intubation was performed in 4.2% of patients receiving ketamine-midazolam, compared to 20.8% of those given placebo-midazolam. The investigators concluded that combining ketamine (2 mg/kg) with midazolam (0.2 mg/kg) may offer greater effectiveness than midazolam alone for initial management of pediatric status epilepticus. Of note, intubation rates were lower in the ket-mid group and there were no reported increased harms.

As promising as these results are, the study is limited by several factors that prevent its generalizability. Rates of seizure cessation in the midazolam-only group were lower than rates seen in prior studies (Chamberlain 2024, Kapur 2019). This difference may be related to factors frequently seen in low- and middle-income country settings. This includes delayed presentation with more advanced illness, limited access to prehospital interventions, slower emergency response times, and constraints in patient monitoring and follow-up. In this study, the true therapeutic effect of ketamine may be hidden due to this bias. This limits our ability to interpret whether ketamine has a true therapeutic advantage or is the result of systemic limitations on the control group’s outcomes. Furthermore, the trial was only conducted at a single institution. Future studies like the UVA-KESETT trial may further elucidate the role of ketamine in the treatment of seizures.

🚨 Clinical Bottom Line

There is insufficient data to support the use of ketamine as a first-line agent for the treatment of status epilepticus. Ketamine is likely to play a role in the treatment of these patients; however, additional large, multicenter, randomized controlled trials are needed to clarify its optimal use within the treatment algorithm.

📚 References

Mion G. History of anaesthesia: The ketamine story – past, present and future. Eur J Anaesthesiol. 2017 PMID: 28731926
Dorandeu F, et al. Treatment of status epilepticus with ketamine, are we there yet? CNS Neurosci Ther. 2013 PMID: 23601960
Tan Y, et al. Therapeutic potential of ketamine in management of epilepsy: Clinical implications and mechanistic insights. Asian J Psychiatr. 2024 PMID: 39366036
Naylor DE, et al. Trafficking of GABA(A) receptors, loss of inhibition, and a mechanism for pharmacoresistance in status epilepticus. J Neurosci. 2005 PMID: 16120773
Scheppke KA, et al. Effectiveness of Ketamine As a Rescue Drug for Patients Experiencing Benzodiazepine-Resistant Status Epilepticus in the Prehospital Setting. Crit Care Explor. 2024;6(12):e1186. Published 2024 Dec 6 PMID: 39642307
Othman AA et al. Combined Ketamine and Midazolam Versus Midazolam Alone for Initial Treatment of Pediatric Generalized Convulsive Status Epilepticus (Ket-Mid Study): A Randomized Controlled Trial. Pediatric Neurology 2025 PMID: 40186980
Chamberlain JM, et al. Efficacy of intravenous lorazepam and diazepam in children with convulsive status epilepticus: A randomized clinical trial. N Engl J Med. 2020 PMID: 24756515
Kapur J, et al. Randomized trial of three anticonvulsant medications for status epilepticus. N Engl J Med. 2019 PMID: 31774955

Post Peer Reviewed By: Anand Swaminathan, MD (X: @EMSwami) and Mark Ramzy, DO (X: @MRamzyDO)

Guest Post

Brendan Freeman DO

Assistant professor of EM

Northwell Health

Katherine Zabinski, MD

Chief Resident

SIUH

🔎 Your Deep-Dive Starts Here

Seizing the Evidence: Should We Consider Ketamine’s Place in Seizure Protocols?

Ketamine was first introduced for human use in 1965 and ...

Neurology

Clinical Conundrum: Pregnant and Puking: What’s Safe and Effective in the ED?

Nausea with or without vomiting is very common in early ...

Obstetrics and Gynecology

Midazolam vs Ketamine as Second Line in Status Epilepticus

Status epilepticus is traditionally defined as a seizure lasting ≥5 ...

Neurology

Clinical Conundrum: What is the Utility of Procalcitonin in the ED?

Procalcitonin is a protein that is upregulated during inflammatory states. ...

Infectious Disease

Sub-Dissociative IV vs Nebulized Ketamine to Treat Pain

Background: IV subdissociative ketamine at a dose of 0.1 to ...

Orthopedics

Unpacking the PEACH Trial: What is Levetiracetam’s Role in Spontaneous Intracerebral Hemorrhage?

BACKGROUND: intracerebral hemorrhage (ICH) makes up 10-15% of all strokes ...

Neurology

The post Seizing the Evidence: Should We Consider Ketamine’s Place in Seizure Protocols? appeared first on REBEL EM - Emergency Medicine Blog.

REBEL MIND: Performance Under Pressure – What Medicine Can Learn from Elite Teams

Mark Ramzy — Wed, 21 Jan 2026 12:00:43 +0000

📌 Key Points

🎯Partnership Focus: New collaboration with Arena Labs aimed at enhancing healthcare worker wellness.

🏃🏽‍️‍➡️Personalized Coaching: Tools and coaching programs designed for stress management and performance improvement.

📊Data-Driven Insights: Utilizing wearable sensor data to tackle burnout effectively.

🌄Broad Impact: Offers a unique opportunity to contribute to large-scale healthcare improvements.

Click here for Direct Download of the Podcast.

📝 Introduction

Welcome back to REBEL MIND, where MIND stands for Mastering Internal Negativity during Difficulty. Here we sharpen the person behind the practitioner by focusing on things that improve our performance, optimizing team dynamics and the human behavior that embodies the hidden curriculum of medicine. In this episode, hosted by Drs. Mark Ramzy and Marco Propersi, we’re excited to introduce a collaboration with Arena Labs. Arena Labs is helping us measure healthcare performance through innovative programs designed to combat burnout and enhance personal wellness using data-driven strategies.

Cognitive Question

What would it look like in emergency medicine and critical care to be set up with the same tools as elite teams and professional athletes when it comes to measuring performance and recovery? How would our patients benefit?

💭 Why This is Important

- Burnout among healthcare workers is a growing concern, especially in such high-pressure environments as emergency and intensive care units. The collaboration with Arena Labs brings forth a vital focus on using data and coaching to build resilience among medical professionals.

🌟Be Brilliant at the Basics

- Ask yourself — “What is it on your time off that gives you a deep sense of fulfillment?”
- On your time off are you doing things that fill your bucket and add to your recovery?

What is Allostasis and Allostatic Load

- Allostasis: Our body’s ability to adapt over time to stress. It’s relevant to the phase you are in during this particular season in your life.
  - Ex. You are a first year medical student freaking out about your very first exam. Over time as you do more exams, they are still stressful, but by now you have developed modified study habits to succeed and get used to the frequent exams
  - In the context of emergency medicine, you may be nervous or stressed about your first shift at a new hospital but overtime you learn the staff, the location of equipment, the acuity of that particular site, the patient population so over time you get used to the stress of a shift at that new hospital

- Allostatic Load: The wear and tear on the body from chronic stress due to maladaptation or poor recovery methods.

- This refers to the cumulative burden of chronic stress and life events. It involves the interaction of different physiological systems at varying degrees of activity.
  - Ex. You are an emergency medicine physician at a very busy, high acuity center and have never prioritized taking care of yourself on/during a shift. As a result, external factors add to not being able to fully recover when you get home or are off shift (ie. Admin work, teaching obligations, family/friends) and so you never fully recover before you have to go back on shift to the same stressors you just exposed yourself to. So the cycle continues

Figure 1: Long term effects of Chronic Stress (Source: Andrew Hogue from NeuroFit)

🏥How This Applies to the Emergency Department or ICU?

- Healthcare workers in emergency departments (ED) and intensive care units (ICU) are often under enormous stress due to the nature of their work. Arena Labs’ program offers tailored solutions, helping ED and ICU staff manage their unique challenges through effective recovery techniques and performance tools. This approach caters specifically to the demanding schedules and the unpredictability inherent in these environments.

👀 Where to Learn More

🚨 Clinical Bottom Line

Join us in this journey towards enhanced well-being and workforce empowerment, ensuring that those who care for us are also cared for.

📚References

Guidi J, et al.
Allostatic Load and Its Impact on Health: A Systematic Review. Psychother Psychosom. 2021; Epub 2020 Aug 14.
PMID: 32799204
Frueh BC, et al.
“Operator syndrome”: A unique constellation of medical and behavioral health-care needs of military special operation forces. Int J Psychiatry Med. Epub 2020 Feb 13.
PMID: 32052666

Meet the Authors

Mark Ramzy, DO

Co-Editor-in-Chief

Cardiothoracic Intensivist and EM Attending RWJBH / Rutgers Health, Newark, NJ

Marco Propersi

Co-Editor-in-Chief

Chair of Emergency Medicine at Vassar Brothers Medical Center, Poughkeepsie, NY

Brain Ferguson

Founder and CEO

Arena Labs

The post REBEL MIND: Performance Under Pressure – What Medicine Can Learn from Elite Teams appeared first on REBEL EM - Emergency Medicine Blog.

RENOVATE Trial: HFNC vs BPAP in Acute Respiratory Failure

Jonathan Bradshaw, DO — Mon, 19 Jan 2026 12:00:25 +0000

📌 Key Points

💨 HFNC met criteria for non-inferiority to BPAP for preventing intubation or death within 7 days in four of the five ARF subgroups.
🧪 Bayesian dynamic borrowing increased power across subgroups but created variable certainty, especially in smaller groups such as COPD.
🫁 The immunocompromised hypoxemia subgroup did not meet non-inferiority, leading to early trial stopping for futility.
️ Rescue BPAP use, subgroup-specific exclusion criteria, and non-standardized BPAP delivery are important contextual factors that influence how subgroup results should be interpreted.

📝 Introduction

Bilevel Positive Airway Pressure (BPAP) has long been a foundational modality in the management of acute respiratory failure (ARF), particularly in COPD exacerbations and cardiogenic pulmonary edema, where it can rapidly reduce work of breathing and improve gas exchange. It remains a core tool in our respiratory support arsenal.
High-flow nasal cannula (HFNC), however, has expanded what we can offer patients by delivering many of the same physiologic benefits through a far more comfortable interface. With high flows, modest PEEP, and effective dead-space washout, HFNC can improve oxygenation and decrease work of breathing while preserving the ability to talk, cough, eat, and interact with staff and family. This combination of physiologic support and tolerability makes HFNC especially attractive in patients where comfort, anxiety, or cardiovascular stability are key considerations, and in settings where prolonged noninvasive support may be needed. Rather than competing with BPAP, HFNC broadens our options in ARF and allows us to better match the modality to the patient and their underlying disease process.
The RENOVATE trial set out to answer a high-impact question across five distinct etiologic groups: Is HFNC non-inferior to BPAP (NIV) for preventing intubation or death in acute respiratory failure?

🧾 Paper

Azoulay É, et al. High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients With Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial. JAMA. 2025 PMID: 39657981

🔙Previously Covered On REBEL:

️ What They Did

CLINICAL QUESTION

Is HFNC non-inferior to BPAP for rate of endotracheal intubation or death at 7 days in patients with acute respiratory failure due to a variety of causes?

STUDY DESIGN

Multicenter, randomized non-inferiority trial
33 Brazilian hospitals
Nov 2019 – Nov 2023
Adaptive Bayesian hierarchical modeling with dynamic borrowing
Open label, outcome adjudicators blinded
Patients were classified into 5 subgroups

SUBGROUPS

1. Non-immunocompromised hypoxemia

SpO₂ < 90% on room air or
PaO₂ < 60 mm Hg on room air plus
- Increased respiratory effort (accessory muscle use, paradoxical breathing, thoracoabdominal asynchrony) or
- Respiratory rate > 25 breaths/min

2. Immunocompromised hypoxemia

Defined as:

- Use of immunosuppressive drugs for >3 months
- OR high-dose steroids >0.5 mg/kg/day
- OR solid organ transplant
- OR solid tumors or hematologic malignancies (past 5 years)
- OR HIV with AIDS / primary immunodeficiency

3. COPD exacerbation with acidosis

High clinical suspicion of COPD as primary diagnosis
RR >25 with accessory muscle use, paradoxical breathing, and/or thoracoabdominal asynchrony
ABG: pH <7.35 AND PaCO₂ >45

4. Acute cardiogenic pulmonary edema (ACPE)

Sudden onset dyspnea and rales
± S3 heart sound
No evidence of aspiration, infection, or pulmonary fibrosis
CXR consistent with pulmonary edema

5. Hypoxemic COVID-19 (added June 2023)

Added due to deviations between expected and observed outcome proportions
Any patient across the other 4 groups with PCR-confirmed SARS-CoV-2 infection in any of the above groups

POPULATION

Inclusion Criteria:

≥18 yrs with ARF* in one of 5 pre-defined subgroups excluding COPD was defined by the following:
Hypoxemia with SpO₂ <90 or PaO₂ <60
Accessory muscle use, paradoxical breathing, and/or thoracoabdominal asynchrony
RR >25 BPM

Exclusion Criteria:

Need for emergency intubation
Prolonged apneic episodes
Cardiorespiratory arrest
GCS <12
HR <50 with decreased consciousness
ABG pH <7.15
Severe agitation requiring heavy sedation
Hemodynamic instability (MAP <65, SBP <90 despite fluids or requiring high-dose pressors)
Contraindications to BPAP (facial trauma, recent esophageal surgery, copious secretions, vomiting, aspiration risk)
Pneumothorax or large pleural effusion
Severe arrhythmia
Thoracic trauma as primary ARF cause
Asthma attack
Cardiogenic shock
ACS requiring urgent cath
ARF within 72h post-extubation
Post-surgical ARF within 72h
Hypercapnic ARF due to neuromuscular/chest wall disease
Palliative care or DNI
Chronic pulmonary disease other than COPD
6 hours BPAP prior to randomization (hypoxemic non-immunocompromised, immunocompromised, and COPD groups)
Prior BPAP use in ACPE

INTERVENTION & COMPARATOR

Intervention (HFNC Group):

Flow:
- COPD: Start 30 L/min
- All others: Start 45 L/min
- Titrated up to 60 L/min or highest tolerated
FiO₂:
- Start at 50% and titrate to maintain target SpO₂
SpO₂ Targets:
- COPD: 88–92%
- Others: 92–98%
Rescue Therapy (COPD & ACPE only):
- If failing maximal HFNC → 1 hour of rescue BPAP
- If failing BPAP → immediate intubation
Weaning
- Begin ≥24 hrs once RR <25 and no distress
- Gradual reductions in FiO₂/flow
- Considered weaned at:
  - FiO₂ <30% and Flow <25–30 L/min

Comparator (BPAP Group):

Via ICU ventilator or BiLevel device
Initial Settings:
- COPD: IPAP 12–16 / EPAP 4
- Others: IPAP 12–14 / EPAP 8
Max settings: IPAP 20 / EPAP 12
SpO₂ Targets:
- COPD: 88–92%
- Others: 92–98%
Titration: Not standardized
Sedation: Not standardized
Weaning:
- After 24 hrs
- At clinician discretion
- Considered weaned at FiO₂ 30% and EPAP/PS <6

OUTCOMES

Primary Outcome:

Endotracheal intubation or death within 7 days.

Secondary Outcomes:

28-day mortality
90-day mortality
Mechanical ventilation free days at 28 days
ICU-free days at 28 days

Tertiary Outcomes:

Hospital and ICU length of stay within 90 days
Vasopressor-free days within 28 days
New DNI orders within 7 days
Patient comfort

📈 Results:

💥 Critical Results

MOR: Median Odds Ratio
MHR: Median Hazard Ratio

💪 Strengths

Broad, multicenter design: Large multicenter randomized trial comparing HFNC vs BPAP across several etiologies of acute respiratory failure in ED and ICU settings.
Etiology-based and COVID-specific subgroups: Patients were stratified into prespecified clinical subgroups (COPD with acidosis, ACPE, immunocompromised hypoxemia, non-immunocompromised hypoxemia), and COVID-19 was later added and analyzed as a separate subgroup rather than being combined with the original ARF categories.
Bayesian hierarchical model with dynamic borrowing: The primary analysis used a Bayesian hierarchical framework that allowed information to be borrowed across subgroups when treatment effects were similar and reduced borrowing when subgroups differed.
Prespecified non-inferiority and futility rules: Each subgroup had predefined non-inferiority and futility boundaries, and enrollment in the immunocompromised subgroup was stopped early after crossing a futility threshold.
Standardized BPAP delivery system: BPAP was delivered using a single BPAP system/interface across participating centers.
Single healthcare system and population: All sites were within one national healthcare system, with broadly similar clinician training, practice patterns, and patient populations for that country.
Current practice relevance: The trial addresses a post-COVID era question in which HFNC is widely used, providing comparative HFNC vs BPAP data across multiple ARF etiologies in a pragmatic ED/ICU population.

⚠️ Limitations

Small subgroup sizes: The COPD (35 vs 42) and immunocompromised (28 vs 22) subgroups included relatively few patients compared with the other etiologic groups.
Dependence on borrowing for COPD estimates: COPD treatment-effect estimates in the primary model were heavily influenced by borrowing from other subgroups, and no-borrowing sensitivity analyses showed wider intervals.
Pre-randomization BPAP and exclusion criteria: COPD patients could receive up to 6 hours of BPAP before randomization, and ACPE patients judged to require immediate BPAP were excluded from enrollment.
Rescue BPAP in the HFNC arm: Patients assigned to HFNC could receive rescue BPAP; BPAP settings were not standardized, and detailed reporting of rescue BPAP management and outcomes (including number of episodes) was limited.
Non-standardized weaning strategies: Weaning protocols for HFNC and BPAP were not tightly protocolized or aligned, and HFNC weaning permitted flows down to 25–30 L/min.
Single-country setting: All participating centers were located in one country.

🛣️Side Tangent on Bayesian Adaptive Model

Prior to our deep dive into the discussion, lets first explain the importance of the statistical method used in the RENOVATE trial, the Bayesian Adaptive Model.
A Bayesian Adaptive Model is a trial design that keeps updating its understanding of which treatment works better as new data are collected, and it allows the trial to change course in real time based on those results.
Now imagine you’re comparing two pairs of running shoes. Your goal is to see which one helps runners finish faster, so you measure their race times. Runners try Shoe A or Shoe B, and as the results come in, you analyze the times.

- If runners wearing Shoe A and Shoe B are finishing within a few seconds of each other, you would conclude the shoes perform similarly, meaning they are non-inferior.
- If runners wearing one shoe are consistently finishing much faster, you can say that shoe is superior, and the trial may stop early because you’ve clearly found the better option.
- If one shoe repeatedly produces slower times compared to the standard, you may stop the trial for inferiority, because continuing would not benefit runners.
This approach allows the study to learn as it goes and make decisions based on accumulating evidence rather than waiting until the very end.
The Bayesian adaptive model also utilizes a statistical tool known as dynamic borrowing. Dynamic borrowing is a statistical method that allows data from related groups to be shared or pooled when their outcomes appear similar, but automatically reduces or stops that sharing when the groups differ, ensuring accuracy and preventing misleading conclusions.

For example, if Shoes A and B are producing similar race times (non-inferior), the coach can combine or “borrow” data from both groups and average their times, which increases statistical precision.
However, if one shoe becomes clearly superior or clearly inferior, dynamic borrowing stops, because the race times are no longer comparable and averaging them would distort the results.
In this running-shoe analogy, the RENOVATE trial was essentially comparing Shoe A (BPAP) and Shoe B (HFNC) to see which helped patients “run faster,” or achieve better clinical outcomes in 5 different pathologies.
In this running-shoe analogy, the RENOVATE trial was essentially comparing Shoe A (BPAP) and Shoe B (HFNC) to see which helped patients “run faster,” or achieve better clinical outcomes across five different respiratory pathologies. As results accumulated, the Bayesian adaptive model used dynamic borrowing and could combine results when both devices performed similarly, but stopped pooling data if one clearly helped patients more or less.

🗣️ Discussion

What RENOVATE asked and what it found: The RENOVATE trial is the first multicenter randomized study to directly evaluate whether HFNC is non-inferior to BPAP for preventing intubation or death across multiple etiologies of acute respiratory failure. Overall, HFNC met non-inferiority criteria in four of the five predefined subgroups, with much of the statistical strength coming from the Bayesian borrowing structure. However, several design and analytic choices limit how confident we can be in these findings across all groups.
Bayesian model, borrowing, and small numbers: The Bayesian hierarchical model improves precision by “sharing” information between subgroups when outcomes look similar, but this does not fully fix the problem of small sample sizes. In subgroups with low numbers, the model still has less power and more uncertainty, and the apparent stability of the estimates is heavily influenced by the borrowing framework rather than large, subgroup-specific datasets.
COPD and ACPE – who actually got randomized: In both COPD and ACPE, enrollment decisions likely removed many of the sickest patients from randomization. COPD patients could be stabilized for up to six hours on BPAP before being randomized, and ACPE patients who clearly required immediate BPAP were excluded altogether. Because the trial never reported how many patients were treated or excluded in the ACPE group, we do not have a clear picture of how sick the randomized patients really were.
Rescue BPAP in the HFNC arm: Rescue therapy adds another layer of ambiguity. Nearly a quarter of COPD patients in the HFNC arm required rescue BPAP, yet the study did not describe the BPAP pressure settings used, how many times rescue could be repeated, or whether these patients ultimately improved, failed, or required intubation. This is particularly important because the primary endpoint is intubation within seven days, and we do not know how much non-standardized BPAP rescue influenced that outcome in patients initially assigned to HFNC.
Different weaning strategies between HFNC and BPAP: Weaning practices also differed meaningfully between HFNC and BPAP. HFNC patients could be considered “weaned” while still receiving flows that are well above physiologic baseline (25–30 L/min), whereas BPAP weaning was left largely to clinician judgment without tightly aligned criteria. This lack of standardized weaning makes it difficult to directly compare the two modalities in terms of duration of support and when a treatment should be considered to have “failed.”
Value of multiple etiologic subgroups: Rather than asking a single global question of whether HFNC works for all causes of acute respiratory failure, the trial was designed with multiple etiologic subgroups. This allows us to compare HFNC and BPAP within distinct pathologies commonly seen in the ED and ICU. In practice, this design helps us look across each subgroup and think about which modality—HFNC or BPAP—may be most appropriate for a given underlying diagnosis.
Immunocompromised subgroup had early futility and inadequate support: In immunocompromised patients, HFNC clearly underperformed BPAP on early outcomes. Intubation rates were higher with HFNC (50.0% vs 31.8%), and early deaths were also higher (17.9% vs 13.6%), leading this subgroup to cross a prespecified futility boundary and stopping further enrollment. By 28 and 90 days, mortality was similar between HFNC and BPAP in this cohort, suggesting that HFNC alone did not provide enough up-front respiratory support for this high-risk group rather than causing a lasting difference in long-term outcomes.
Why COVID was separated from the original ARF subgroups: Early in the COVID-19 pandemic, clinicians were making treatment decisions in real time without established guidelines or a solid understanding of disease trajectory. Many COVID patients behaved clinically like an immunocompromised or atypical ARF cohort. If COVID patients had been left inside the original ARF subgroups, they could have distorted those results and biased the trial toward an apparent signal of HFNC futility. By separating COVID into its own subgroup, the investigators preserved the integrity of the non-COVID etiologic groups while still including COVID patients in the overall study population. This approach allowed for cleaner estimates within each subgroup and more appropriate borrowing across groups without letting a large, atypical population dominate the model.
Standardized BPAP delivery as a control: Using one BPAP delivery method for all patients created a built-in control on the BPAP side of the trial. The interface and mode were standardized, so the main difference between patients was their underlying disease and assignment to HFNC vs BPAP. This consistency across BPAP subgroups reduces “noise” in how BPAP was delivered and makes it easier to attribute differences in outcomes to the disease process and modality choice rather than variation in the BPAP setup itself.
Single-country setting and external validity: Running the entire study in one country means clinicians share similar training, practice patterns, and system-level resources, which helps keep management more consistent across subgroups and centers. The trade-off is external validity: what is considered “standard” care in this health system may look very different in other countries, particularly in resource-limited settings, so these findings may not translate perfectly to other practice environments.

📘 Author's Conclusion

💬 Our Conclusion

🚨 Clinical Bottom Line

📚 References

RENOVATE Investigators and BRICNet Authors.
High-flow nasal oxygen vs noninvasive ventilation in patients with acute respiratory failure: The RENOVATE randomized clinical trial. JAMA. 2025;333(10):875–890.
PMID: 39657981
Tempo G, Grieco DL.
Article review: The RENOVATE randomised clinical trial. European Society of Intensive Care Medicine (ESICM) Article Review. 2025.
Available here
Roca O, Messika J, Caralt B, et al.
Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: The utility of the ROX index. J Crit Care. 2016;35:200–205.
PMID: 27481760
Rochwerg B, Brochard L, Elliott MW, et al.
Official ERS/ATS clinical practice guidelines: Noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50(2):1602426.
PMID: 28860265

Post Peer Reviewed By: Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), Frank Lodeserto, MD and Anand Swaminathan, MD (X: @EMSwami)

👤 Guest Contributor

Jonathan Bradshaw, DO
Emergency Medicine Resident (PGY-3)
Cape Fear Valley Medical Center
Fayetteville, NC

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REBEL Core Cast 148.0–Demystifying Non-Invasive Ventilation & HiFlow

Frank J. Lodeserto MD, Eric Acker MD — Mon, 12 Jan 2026 13:00:11 +0000

🗝️ Key Points

💨 NIV = Support without a tube: CPAP, BiPAP, and HFNC improve oxygenation and reduce the work of breathing.
🫁 CPAP = Continuous pressure: Best for hypoxemic patients (e.g., pulmonary edema, OSA).
️ BiPAP = Two pressures (IPAP/EPAP): Great for hypercapnic failure (e.g., COPD, obesity hypoventilation).
🌬️ HFNC = Heated, humidified high flow: Reduces effort, improves comfort, and enhances oxygen delivery.
🩺 Supportive, not definitive: NIV stabilizes patients while the underlying cause is treated.

Click here for Direct Download of the Podcast.

📝 Introduction

Non-invasive ventilation (NIV) refers to respiratory support provided without endotracheal intubation. The most common modalities include continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), and high-flow nasal cannula (HFNC). These therapies aim to improve oxygenation, reduce the work of breathing, and potentially prevent invasive mechanical ventilation.

💨 CPAP and BiPAP

CPAP delivers a single, continuous pressure during inspiration and expiration. This pressure (commonly 5–10 cm H₂O) helps recruit atelectatic alveoli, reduce shunt, and improve oxygenation. It is commonly used for conditions like pulmonary edema, obstructive sleep apnea, or mild hypoxemia without significant ventilatory failure.
BiPAP alternates between two pressures:
- Inspiratory positive airway pressure (IPAP), augments tidal volume and unloads inspiratory muscles.
- Expiratory positive airway pressure (EPAP), maintains alveolar recruitment and improves oxygenation.
  The differential between IPAP and EPAP is critical for reducing hypercapnia in patients with COPD exacerbations or acute hypercapnic respiratory failure.
Indications
- CPAP: hypoxemia without major ventilatory failure (e.g., cardiogenic pulmonary edema, atelectasis, OSA).
- BiPAP: hypercapnia with increased work of breathing (e.g., COPD exacerbation, neuromuscular weakness, obesity hypoventilation).
A helpful way to conceptualize CPAP and BiPAP is through the hairdryer analogy. Imagine placing a hairdryer in your mouth:

🩺 Clinical Considerations

Masks can be uncomfortable, impair secretion clearance, and limit oral intake.
Some patients require sedation to tolerate NIV, but this carries risks in patients with unprotected airways.
NIV is thus a high-stakes intervention requiring close monitoring.
Common starting dose to understand titration, but start at the level appropriate for your patient: IPAP 10 cm H₂O / EPAP 5 cm H₂O (“10/5”) and are titrated:
- Increase IPAP to improve tidal volume and CO₂ clearance.
- Increase EPAP to recruit alveoli and improve oxygenation.
- Both may be raised simultaneously if the patient is both hypoxemic and hypercapnic.

🚀 High-Flow Nasal Cannula (HFNC)

H: Heated & humidified – improves mucociliary clearance, prevents airway drying, and enhances tolerance. I: Inspiratory flow – high flow meets or exceeds patient demand, reducing respiratory rate and effort.
F: Functional residual capacity – modest generation of positive end-expiratory pressure (PEEP), promoting alveolar recruitment.
L: Lighter – generally more comfortable and less restrictive than mask-based NIV.
O: Oxygen dilution – minimizes entrainment of room air, delivering higher and more predictable FiO₂.
W: Washout – flushes anatomical dead space, reducing CO₂ rebreathing.
HFNC delivers heated, humidified oxygen at high flow rates (30–60 L/min) through wide-bore nasal prongs. A mnemonic, H-I-F-L-O-W, helps summarize its mechanisms:
Indications: Traditionally used for acute hypoxemic respiratory failure (e.g., pneumonia), HFNC is increasingly studied for hypercapnic failure as well, with trials suggesting non-inferiority to BiPAP in select populations.

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)

👤 Show Notes

Syed Moosi Raza, MD

PGY 3 Internal Medicine Resident

Cape Fear Valley Internal Medicine Residency Program Fayetteville NC Aspiring Pulmonary Critical Care Fellow

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The RSI Trial: Ketamine vs Etomidate in Rapid Sequence Intubation

Anand Swaminathan — Thu, 08 Jan 2026 12:00:43 +0000

📌 Key Points

💀 Mortality: No statistically significant difference in 28-day mortality between ketamine vs etomidate for intubation in critically ill patients, though there was a ~1% absolute difference favoring ketamine. 📉
🫀⚠️ Hemodynamics: Ketamine induction was associated with more cardiovascular collapse, mainly driven by new/increased vasopressor use (dose escalation or addition of a vasoactive agent). 💉⬆️

Click here for Direct Download of the Podcast.

📝 Introduction

Etomidate or ketamine? The debate over the ideal agent for emergency rapid sequence intubation (RSI) has raged for years with no clear winner. Etomidate has been touted in the past for its rapid onset and minimal intrinsic effects on hemodynamics. However, the drug is well known as a transient adrenal suppressant though the impact of this suppression isn’t clear. Ketamine has risen in recent years as an alternative, due to its perceived hemodynamic stability, analgesic properties and absence of adrenal suppression. Additionally, recent data points towards improved mortality when ketamine was selected over etomidate (Kotani 2023). High quality randomized controlled trials are needed to further elucidate which agent should be selected in critically ill patients.

🧾 Paper

Casey JD et al. Ketamine or etomidate for tracheal intubation of critically ill adults. NEJM 2025. PMID: 41369227

🔙Previously Covered On REBEL

REBEL EM: The EvK Trial: Ketamine vs Etomidate for Rapid Sequence Intubation
REBEL EM: From Debate to Data: Emerging Insights into RSI Induction with Ketamine vs Etomidate

️ What They Did

CLINICAL QUESTION

In critically ill adults undergoing tracheal intubation, does the use of ketamine instead of etomidate result in improved 28 day mortality?

STUDY DESIGN

Multicenter, randomized, open-label trial in both emergency departments and ICUs.

POPULATION

Inclusion Criteria:

Critically ill patients > 18 years of age undergoing tracheal intubation with the use of an induction agent

Exclusion Criteria:

Known pregnancy
Prisoners
Primary diagnosis of trauma
Need for immediate intubation precluding randomization
Clinicians determined that the use of ketamine or etomidate was either necessary or contraindicated

INTERVENTION & COMPARATOR

Intervention (HFNC Group):

Ketamine administered based on a provided nomogram: full dose (2.0 mg/kg), intermediate dose (1.5 mg/kg) or reduced dose (1.0 mg/kg)

Comparator (BPAP Group):

Etomidate administered based on a provided nomogram: full dose (0.3 mg/kg), intermediate dose (0.25 mg/kg) or reduced dose (0.2 mg/kg)

OUTCOMES

Primary: In-hospital death from any cause by day 28.

Secondary:

- - Cardiovascular collapse during intubation defined as SBP < 65 mm Hg, receipt of new or increased dose of vasopressors or cardiac arrest.

Exploratory Procedural:

- - Lowest systolic blood pressure
  - Lowest systolic blood pressure below 80 mmHg
  - Highest systolic blood pressure above 180 mmHg
  - Lowest oxygen saturation
  - Lowest oxygen saturation below 80%
  - Successful first attempt intubation
  - Time from induction to intubation

Exploratory Clinical:

- - Number of ventilator free days
  - Vasopressor-free days
  - ICU free days

Safety:

- Systolic blood pressure at 24 hours after enrollment
- Ongoing receipt of vasopressors at 24 hours

📈 Results:

2365 patients were randomized
- Ketamine: 1176
- Etomidate: 1189
> 99% of patients received the drug they were randomized to receive
NMBA: 69% of patients in both groups received rocuronium
~ 95% of patients had video laryngoscopy for the primary intubation attempt

💥 Critical Results

💪 Strengths

Multicenter ED + ICU cohort of critically ill patients → improves external validity
Strong randomization → balanced baseline characteristics
Right population for the question → appropriately focused on a sick cohort where induction choice matters most
High protocol adherence → most patients received the agent they were randomized to
Excellent follow-up → minimal loss to follow-up / outcome capture

⚠️ Limitations

No blinding → potential performance/resuscitation bias
Trauma excluded → limits applicability to peri-intubation trauma care
Case-mix skewed toward septic shock → may reduce generalizability to other shock etiologies
Power assumptions → designed to detect a 5% mortality difference (possibly overly ambitious)
Equipoise-only enrollment → excluded patients with clear indication/contraindication → selection bias + reduced real-world applicability
Composite secondary outcome with non-equivalent endpoints (e.g., cardiac arrest vs vasopressor titration)
Ketamine dosing by actual body weight (vs ideal) → may have increased dose/exposure in some patients

🗣️ Discussion

The increase in cardiovascular collapse seen with ketamine was driven by the “new or increased vasopressor use” piece of the composite outcome not by the more clinically relevant severe hypotension (SBP < 65 mm Hg) or cardiac arrest.
The increase in CV collapse is a secondary outcome and hypothesis generating only
Care beyond induction agent isn’t clearly delineated and may have varied between groups
Reasons why there was more CV collapse in the ketamine group:
- Patients in the etomidate group were more likely to be on pressors or have pressor increases prior to induction agent administration
- Ketamine has analgesic properties which may affect hemodynamics (etomidate does not have analgesic effects)
- The standard ketamine dose of 2 mg/kg is higher than the induction dose used by most (1-1.5 mg/kg)
- Ketamine dosing was based on actual body weight though ideal body weight dosing is more accepted. This may have resulted in unnecessarily large ketamine doses that may have had a greater effect on hemodynamics.
This is a study of patients with clinical equipoise
- Patients who the clinician determined would clearly benefit from one agent or the other or in whom one agent or the other was contraindicated were excluded from the study.
- This may add a selection bias to the results.
Clinicians were not blinded to the induction agent administered
- The absence of blinding can introduce bias.
- For instance, knowledge of the agent the patient was randomized to may result in different resuscitative treatment prior to intubation.
An induction agent nomorgram was provided to allow clinicians to choose their induction dose depending on patient stability.
A 5% difference in mortality may be overly ambitious. As Josh Farkas points out in his post on this article, PCI for STEMI only has a 3% absolute difference in mortality versus standard care.
The 1% absolute difference in mortality while not statistically significant would be clinically significant if it was real.
- The study would have to be much larger to show a statistically significant 1% difference.
About 2% of patients in each group received additional medications during induction (propofol, benzodiazepines, opiates). It is unclear why these agents were selected in specific cases and how they may have affected the outcomes in question.

📘 Author's Conclusion

“Among critically ill adults undergoing tracheal intubation, the use of ketamine to induce anesthesia did not result in a significantly lower incidence of in-hospital death by day 28 than etomidate.“

💬 Our Conclusion

In this well done RCT, induction with ketamine did not result in a lower 28-day mortality when compared to induction with etomidate in critically ill adults. The secondary outcome of an increase in cardiovascular collapse is interesting and should be studied more in the future.

🚨 Clinical Bottom Line

This data should not drive clinicians to abandon the use of ketamine in RSI. To the contrary, the study leaves open the possibility of a clinically meaningful difference in mortality favoring ketamine that may be borne out in a larger study. However, etomidate can be considered as a first-line option for RSI and may be the superior drug in patients at high-risk for cardiovascular decompensation.

Post Peer Reviewed By: Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), Frank Lodeserto, MD and Anand Swaminathan, MD (X: @EMSwami)

📚 References

Kotani Y et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: a meta-analysis of randomized trials J Crit Care 2023;77:154317. PMID: 37127020

👤Associate Author

Anand Swaminathan

MD, MPH

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REBEL MIND – The Dunning Kruger Effect: Why Looking Inward Improves Patient Care

Mark Ramzy — Wed, 07 Jan 2026 12:00:32 +0000

📌 Key Points

🧠 We don’t know what we don’t know: Low experience can inflate confidence; true expertise usually brings humble certainty.

🏥 ED relevance is universal: From central lines to transvenous pacing, over- or under-confidence shows up at every level—intern to seasoned attending.

🧩 Metacognition matters: Accurate self-assessment is a clinical skill; reflection + feedback loops keep us calibrated.

🛠️ Practice beats bravado: Skill decay is real; deliberate practice and HALO (high-acuity, low-occurrence) refreshers protect patients.

🤝 Psychological safety ≠ niceties: “Confident humility” enables questions, feedback, and better resuscitation decisions—especially under uncertainty.

Click here for Direct Download of the Podcast.

📝 Introduction

Welcome to REBEL MIND—Mastering Internal Negativity during Difficulty. In this series, we turn the same critical lens REBEL EM uses for literature inward—into mindset, leadership, and psychological safety—so we can deliver better care outward to patients and teams.

In this episode and blog post, hosts Mark Ramzy and Kim Bambach (Assistant Professor of Emergency Medicine, The Ohio State University) explore a deceptively simple question: How accurately can we assess our own performance? The answer hinges on a classic cognitive bias that touches all of us in emergency medicine.

🧾 Paper

Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999 Dec;7 PMID: 10626367

Cognitive Question

How accurately can we assess our own performance?

💭 What is the Dunning-Kruger Effect?

The Dunning–Kruger Effect is a cognitive bias where:

Lower-skill individuals tend to overestimate their competence, and
Higher-skill individuals often underestimate theirs.

Translation for the busy clinician: early on the learning curve, confidence spikes (“Mount Stupid”) because we don’t yet see the complexity. As experience accrues, confidence dips (“Valley of Despair”) with growing awareness, then rises again—grounded in nuance and humility.
Key insight: True expertise ≠ louder certainty; it’s often quieter, more curious, and more collaborative.

How It Applies to the Emergency Department

Procedures (e.g., central lines, TVP): Watching a 5-minute video creates “I got this” energy—until the wire won’t pass, the patient thrashes, or you hit carotid. Competence includes troubleshooting in context.
Skill Decay is Inevitable: If you haven’t done a chest tube or a TVP in months, you’re not as sharp as last time. Without deliberate refreshers, you drift below the safe-performance line.
Everyone’s a Novice Somewhere: New disease entities, evolving algorithms, new tools (POCUS, decision support) mean even attendings routinely re-enter novice zones.
Feedback Blind Spots: Lower performers can both overestimate their skills and resist feedback—while many high performers (particularly women, per discussed literature) undervalue their abilities.
Culture is Clinical: The ED demands decisive action amid uncertainty. Psychological safety + confident humility lets teams surface alternative diagnoses, challenge momentum, and correct course fast.

⏩Immediate Action Steps for Your Next Shift

Run a 60-second debrief on two cases
What went well? What would I do differently next time?
Write one improvement you’ll test today.
Play “What if the opposite were true?”
Anchored on “lumbosacral strain”, Ask, What if fever/incontinence appears? How does that change my path?
Solicit 360° micro-feedback
Ask a nurse, resident, and peer: “One thing I did well; one thing to improve.” Say “thank you,” not “but.”
Schedule a HALO refresher this week
Pick one high-acuity, low-occurrence procedure (TVP, cric, thoracotomy).
Do a 10-minute mental model + equipment walk-through; book sim time if available.
Adopt a pre-procedure pause
If X goes wrong, I’ll do Y.
Name two likely failure modes (e.g., “wire won’t advance,” “delirium/agitation”) and your first corrective step.
Language shift on shift
Swap “I’m sure” → “I’m reasonably confident, here’s my plan B.” Invite input: “What am I missing?”

Conclusion

The Dunning–Kruger Effect isn’t a moral failing; it’s a predictable human pattern that every clinician rides—often multiple times per day in the ED. The antidote is metacognition: routine reflection, explicit debiasing, deliberate practice, and feedback within a psychologically safe culture.

🚨 Clinical Bottom Line

Competence is quiet and curious. The more we know, the more we recognize what we don’t—and the better we become at caring for patients and each other.

Meet the Authors

Mark Ramzy, DO

Co-Editor-in-Chief

Cardiothoracic Intensivist and EM Attending RWJBH / Rutgers Health, Newark, NJ

Kim Bambach, MD

Podcasting Manager

Assistant Professor of Emergency Medicine Ohio State University

The post REBEL MIND – The Dunning Kruger Effect: Why Looking Inward Improves Patient Care appeared first on REBEL EM - Emergency Medicine Blog.

POCUS Use in Shock Resuscitation: Evidence for Patient and System-Level Benefits

Christopher Karnicki, MD, MS — Mon, 05 Jan 2026 12:00:05 +0000

🗝️ Key Points

📚Evidence suggests POCUS influences physician decision-making around use of IV fluids and vasoactive drugs
💪🏽Evidence supports its role in improving lactate clearance, one of many surrogates for shock resolution
🖥️POCUS may reduce 28-day mortality, duration of vasoactive medications, and the need for renal replacement therapy
🙅🏽‍️There was little to no effect on mechanical ventilation requirements, ICU/hospital admissions, or length of stay

📝 Introduction

Shock is a life threatening condition that requires rapid resuscitation, and targeted treatment. Due to its complex nature, shock management poses many challenges for physicians in the acute care setting, more specifically, in the emergency department (ED). Point-of-care-ultrasound (POCUS) has emerged as a promising diagnostic and therapeutic clinical tool in this context, allowing ED physicians to assess hemodynamics and guide treatment interventions in real-time at the bedside.

As POCUS becomes increasingly integrated in critical care and emergent care settings, understanding its impact on real-time guidance and management of treatment and on patient outcomes is of growing importance. POCUS as a clinical tool is already widely used for procedural guidance and focused assessments (i.e using FAST exams for identification of pericardial effusions, pneumothoraces or hypovolemia in trauma).

The appeal of POCUS lies in its non-invasive nature and immediate availability at the bedside to allow physicians to make critical decisions without the need for radiation exposure. This study is a systematic review and meta-analysis that evaluates the impact of POCUS-guided resuscitation on both patient-centered outcomes which include mortality, lactate clearance and organ support, as well as hospital-centered outcomes, including ICU utilization and diagnostic resource use.

🧾 Paper

Basmaji J, Arntfield R, Desai K, et al. The impact of point-of-care ultrasound-guided resuscitation on clinical outcomes in patients with shock: A systematic review and meta-analysis*. Critical Care Medicine. 2024;52(11):1661-1673. PMID: 39298556

🔙Previously Covered and Related Content:

REBEL EM: Serial PoCUS for ED Patients with Acute Dyspnea
REBEL EM: The Reason Trial – POCUS in Cardiac Arrest
St. Emlyn’s: POCUS For The Breathless Patient
EM Crit: Rapid Ultrasound for Shock and Hypotension – the RUSH Exam

️ What They Did

CLINICAL QUESTION

What is the therapeutic impact of point-of-care ultrasound (POCUS) for changing physician management, resuscitative therapies and diagnostic tests and clinical outcomes in patients with shock?

STUDY DESIGN

Meta-analysis of randomized control trials or controlled cohort studies that enrolled adult patients with shock or hypotension, compared POCUS-guided resuscitation to standard care, and reported relevant outcomes.
Eighteen RCTs were included after screening over 8,500 citations, each comparing POCUS-guided management to usual care without POCUS.
Eligible studies enrolled adult patients with shock of any etiology and used bedside ultrasound to guide fluid administration, vasoactive therapy, or diagnostic decision-making.
The authors followed PRISMA and Cochrane standards, used dual independent screening, and rated evidence certainty with GRADE.
To unify heterogeneous data, consistent definitions were applied for key outcomes such as lactate clearance, mortality, and organ support needs.
Continuous outcomes were standardized by converting medians to means and imputed standard deviations where necessary.
Random-effects meta-analytic models were used to pool results, and heterogeneity was assessed using statistics with prespecified subgroup analyses by POCUS protocol type which allowed the authors to synthesize diverse studies into a coherent analysis of both patient-centered and hospital-centered outcomes in POCUS-guided shock resuscitation.

POPULATION

Inclusion Criteria:

Adult patients over the age of 18 years old with the following:
- Shock or systolic hypotension, typically defined as a systolic blood pressure less than 100 mm Hg,
- Undergoing resuscitation in the ICU or emergency department.

Exclusion Criteria:

Scoping reviews
Systematic reviews
Meta-analyses
Animal or experimental studies
Non-research articles
Studies without a control group
Those not using POCUS as part of resuscitation strategy

INTERVENTION & CONTROL

Intervention:

The POCUS-guided resuscitation, in which bedside ultrasound was performed by trained clinicians to assess cardiovascular, pulmonary, and vascular status, with findings immediately integrated into clinical decision-making to guide fluid administration, vasoactive therapy, and other diagnostic or therapeutic interventions.

Control:

The comparison group consisted of patients receiving usual care or resuscitation without POCUS guidance, relying instead on standard clinical assessment, vital signs, laboratory tests, and conventional imaging when indicated.

OUTCOMES

Primary Outcome:

Whether POCUS changed any of the following:
- IV fluid administration
- Inotrope and vasopressor initiation or escalation
- Ordering of diagnostic tests such as echocardiography or CT scans

Secondary Outcomes:

Sought to determine if POCUS altered the following:
- IV fluids administered at 6, 24, and 72 hours
- Use of inotropes or vasopressors
- Number of diagnostic imaging studies performed

Safety and hospital-centered Outcomes:

28-day mortality
Lactate clearance at 6 and 24 hours
Incidence of acute kidney injury
Need for organ support therapies such as mechanical ventilation, renal replacement therapy, and vasoactive medications
ICU and hospital admission rates and overall length of stay

📈 Results

OUTCOMES

💥 Critical Results

💪🏽 Strengths

First of its kind: First comprehensive systematic review of evaluating POCUS-guided resuscitation involving clinical decisions, therapies, and patient outcomes
Minimized risk of bias: Included only randomized controlled trials (RCTs)
Other factors considered: Considered both patient-centered outcomes (i.e. mortality) and healthcare utilization metrics.
Specific enrollment: focused on ICU patients with shock of any etiology, allowing for broad generalizability and strong external validity to real-world critical care settings.
Accounted for bias through a formal Risk of Bias Assessment using Cochrane methodology, with most outcomes deemed at low risk of publication bias.
Posed the right clinical question: Examined how rapidly expanding technology like POCUS can directly influence patient outcomes in shock resuscitation, a topic of clear clinical relevance for emergency and critical care providers.
Operationally minded study: Determined whether a lower-cost, faster, noninvasive imaging modality could improve efficiency, reduce resource utilization, and potentially lower healthcare costs.
Actively searched for missing data: Authors contacted six original study authors, four of whom provided additional information or clarifications that strengthened the dataset.
Bias reduction: Incorporated a system where two independent authors performed study screening and data extraction, minimizing the potential for reviewer bias and improving methodological rigor.

⚠️ Limitations

Missing details: Some studies did not report operator competency, training or experience which may influence the results
Introducing bias: Certain evidence was low or very low for several outcomes which include (i.e. AKI, RRT duration, ICU admissions) which may reflect risk of bias
Small ARR: The absolute risk reduction in some outcomes mentioned (i.e. mortality) were relatively small and may not be clinically relevant in all settings
Cherry-picked trials: The study did not include data from non-randomized controlled trials which could influence data.
Patients left out: The analysis was unable to investigate specific subgroup effects, such as outcomes in patients with significant comorbidities like heart failure or chronic kidney disease, limiting insights into how POCUS-guided resuscitation performs across diverse patient populations.
Lacked precision: Some pooled estimates were constrained by small sample sizes, wide confidence intervals, and low certainty of evidence, reducing the precision and strength of certain conclusions.
Lack of multicenter studies: With the exception of a single multicenter trial, all included studies were conducted at single centers, which may limit the generalizability of findings to different healthcare settings or practice environments.
All eggs in one basket: The meta-analysis assumes POCUS as the primary driver of improved outcomes, though in clinical reality, multiple concurrent variables—such as clinician expertise, resuscitation protocols, and system-level factors—also influence patient outcomes.

🗣️ Discussion

Clinical Effectiveness and Impact

POCUS-guided resuscitation demonstrates clear clinical benefits, including reduced 28-day mortality, shorter vasoactive medication duration, and improved lactate clearance.
These outcomes reflect more precise, physiology-driven resuscitation, allowing clinicians to tailor therapy in real time rather than relying on delayed or indirect data.
POCUS acts as a bedside extension of the physical exam, transforming how shock is diagnosed and managed in fast-paced settings like the emergency department and ICU.

Operator Competency and Standardization

The operator-dependent nature of POCUS is a critical limitation. Variability in training, image acquisition, and interpretation likely contributed to the heterogeneity of results across studies.
Inexperienced users risk misdiagnosis or inappropriate management for example, over-resuscitating a patient with cardiogenic shock due to misinterpretation of ventricular function or IVC dynamics.
- The solution is not simply to “take a course” or assume competency after limited exposure; rather, institutions should establish structured, longitudinal training pathways that emphasize hands-on experience, supervised image acquisition, and iterative feedback.
- True proficiency in POCUS develops over time through deliberate practice, mentorship, and exposure to a broad spectrum of pathologies—not from a single workshop or certification.
Standardized competency and quality assurance programs are essential to safely expand POCUS use and ensure consistent benefit across institutions.
- A robust QA/QI program should include routine image review (for example, weekly “tape review” sessions led by credentialed faculty), correlation of ultrasound findings with patient outcomes or advanced imaging, and ongoing peer feedback.
- These programs provide both accountability and continued education, helping maintain high interpretive accuracy and reinforcing the culture of continuous improvement that underpins safe, effective ultrasound practice.

Precision and Generalizability

The precision and scale of existing data limit how confidently we can apply these findings to every setting.
- Most included studies were small and single-center, meaning the results may not fully capture the diversity of real-world shock patients.
- A patient population with higher rates of comorbidities, complex social factors, and delayed presentations—may respond differently than those in smaller, controlled trials.
- Highlights the challenge of implementing POCUS without the same access to specialists or robust QA infrastructure.
- While the signal for benefit is strong, local context—resources, patient mix, and training—still matters when translating this evidence into daily practice.
Future multicenter studies are crucial not just for validation, but for equity
- Broader enrollment across academic, community, and resource-limited settings will tell us whether POCUS-guided resuscitation improves outcomes universally or if benefits depend on environment and experience.
- Institutions should interpret the findings as an invitation to adapt, building local protocols, training, and QA systems that make POCUS effective for their unique patient populations rather than waiting for a perfect, one-size-fits-all dataset.

Cost, Value, and Implementation

Although often described as “low-cost,” the initial investment for ultrasound devices and training can be significant, particularly for smaller or community hospitals.
POCUS may deliver substantial return on investment (ROI) by reducing unnecessary imaging, improving resource allocation, and potentially shortening ICU stays.
Even without direct cost-effectiveness data in this meta-analysis, the operational efficiency and diagnostic precision that POCUS provides make it a strong candidate for institutional investment.

Moving Toward Standard of Care

POCUS should no longer be viewed as an optional or niche skill—it has evolved into a core component of shock resuscitation.
Hospitals and departments should ensure 24/7 access to ultrasound equipment and formally trained providers capable of integrating POCUS findings into patient care.
The absence of POCUS capability now represents a potential gap in quality and safety, particularly in the ED and ICU where time-sensitive decisions are critical.
Future research should focus on standardizing POCUS protocols for undifferentiated shock, defining benchmarked training pathways and competency assessments, and rigorously exploring cost-effectiveness and resource-utilization outcomes to guide widespread implementation.
- For example, the international multicenter randomized trial titled SHoC‑ED Series, was a study that enrolled patients with undifferentiated hypotension across six EDs (Canada and South Africa). It highlights the move toward more robust, generalizable data3 which provides clinicians a clearer roadmap for integrating POCUS into everyday practice, enabling smarter deployment of equipment, training, and quality systems.

📘 Author's Conclusion

“POCUS-guided resuscitation in shock may yield important patient and health system benefits. Due to lack of sufficient evidence, we were unable to explore how the thresholds of operator competency, frequency, and timing of POCUS scans impact patient outcomes.”

💬 Our Conclusion

This systematic review and meta-analysis provides evidence that POCUS-guided resuscitation in adult patients with shock offers both meaningful clinical and health system benefits to improve patient outcomes. POCUS appears to be a tool to improve markers of shock resolution such as lactate clearance, and likely reduces 28-day mortality, duration of vasoactive medication, need for renal replacement therapy, and without use of invasive therapies or prolonging ICU/hospital stays.

We believe that the findings support incorporating POCUS into shock resuscitation protocols as a non-invasive bedside tool to guide clinical-decision making.

🚨 Clinical Bottom Line

POCUS should be considered an essential tool in the resuscitation of undifferentiated shock, providing real-time physiologic data that directly guides clinical decision-making in time-sensitive environments like the ED and ICU. Its non-invasive, radiation-free, and efficient nature improves patient outcomes through faster, more targeted interventions.

📚 References

Volpicelli G,et al.
Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med.
PMID: 23584471
Bagheri-Hariri S, et al.
The impact of using RUSH protocol for diagnosing the type of unknown shock in the emergency department. Emerg Radiol.
PMID: 25794785
Atkinson P, Taylor L, et al.
Does Point of Care Ultrasound Improve Resuscitation Markers in Undifferentiated Hypotension? An International Randomized Controlled Trial From The Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Series. Cureus.
PMID: 32968565

Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Marco Propersi, DO (X: @Marco_Propersi)

👤 Guest Authors

Christopher Karnicki, MD, MS

EM PGY-3

SBH Health System – Bronx, NY

Jeremy Robison, DO

Associate Program Director

SBH Health System – Bronx, NY

The post POCUS Use in Shock Resuscitation: Evidence for Patient and System-Level Benefits appeared first on REBEL EM - Emergency Medicine Blog.

Rib Fracture Risk: Using RibScore + SCARF to Predict Decline

Eric Steinberg DO, MEHP — Mon, 29 Dec 2025 12:00:56 +0000

🗝️ Key Points

🧓 Rib fractures in older adults can decompensate late — early vitals and a “normal-ish” exam don’t rule out impending respiratory decline.
🖥️ RibScore = anatomy/CT risk — helps predict pulmonary complications and supports disposition decisions (floor vs stepdown/ICU).
🫁 SCARF = bedside physiology & function — repeatable and trendable; flags patients who need escalated monitoring and/or analgesia.
🤝 Together they’re stronger than either alone — pairing anatomic burden + physiologic reserve reduces false reassurance and catches high-risk patients early.
💊 High or rising scores should trigger action — multimodal pain control, early RT/incentive spirometry, and a lower threshold for higher-acuity care.

🤕 Case

75-year-old “Nana Eleanor” took her granddaughter ice skating for a birthday outing. Determined to prove she was still spry, she waved away the kiddie support walker, noting she had “been skating since Nixon.” During a mid-glide selfie attempt she drifted sideways, slipped on melted ice, and struck the boards.”EMS found her seated upright, mildly breathless but joking, “Next time I’ll stick to shuffleboard.” In the ED, vitals were notable for a respiratory rate of 25, SpO₂ 94% on room air, and normal blood pressure. No other injuries were identified. Chest CT showed multiple bilateral rib fractures without flail chest.

📌 Background:

Rib fractures are among the most common injuries in older trauma patients and can look deceptively “benign” early—until pain-limited ventilation, atelectasis, pneumonia, and respiratory failure develop hours to days later. Disposition decisions based on fracture count alone often miss the interaction between anatomic injury burden and physiologic reserve, especially in frail patients with limited pulmonary “margin.” RibScore offers an anatomy/CT-based estimate of pulmonary complication risk, while SCARF captures dynamic bedside physiology and functional respiratory performance that can worsen despite stable imaging. Using both together helps identify who needs earlier admission, aggressive multimodal analgesia, and closer respiratory monitoring—before decompensation declares itself.

🔗 Scoring Tools:

➡️ SCARF Score

➡️ Rib Score

🎯 Quick Hits

💬 Case Resolution

Mrs. Eleanor was admitted for close monitoring after a high RibScore and rising SCARF scores suggested she was at risk for respiratory decline. The team escalated multimodal pain control, including a serratus anterior plane block and a ketamine infusion, during which she cheerfully informed the resident that the ceiling tiles looked like “tiny skating judges holding up scorecards.” With effective analgesia and pulmonary hygiene, her oxygenation improved and she avoided ICU transfer. Upon discharge, she promised her granddaughter they would return to the rink, “but next time, no selfies and maybe a helmet.”

🚨 Clinical Bottom Line

RibScore:
- Anatomy-based.
- Best for predicting complications based on CT findings.
- Helpful for triaging and anticipating need for admission and respiratory decline.
SCARF Score: Physiology-based. Best for identifying patients with rib fractures who may warrant escalation of analgesia and/or level of care (e.g., stepdown, ICU).
*When used together, the sensitivity for detecting pulmonary complications is >95%!

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_Propersi), and Mark Ramzy, DO (X: @MRamzyDO)

🧭 Prep Sheets

Sequential Clinical Assessment of Respiratory Function (SCARF) Score

Rib Score

👤 Author

Eric Steinberg

DO, MEHP

Content Director, MDCalc, Residency Director, Emergency Medicine St. Joseph's University Medical Center, Paterson, NJ

Meet The Team

🔎 Your Deep-Dive Starts Here

It seems we can't find what you're looking for.

The post Rib Fracture Risk: Using RibScore + SCARF to Predict Decline appeared first on REBEL EM - Emergency Medicine Blog.

Clinical Conundrum: How Effective is Oseltamivir in Influenza?

Anand Swaminathan — Wed, 24 Dec 2025 12:00:14 +0000

👉 Bottom Line Up Top

Oseltamivir may be beneficial in particular patient populations, but, in healthy patients with mild-to-moderate influenza, the risk of side effects from the medication outweighs the benefit of a marginally shorter symptom duration.

🤕 Case

A 52-year-old man with no significant PMHx presents with cough, fever, myalgias and nasal congestion. Vitals are BP 127/75, HR 92, Temp 101.2 °F, O2 sat 99% on RA, RR 16. The patient is non-toxic appearing, and a rapid flu swab comes back positive for influenza A. As you are giving the patient discharge instructions, he asks about being prescribed Tamiflu (oseltamivir).

🗣️ What Your Gut Says

Oseltamivir is an anti-influenza antiviral. May as well prescribe it.

📈 What The Evidence Says

Annual influenza cases exceed one billion worldwide, with the vast majority of patients experiencing mild to moderate severity of illness. This massive health burden explains the extensive research into antivirals, including oseltamivir (Tamiflu). Initial studies supported the utility of oseltamivir for preventing complications, hospitalization and shortening disease course in patients with mild to moderate influenza. However, subsequent analysis determined that Roche (the manufacturer of oseltamivir), purposefully hid data from reviewers, biasing the initial interpretations (Krumholz 2014, Fremantle 2014). Subsequent analysis of the full set of data tempered expected benefits (Jefferson 2014).

Oseltamivir has been consistently found to reduce time to first alleviation of symptoms by approximately 16 hours in adults and 30 hours in children (Jefferson 2014). While earlier alleviation (even if less than a full day) is promising, the trade-off is an increase in side effects, including nausea (NNH = 28), vomiting (NNH = 22), headaches (NNH = 32) and neuropsychiatric effects (NNH = 94). No differences were found in the subsequent development of pneumonia in either kids or adults and no differences were found in subsequent otitis media, bronchitis or sinusitis in kids.

More importantly, none of the available antiviral agents (oseltamivir, zanamivir, baloxivir) have been found to reduce subsequent hospitalization or mortality in nonsevere influenza (Hanula 2024, Gao 2025). Hospitalization is one of the most important outcomes to look at due to the burden on both patients and the healthcare system.

Based on all of the available data, the IDSA recommends treatment with antivirals in the following circumstances: (IDSA Practice Guidelines 2018)

All patients requiring hospitalization.
Outpatients of any age with progressive illness, regardless of illness duration
Outpatients at high-risk for complications including those with chronic medical conditions and immunocompromised patients.
Children < 2 years of age and adults > 65 years of age.
Pregnant women and those < 2 weeks postpartum.

Alternatively, chemoprophylaxis with oseltamivir and baloxavir can be beneficial for household contacts. The IDSA recommends consideration for chemoprophylaxis in adults or children who have been in close contact with an influenza patient if the exposure is < 48 hours prior to presentation (IDSA 2018). This recommendation applies to healthcare workers as well. Dosing information can be found here for oseltamivir. Baloxavir data is more recent and its use is not discussed in the 2018 IDSA guidelines. A single weight-based dose was found to reduce the risk of developing influenza in close household contacts by 11% (NNT = 9) (Ikematsu 2020).

🚨 Clinical Bottom Line

In healthy patients with mild to moderate influenza, oseltamivir does not offer any benefit over general supportive care but is likely to cause undesirable side effects like nausea, vomiting and headache.

📚 References

Krumholz HM, Hines HH. Neuraminidase inhibitors for influenza: the whole truth and nothing but the truth. BMJ 2014; 348. PMID: 24811413
Freemantle N et al. Oseltamivir: the real world data. BMJ 2014; 9:348. PMID: 24811409
Jefferson T et al. Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children (Review). Cochrane Database Syst Rev 2014. PMID: 24718923
Hanula R et al. Evaluation of oseltamivir used to prevent hospitalization in outpatients with influenza: a systematic review and meta-analysis. JAMA Int Med 2024; 184(1): 18-27. PMID: 37306992
Gao Y et al. Antiviral medications for treatment of nonsevere influenza: a systematic review and network meta-analysis. JAMA Intern Med. 2025;185:292-301. PMID: 39804622
Landel de Almeida Lobo G, Lee S. Antiviral Medications for Treatment of Nonsevere Influenza. Ann Emerg Med 2025. PMID: 40590823
Ikematsu H et al. Baloxavir marboxil for prophylaxis against influenza in household contacts. NEJM 2020; 383(4): 309-20. PMID: 32640124

Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Marco Propersi, DO (X: @Marco_Propersi)

👤 Associate Editor

Anand Swaminathan

MD, MPH

All Things REBEL EM

Meet The Team

The post Clinical Conundrum: How Effective is Oseltamivir in Influenza? appeared first on REBEL EM - Emergency Medicine Blog.

REBEL EM – Emergency Medicine Blog

REBEL MIND – Growth vs Fixed Mindset in Medicine

🧭 REBEL Rundown

🔑Key Points

👀Previously Covered and Related Content:

📝 Introduction

Cognitive Question

🌱What is Growth vs Fixed Mindset?

🏥How This Applies to the Emergency Department or ICU?

⏩Immediate Action Steps for Your Next Shift

💬Conclusion

🚨 Clinical Bottom Line

Further Reading and References

Meet the Authors

Mark Ramzy, DO

Kimberly Bambach, MD

Frank Lodeserto, MD

MDCalc Wars: HAT vs SEDAN — Hemorrhage Risk After Stroke Thrombolysis

🧭 REBEL Rundown

🗝️ Key Points

🤕 Case

🔗 Scoring Tools

🎯 Quick Hits

💬 Case Resolution

🚨 Clinical Bottom Line

FAQ

🧭 Prep Sheets

👤 Author

Eric Steinberg

DO, MEHP

🔎 Your Deep-Dive Starts Here

The Queen of Hearts Returns: AI vs Physicians in STEMI-Equivalent and STEMI-Mimic ECGs

🧭 REBEL Rundown

📌 Key Points

📝 Introduction

🧾 Paper

️ What They Did

📈 Results

💥 Critical Results

💪 Strengths

⚠️ Limitations

🗣️ Discussion

Not All Occlusions Meet STEMI Criteria

Different Specialties, Different Priorities

ECG Patterns That Still Challenge Experienced Clinicians

Potential Clinical Role for AI

State of the Evidence

📘 Author's Conclusion

💬 Our Conclusion

🚨 Clinical Bottom Line

👉 FAQ

📚 References

👤 Guest Authors

Joseph Bove, DO FAAEM

Anika Suri, MD

🔎 Your Deep-Dive Starts Here

Clinical Conundrum: Is Acetaminophen Safe in Pregnancy?

🧭 REBEL Rundown

👉 Bottom Line Up Top

🤕 Case

🗣️ What Your Gut Says

📝 Introduction

📈 What The Evidence Says

💬 Our Conclusion

🚨 Clinical Bottom Line

📚 References

👤 Associate Editor

Anand Swaminathan

MD, MPH

🔎 Your Deep-Dive Starts Here

Diastology: Use E/e’ to Estimate Left Atrial Pressure

🧭 REBEL Rundown

📌 Key Points

📝 Introduction

🩺 Case: Acute dyspnea with an unclear story

🎯 The goal of POCUS diastology

🧬 Pathophysiology Refresher

🛰️ The POCUS method: E/e’ to estimate LAP

E/e’ = Mitral inflow (E) ÷ Mitral annular velocity (e’)

😅 Spectral Doppler feels intimidating (so let’s make it practical)