SMART EM

SMART Kid Fractures

newman@smartem.org (David H Newman) — Thu, 18 Apr 2013 03:44:06 +0000

Johnny fell down and his ankle is tender, but the film is normal. Now what? This classic teaching goes back to 1895, the advent of x-rays. So we went back farther... time travel is revealing.

SMART Pseudoaxioms 1: The Digital Axiom

newman@smartem.org (David H Newman) — Sat, 26 Jan 2013 23:53:27 +0000

‘Pseudaxioms’ is a chapter in Hippocrates’ Shadow, and the concept is simple: just as there is pseudoscience, there are pseudoaxioms—false axioms about health and health care that have hardened into ‘fact’. Some trickle into public consciousness while others remain on the health care side. As part of an ongoing pseudoaxiom sunshine project, SMART EM introduces our latest: The Digital PseudoAxiom. Join us as we trace the history and origins of a stubborn and long-lived pseudoaxiom

SMART SAH: A Picture is Worth a Thousand LPs

newman@smartem.org (David H Newman) — Wed, 07 Nov 2012 19:05:27 +0000

Subarachnoid hemorrhage is the bogeyman of headache—but it is real. This month we asked what may be medicine's most fundamental question: how can we ferret out the bogeyman without creating so much collateral damage that we've done more harm than good? We have an answer that is simple, surprising, and scientific. This one is a game-changer.

SMART Coronary CT: The Latest and Greatest

newman@smartem.org (David H Newman) — Tue, 21 Aug 2012 20:36:32 +0000

Coronary computed tomographic angiography: seeing the arteries is, apparently, believing. Here it is, an update on the two hottest trials in EM—and the editorial that could change everything.

SMART Thrombolytics for Acute Stroke

newman@smartem.org (David H Newman) — Thu, 28 Jun 2012 15:09:11 +0000

This week The Lancet published the largest ever randomized trial of thrombolytics for acute stroke. Hands are wringing, teeth are gnashing, and department heads are fighting.

It is the biggest, baddest controversy in our field: Do clot-busters benefit stroke patients?

Let's do this.

SMART Testing: Back to basics

newman@smartem.org (David H Newman) — Wed, 02 May 2012 03:08:10 +0000

In medicine we love us a good diagnostic test; we're always looking for the next one. It is strange, then, that we should be so aloof to the basics of diagnostic testing. This month's audio is a primer on testing—and it changes everything. We're going back to basics: if you learn the four axioms of diagnostic testing you'll know more about how to choose and how to interpret diagnostic tests than just about everyone. Weird thing is that it turns out you knew it all already... you just needed a reminder.

SMART Updates 2012

newman@smartem.org (David H Newman) — Wed, 07 Mar 2012 02:34:03 +0000

This is a month for reflection, so we're reflecting on some of our previous podcasts. In fact we're updating earlier material based on the latest literature. Previous podcasts like Chest Pain Risk, Stress Testing, and Subarachnoid Hemorrhage are getting a fresh new coat. The updates are brief but they're dense, so be prepared for some practice-changers. Much to discuss.

Tolstoy once said "Everyone thinks of changing the world, but no one thinks of changing himself." Perhaps it is time.

Stress Testing: A Moment of Clarity

newman@smartem.org (David H Newman) — Wed, 25 Jan 2012 21:52:50 +0000

The 'stress test' is a part of our cultural lexicon, whether it's for banks or the human heart, and the concept is elegant: take a machine to its limits, and when you find the cracks shore them up.

SMART Cardiac Arrest: Pharmacotherapy

newman@smartem.org (David H Newman) — Wed, 30 Nov 2011 19:58:06 +0000

"Epi!" The frenzied voice calling for drugs has become a cultural icon for resuscitation. It is a note of angst, and a flicker of hope, amidst the panic of cardiac arrest. The power of drugs for cardiac arrest has been largely unquestioned for decades. Now, a recent and growing body of high quality literature has emerged to challenge the status quo. It is a curious and rebellious mix of studies... and a challenge to faith. Is it time to leave the drug box behind? Find out.

Antibiotics for Cirrhotic UGIB - a quickie

newman@smartem.org (David H Newman) — Wed, 12 Oct 2011 17:41:43 +0000

Cirrhotics bleed and they get infected. It is, apparently, a law of nature. Question is, when they're bleeding is it worthwhile to treat them prophylactically with antibiotics? This review is more of a snorkel than a deep dive, since the literature is both thick and thin: Thick enough to review, but thin enough to make a deep dive unnecessary. Join us for both a brief review, and a gloating rant.

Upper GI Bleed 2

newman@smartem.org (David H Newman) — Fri, 23 Sep 2011 20:56:20 +0000

In July we scoured the data on PPIs for ulcer bleeding. This month we tackle the other, often scarier cause of upper GI bleeding, esophageal varices. We dived deep (deeper than ever) to find the best and most relevant data on the commonly used pharmacologic agents for variceal bleeding: somatostatin analogues, like octreotide. This one was a twisted road, and there were a whole lot of pigs on the road. They were mostly wearing lipstick. Come with us to the zoo....

The Placebo Paradox

newman@smartem.org (David H Newman) — Thu, 11 Aug 2011 03:48:40 +0000

Deep inside most medical providers there is a war of the psyche; a battle between art and science. We are ambassadors for ‘science’, true believers. Yet we are baffled and unsettled every day by events and conditions that defy the scientific precepts on which we stand.

Upper GI Bleed: PPI

newman@smartem.org (David H Newman) — Fri, 15 Jul 2011 23:46:49 +0000

Upper GI bleeds are common, and they’re messy. We wanted to know how good the data are for the pharmacological interventions that have become standard fare for upper GI bleeds. Turns out the data are messy too.

In fact, because no one else would, we did our own little meta-analysis. Good news is we have a concrete answer on PPIs for upper GI bleeding. Bad news is that the news is not good. And not at all what we expected.

Threatened Ab: Knowledge is Power

newman@smartem.org (David H Newman) — Wed, 08 Jun 2011 14:56:04 +0000

Threatened abortion is among the most common conditions in outpatient settings. The explosive growth of ultrasound imaging, and increasingly limited access to specialty care have combined to make first trimester bleeding a disease for emergency and primary care docs. Thing is, there is no therapeutic intervention that can alter the course of ‘Threatened Ab’. Which means that knowledge is our only power—the power to guide and inform.

CT Consent

newman@smartem.org (David H Newman) — Wed, 27 Apr 2011 15:00:47 +0000

We do it every day. Editorials and experts everywhere are asking us to do it more, and more completely. But no one ever showed us the numbers. So here it is, a reasonable, data driven set of risks that we can tell our patients who are considering undergoing CT scan. Risk of the dye, risk of the radiation, and risk of false positives. It’s all here, adults and kids alike. Deep dive in, this data is flat out fun.

Chest Pain Risk

newman@smartem.org (David H Newman) — Tue, 05 Apr 2011 16:20:57 +0000

Risk stratification is the emergency physician’s best friend. We stratify, it’s what we do. So how likely is it that a 56 y/o gentleman with mild exertional chest pain, a non-diagnostic EKG, and a negative troponin is going to have an MI or die in the next 30 days? Covered. How about the 38 y/o with a good story? Done. What about the 47 year old diabetic with a decent story? Solved. This month we’ve got your rapid fire, quickie lecture on chest pain risk. It’s what we do.

Otitis Media

newman@smartem.org (David H Newman) — Fri, 18 Feb 2011 16:25:39 +0000

Antibiotics for Otitis Media: Feel Better?

Otitis media is the primary reason that children in western developed nations spend 6-7 weeks per year taking antibiotics before their 2nd birthday. Seriously. Is it worth it? What’s in it for them? What’s in it for moms and dads? Who are we helping and who are we hurting?

Come on a deep dive through the swamps of the AAP guidelines, the strange world of antibiotic recommendations, and the clinical evidence for the treatment of ear infections.

There’s a few surprises in the swamp.

Pediatric UTI: It's About the Future

newman@smartem.org (David H Newman) — Sun, 23 Jan 2011 16:28:54 +0000

UTI’s are the ‘in thing’. Particularly with the heptavalent pneumococcal vaccine in play, and bacteremia increasingly a part of our past, UTI’s have become the number one concern in febrile children over 2 months of age. So if you’re wondering about how and why fevers matter in kids, and what to do about them, we’ve got your answer.

Come with us on a dive where you’ll learn about why UTI’s matter, how they got top billing, and what to do about them. It’s not pretty.

Subarachnoid Hemorrhage: A Rational Approach

newman@smartem.org (David H Newman) — Sat, 18 Dec 2010 16:39:44 +0000

In October of 2010 the prestigious British Medical Journal published the largest, and by far the best, study ever done on the diagnosis of SAH in the ED. The data are revolutionary, and they prompted us to take a new look at the classic teaching and modern approach to this diagnosis.

Minor Head Injury: Who Has The Badness?

newman@smartem.org (David H Newman) — Tue, 16 Nov 2010 16:50:09 +0000

Minor head injuries are a staple of urgent and emergent care medical practice. Primary care doctors, emergency physicians, and office practitioners everywhere have to make quick decisions about which patients may have the needle in the haystack—the serious intracranial injury. We scoured the literature for the most accurate predictors and the most valuable decision aids, and we found the good stuff. There is little need to fear the needle, we have your needle-finder. After this month’s SMART EM you’ll be doing less irradiating, more talking, and less stressing.

Pulmonary Embolism: Diagnosis and Treatment

newman@smartem.org (David H Newman) — Mon, 18 Oct 2010 17:18:53 +0000

PE remains among the most discussed entities in medicine. The condition is known to be common, potentially deadly, and a clinical chameleon. This combination that has led to fear, uncertainty, and frequent over-testing. The irony is that PE is among the most well studied topics in clinical medicine. Therefore this month we studied the studies, and we have some surprising answers. To our delight we found that the data offers us a validated, rational approach to PE diagnosis that can reduce testing, and let our patients rest easier. All it took was a deep dive....

Heparin for Coronary Syndromes

newman@smartem.org (David H Newman) — Thu, 14 Jul 2011 17:22:19 +0000

Heparin is the world’s ‘standard-of-care’ anticoagulant for the treatment of coronary syndromes. Not only is heparin recommended by all cardiac guidelines, it’s also the reference standard against which new anticoagulants are compared. The answer to whether or not heparin during coronary syndromes saves lives, or provides meaningful benefits, is the answer to the effectiveness and validity of present and future of acute coronary therapy. This month we found the root literature on heparin, and walked through the studies and their results. We have an answer.

Treatment of Acute Pharyngitis

newman@smartem.org (David H Newman) — Thu, 12 Aug 2010 17:25:50 +0000

At 14 million outpatient visits each year pharyngitis (sore throat) is a common complaint in any emergency department. This is an arena, however, where professional society guidelines and conventional teaching do not do justice to the existing data. We scoured the world’s literature for high quality data, and offer a comprehensive review of potential benefits and harms of antibiotic and symptom therapy for streptococcal pharyngitis.