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Emergentology: Separating Fact from Fiction

Walker, Graham MD

doi: 10.1097/01.EEM.0000450849.85098.6b

Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (, a medical calculator for clinical scores, equations, and risk stratifications, and The NNT (, a number-needed-to-treat tool to communicate benefit and harm. Follow him @grahamwalker for daily thoughts on emergency medicine, and read all of his past columns at





Calling all enterprising, research-savvy physicians and medical students! Want a guaranteed professorship at the Ivory Tower of your choice? I have your solution right here: reproduce and re-evaluate old studies.

Open any medical textbook, and you'll find any number of medical “facts” that make absolutely no sense whatsoever when the primary references are held up to investigation and gentle criticism. It's time to end a lot of this nonsense, and practice more evidence-based, appropriate, lower-risk medical care, but we need some straightforward research to move things forward (and then we just need medicine to listen).

We're starting to see this in some fields and with some diseases, thanks to a number of great studies from emergency medicine researchers like Jeffrey Kline, MD, and his extensive study of pulmonary embolism, and Ian Stiell, MD, and Jeffrey Perry, MD, for their work on subarachnoid hemorrhage and syncope (and many others). Often these researchers are developing decision aids to help quantify risk and reduce need for advanced imaging and admission. These studies not only help elucidate which risk factors are particularly important, but they also shed some light on patient outcomes with different disease processes. Physicians, for example, typically overestimate the risk of death from pulmonary embolism.

David Newman, MD, and Ashley Shreves, MD, introduced me to this line of inquisition, mostly through their deep dives of the medical literature on their website and free podcast, (SMART EM stands for Scientific Medicine and Research Translation for Emergency Medicine, and in full disclosure, they were some of my smartest attendings in residency, and are my co-founders of

Their podcasts are a little difficult to swallow when you first start listening. They introduce a topic that you have held near and dear to your medical brain and heart: that local injections of lidocaine with epinephrine into fingers are absolutely contraindicated, for example, or that Salter-Harris 1 fractures have no radiographic injury and require immobilization. They walk you through the concept you have been taught and why it makes sense that you shouldn't put epinephrine into a finger. They cite textbook after textbook, not always in our own field, discussing digital anesthesia techniques. And then, after all that build-up, they start reviewing the primary references, tracing backwards through medical history, and then go back to the very first article or mention of a particular subject. This is often from the late 1800s or early 1900s. One by one, they intellectually dismantle each keystone of the medical concept, and your medical worldview comes crashing down within 30 minutes.

My reaction always includes all five stages of grief. First I deny that there is any possibility that they are right, and want to see the primary papers myself. “No way. There's just no way. This is not how we got to this point in medicine.”

Then I'm angry. “Why have I been wasting my time learning this garbage? Does anything I've learned or anything I do actually matter?”

And I bargain: “Please, please let there be something that legitimately helps my patients.”

Then the depression sets in. I can't believe these “pseudo-axioms,” as David describes them, have made it into textbooks and review courses; some even have mnemonics dedicated to them.

Finally, I end up accepting this, change my practice a bit, and become more skeptical about … well … everything in medicine.

If you listen to podcasts or spend any significant amount of time on a treadmill or a bike or in a car, download some from SMART-EM. They are a fascinating example of how the road to hell is paved with good intentions.

This is why we need to reproduce studies on mortality, risk, and management. We do a disservice to our patients by exposing them to increased iatrogenic medical risk by doing procedures or studies to them they may not need or admitting them to the hospital when they're actually safe to go home. That's what happens when we rely on outdated assumptions and misunderstandings of pathophysiology and risk.

I believe the more we truly know about a disease process, the less we will actually do to a patient with that disease process (after figuring out high- and low-risk features of that disease or complaint, like we have done with back pain red flags). This is the new frontier of improved outcomes, lower costs, and lower risks for our patients. It's not a new whizbang drug, but shedding some of our 19th and 20th Century truths, and separating the fact from the fiction.

Does every pulmonary embolism require admission? Probably not, and more and more literature is going to show this in the coming years. Could oxygen actually be doing harm in nonhypoxic patients? Quite possibly. Do all patients with pneumothorax require a chest tube? What about a hemothorax? A 2012 study randomizing patients with simple diverticulitis to antibiotics or no antibiotics found no difference in the rate of complication (abscess, perforation) or hospital length of stay. Antibiotics for simple sinusitis are also no longer recommended. Even the American Academy of Pediatrics is finally starting to admit that many children with otitis media — their favorite cause of fever (“That ear looks a little red. Here's some amoxicillin”) — may not need antibiotics either.

It's even more important that we figure out what we should be doing and what we shouldn't as we move from “Don't just stand there! Do something!” to “Don't just do something! Stand there!” And that's the hard part. Someone once said, “Half of what we learn in medical school is wrong. The problem is we just don't know which half.” Hopefully with new researchers taking a keen eye at these simple “medical truths” (and IRBs supporting research that may question the all-godly “standard of care”), we can provide better, more appropriate care to patients and spend less time worrying about interventions that were never true or important in the first place.

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