The use of heparin in acute coronary syndrome was one of the primary gateways into my hatred of guidelines. Medical guidelines contain a lot of recommendations that aren’t exactly evidence based. When you dig into the evidence for heparin in NSTEMI, it becomes pretty clear that it shouldn’t be used, with no long term benefits but clear harms. In fact, …

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Does N95 mask fitting really require you to me clean shaven? Might the practice actually be making you less safe?

The June 2026 First10em #FOAMEd Research Roundup Featuring appraisals of high quality recent RCTs, and for some reason Neanderthal dentistry

Strike 2 against whole blood. This time, mortality was 5% higher (but statistically negative) when whole blood was used in the prehospital setting. The TOWAR study

One of the downsides of subscribing to more than 50 journal feeds is the huge number of interesting papers that I flag for later, but never find time to fully appraise. I have been clearing some of these old PDFs out of my computer, but I figured that if the titles caught my eye, you might find them interesting as well.

It should be the easiest patient of the day. It is just a sore throat. The patient is fine. No signs of epiglottitis or deep space infection. They are clearly going home. But you are working with a curious student, and their questions unearth a tremendous amount of uncertainty. How important is it to identify streptococcus at the cause of pharyngitis, and how accurate are our various tools?

Only a few weeks have passed since I last wrote about negative trials for invasive therapy in pulmonary embolism. You wouldn’t think I would need to spend more time talking about negative research, but the HI-PETHO trial is different, because it is reported as positive, and some people seem to agree. Let’s review the details so you don’t fall into the same trap. 

Despite incredibly underwhelming evidence from the outset, a massive amount of money was spent (or wasted) on Paxlovid during the COVID pandemic. Some of the issues are endemic to medical science. When we allow companies to test their own products with billions of dollars on the line, the results are horrendously biased from the outset. Unfortunately, despite incredibly weak and biased data, Paxlovid (among many other COVID therapeutics) was pushed forward using the incredibly flawed logic that we should lower our scientific standards during a pandemic.

A 2 month old boy is brought into the resus room of your community hospital looking completely blue. The mother rather anxiously states that they have been followed at the large pediatric hospital for Tetralogy of Fallot and are awaiting elective repair. Now their child is completely blue, and you were the closest hospital. They were warned about “spells” but can’t remember what to do.

More on Sick PE Treatment in 2026

I think there are some very interesting papers in here this month. There are a couple big RCTs, but if you aren’t in the mood for EBM right now, I suggest at least having a look at the final paper, and imagine yourself volunteering to participate.

The May edition of the Journal Club is out now! This is a long podcast, but packed full of fun EBM and some practice changing papers and we even manage to

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So that is the most ridiculous title that I have ever employed on this blog. Avalanches... Broome.. has Casey finally lost the plot? Well, maybe - but I blame Dr Morgenstern. He sent me an article to review for this month's Journal Club and it forced me down a deep rabbit hole into a snowy academia that I never knew existed.

Addictions are incredibly challenging to treat in the emergency department, although hopefully everyone has accumulated a few wins with suboxone over recent years, and so maintains at least a modicum of optimism. Methamphetamine is much less common around me, but the primary drug of abuse in many areas of the world, and, unlike opioids, methamphetamine addiction does not have approved pharmacotherapeutic options.

This talk is from the Spring Sessions in EM conference in Broome last year. I invited my mate Scott Weingart to "virtually work in Broome ED" for a shift.

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I have written fairly extensively about the management of high risk PE. Despite their growing popularity, I have remained quite skeptical of catheter directed therapies. If you are going to give a thrombolytic, my sense is that it is going to be just as effective if given through a peripheral vein, and that fancy catheters add nothing but risk and cost.

Although guidelines have long suggested higher blood pressure targets in spinal cord injury, that recommendation has never been based on high quality evidence. (Walters 2013; Sanchez 2020) (This is the first ever RCT.) We have a bad habit of treating numbers in medicine, and often making things worse. (Remember the recent paper discussing worse outcomes when we lower blood pressure in ICH, for example…

At this point, most people in the emergency medicine and critical care worlds just assume that balanced (ie, 1:1:1) transfusion is a proven intervention, and the focus has mostly moved on the the potential of whole blood. I am in an almost nonexistent minority when I argue that balanced transfusion is certainly not proven, and may even turn out to be harmful, but that is what the data seems to say.

Classic medicine: running high cost RCTs that are too small to give real answers Préterre C, Gaultier A, Obadia M, Vignal C, Mourand I, Plat J, Sablot D, Gaudron M, Rodier G, Godeneche G, Urbanczyk C, Marc G, Massardier E, Adam S, Boulanger M, Marcel S, Mechtouff L, Ronzière T, Calvière L, Godard-Ducceschi S, Barbin L, Lebranchu P, Guillon B; THEIA collaborators.

Dynamic left ventricular outflow tract obstruction (LVOTO) is not a condition I learned about during residency, and it is not a condition I have diagnosed regularly, although I have probably missed it many many times. On First10EM, I usually prefer to start with a presenting symptom than a diagnosis, because that is how patients present. In fact, that is exactly how I started with LVOTO - in…

Most resuscitation is pretty straightforward. No matter how sick the patient is, we select from a fairly limited list of interventions. Hypoxia: does the patient need facemask oxygen, highflow, BiPAP, or intubation? Hypotension: fluids, blood, vasopressors? This basic, well used menu serves us incredibly well for the vast majority of resuscitation. It is simple, which helps manage stress in inherently high stress situations.

After more than a decade on the job, it feels like I should have this emergency medicine thing figured out, but that just doesn’t seem to be how things work. There are constantly new presentations; patients that provoke new questions. However, I find it incredibly disconcerting when something is time sensitive and life threatening - the central area of my expertise - and I have literally never heard of it.

The big paper of the month: ketamine vs etomidate for RSI Casey JD, Seitz KP, Driver BE, et al. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2025 Dec 9. doi: 10.1056/NEJMoa2511420. Epub ahead of print. PMID: 41369227 On its face, this is a fairly simple pragmatic RCT comparing etomidate to ketamine as the induction agent in critically ill adults.

There are many different approaches to stable patients with atrial fibrillation who present to the emergency department. Personally, I have leaned towards electrical cardioversion over chemical cardioversion in patients in whom cardioversion is appropriate. In the places I work, it is usually faster and easier to get a patient sedated and electrically cardioverted than to wait for drugs to work. However, that is largely because procainamide (the best current best option) is not actually that effective, and is well known for its adverse effects.

In the Rapid Review series, I briefly review the key points of a clinical review paper (which often extends to multiple papers because I can’t help myself). The topic this time: Calciphylaxis The papers: Nigwekar SU, Thadhani R, Brandenburg VM. Calciphylaxis. N Engl J Med. 2018 May 3;378(18):1704-1714. doi: 10.1056/NEJMra1505292. PMID: 29719190 Chewcharat A, Nigwekar SU. Ten tips on how to deal with calciphylaxis patients.

Some topics just get people excited. The drugs we use during intubation - well, people are going to have an opinion. Etomidate was popular while I trained, but was actually hard to find in the emergency department. Then came worries of adrenal suppression. Was etomidate just changing biochemical outcomes, or was it actually changing patient outcomes? Was etomidate increasing mortality? That debate drove many into the arms of ketamine, but the data has always been questionable.

You are at a conference. You had 1 glass of wine too many last night, so you had to add an extra coffee to get moving this morning. Then you feel a slight flutter in your chest. Caffeine is a stimulant, right? Could it be causing atrial fibrillation? The paper Wong CX, Cheung CC, Montenegro G, Oo HH, Peña IJ, Tang JJ, Tu SJ, Wall G, Dewland TA, Moss JD, Gerstenfeld EP, Tseng ZH, Hsia HH, Lee RJ, Olgin JE, Vedantham V, Scheinman MM, Lee C, Sanders P, Marcus GM.

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In the Rapid Review series, I briefly review the key points of a clinical review paper (which often extends to multiple papers because I can’t help myself). The topic this time: Sweet’s syndrome (aka acute febrile neutrophilic dermatosis)

Two new Cochrane reviews show strong and consistent evidence that HPV vaccines are effective in preventing cervical cancer and pre-cancerous changes, especially when given to young people before they ...

As far as I can tell, despite talking about the paper widely at conferences, I never included a write up of the original ANDROMEDA-SHOCK trial on First10EM. (Hernández 2019) (There is a massive file of all the topics I want to cover, and would cover if this was a job rather than a hobby. I assume it just got lost in there.) As a reminder, that trial showed that clinical management of septic shock patients based on capillary refill time was not statistically different from management guided by trending lactates, although there was some optimism because the point estimate for all cause mortality was actually 9% better.