Broome Docs

Welcome to the June 2026 edition of the podcast. We are tackling all of our favourite subjects – PE, trauma, stroke, COVID, contrast controversies and prehistoric dentistry. What more could you ask for in a podcast? SO have a listen, read the free PDFs below, and you too could save a life or at least relieve your friend’s dental pain with some stone tools.

Butler CC, Pinto AD, Harris V, Holmes J, Rahman NM, Cureton L, Hayward G, Richards DB, Lowe DM, Standing JF, Breuer J, Hood K, Png ME, Petrou S, Dorward J, Patel MG, Thomas NPB, Evans P, Hart ND, Jani BD, Hosseini B, Murthy S, McBrien K, Condon A, McDonald EG, Daley P, Greiver M, da Costa BR, Selby P, Jüni P, Lee TC, Shi H, Detry MA, Saunders CT, Fitzgerald M, Berry NS, Saville BR, Khoo SH, Nguyen-Van-Tam JS, Hobbs FDR, Yu LM, Little P; PANORAMIC Trial and CanTreatCOVID Trial Collaborative Groups. Oral Nirmatrelvir-Ritonavir for Covid-19 in Higher-Risk Outpatients. N Engl J Med. 2026 Apr 23;394(16):1583-1594. doi: 10.1056/NEJMoa2502457. PMID: 42019019

This paper actually describes two separate open-label adaptive platform RCTs: PANORAMIC out of the UK and CanTreatCOVID out of Canada. The trials are pretty similar. If you want the full details you can read Justin’s full rant on here.

Bottom line: Maybe Paxlovid should join Tamiflu on the shelves of the medical misadventure museum?

Lu Y, Guan L, Wu J, Yang Q, Zhang M, Zhou D, Yang H, Pan Y, Wang L, Qiu B, Liu C, Wang Y, Yang Y, Zhou X, Qu H, Liao X, Liu L, Zhao X, Bath PM, Johnston SC, Amarenco P, Turc G, Shi FD, Wang Y, Wang Y; EMPHASIS Investigators. Efficacy and safety of minocycline in patients with acute ischaemic stroke (EMPHASIS): a multicentre, double-blind, randomised controlled trial. Lancet. 2026 Feb 14;407(10529):679-688. doi: 10.1016/S0140-6736(25)01862-8. Epub 2026 Jan 30. PMID: 41628627

So, now acne medication has about the same level of evidence for acute stroke as does tPA?

Bottom line: In this high quality double-blind RCT, minocycline improved functional outcomes from ischemic stroke. 

Broderick JP, Naidech AM, Elm JJ, Toyoda K, Dowlatshahi D, Demchuk AM, Khatri P, Steiner T, Bath PM, Audebert HJ, Vagal A, Yoshimura S, Mayer SA, Wang LL, Sabagha N, Mocco JD, Molina C, Aviv R, Stinson E, Quadri SA, Carrozzella J, Huynh T, Phan A, Beall J, Davis I, Sakai N, Ohta T, Yokosawa M, Hara T, Sangha N, Morita K, Dominc Tse MY, Streib CD, Miyashita F, Silva Y, Nagakane Y, Gheorghiu T, Sun CH, Hirano T, Poli S, Izumo T, Fukuda-Doi M, Ihara M, Koga M, Buck B, Walsh KB, Spokovny I, Grotta JC; FASTEST Investigators. Recombinant factor VIIa versus placebo for spontaneous intracerebral haemorrhage within 2 h of symptom onset (FASTEST): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial. Lancet. 2026 Feb 21;407(10530):773-783. doi: 10.1016/S0140-6736(26)00097-8. Epub 2026 Feb 4. PMID: 41653933

Recombinant factor VIIa seems like a great idea in principle, yet we know that is rarely one that translates into real world benefits…

Bottom line: An expensive drug that probably does nothing and may cause harm. Sounds like something we should avoid but probably won’t!

Sperry JL, Guyette FX, Cotton BA, Luther JF, Utarnachitt RB, Kutcher ME, Daley BJ, Peetz AB, Patel MB, Goodman MD, Claridge JA, Patel N, Harbrecht BG, Hashmi ZG, Zarychanski R, Neal MD, Yazer MH, Martin-Gill C, Vincent LE, Harner AM, Meyer DE, Latimer AJ, Robinson BR, McKnight CL, Hinckley WR, Miller KR, Jansen JO, Martin D, Fox EE, Rosario-Rivera BL, Wisniewski SR; TOWAR Study Group. Prehospital Resuscitation with Type O Whole Blood for Trauma and Hemorrhage. N Engl J Med. 2026 May 18. doi: 10.1056/NEJMoa2602167. PMID: 42150044

Last episode we looked at the SWIFT trial out the UK which was asking the same question and came up negative. So this new trail from the United States (that’s the country just below Canada on a map) is more data that keeps our Bayesian needle exactly in the same place… meh!

Bottom line: It is not unexpected, but this cluster RCT shows no benefit from whole blood, and the point estimate is a major red flag. 

Rosenfield K, Klok FA, Piazza G, Sharp ASP, Ní Áinle F, Jaff MR, Barco S, Goldhaber SZ, Kucher N, Lang IM, Schmidtmann I, Sterling KM, Araszkiewicz A, Arora V, Cires-Drouet R, Coghlan J, Hobohm L, Ito WD, Jacobson K, Kaiser C, Kopec G, Marx K, McElwee S, Meneveau N, Monteleone P, Montero-Cabezas JM, Olivier CB, Park J, Roik M, Sakhuja R, Tego A, Theurl M, Visveswaran G, Vos JA, Young MN, Asch FM, Konstantinides SV; HI-PEITHO Investigators. Ultrasound-Facilitated, Catheter-Directed Fibrinolysis for Acute Pulmonary Embolism. N Engl J Med. 2026 Mar 28. doi: 10.1056/NEJMoa2516567. PMID: 41910345

We have heard a lot from the interventional folk about invasive devices for the management of biggish PEs in recent times. I wrote an overview earlier this year.

(You can listen to Weingart and Justin argue about HI-PEITHO over on EmCrit.) It is a fun chat between a polite American and a ranty Canadian (i.e. equally polite…)

Bottom line: Despite widely being discussed as a positive trial, there were no real differences – peripheral IV tPA is probably still the more available and reliable treatment option.

Vedantham S, Kahn SR, Marston WA, Weinberg I, Sista AK, Magnuson EA, Cohen DJ, Wasan SM, Razavi MK, Goldhaber SZ, Sanfilippo KM, Comerota AJ, Azene EM, Chaar CIO, Leung DA, Kolli KP, Kalva SP, Rostambeigi N, Desai A, Desai KR, Tafur AJ, Khalsa B, Majerus E, Wang B, Wang Y, Nieters P, Derfler MC, Oliver A, Hardy C, Bashir R, Winokur R, Weger N, Khaja MS, Sharma A, Mani N, Kavali P, Thukral S, Lake LL, Mikkelsen K, Parpia S; C-TRACT Trial Investigators. Endovascular Therapy for Post-Thrombotic Syndrome – A Randomized Trial. N Engl J Med. 2026 Apr 13:10.1056/NEJMoa2519001. doi: 10.1056/NEJMoa2519001. PMID: 41972998

Bottom line: Fractional benefits and possible harms… not really a fair fight as one group got dual anticoags. But good to know what is on offer for our chronic post DVT patients.

Phillips A, Blumenberg A. The dose of iodinated contrast required for a CT scan is below the toxicological threshold of concern for nephrotoxicity: a toxicological perspective. JEM Rep. 2026 Jun;5(2). doi: 10.1016/j.jemrpt.2026.100220

The best evidence that we have tells us that CT contrast simply does not cause kidney injury.

This is an interesting Toxicological perspective on the debate about AKI due to contrast.

Short answer: for diagnostic CT studies we are well below the “Threshold of Toxicologic Concern.” Carry on and contrast.

Greaves RL, Quay A, Bolot R, King J, Gibbs C. Safety of Peripheral Vasoactive Drug Administration in Prehospital and Retrieval Medicine (SPOTLESS-2): A Prospective Observational Cohort Study. Acad Emerg Med. 2026 Apr;33(4):e70271. doi: 10.1111/acem.70271. PMID: 41947342

This is one of my passion projects… the safety and efficacy of peripheral vasopressors can make a big difference to rural Resus patients. This data out of Queensland supports all of my biases and backs up my beliefs!

Bottom line: Peripheral vasopressors are safe to use, and considering the harms of central lines, are honestly the preferred option for early resuscitation in almost all patients. 

Mori H, Yamasaki K, Saishoji Y, Torisu Y, Mori T, Nagai Y, Izumi Y. Diagnostic accuracy of tongue coating in identifying acute appendicitis: a prospective cohort study. Emerg Med J. 2025 Jul 22;42(8):519-525. doi: 10.1136/emermed-2024-214210. PMID: 40169241

The TCI (Tongue Coating Index) is probably about as useful as any other clinical decision score in acute appendicitis. It is very cheap and fast, so why not have a look. Worst case scenario is second-hand halitosis?

I will leave it up to you to decide whether that is because the tongue coating index is valuable, or because most of the clinical decision rules in existence are absolute garbage and are probably making you worse at your job.

Justin says he will buy a pint for anyone who calls a surgeon without imaging and tries to convince them that there is an acute appendicitis based primarily on your tongue exam. Challenge accepted.

Bottom line: Glossal Gestalt for the win?

Zubova AV, Zotkina LV, Olsen JW, Kulkov AM, Moiseyev VG, Malyutina AA, Davydov RV, Markin SV, Maksimovskiy EA, Chistyakov PV, Krivoshapkin AI, Kolobova KA. Earliest evidence for invasive mitigation of dental caries by Neanderthals. PLoS One. 2026 May 13;21(5):e0347662. doi: 10.1371/journal.pone.0347662. Erratum in: PLoS One. 2026 Jun 5;21(6):e0351227. doi: 10.1371/journal.pone.0351227. PMID: 42127021

A fascinating insight into the culture of our Neanderthal cousins – they were likely doing dentistry – planning, making tools and carrying out prolonged procedures in Siberia nearly 60,000 years ago

Given the relative unavailability of acute dental services in most rural places in the world – it is a relief to know that our ancient cousins managed to do this sans anaesthesia with some rock tools. Much cheaper if you have the will power and pain tolerance.

This is a re-release of one of my favourite lectures. When I was invited to speak at SMACC Gold 2015 I was given a free range to speak about whatever I desired. Daunting, to be given this choice as it is easy to do something easy, something that has hard science… so I chose the difficult path of trying to sell the concept of empathy to a room of super bright and caring critical care doctors and nurses.

Not your standard SMACC talk. This one ranges over the neurobiology of empathy, the social science and the more practical modern application of empathy in clinical medicine. You can learn a lot of history too – its a bit of a whistle-stop tour through some of the dark days of western culture.

So grab a cuppa and sit down for this 30 minute chat.

In this video I go over my old SMACC Dublin Diagnsotics talk and revisit the Bayesian reasoning that lays at the heart of what we do in the ED.  If you ned to go back and listen to the original talk, its worth the visit – all you need to know about Bayes’ theorum for ED docs in 22 minutes!

The new Docnomo / Fagan nomogram interactive tool on the website is unveiled and demonstrated with discussions around PE, small bowel obstruction and paediatric appendicitis.

Enjoy the nerdiness!

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 escape our usual evidentiary nihilism.

Links are in the description below to the PDFs and you can listen on your favourite app or just watch the video on Youtube

Smith JE, Cardigan R, Sanderson E, Silsby L, Rourke C, Barnard EBG, Basham P, Antonacci G, Charlewood R, Dallas N, Davies J, Goodwin E, Hawton A, Hudson C, Lucas J, Keen K, Lyon RM, Nolan B, Perkins GD, Rundell V, Smith L, Stanworth SJ, Weaver A, Woolley T, Green L; SWiFT Trial Group. Prehospital Whole Blood in Traumatic Hemorrhage – a Randomized Controlled Trial. N Engl J Med. 2026 Mar 17. doi: 10.1056/NEJMoa2516043. Epub ahead of print. PMID: 41841706

Bottom line: This first RCT of whole blood in trauma showed no benefit over component therapy. We definitely need, and will see, many more trials of whole blood in the future.

You can read more from Justin here. 

Sajdeya R, Yanez ND, Kampp M, Goodman MD, Zonies D, Togioka B, Nunn A, Winfield RD, Martin ND, Kohli A, Huynh TT, Okonkwo DO, Poblete RA, Gilmore EJ, Chesnut RM, Bunnell AE, Ohnuma T, Hashemaghaie M, Treggiari MM. Early Blood Pressure Targets in Acute Spinal Cord Injury: A Randomized Clinical Trial. JAMA Netw Open. 2025 Sep 2;8(9):e2525364. doi: 10.1001/jamanetworkopen.2025.25364. PMID: 40965887

Bottom line: This small, flawed RCT demonstrated no benefit from higher blood pressure targets (MAP 85-90) when compared to conventional targets (MAP 65-70), but does demonstrate harm. There is tremendous uncertainty, but we should clearly favour conventional BP targets until new research is published.

Justin’s full rant can be found here.

Lookstein RA, Konstantinides SV, Weinberg I, Dohad SY, Rosol Z, Kopeć G, Moriarty JM, Parikh SA, Holden A, Channick RN, McDonald B, Nagarsheth KH, Yamada K, Rosovsky RP; STORM-PE Trial Investigators. Randomized Controlled Trial of Mechanical Thrombectomy With Anticoagulation Versus Anticoagulation Alone for Acute Intermediate-High Risk Pulmonary Embolism: Primary Outcomes From the STORM-PE Trial. Circulation. 2026 Jan 6;153(1):21-34. doi: 10.1161/CIRCULATIONAHA.125.077232. Epub 2025 Nov 3. PMID: 41183181.

Bottom line: This is basically a pilot trial, looking at disease oriented rather than patient oriented outcomes. It is an unblinded trial, designed and run by the device manufacturer. Even with those biases, the results are completely underwhelming.

Kjaergaard J, Bang LE, Sonne-Holm E, Wiberg S, Holmvang L, Lassen JF, Sørensen R, Høfsten DE, Ulriksen PS, Jawad S, Palm P, Søe C, Ersbøll MK, Boesgaard S, Møller JE, Thune JJ, Hassager C, Tilsted HH, Lønborg J, Egstrup M, Kristiansen OP, Seven E, Lindholm MG, Eskesen K, Fanø S, Carlsen J. Randomized trial of low-dose -, ultrasound assisted thrombolysis or heparin for pulmonary embolism. Cardiovasc Res. 2026 Jan 29:cvag038. doi: 10.1093/cvr/cvag038. PMID: 41610160

Bottom line: Although thrombolysis might improve the radiological clot burden, there is harm and no evidence of patient-oriented benefits

Morgenstern’s deep thoughts on these two papers can be found in this post. 

You can read my big picture review of modern PE management here.

McKetin R, Shoptaw S, Saunders L, Nguyen L, Clare PJ, Dore GJ, Turner A, Dean OM, Kelly PJ, Arunogiri S, Koeijers J, Degan TJ, Degenhardt L, Farrell M, Goodman-Meza D, Sinclair B, Reid D, Cordaro F, Hill H, Lundin R, Hayllar J, Christmass M, Liaw W, Liu D, Woods A, Brewerton B, Holyoak E, Wu BT, Maher H, O’Dea N, Keygan J, Kontogiannis A, Palmer L, Morrison C, Wrobel A, Hyland B, Kiden G, Romeo V, Kyaw KWY, Byrne M, Colledge-Frisby S, Zahra E, Berk M. Mirtazapine for Methamphetamine Use Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2026 Apr 1:e260159. doi: 10.1001/jamapsychiatry.2026.0159. PMID: 41920558

Bottom line: In this double-blind placebo-controlled RCT, mirtazapine resulted in less self-reported days using methamphetamine in the next 28 days.

Tan H, Chandru P. Radiologist Approval for CTPA in the ED: A Single-Centre Pilot Study Did Not Demonstrate a Statistically Significant Difference in Diagnostic Yield. Emerg Med Australas. 2026 Feb;38(1):e70237. doi: 10.1111/1742-6723.70237. PMID: 41705429

Bottom line: Not a great trial, probably not gonna change practice… but might help at your next department meeting about CTPA processes.

Luckey A, Balasegaram M, Barbee LA, Batteiger TA, Broadhurst H, Cohen SE, Delany-Moretlwe S, de Vries HJC, Dionne JA, Gill K, Kenyon C, Kittiyaowamarn R, Lewis D, Mueller JP, Naicker V, O’Brien S, O’Donnell JP, Phanuphak N, Spooner E, Srinivasan S, Taylor SN, Unemo M, Zwane Z, Hook EW 3rd; Zoliflodacin Phase 3 Study Group. Zoliflodacin versus ceftriaxone plus azithromycin for treatment of uncomplicated urogenital gonorrhoea: an international, randomised, controlled, open-label, phase 3, non-inferiority clinical trial. Lancet. 2026 Jan 10;407(10524):147-160. doi: 10.1016/S0140-6736(25)01953-1. Epub 2025 Dec 11. PMID: 41391465

Justin has a thing: complaining about non-interiority trials.

Bottom line: Zoliflodacin is clearly inferior to the current standard of care, despite the very misleading conclusions in this paper.

Ali S, Klassen TP, Candelaria P, Bhatt M, Sawyer S, Stang A, Yaskina M, Heath A, Pechlivanoglou P, Offringa M, Drendel AL, Hickes S, Poonai N; KidsCAN PERC Innovative Pediatric Clinical Trials No OUCH Study Team. Acetaminophen (Paracetamol) or Opioid Analgesia Added to Ibuprofen for Children’s Musculoskeletal Injury: Two Randomized Clinical Trials. JAMA. 2026 Mar 10;335(10):863-873. doi: 10.1001/jama.2025.25033. PMID: 41505155

Bottom line: for minor painful MSK injuries adding paracetamol or opiates to ibuprofen was not helpful.

Qandil M, Ransom P, Shammala MA, Srour A, Khafaja M, Alkhateeb N, Jafar AJN, Abughali S. Pericardiocentesis, drainage and instilled tranexamic acid: definitive management in a 25-case series of penetrating cardiac tamponade. Injury. 2026 Feb 16:113106. doi: 10.1016/j.injury.2026.113106. Epub ahead of print. PMID: 41760498

Bottom line: an amazing case series collected in a war zone challenges our thinking about penetrating chest trauma.

You can read my full discussion and thoughts from the authors here: Pericardiocentesis in a War Zone

Eisendle F, Roveri G, Rauch S, Thomassen Ø, Dal Cappello T, Assmus J, Malacrida S, Kammerer T, Schweizer J, Borasio N, Dörck V, Falk M, Falla M, Fruzzetti N, Maxenti M, Mydske S, Sasso GM, Vinetti G, Wallner B, Brattebø G, Brugger H, Strapazzon G. Respiratory Gas Shifts to Delay Asphyxiation in Critical Avalanche Burial: A Randomized Clinical Trial. JAMA. 2025 Oct 8;334(19):1720–7. doi: 10.1001/jama.2025.16837. Epub ahead of print. PMID: 4106066

Bottom line: There is enough air in snow for a basic fan to allow respiration under 50 cm of snow for up to 35 minutes. That is interesting, but perhaps not all that useful information. 

You can read all about the logistics of avalanche rescue here: Avalanche Survival in Broome

Welcome back to another instalment of the Journal Club with my old friend Dr Justin Morgenstern (he is younger than me, but we have been mates for a while…)

This month we tackle bleeding brains, clotting eyes, doing less for pneumothoraces (or is it pneumothoraci? Oh, well its defintitley pl(e)ural!! hehehehe!!). We chat about intra-cardiac arrest echo and Macgyvering urine collection devices for a female patients… quite a mix eh?

As always the PDFs are clickable on the titales below, so read, critique and decide for yourself.

The YouTube version is below or over at Justin’s Youtube channel if you need more middle-aged, hirsute men on your algorithm!

Eyeball Strokes are not that dissimilar to other strokes… a total evidentiary mess!

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.Intravenous alteplase versus oral aspirin for acute central retinal artery occlusion within 4·5 h of severe vision loss (THEIA): a multicentre, double-dummy, patient-blinded and assessor-blinded, randomised, controlled, phase 3 trial. Lancet Neurol. 2025 Nov;24(11):909-919. doi: 10.1016/S1474-4422(25)00308-4. PMID: 41109232

Traumatic pneumothorax: Less is more; more or less…

Harrison M. Non-Invasive Management of Blunt Traumatic Pneumothorax-a Meta-Analysis. Emerg Med Australas. 2025 Dec;37(6):e70164. doi: 10.1111/1742-6723.70164. PMID: 41163445

Bottom line: Conservative management is a good option even for patients with blunt trauma, as long as you are being selective about the patient you chose, and consider factors like length of transfer to a trauma center, positive pressure use, and ease of chest tube placement in whatever setting the patient might be monitored. 

To Shock, or not to shock, that is the question… but weird data here makes it an odd answer

Gaspari R, Lindsay R, She T, Acuna J, Balk A, Bartnik J, Baxter J, Clare D, Caplan RJ, DeAngelis J, Filler L, Graham P, Hill M, Hipskind J, Joseph R, Kapoor M, Kummer T, Lewis M, Midgley S, Nalbandian A, Narveas-Guerra O, Nomura J, Sanjeevan I, Scheatzle M, Schnittke N, Secko M, Soucy Z, Stowell JR, Theophanous RG, Tozer J, Yates T, Gleeson T. Incidence and Clinical Relevance of Echocardiographic Visualization of Occult Ventricular Fibrillation: A Multicenter Prospective Study of Patients Presenting to the Emergency Department After Out-of-Hospital Cardiac Arrest. Ann Emerg Med. 2025 Oct;86(4):328-336. doi: 10.1016/j.annemergmed.2025.04.014. Epub 2025 Jun 30. PMID: 40590825

Don’t feel pressure to fix the pressure… your patient may benefit?

Shi AC, Taylor T, Huang CC, Singhal AB, Goldstein JN, Bevers MB, Hou PC. Early Intensive Blood Pressure Reduction After Intracerebral Hemorrhage Is Associated With Worse Functional Outcome: The Risk of Overshooting Blood Pressure Goals. Ann Emerg Med. 2025 Dec 9:S0196-0644(25)01303-4. doi: 10.1016/j.annemergmed.2025.10.009. Epub ahead of print. PMID: 41369631

Clinical decision rules vs commonsense…

Kerr G, Chown A, Mercuri M, Clayton N, Mercier É, Morris J, Jeanmonod R, Eagles D, Varner C, Barbic D, Parpia S, Buchanan IM, Ali M, Kagoma YK, Shoamanesh A, Engels P, Sharma S, Worster A, McLeod S, Émond M, Stiell I, Papaioannou A, de Wit K. Applying the Canadian Head CT Criteria to Older Adults Seen in the Emergency Department After a Fall. J Am Geriatr Soc. 2026 Feb;74(2):509-515. doi: 10.1111/jgs.70191. Epub 2025 Oct 31. PMID: 41170758

Adding insult to injury – food in the ED ‘aint great

Barrington V, Carter V, Tagg A, Hitch D. Food as a Component of Patient-Centred Care in Emergency Departments: Preliminary Findings. Emerg Med Australas. 2025 Oct;37(5):e70126. doi: 10.1111/1742-6723.70126. PMID: 40890898

Justin makes some rash decisions about golfers legs…

Cook K. Rash following a round of golf. Emerg Med J. 2026 Feb 24;43(3):150-166. doi: 10.1136/emermed-2025-215366. PMID: 41735021

Madame’s MacGyver Urinal. A problem that needed solving 100 years ago

Booth S, Ellis P, Lyttle MD, Lochab S, Pegrum J, Thomas S. Disposable female urinal bottle (the UniWee) improves patient experience for immobile women with lower limb fractures. Emerg Med J. 2025 Apr 22;42(5):326-333. doi: 10.1136/emermed-2024-214181. PMID: 40081970

Welcome to the first post for 2026. Dr Justin joins me once again for an episode of the Journal Club where we do some deep dives into the recent acute AF literature. We take apart the RSI trial (for those in the Antipodes who don’t have etomidate on the shelf – don’t panic – its a negative trial. And we discuss the relative cuteness of suburban racoons in Canada as captured on mobile phones.

As usual the PDFs are available at the links that you can click below – so read these for yourself and discuss widely.

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

Svendsen JH, Diederichsen SZ, Højberg S, Krieger DW, Graff C, Kronborg C, Olesen MS, Nielsen JB, Holst AG, Brandes A, Haugan KJ, Køber L. Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study): a randomised controlled trial. Lancet. 2021 Oct 23;398(10310):1507-1516. doi: 10.1016/S0140-6736(21)01698-6. Epub 2021 Aug 29. Erratum in: Lancet. 2021 Oct 23;398(10310):1486. doi: 10.1016/S0140-6736(21)02090-0. PMID: 34469766

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. Caffeinated Coffee Consumption or Abstinence to Reduce Atrial Fibrillation: The DECAF Randomized Clinical Trial. JAMA. 2025 Nov 9:e2521056. doi: 10.1001/jama.2025.21056. Epub ahead of print. PMID: 41206802

Stiell IG, Taljaard M, Eagles D, Yadav K, Vadeboncoeur A, Hohl CM, Archambault PM, Birnie D, Brown E, Campbell SG, Chen Y, Clement CM, Cournoyer A, de Wit K, Emond M, Macle L, McRae AD, Mercier E, Morris J, Mohamad G, Nemnom MJ, Nicholls SG, Pare D, Parkash R, Sivilotti M, Thavorn K, Perry JJ. Vernakalant versus procainamide for rapid cardioversion of patients with acute atrial fibrillation (RAFF4): randomised clinical trial. BMJ. 2025 Nov 11;391:e085632. doi: 10.1136/bmj-2025-085632. PMID: 41218981

Stewart D. Emotional Analgesia and the Decline of Rational Decision Making in Emergency Medicine. Emerg Med Australas. 2025 Dec;37(6):e70180. doi: 10.1111/1742-6723.70180. PMID: 41305908

Trainee Emergency Research Network (TERN). Understanding corridor and escalation area care in 165 UK emergency departments: a multicentre cross-sectional snapshot study. Emerg Med J. 2025 Dec 27:emermed-2025-215301. doi: 10.1136/emermed-2025-215301. Epub ahead of print. PMID: 41365687

Charlton N, Berry DC, Kannan V, Yee R, Carlson JN, Orkin AM. The use of expired resuscitation medications for life-threatening first aid conditions: a systematic search and narrative review. Resusc Plus. 2025 Sep 23;26:101110. doi: 10.1016/j.resplu.2025.101110. PMID: 41142213

Brindley PG, Morgan M. Diagnosing dying: is it time for doctors to write “dying certificates”? BMJ. 2024 Jun 4;385:q1167. doi: 10.1136/bmj.q1167. PMID: 38834200

Apostolov A, Bradley A, Dreher S, Dwyer C, Edwards J, Evans ME, Gu N, Hansen J, Lewis JD, Mashburn AT, Miller K, Richardson E, Roller W, Stark A, Swift J, Zuniga O, Lesch R. Tracking domestication signals across populations of North American raccoons (Procyon lotor) via citizen science-driven image repositories. Front Zool. 2025 Oct 2;22(1):28. doi: 10.1186/s12983-025-00583-1. PMID: 41039604

Welcome back tot he final edition of the podcast for 2025. Another collection of big paers, long rants and of course – flying rhinoceros physiology. Its all FOAMed goodness.

Byrne A, Macdonald DB, Kirkpatrick IDC, Pham M, Green CR, Copaescu AM, McInnes MDF, Ling L, Ellis A, Costa AF. CAR/CSACI Practice Guidance for Contrast Media Hypersensitivity. Can Assoc Radiol J. 2025 Aug;76(3):400-416. doi: 10.1177/08465371241311253. Epub 2025 Jan 11. PMID: 39797723

Basically: DO NOT use steroids to “pre-treat” patients with IV contrast allergies. Keep calm and carry on to CT… A longer write up can be found here.

Alexandrov AW, Shearin AJ, Mandava P, Torrealba-Acosta G, Elangovan C, Krishnaiah B, Nearing K, Robinson E, Guthrie-Chu C, Holzmann M, Fill B, Trivedi DR, Richardson A, Middleton S, Brewer BB, Liebeskind DS, Goyal N, Grotta JC, Alexandrov AV; ZODIAC Investigators. Optimal Head-of-Bed Positioning Before Thrombectomy in Large Vessel Occlusion Stroke: A Randomized Clinical Trial. JAMA Neurol. 2025 Sep 1;82(9):905-914. doi: 10.1001/jamaneurol.2025.2253. PMID: 40465238

Summary: HEADS DOWN! – if you have a patient in the ED awaiting EV thrombectomy for large vessel CVA the nursing them on a flat (0 degrees) bed may be the best option compared to 30 degrees up which every other patient should probably be at.

Strayer RJ, Oliver M, Chen A, Gerges L, Caputo ND. 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 Sep;76:88-94. doi: 10.1016/j.jemermed.2025.04.016. Epub 2025 May 22. PMID: 40533376

Summary: there is no evidence that continuous suction during RSI will do your patient harm or make them hypoxic… so suck away.

ANDROMEDA-SHOCK-2 Investigators for the ANDROMEDA Research Network, Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), and Latin American Intensive Care Network (LIVEN); Hernandez G, Personalized Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial. JAMA. 2025 Oct 29:e2520402. doi: 10.1001/jama.2025.20402. Epub ahead of print. PMID: 41159835

Summary: doing “personalised” resuscitation for septic patients is what we should probably be doing for our sick patients. This trial showed one way to do this using capillary refill as a target.

A longer, more detailed write up of this paper can be found here. 

Muller G, Contou D, Ehrmann S, Martin M, Andreu P, Kamel T, Boissier F, Azais MA, Monnier A, Vimeux S, Chenal A, Nay MA, Salmon Gandonnière C, Lascarrou JB, Roudaut JB, Plantefève G, Giraudeau B, Lakhal K, Tavernier E, Boulain T; CRICS-TRIGGERSEP F-CRIN Network and the EVERDAC Trial Group.. Deferring Arterial Catheterization in Critically Ill Patients with Shock. N Engl J Med. 2025 Oct 29. doi: 10.1056/NEJMoa2502136. Epub ahead of print. PMID: 41159885

Summary: Arterial lines do not save lives. This trial had some super sick, septic patients and there was no overall benefit from art lines over NIBP cuffs…. but there are harms and benefits to both, so think about your practice and what works..

Rippey J, Morris F, Moseley C, Sowerby J, Chiverton L, Mason J. Post-Procedure Perforation Rates in Ultrasound Transducer Covers Used for Ultrasound-Guided Percutaneous Procedures in Emergency Medicine: A Comparison Between Polyurethane Covers and Polyethylene Covers. Australas J Ultrasound Med. 2025 Sep 25;28(4):e70025. doi: 10.1002/ajum.70025. PMID: 41017784

Summary: Ultrasound probe covers leak. You should not trust the last person who used the probe and assume it is dirty before you do a sterile procedure. Clean the probe properly yourself!

Dubucs X, Gingras V, Boucher V, Carmichael PH, Ruel M, De Wit K, Grewal K, Mercier É, Blanchard PG, Benhamed A, Charpentier S, Émond M. Risk Factors for Traumatic Intracranial Hemorrhage in Older Adults Sustaining a Head Injury in Ground-Level Falls: A Systematic Review and Meta-analysis. Ann Emerg Med. 2025 Jul 22:S0196-0644(25)00313-0. doi: 10.1016/j.annemergmed.2025.05.021. Epub ahead of print. PMID: 40699169

Summary:  Biased data sets can result in weird conclusions that need further thought. Don’t believe the hype, DOACS do not protect your brain if you fall over!

Ilgen JS, Dhaliwal G. Educational Strategies to Prepare Trainees for Clinical Uncertainty. N Engl J Med. 2025 Oct 23;393(16):1624-1632. doi: 10.1056/NEJMra2408797. PMID: 41124633

“Uncertainty is ubiquitous in medical practice. If there was no uncertainty, society would not need physicians to render judgments.”

Summary: We should routinely train doctors to deal with uncertain situations – the rest is pretty simple.

Atkinson P, Lang E. Can emergency medicine be saved? CJEM. 2025 Oct;27(10):760-763. doi: 10.1007/s43678-025-01034-w. Epub 2025 Oct 18. PMID: 41108498

Summary: An editorial that is worth a read. Big picture thinking about what Emergency Medicine is and should be.

Radcliffe RW, Jago M, Morkel PV, Morkel E, du Preez P, Beytell P, Kotting B, Manuel B, du Preez JH, Miller MA, Felippe J, Parry SA, Gleed RD. THE PULMONARY AND METABOLIC EFFECTS OF SUSPENSION BY THE FEET COMPARED WITH LATERAL RECUMBENCY IN IMMOBILIZED BLACK RHINOCEROSES (DICEROS BICORNIS) CAPTURED BY AERIAL DARTING. J Wildl Dis. 2021 Apr 1;57(2):357-367. doi: 10.7589/2019-08-202. PMID: 33822147

Summary: You just need to look at this picture to appreciate how easy your job is!

This short video explains my top 10 tips and non-technical tricks for making your patient’s experience better in the ED when they are a DIVA (Difficult IV access). This is a common problem and one that can be immensely satisfying to do well for both you and your patient.

Subscribe tot he Youtube channel for my other US videos, tip and nerdy podcasts with Dr Justin Morgenstern.

The latest podcast with Dr. Justin Morgenstern. We look at all the latest evidence and a few older pieces from the world of Emergency care. This month we tackle: AI bots for OMIs, paracentesis plumbing, antiplatelet pharma, facial fractures and a sublingual anaphylaxis agent!  Its a lot!  #FOAMed

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 Jul 30;97:193-199. doi: 10.1016/j.ajem.2025.07.061. Epub ahead of print. PMID: 40763602

Daniel NJ, Storn JM, Weinberg NE, Galvin WA, Irons HR, Barksdale AN, Rischall ML, Bilodeau SM, Gale JY, Willet KG, Wilson A, Keiper K, Chevalier J. Assessment of sous vide water baths in the acute rewarming of frostbitten extremities: A multicenter study. Acad Emerg Med. 2025 May;32(5):574-577. doi: 10.1111/acem.15061.PMID: 39654121

Konerman MA, Price J, Torres D, Li Z. Randomized, controlled pilot study comparing large-volume paracentesis using wall suction and traditional glass vacuum bottle methods. Therap Adv Gastroenterol. 2014 Sep;7(5):184-92. doi: 10.1177/1756283X14532704. PMID: 25177365

 This post from Maimonides goes into a little more detail. 

Kutcher SA, Dendu

kuri N, Dandona S, Nadeau L, Brophy JM. Ticagrelor Compared to Clopidogrel in Acute Coronary Syndromes trial (TC4): a Bayesian pragmatic cluster randomized controlled trial. CMAJ. 2025 Mar 30;197(12):E309-E318. doi: 10.1503/cmaj.241862. PMID: 40164463

Lajeunesse MD, Olivera TR, April MD, Benesch HA, Castaneda P, Couperus KS, Dang VN, Park MS, Deboer RS, Dougherty CA, Downing NC, Gray MW, Hull AM, Jimenez BL, Klausner MJ, Sakai JHM, McLean TJ, Nepal N, Patten HW, Schwartz BT, Walther ND, Wolterstorff CS, Oliver JJ. Trigger Point Injection for Myofascial Pain Syndrome of the Low Back: A Partially Blinded Three-Arm Randomized Controlled Trial. Ann Emerg Med. 2025 Jun 17:S0196-0644(25)00298-7. doi: 10.1016/j.annemergmed.2025.05.008. PMID: 40531073

Rech MA, Carpenter CR, Aggarwal NT, Hwang U. Anti-Amyloid Therapies for Alzheimer’s Disease and Amyloid-Related Imaging Abnormalities: Implications for the Emergency Medicine Clinician. Ann Emerg Med. 2025 Jun;85(6):526-536. doi: 10.1016/j.annemergmed.2024.12.002. Epub 2025 Jan 17. PMID: 39818674

More details here.

Castillo Diaz F, Anand T, Khurshid MH, Kunac A, Al Ma’ani M, Colosimo C, Hejazi O, Ditillo M, Magnotti LJ, Joseph B. Look me in the face and tell me that I needed to be transferred: Defining the criteria for transferring patients with isolated facial injuries. J Trauma Acute Care Surg. 2025 May 9. doi: 10.1097/TA.0000000000004651. Epub ahead of print. PMID: 40341445

Kraus CN, Wargacki S, Golden D, Lieberman J, Greenhawt M, Camargo CA Jr. Integrated phase I pharmacokinetics and pharmacodynamics of epinephrine administered through sublingual film, autoinjector, or manual injection. Ann Allergy Asthma Immunol. 2025 May;134(5):580-586. doi: 10.1016/j.anai.2025.01.006. Epub 2025 Jan 16. PMID: 39826899

Welcome back to a somewhat delayed, yet typically on target episode of the Journal Club with Dr Morgenstern.

This month is a really eclectic bunch of papers from all walks of science – bench science to the purely clinical and a bit about fruit in the mix there.

Papers are listed below for reference. Enjoy over a long drive or a slow shift !

Gualtieri R, Verolet C, Mardegan C, Papis S, Loevy N, Asner S, Rohr M, Llor J, Heininger U, Lacroix L, Pittet LF, Posfay-Barbe KM. Amoxicillin vs. placebo to reduce symptoms in children with group A streptococcal pharyngitis: a randomized, multicenter, double-blind, non-inferiority trial. Eur J Pediatr. 2024 Nov;183(11):4773-4782. doi: 10.1007/s00431-024-05705-1. Epub 2024 Aug 31. PMID: 39215861

Related: You don’t understand non-inferiority trials (and neither do I)

Leech C, Nutbeam T, Chu J, Knight M, Hinshaw K, Appleyard TL, Cowan S, Couper K, Yeung J. Maternal and neonatal outcomes following resuscitative hysterotomy for out of hospital cardiac arrest: A systematic review. Resuscitation. 2025 Feb;207:110479. doi: 10.1016/j.resuscitation.2024.110479. Epub 2024 Dec 29. PMID: 39736393

This paper is not going to change your day to day clinical practice, but might help set our expectations if you are faced with performing a perimortem hysterotomy.

Li B, Elsten-Brown J, Li M, Zhu E, Li Z, Chen Y, Kang E, Ma F, Chiang J, Li YR, Zhu Y, Huang J, Fung A, Scarborough Q, Cadd R, Zhou JJ, Chin AI, Pellegrini M, Yang L. Serotonin transporter inhibits antitumor immunity through regulating the intratumoral serotonin axis. Cell. 2025 Jul 10;188(14):3823-3842.e21. doi: 10.1016/j.cell.2025.04.032. Epub 2025 May 21. PMID: 40403728

Keijzers G. Deliberate clinical inertia: A paradoxical strategy to improve patient flow? Emerg Med Australas. 2025 Apr;37(2):e70016. doi: 10.1111/1742-6723.70016. PMID: 40045755

Deliberate clinical inertia: the conscious process of ‘doing nothing’ as a positive response to clinician and system intervention bias.

Zaman F, Bach C, Junaid I, Papatsoris AG, Pati J, Masood J, Buchholz N. The floppy iris syndrome – what urologists and ophthalmologists need to know. Curr Urol. 2012 May;6(1):1-7. doi: 10.1159/000338861. Epub 2012 Apr 30. PMID: 24917702

Endo A, Yamakawa K, Tagami T, et al. Efficacy of targeting high mean arterial pressure for older patients with septic shock (OPTPRESS): a multicentre, pragmatic, open-label, randomised controlled trial. Intensive Care Med. 2025 May;51(5):883-892. doi: 10.1007/s00134-025-07910-4. Epub 2025 May 13. PMID: 40358717

Bottom line: Although I don’t think the massive mortality difference is believable, everything in this trial points at harm from targeting higher MAPs. 65 is the target.

Dönmez S, Şener A, Işık Nİ, Koca S, Akbaş İ. Analgesic and Anxiolytic Effects of Virtual Reality and Classical Music Therapy on Tension-Type Headache: A Randomized Controlled Trial. Ann Emerg Med. 2025 Jun 4:S0196-0644(25)00278-1. doi: 10.1016/j.annemergmed.2025.04.032. Epub ahead of print. PMID: 40464717

Chen YH, Zink T, Chen YW, Nin DZ, Talmo CT, Hollenbeck BL, Grant AR, Niu R, Chang DC, Smith EL. Postoperative Aspiration Pneumonia Among Adults Using GLP-1 Receptor Agonists. JAMA Netw Open. 2025 Mar 3;8(3):e250081. doi: 10.1001/jamanetworkopen.2025.0081. PMID: 40036031

Bottom line: Although there are anecdotal reports coming from anesthesia about an increased risk of aspiration with GLP1 agonists, that concern does not appear to be supported by this large observational data set. 

Barone JE. Comparing apples and oranges: a randomised prospective study. BMJ. 2000 Dec 23-30;321(7276):1569-70. doi: 10.1136/bmj.321.7276.1569. PMID: 11124178