Emergency Medical Minute

Our near daily podcasts move quickly to reflect current events, are inspired by real patient care, and speak to the true nature of what it's like to work in the Emergency Room or Pre-Hospital Setting. Each medical minute is recorded in a real emergency department, by the emergency physician or clinical pharmacist on duty – the ER is our studio and everything is live.

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Monday · 3 min
Podcast 1024: Caffeine Toxicity
Contributor: Taylor Lynch, MD Educational Pearls: Excessive caffeine intake can be dangerous. For normal adults, the toxicity level starts at 1000mg, which is equivalent to about 10 cups of coffee or 5 celsius drinks. For normal adults, lethal levels are about 5-10 grams, which is equivalent to about 50-100 cups of coffee. Most of these outcomes are not from drinking caffeine, but instead concentrated caffeine pills. For children, toxic levels are 15mg per kg of the child. Within the last 10 years 20-40 deaths due to caffeine intake have been reported. This may be lower than the actual number due to cardiac arrests that potentially could have been caused from caffeine intake. Clinical presentation of caffeine toxicity can present in many ways. Most common symptoms include agitation and jitteriness The far end of the spectrum includes seizures, tachydysrhythmias, and eventually cardiovascular collapse. Caffeine is a part of the methylxanthine class. Caffeine is a phosphodiesterase inhibitor, which causes the release of calcetamines that act on your beta-2 receptors. This activates the sodium potassium ATPase and causes potassium to shift intracellular. The clinical presentation of this mechanism is a patient with low potassium and agitation. Treatments for toxic caffeine levels include: Replacing potassium, but slowly since the total potassium levels in the body are normal and will eventually return to normal once the caffeine wears off. Benzodiazepines Activated charcoal Dialysis, since caffeine is dialyzable References National Center for Biotechnology Information. "PubChem Compound Summary for CID 2519, Caffeine" PubChem, https://pubchem.ncbi.nlm.nih.gov/compound/Caffeine. Accessed 9 July, 2026. Murray A, Traylor J. Caffeine Toxicity. [Updated 2025 Feb 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532910/ Cyril Willson, The clinical toxicology of caffeine: A review and case study, Toxicology Reports, Volume 5, 2018, Pages 1140-1152, ISSN 2214-7500, https://doi.org/10.1016/j.toxrep.2018.11.002. Summarized by Aaryn David | Edited by Aaryn David & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf Golf Fundraiser: https://www.zeffy.com/en-US/ticketing/emergency-medical-minute-charity-golf--2026
September 28 · 5 min
Podcast 1023: Torsades de pointes
Contributor: Aaron Lessen, MD Educational Pearls: Case review of a patient with recurrent episodes of syncope and shortness of breath, during which she is found to have intermittent runs of polymorphic ventricular tachycardia Torsades de pointes is polymorphic ventricular tachycardia occurring in the setting of a prolonged QT/QTc Risk of torsades increases substantially when QTc exceeds 500ms Causes: Common reversible causes include QT-prolonging medications, hypokalemia, hypomagnesemia, hypocalcemia, bradycardia, and structural heart disease Congenital causes of a prolonged QT interval are primarily inherited genetic mutations affecting cardiac myocyte ion channels leading to delayed ventricular repolarization Treatment: Stop any QT-prolonging medications and correct electrolytes IV magnesium to suppress recurrent torsades Increasing the heart rate with isoproterenol or temporary pacing can prevent the pauses that trigger recurrent episodes If the rhythm degenerates into ventricular fibrillation → defibrillate References Wigginton JG, Agarwal S, Bartos JA, Coute RA, Drennan IR, Haamid A, Kudenchuk PJ, Link MS, Panchal AR, Pelter MM, Del Rios M, Rodriguez AJ, Perman SM, Sanko S, Kotini-Shah P, Kurz MC. Part 9: Adult Advanced Life Support: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025 Oct 21;152(16_suppl_2):S538-S577. doi: 10.1161/CIR.0000000000001376. Epub 2025 Oct 22. PMID: 41122884. Summarized by Meg Joyce, MS3 | Edited by Meg Joyce & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Golf Fundraiser: https://www.zeffy.com/en-US/ticketing/emergency-medical-minute-charity-golf--2026
September 21 · 4 min
Podcast 1022: Emergent Dialysis
Contributor: Taylor Lynch, MD Educational Pearls: When a patient who missed dialysis presents to the emergency department, our clinical concern is who needs to be admitted to the hospital for emergent dialysis and who can wait for their next regularly scheduled session. Dialysis sessions typically occur on Monday, Wednesday, and Friday, or Tuesday, Thursday, and Saturday. Acronym for indications for emergent dialysis: AEIOU Acidosis Patients may have an underlying cause for acidosis such as sepsis or DKA. Treat the underlying cause, but if the acidosis is unable to be corrected, the patient needs dialysis. Electrolytes Most commonly elevated is potassium. In general, dialysis patients tend to have higher potassium levels, so don't just treat the number. Look for potassium greater than 6.5 or if EKG changes are present. Ingestion Intoxication with substances such as Lithium, Ethylene Glycol, Methanol, Salicylates. Overload Patients may present with evidence of fluid overload such as new oxygen requirement or pulmonary edema. If they are making urine, treat with diuretics, but if unresponsive to medical therapy, they will require dialysis. Uremia Build-up of nitrogenous waste products in the blood, which is indicated by an elevated BUN. Patients may develop complications such as altered mentation or pericardial effusions and subsequent cardiac tamponade. Keep in mind creatinine itself is not an indication for emergent dialysis. Serves as a surrogate marker of kidney function. Can be high or low depending on muscle mass or kidney filtration, and the patient may or may not need dialysis. References: Jentzer JC, Bihorac A, Brusca SB, et al. Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives. J Am Coll Cardiol. 2020;76(9):1084-1101. doi:10.1016/j.jacc.2020.06.070 Summarized by Ashley Lyons, OMS4 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf
September 14 · 4 min
Podcast 1021: Pulmonary Edema From Naloxone Administration
Contributor: Travis Barlock, MD Educational Pearls: What is pulmonary edema? Pulmonary edema is the accumulation of fluid initially in the interstitium of the lungs, that when severe enough can also accumulate in the alveolar air sacs. It develops when the rate of fluid filtration through the pulmonary vasculature out-paces the lymphatics ability to drain the fluid. There are 2 theories for what causes pulmonary edema in the setting of naloxone administration: catecholamine surge vs negative pressure/barotrauma Catecholamine Surge : Naloxone administration precipitates an acute opioid withdrawal in which epinephrine and norepinephrine surge causing marked vasoconstriction on both the heart and the lungs Negative Pressure/Barotrauma: This mechanism is not directly naloxone related but may be confounded by opioid effects. High dose synthetic opioids can induce sustained laryngospasm that is not mu-opioid mediated (thus not easily reversed by naloxone). With rapid awakening, respiratory muscles induce a negative pressure in the thoracic cavity against a closed glottis. This results in an alveolar barotrauma and a transudative pulmonary edema. What is the treatment for pulmonary edema secondary to opioid overdose reversal? Positive pressure ventilation is the mainstay treatment (CPAP/BiPAP) with oxygen supplementation. Importantly, diuretics are not recommended. The patient is not fluid overloaded like in the case of other pulmonary edemas, and diuresing the patient can worsen kidney injury which is already at an increased risk in opioid overdoses (rhabdomyolysis in particular). References: Saari TI, Strang J, Dale O. Clinical Pharmacokinetics and Pharmacodynamics of Naloxone. Clin Pharmacokinet. 2024;63(4):397-422. doi:10.1007/s40262-024-01355-6 DailyMed - NALOXONE HYDROCHLORIDE injection, solution. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=201fdedf-1736-4e52-9d7d-de14292547fd Boyer EW. Management of Opioid Analgesic Overdose. New England Journal of Medicine. 2012;367(2):146-155. doi:10.1056/NEJMra1202561 Dezfulian C, Orkin AM, Maron BA, et al. Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association. Circulation. 2021;143(16):e836-e870. doi:10.1161/CIR.0000000000000958 Kienbaum P, Thurauf N, Michel M, Scherbaum N, Gastpar M, Peters J. Profound Increase in Epinephrine Concentration in Plasma and Cardiovascular Stimulation after [micro sign]-Opioid Receptor Blockade in Opioid-addicted Patients during Barbiturate-induced Anesthesia for Acute Detoxification Anesthesiology. 1998;88(5):1154-1161. doi:10.1097/00000542-199805000-00004 Summarized by Dan Orbidan, OMS3 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf
September 7 · 6 min
Podcast 1020: Benign Paroxysmal Positional Vertigo (BPPV)
Contributor: Alec Coston, MD Educational Pearls: Benign Paroxysmal Positional Vertigo (BPPV) Common inner ear condition that can cause dizziness Diagnosis of BPPV can help to avoid admissions and extra imaging Three categories: positional, horizontal, and anterior Positional is the most common Dizziness is not a positive indicator, a torsional nystagmus must be induced Dix's hallpike maneuver is done to diagnose and an epley maneuver is then used for treatment Horizontal Usually determined to be the case if the vertigo seems positional and the dix hallpike does not work. A supine roll test would then be done to help diagnose. Instead of a rotational nystagmus, a unilateral horizontal nystagmus is expected. The two patterns are termed geotropic and apogeotropic. Geotropic means the fast phase beats toward the ground, and is treated by a barbeque roll maneuver. Apogeotropic means the fast phase beats toward the ceiling, and is treated by Gufoni maneuver. Anterior is more rare Most cases require neuro consults Determined by attempting to induce a down-beating nystagmus, which is a higher risk nystagmus. Treatment is tilting their head back up in a similar way Inducing the nystagmus is not sided and is more central References You, P., Instrum, R. and Parnes, L. (2019), Benign paroxysmal positional vertigo. Laryngoscope Investigative Otolaryngology, 4: 116-123. https://doi.org/10.1002/lio2.230 Ling X, Zhao D-H, Shen B, Si L-H, Li K-Z, Hong Y, Li Z-Y and Yang X (2020) Clinical Characteristics of Patients With Benign Paroxysmal Positional Vertigo Diagnosed Based on the Diagnostic Criteria of the Bárány Society. Front. Neurol. 11:602. doi: 10.3389/fneur.2020.00602 Rah YC. Advances in Benign Paroxysmal Positional Vertigo: Updated Insights on Diagnostic Pitfalls and Management. J Audiol Otol. 2026 Jan;30(1):1-12. doi: 10.7874/jao.2025.00717. Summarized by Aaryn David | Edited by Aaryn David & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf
August 31 · 3 min
Podcast 1019: Trauma Blunt Cardiovascular Injuries (BCVI)
Contributor: Aaron Lessen, MD Educational Pearls: Blunt cerebrovascular injury (BCVI) BCVI is a traumatic injury to the carotid or vertebral arteries Patients may initially have no neurologic symptoms In some cases, a thrombus can form at the site of the injury and later cause ischemic stroke, sometimes hours after the original trauma CT angiography (CTA) of the neck is a useful screening tool for BCVI HIstorically, CTA was reserved for patients with high-risk mechanisms or neurologic symptoms CTA screening has expanded as understanding of BCVIs and their prevention progresses The Denver criteria were developed to identify patients with increased risk for BCVI High-risk findings include cervical spine injuries and severe facial or skull-base fractures Screening practices still vary between trauma centers, though expansion of proactive CTA is an increasingly common practice References Kim DY, et al. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020. Biffl WL, et al. Screening for and treatment of blunt cerebrovascular injuries: Western Trauma Association critical decisions algorithm. J Trauma. 2009. Brommeland T, et al. Best practice guidelines for blunt cerebrovascular injury. Scand J Trauma Resusc Emerg Med. 2018. Harper PR, et al. Routine CTA screening identifies blunt cerebrovascular injuries missed by clinical risk factors. Trauma Surg Acute Care Open. 2022. Summarized by Sam Pahl | Edited by Sam Pahl & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf
August 24 · 2 min
Podcast 1018: Occult Ventricular Fibrillation on Echocardiography
Contributor: Aaron Lessen, MD Educational Pearls: Big question in cardiac arrest: is the rhythm shockable? Shockable: ventricular fibrillation (VF) and pulseless ventricular tachycardia Non-shockable: asystole and pulseless electrical activity (PEA) Rhythm classification is typically based on ECG, but echocardiography can directly visualize myocardial fibrillation Occult VF: a rhythm that appears non-shockable on ECG but demonstrates VF on echocardiography A 2025 multicenter prospective study looked at 811 patients with out-of-hospital cardiac arrest 5.3% had occult VF detected by echocardiography Of the patients with occult VF: 81.4% had PEA on ECG 18.6% had asystole on ECG Patients with occult VF were less likely to receive defibrillation because their ECG suggested a nonshockable rhythm Clinical takeaway: echocardiography during cardiac arrest may reveal a potentially shockable rhythm hiding behind an apparently nonshockable ECG This identifies a subset of cardiac arrest patients who would otherwise be managed as PEA or asystole based on ECG References Gaspari R, Adhikari S, Gleeson T, Kapoor M, Lindsay R, Noble V, Nomura JT, Weekes A, Theodoro D. Occult Ventricular Fibrillation Visualized by Echocardiogram During Cardiac Arrest: A Retrospective Observational Study From the Real-Time Evaluation and Assessment for Sonography-Outcomes Network (REASON). J Am Coll Emerg Physicians Open. 2025 Jan 13;6(1):100028. doi: 10.1016/j.acepjo.2024.100028. PMID: 40012664; PMCID: PMC11853361. Summarized by Meg Joyce, MS3 | Edited by Meg Joyce & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/
August 17 · 2 min
Podcast 1017: CPR Hand Placement
Contributor: Taylor Lynch, MD Educational Pearls: CPR is an important life-saving measure designed for anyone to perform. Chest compressions works by two mechanisms: Cardiac pump: Direct squeezing of the heart Thoracic pump: Increasing intrathoracic pressure, causing increased blood flow Proper hand placement per current AHA guidelines: Hands are placed in the center of the chest, on the lower half of the sternum A recent study challenged this approach, using TEE during chest compressions to visualize the cardiac structures being compressed. They found that when hands were placed ~1cm to the left of the sternum, this compressed the left ventricular outflow tract, potentially restricting forward blood flow. Hand placement ~4cm to the left of the sternum resulted in more effective compression of the left ventricle. While this is not yet reflected in AHA guidelines, the study presents an interesting finding that may influence how CPR is performed in the future. Key takeaway: Always prioritize administering high quality compressions. References: American Heart Association. 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(23_suppl_1). doi:10.1161/CIR.0000000000001378. Chu S, Cheng C, Chang C, et al. Transesophageal echocardiography during CPR in patients with out-of-hospital cardiac arrest: the EXECT-CPR randomized clinical trial. JAMA Intern Med. 2026;186(5):557-566. doi:10.1001/jamainternmed.2026.0102. Summarized by Ashley Lyons, OMS4 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf
August 10 · 6 min
Podcast 1016: Hypokalemia
Contributor: Meghan Hurley, MD Educational Pearls: What is hypokalemia? Hypokalemia is when the measured blood level of potassium falls below 3.5 mEq/L (normal 3.5 - 5.2 mEq/L). Can generally be considered in mild (3.0 - 3.5 mEq/L); moderate (2.5 - 2.9 mEq/L); and severe ( Should be noted that blood levels of potassium can be low while total body potassium is normal due to intracellular shift by certain agents like β-2 agonists (e.g. Albuterol) or insulin. There is no appreciable loss of insulin despite hypokalemia being present in labs. What are the most common causes of hypokalemia? Medications are a predominant cause; mainly loop and thiazide diuretics. Gastrointestinal losses such as prolonged emesis or diarrhea (can occur in the setting of chronic illness and treatment such as chemotherapy patients with emesis). Other renal losses (e.g. hyperaldosteronism and renal tubular acidosis). A fun-fact renal loss: A compound found in some licorice (Glycyrrhizic acid) can inhibit 11-ß-hydroxysteroid dehydrogenase enzyme type 2 and cause mineralocorticoid excess. See a 2023 case study in references for Lethal Arrhythmia Induced by Licorice. What is a less common cause of hypokalemia? Hypokalemic Periodic Paralysis (HypoPP) is a genetic autosomal dominant channelopathy where patients leak potassium at rest causing a flaccid paralysis of muscle. Typically impacting legs more than arms, and proximal muscles more than distal muscles. Can be triggered carbohydrate rich meals, rest after exercise, febrile illness, and fasting. Male predominance, typically in early adulthood. Treatment is avoidance of triggers and supplementation with conservative oral potassium to avoid overcorrection during attacks. What are some symptoms and findings associated with hypokalemia? Patients may present with generalized weakness and fatigue. Highly crucial to monitor for EKG changes in the setting of hypokalemia. May notice flattening of T wave with the development of a U wave at certain potassium levels. The lower the potassium levels, the more likely a TU fusion can be seen. Prolongs QT interval which puts patients at risk for lethal arrhythmias. What are treatment considerations for hypokalemia? At milder levels of hypokalemia that are asymptomatic and a reversible cause is identified, oral repletion via potassium tablets should be considered. Patients may be a candidate to complete their course of treatment in the Emergency Room. At higher symptomatic levels with distinct EKG changes, more aggressive repletion (including IV Potassium) should be considered. Patients may be candidates for admission. Always monitor and replace magnesium levels as well, as they tend to follow potassium levels as well. Consider intracellular shifts as a source of hypokalemia to avoid risk of overcorrection into hyperkalemia. Hypokalemia can cause deadly heart rhythms such as ventricular fibrillation and ventricular tachycardia including Torsades Des Pointes that will be refractory to defibrillation. Treatment considerations at this point include: Consideration of esmolol Double Sequential Defibrillation Extracorporeal Membrane Oxygenation (ECMO). Key takeaways? Hypokalemia is most often associated with medication side effects or total volume loss from emesis or diarrhea. Depending on the degree of hypokalemia, different treatment considerations must be made. Monitor patient EKG closely for changes that can progress to lethal arrhythmias. References: Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet. 2020;396(10265):1807-1816. doi:10.1016/S0140-6736(20)32338-2 Cheskes S, Verbeek PR, Drennan IR, et al. Defibrillation Strategies for Refractory Ventricular Fibrillation. New England Journal of Medicine. 2022;387(21):1947-1956. doi:10.1056/NEJMoa2207304 Oswald S, Ravioli S, Schwarz C, Lindner G. Hypokalaemia in the emergency department: aetiology, diagnosis, and management. Swiss Medical Weekly. 2026;156(4):4767-4767. doi:10.57187/4767 Gao Z, Xing H, Zhang J, Chen S, Gao Z. Hypokalemic periodic paralysis: novel perspectives from genetic mutations to clinical management. Gene. 2026;999:150172. doi:10.1016/j.gene.2026.150172 Han EJ, Park JS. Lethal Arrhythmia Induced by Licorice. J Korean Med Sci. 2023;38(12):e107. doi:10.3346/jkms.2023.38.e107 Lee YH, Lee KJ, Min YH, et al. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016;107:150-155. doi:10.1016/j.resuscitation.2016.07.243 Summarized by Dan Orbidan, OMS3 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf
August 3 · 7 min
Podcast 1015: Calcium in Hyperkalemia
Contributor: Meghan Hurley, MD Educational Pearls: What is hyperkalemia? Hyperkalemia is when the measured blood level of potassium reaches above 5.2 - 5.5 mEq/L (normal 3.5 - 5.2 mEq/L). What are common causes of hyperkalemia? Chronic or acute kidney disease. Medications that impact the Renin-Angiotensin-Aldosterone-System (RAAS). Hypoaldosteronism and primary adrenal insufficiency (Addison's Disease). What are concerns of hyperkalemia? The biggest concern with hyperkalemia is the impact on the cardiac conduction system. At differing levels of hyperkalemia, the patient may initially have peaked T waves, that then progress into a widening of the QRS complex which may eventually lead to a sine wave pattern. This increases risk for cardiac arrest with ventricular fibrillation, PEA, and asystole. What is the treatment algorithm for hyperkalemia? Works through a three-tier approach. First tier treatment is with a calcium agent (calcium gluconate or chloride). Thought for the longest time to "stabilize the cardiac membrane/action potential". Recent research shows the true mechanism of action is likely through acting on calcium dependent channels. Does not fix underlying hyperkalemia, but buys time for the heart. Second tier treatment is inducing intracellular potassium shift. Can be achieved through agents such as insulin (which may need to be bolused with glucose to prevent hypoglycemia), albuterol, or sodium bicarbonate. Third tier is potassium elimination If the patient is producing urine, loop or thiazide diuretics can be considered. Hemodialysis may also be considered based on patient condition. Long term (and slowest method of elimination) through fecal excretion. Unlikely to see benefits in emergency management. Key Takeaways? Hyperkalemia is a condition that can be brought on by primarily renal conditions and medication side effects. Careful attention must be paid to the patient's cardiac status, and urgent cardiac stabilization (though now we may know that calcium doesn't truly "stabilize" the cardiac membrane) must be performed to prevent deadly arrhythmias. Definitive management involves addressing the offending agent, offloading potassium, and stabilizing the patient long term. References: Geldermann N, Dzimiera J, Fischer H, Christ M. Acute hyperkalaemia in emergency care: evidence-based approaches. Emerg Med J. 2026;43(5):305-311. doi:10.1136/emermed-2025-215469 Piktel JS, Wan X, Kouk S, Laurita KR, Wilson LD. Beneficial Effect of Calcium Treatment for Hyperkalemia is Not Due to "Membrane Stabilization." Crit Care Med. 2024;52(10):1499-1508. doi:10.1097/CCM.0000000000006376 Hunter RW, Bailey MA. Hyperkalemia: pathophysiology, risk factors and consequences. Nephrol Dial Transplant. 2019;34(Suppl 3):iii2-iii11. doi:10.1093/ndt/gfz206 Summarized by Dan Orbidan, OMS3 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf
July 27 · 2 min
Podcast 1014: Eating and Drinking on Shift
Contributor; Aaron Lessen, MD Educational Pearls: A 2026 survey asked Canadian emergency medicine (EM) physicians about their eating and drinking habits while on shift. Among 527 respondents, 35% reported that they never or hardly ever ate during shifts, and 37% said the same about drinking water. Lack of time was the most commonly cited barrier, reported by 91% of respondents. Lack of available food, personal health goals, perceived mental clarity, and emergency department culture were also commonly identified factors. Physicians who did not eat or drink on shift often reported that this negatively affected their work. Years in practice were associated with eating more often while on shift, suggesting that newer physicians may be less likely to eat during shifts. A 2023 study by Kontrick et al. found that 89% of US-based EM residency programs did not have a dedicated meal break, which may help explain why early-career physicians are less accustomed to eating during clinical shifts. Studies outside of emergency medicine have also suggested that inadequate food and fluid intake can affect fatigue, mood, attention, and cognitive performance, though direct evidence in emergency department physicians and patient care remains limited. Future studies could examine whether physician eating and drinking habits during shifts are associated with patient outcomes and broaden the scope of this study to other emergency department providers, nurses, and technicians. References: Farquhar, Madeleine et al. "A lot on their plates? Examining the on-shift eating and drinking habits of Canadian emergency medicine physicians." CJEM vol. 28,1 (2026): 64-73. doi:10.1007/s43678-025-01044-8 Kontrick, Amy V et al. "Do emergency medicine residents have access to healthy food options during work hours?." AEM education and training vol. 7,4 e10890. 17 Jul. 2023, doi:10.1002/aet2.10890 Lemaire, Jane B et al. "Physician nutrition and cognition during work hours: effect of a nutrition based intervention." BMC health services research vol. 10 241. 17 Aug. 2010, doi:10.1186/1472-6963-10-241 Wittbrodt, Matthew T, and Melinda Millard-Stafford. "Dehydration Impairs Cognitive Performance: A Meta-analysis." Medicine and science in sports and exercise vol. 50,11 (2018): 2360-2368. doi:10.1249/MSS.0000000000001682 Summarized by Sam Pahl | Edited by Sam Pahl & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf
July 20 · 3 min
Podcast 1013: Thoracotomy Indications
Contributor; Taylor Lynch, MD Educational Pearls: Thoracotomy Thoracotomy is used in traumatic cardiac arrest to replace conventional CPR with direct access to the chest. Goals include identifying and controlling reversible causes of bleeding, prioritizing blood flow to the heart and brain, and performing open cardiac massage. Trauma categories Penetrating trauma: Gunshot wounds and stab wounds. Has a higher chance of survival because the injury may be localized and directly repairable. Cardiac stab wounds may have the highest survivability because the defect can be visualized, repaired, and treated with blood administration. Blunt trauma: Motor vehicle collisions and falls from height. Has a much lower chance of survival. Western guidelines EMS must witness the patient lose pulses. Penetrating trauma: CPR for less than 15 minutes. Blunt trauma: CPR for less than 10 minutes. Survival decreases to essentially zero beyond these time limits. Eastern guidelines Focus on the presence of signs of life in blunt or penetrating trauma. Signs of life may include: Pupillary response. Measurable blood pressure. Purposeful movement. Patient selection Thoracotomy should only be performed when the patient has a reasonable chance of survival. It is a highly morbid procedure with significant occupational risks, including needlestick injury. Appropriate patient selection and timing are essential. Procedure Begin on the left side of the chest. Cross-clamp the aorta to restrict blood flow below the heart and prioritize circulation to the heart and brain. Identify and repair visible sources of bleeding involving structures such as the heart or lungs. Perform open cardiac massage as the equivalent of CPR. ACLS medications may still be administered. References: Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World J Emerg Surg. 2006;1:4. Published 2006 Mar 24. doi:10.1186/1749-7922-1-4 Rhee, Peter M. ; Acosta, Jose ; Bridgeman, Amy et al. / Survival after emergency department thoracotomy : Review of published data from the past 25 years. In: Journal of the American College of Surgeons. 2000 ; Vol. 190, No. 3. pp. 288-298. Nunn, Andrew ; Prakash, Priya ; Inaba, Kenji et al. / Occupational exposure during emergency department thoracotomy : A prospective, multi-institution study. In: Journal of Trauma and Acute Care Surgery. 2018 ; Vol. 85, No. 1. pp. 78-84. Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359-1363. doi:10.1097/TA.0b013e318270d2df Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;79(1):159-173. doi:10.1097/TA.0000000000000648 Summarized by Steven Fujaros NREMT | Edited by Steven Fujaros & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf
July 13 · 1 min
Podcast 1012: Meth Sedation
Contributor: Aaron Lessen, MD Educational Pearls: Agitated patients who are intoxicated with methamphetamine pose a unique challenge when selecting a sedative to counter their symptoms. Is there a superior medication? A recent study compared the efficacy of commonly used medications for methamphetamine-induced agitation in the emergency department. The study compared IM Droperidol 5mg, IM Olanzapine 10mg, IM Midazolam 5mg, and IM Lorazepam 2mg. The study concluded that Droperidol, Olanzapine, and Midazolam performed similarly, with a median time to adequate sedation of 15 minutes. Lorazepam took the longest, with a median time of 30 minutes to achieve adequate sedation. Patients who received Lorazepam also required rescue medication more frequently after the initial dose. Key takeaway: Droperidol, Olanzapine, and Midazolam may be more effective than Lorazepam for treating methamphetamine-induced agitation. References: Martel M, Klein LR, Cole JB, et al. Intramuscular droperidol, olanzapine, midazolam, or lorazepam to treat methamphetamine intoxication in the emergency department. Am J Emerg Med. 2021;49:142-148. doi:10.1016/j.ajem.2021.05.045 Summarized by Ashley Lyons, OMS4 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf
July 6 · 7 min
Podcast 1011: Creepy Crawlies
Contributor: Meghan Hurley, MD Educational Pearls: What animal is the most lethal to humans? Depending on how we define lethal, and animal, this answer is actually not straight forward. Globally and in the U.S. the most lethal animal is humans, accounting for ~436,000 to ~20,000 deaths (homicides) per year on average respectively. In the United States the most lethal animal is of the Hymenoptera order (bees, wasps, and hornets). It accounts for approximately ~60 deaths per year from anaphylaxis. Globally the number is harder to track, but is estimated between 250–3,800 deaths globally annually. Globally the most lethal animal is venomous snakes, accounting for between 60,000-150,000 per year (whereas in the United States this number is closer to ~5). Mosquitos, as a vector however for the pathogens they transmit, out rank all as the most lethal globally (excluding humans). What are the key take-aways for each insect discussed in this episode? Mosquitos: In the United States, of lesser concern. Can potentially transmit West Nile Virus in the United States. Otherwise, treatment for general mosquito bites is topical antihistamines and over the counter steroid creams. Hymenoptera order (bees, wasps, and hornets): Distributed throughout the US, and can also live in the ground. Bees lose their stinger during a sting. Whereas wasps do not and can sting multiple times. Typically stings are just localized for symptoms (pain and swelling) but can become anaphylactic. Treat with IM Epinephrine as the first line. Consider bronchodilators from bronchospasms. Multiple stings (around ~100), can cause end organ damage and rhabdomyolysis outside of just anaphylaxis alone. Require more aggressive management. Fire Ants: Behave similar to bees (in swarm mentality), but have differing venoms. Can also cause global symptoms. Black Widow: No deaths from Latrodectus hesperus (Western Black Widow) recorded in the United States. There are 3 deaths globally from widow species. Two from Madagascar, and one from a Mediterranean species of widow. Debate in the toxicology community about use of the antivenom, which may account for more deaths than the bite itself. Black Widow bites are typically painful. Which is different from bites from recluse species. Brown Recluse: Rare in Colorado Typically painless bite, that creates a center necrotic eschar. Tend to also not be lethal. Bed Bugs Typically harmless and more of a nuisance to have. Can cause localized infections. Bite presents in a "Breakfast, Lunch, and Dinner" formation (i.e. linear 2-3 or more bites as the bug tracks and feeds on skin). Will feed primarily on exposed skin. The biggest concern is ensuring no cross contamination from patient to provider or facility. Bed bug bite delivers a small amount of local anesthetic, which can make them hard to detect. References Haskell MG, Langley RL. Animal-Encounter Fatalities, United States, 1999-2016: Cause of Death and Misreporting. Public Health Rep. 2020;135(6):831-841. doi:10.1177/0033354920953211 Herness J, Snyder MJ, Newman RS. Arthropod Bites and Stings. AFP. 2022;106(2):137-147. GBD 2019 Snakebite Envenomation Collaborators. Global mortality of snakebite envenoming between 1990 and 2019. Nat Commun. 2022;13(1):6160. doi:10.1038/s41467-022-33627-9 Wei YL, Wu Z, Li RL, Tang F. Review of selected mosquito-borne diseases: arboviruses (dengue, chikungunya, Zika, West Nile, Japanese encephalitis, yellow fever) and parasitic diseases (malaria, lymphatic Filariasis). Front Public Health. 2025;13:1712094. doi:10.3389/fpubh.2025.1712094 Forsberg K, Sheats KJ, Blair JM, et al. Surveillance for Violent Deaths - National Violent Death Reporting System, 50 States, the District of Columbia, and Puerto Rico, 2022. MMWR Surveill Summ. 2025;74(5):1-42. doi:10.15585/mmwr.ss7405a1 Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf
June 29 · 3 min
Podcast 1010: First Pass Intubation Success
Contributor: Travis Barlock, MD Educational Pearls: First-pass success is critical to limit complications from apnea, hypoxia, and airway trauma. Complication rate for patients intubated on the first pass is 14% Complication rates increase to 47% after two attempts, 64% after three, and 71% after the fourth attempt How to improve likelihood of first-pass success: Use Video laryngoscopy (VL). VL increases chance of first-pass success to 85% from 71% Use a bougie, especially in patients with anatomically difficult or otherwise obstructed airways. The BEAM study cites a success rate in these patients of 96% with a bougie, compared to 82% without Use a Checklist mnemonic (SOAPME) Suction – On, ready, and within reach Oxygen – Patient is preoxygenated Adjuncts – Oral/nasal adjuncts and BVM ready Positioning - Patient positioned properly; consider obesity, using semi-Fowler/head-up positioning Medications – Rapid sequence intubation (RSI), sedation, vasopressor, and other medications prepared as necessary Equipment – Laryngoscope (blade), tube, bougie/stylet, syringe, scalpel/cric kit, others ready as necessary References Sakles, J.C., Chiu, S., Mosier, J., Walker, C. and Stolz, U. (2013), The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. Acad Emerg Med, 20: 71-78. https://doi.org/10.1111/acem.12055 Prekker ME, Driver BE, Trent SA, et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. New England Journal of Medicine. 2023;389(5). doi:https://doi.org/10.1056/nejmoa2301601 Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179–2189. doi:10.1001/jama.2018.6496 ‌Turner JS, Bucca AW, Propst SL, et al. Association of Checklist Use in Endotracheal Intubation With Clinically Important Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(7):e209278. doi:10.1001/jamanetworkopen.2020.9278 Turner, Joseph S et al. "Feasibility of upright patient positioning and intubation success rates At two academic EDs." The American journal of emergency medicine vol. 35,7 (2017): 986-992. doi:10.1016/j.ajem.2017.02.011 Summarized by Sam Pahl | Edited by Sam Pahl & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf
June 22 · 35 min
On the Streets- Zero to Rodeo
Dan Orbidan, OMS-II and Dr. Travis Barlock, MD discuss a real out of hospital call. This episode covers the implications of a pharmacologically abnormal patient presentation and the pre and post hospital considerations for patient management and care.
June 15 · 36 min
Carepoint Journal Club- Neurology
Carepoint Journal Club is a quarterly series with discussions about a medical topic, brought to you by Carepoint's Emergency Physicians.
June 8 · 1 min
Podcast 1009: Prevention for Recurrent UTI
Contributor: Aaron Lessen, MD Educational Pearls: UTIs are commonly seen in older women We often see them taking long-term prophylactic antibiotics because of common recurrence. Around 20-30% of older women who develop a UTI have a recurrence due to either diagnostic failure, treatment failure or non-compliance with treatment. UTI signs and symptoms Burning sensation when urinating Strong urge to urinate Urinating often and passing small amounts of urine. Pelvic pain There are currently more guidelines and studies on treatments to prevent these recurrent UTIs in women that we can start in the Emergency Department. Vaginal estrogen has been shown to significantly reduce this issue of recurrence. Very simple prescriptions can be prescribed in the ED It has little systemic absorption and is generally very safe and effective. References Wells BA, De EJB, Visingardi J, Feustel PJ. IP15-36 IMPACT OF VAGINAL ESTROGEN ON SERIOUS ADVERSE OUTCOMES IN POSTMENOPAUSAL WOMEN WITH RECURRENT URINARY TRACT INFECTIONS: A RETROSPECTIVE STUDY. Journal of Urology [Internet]. 2025 May 1;213(5S):e778. Available from: https://doi.org/10.1097/01.JU.0001109984.67114.74.36 Ackerman AL, Bradley M, D'Anci KE, Hickling D, Kim SK, Kirkby E. Updates to Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2025). J Urol. 0(0). doi: 10.1097/JU.0000000000004723 Kaufman MR, Ackerman LA, Amin KA, et al. The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause. J Urol. 0(0). doi:10.1097/JU.0000000000004589 Meister MR, Wang C, Lowder JL, Mysorekar IU. Vaginal Estrogen Therapy Is Associated With Decreased Inflammatory Response in Postmenopausal Women With Recurrent Urinary Tract Infections. Female Pelvic Med Reconstr Surg. 2021 Jan 1;27(1):e39-e44. doi: 10.1097/SPV.0000000000000790. PMID: 31725016; PMCID: PMC7737516. Nazarko L. Recurrent lower urinary tract infection in older women [Internet]. Urology & Continence Care Today. Available from: https://www.ucc-today.com/journals/issue/launch-edition/article/recurrent-lower-urinary-tract-infection-in-older-women-ucct Summarized by Aaryn David & Ahmed Abdel-Hafiz | Edited by Aaryn David & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf
June 1 · 2 min
Podcast 1008: Acupuncture for Low Back Pain in Older Adults
Contributor: Aaron Lessen, MD Educational Pearls: Back pain is a common presenting complaint in the emergency department. Challenges arise when tailoring care to elderly populations using standard medical therapy: Muscle relaxants carry the risk of CNS depression or anticholinergic effects such as urinary retention and confusion. Pain medications such as opiates have side effects including constipation, respiratory depression, and hypotension. NSAIDs carry a risk of GI bleeding and worsening kidney function with chronic use. A randomized clinical trial assessing the effects of acupuncture on low back pain took 800 adults aged 65 and older with chronic low back pain and placed them into one of three treatment arms: Usual medical care Standard acupuncture consisting of 8–15 treatment sessions over 12 weeks, plus usual medical care Standard acupuncture consisting of 8–15 treatment sessions over 12 weeks, plus 4-6 maintenance sessions during the next 12 weeks, plus usual medical care Using the Roland-Morris Disability Questionnaire (RMDQ) score, they assessed disability at 6 months and 12 months. The study found that those who had undergone treatment with acupuncture had significantly greater improvements in disability related to low back pain compared to the group that was only treated with usual medical care. Acupuncture is not used in the ER, but could represent a relatively safe adjunctive therapy for patients who are not responding to standard medical therapy alone. References: American College of Surgeons Committee on Trauma. Best practices guidelines: geriatric trauma management. American College of Surgeons; 2023. Accessed May 27, 2026. https://www.facs.org/media/ubyj2ubl/best-practices-guidelines-geriatric-trauma.pdf DeBar LL, Wellman RD, Justice M, et al. Acupuncture for chronic low back pain in older adults: a randomized clinical trial. JAMA Netw Open. 2025;8(9):e2531348. doi:10.1001/jamanetworkopen.2025.31348 Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P
May 25 · 4 min
Podcast 1007: Caffeine Pharmacology
Contributor: Travis Barlock, MD Educational Pearls: Caffeine Geography and Types: Caffeine is found throughout the world and has evolved independently in various plants that are not evolutionarily related through direct lineage, but rather demonstrate convergent evolution (i.e. different species evolve the same traits). These plants use caffeine as an insecticide. Examples of caffeine sources include coffee, tea, yerba-mate, guaraná, cacao, and yaupon holly. Roughly 85% of Americans are estimated to consume caffeine daily. Caffeine Pharmacology in Humans: In humans, caffeine is a nonselective competitive antagonist (blocker) of adenosine receptors (A1 and A2A). During waking hours, neuronal metabolic activity consumes ATP, and a byproduct of ATP hydrolysis is created: adenosine. Adenosine proceeds to build a "sleep pressure". Acting on A1 and A2A adenosine receptors to induce sleep (on A1, it suppresses neuronal "wakefulness" and on A2A it is believed to be an inducer of sleep). Caffeine, by blocking those receptors, blunts sleep induction and feelings of being tired. Caffeine has a half-life of around 6 hours, and a quarter life of approximately 12 hours, which is when the caffeine will off-load and adenosine can once again occupy those receptors, potentially causing a "crash". Thus, for shift-workers, it is important to time caffeine intake roughly 10 hours before target bed time. Caffeine exerts other effects on the body. It is methylxanthine similar to theophylline, which works as a bronchodilator (via phosphodiesterase and adenosine pathways). Caffeine has clinical use to promote bronchodilation in pre-term infants. Caffeine exerts diuretic effects as well (blocking proximal renal tubule reabsorption). Recent ingestion of caffeine may blunt therapeutic use of adenosine in patients with SVT. Key Takeaway? Caffeine exerts a wide variety of effects beyond making us feel more awake. It has cardiovascular, pulmonary, and renal implications in its pharmacodynamics. References Benarroch EE. Adenosine and its receptors: multiple modulatory functions and potential therapeutic targets for neurologic disease. Neurology. 2008;70(3):231-236. doi:10.1212/01.wnl.0000297939.18236.ec Mitchell DC, Knight CA, Hockenberry J, Teplansky R, Hartman TJ. Beverage caffeine intakes in the U.S. Food Chem Toxicol. 2014;63:136-142. doi:10.1016/j.fct.2013.10.042 Bruschettini M, Brattström P, Russo C, Onland W, Davis PG, Soll R. Caffeine dosing regimens in preterm infants with or at risk for apnea of prematurity - Bruschettini, M - 2023 | Cochrane Library. Accessed May 23, 2026. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013873.pub2/full?cookiesEnabled Huang R, O'Donnell AJ, Barboline JJ, Barkman TJ. Convergent evolution of caffeine in plants by co-option of exapted ancestral enzymes. Proc Natl Acad Sci U S A. 2016;113(38):10613-10618. doi:10.1073/pnas.1602575113 Cabalag MS, Taylor DM, Knott JC, Buntine P, Smit D, Meyer A. Recent caffeine ingestion reduces adenosine efficacy in the treatment of paroxysmal supraventricular tachycardia. Acad Emerg Med. 2010;17(1):44-49. doi:10.1111/j.1553-2712.2009.00616.x Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf

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