The future funding of FOAM

Free Open Access Medical Education or FOAM has been free to users and producers largely due to the generosity of this man


the Godfather of FOAM, Mike Cadogan.

When I last spoke to him over a year ago, he was pouring over $75,000 a year of his own money to pay for technical support, Word Press fees and bandwidth to make FOAM happen.

A lot of us, me included (probably one of the narcissists he refers to), have taken this philanthropy for granted.

I have recently looked to getting funding from my employer to start another FOAM project, thus not putting more financial burden on Mike, but was quite happy to let him keep funding this website, leaving me only paying US$ 20/month for the audio hosting.

In the last few days we have had a wake up call from Mike in his post 5 Lessons Learned  This post is partly about self-care, valuing real life family and friends over a virtual life, and saying no, but it is also about the financial cost of FOAM.

We the FOAM producers need to find alternative, sustainable funding streams for FOAM.  I’m sure many already are eg EMCRIT’s CME option. Others of us need to obtain funding.  5 years from creation, FOAM has proved itself as one of, if not the of the best forms of medical education and practice improvement.  Now we need to get our employers and institutions to recognise this and fund FOAM.

We each need to go to our employers and say FOAM is the best thing in Continuous Quality Improvement (or what ever the latest buzz word is) since sliced bread and they need to contribute to it.

I have asked The Frontier Group, who provides a lot of the technical support for FOAM, for the true monetary cost of EM Tutorials (and for my next FOAM project), and I have started negotiations with my employer to get it to pay those costs.

In New Zealand each District Health Board gets tens of thousands of dollars a year per junior doctor of government funding for training.  This money largely just disappears into the hospitals’ coffers.  We need to claim some or all of that money and actually use it for education.  I’ve started negotiations at my hospital to have at least a good chunk of this money ring-fenced for education, managed by an education committee, and some of that will go to funding this website and podcast.

I suggest other FOAM producers start similar negotiations with their employers so that there is Learning and Development money  being used to ensure the amazing educational resource, that Mike has largely created and funded himself, is sustainable without draining his pocket anymore.






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Trauma: Lessons from the Military. Wing Commander Dr Paul Nealis



Key points

Stop bleeding!

Tourniquets are great.

Pack bleeding wounds firmly.  A roll of gauze works well. “Haemostatic dressings” eg quik clot, don’t seem to make much difference.  It appears the pack needs to be absorbent probably because they absorb water out of the blood in the wound thereby increasing the concentration of clotting factors.

Don’t get hung up on big IV lines.  The difference in flow rate between a 18 and 16 gauge is not that great.  If the patient is bleeding out that fast they aint going to make it, and sometimes 18s are just easier to get in especially in a shocked patient.

Permissive hypotension: aim for a systolic of 80 (90 if head injury).  Don’t rely on mental status (BP 60 systolic but compensating and still conscious… 60 and compensating  still conscious …. 60 and still conscious … dead).

For massive haemorrhage transfuse and give tranexamic acid early.  For us this may mean sending an “unknown patient” label down to get some O-negative blood from the lab before the patient arrives.  Get FFP thawing ASAP. Get platelets ASAP.

Use ketamine rather than fentanyl in major trauma -> lives saved,  presumably by avoiding the sympatholytic effects of fentanyl

Ketamine appears to reduce the incidence of Post Traumatic Stress Disorder by 60%!  This may be by reducing the patients’ experience of pain and mutilation.

ED teams (in the military ED docs and nurses and military medics) resuscitate the patient, others behind the red line.  When the external bleeding has been stopped and the patient resuscitated, then the anaesthetist and surgeon are invited to take the patient to theatre/operating room

Some of the slides:

Audio only:

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Disaster Medicine. Wing Commander Dr Paul Nealis

Be prepared.

Be prepared for the unexpected, logistical challenges, politics and politicians, strange infections, psychological stress,  Aussie docs not recognising melioidosis and a mysterious man in a Hawaiian shirt … with a small fleet of Black Hawk helicopters.

You need to be flexible, creative and psychologically tough.

Military doctor Paul Nealis discusses disaster medicine in the context of the 2004 Boxing Day tsunami in Sumatra.






Audio only


To volunteer:

NZ Medical Assistance Team

Australian Medical Assistance Teams (AUSMAT)

This presentation may not reflect the views of the NZ Ministry of Defence

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Anaesthetising and shocking an 89-year-old

About once a year I get to cardiovert a nonagenarian.  There are a lot of good learning points from a case like this and I used a different anaesthetic from earlier posts (see Salvage Cardioversion of a Surgical Patient and Fast AF)

The case

This one was a sprightly 89-year-old (near enough to a nonagenraian) who had developed chest pain and a rapid palpitation after an afternoon at the beach with family.

She had had a few episodes of AF before, that last about 5 months ago, and she was conveniently on warfarin due to this.  She was very clear that her heart rhythm had been regular for the last several months.  She had a history of hypertension and congestive heart failure but was not on any diuretics.

Her pain had settled and her blood pressure was high normal in ED and she had no signs of failure.   No other precipitatant for her fast AF was found (eg fever, hypovolaemia).

We were debating the pros and cons of wait-and-see vs rate control vs chemical or electrical cardioversion.

Her rate was 160 so I keen to convert or slow.

As this patient was warfarinised the time of onset of AF was less important, for patient with normal coagulation we don’t want to cardiovert if the atrial fibrillation has been going for ore than 72 hours for fear of throwing off a thrombus from the quivering atria.  In these patients we want to rate control rather than chemically (eg procainamide or amiodarone) or electrically cardioverting.

While we debating the options between ourselves and with the patient she developed 9/10 chest pain again so the decision was made for us.

We gave her 50µg (~ 1µg/kg) of fentanyl with no effect on the pain.

It was time for electricity.

The Procedure

We obtained a written request for treatment and anaesthesia (AKA consent) from the patient.  (By the way we were not going to “sedate” this patient.  “Procedural Sedation” is an old lie from when we were trying to pretend we weren’t doing anaesthetics in ED.  We are anaesthetising people – call it anaesthesia)

The patient was given oxygen by nasal prongs and “non-rebreather” mask.  All airway equipment was prepared including having all RSI drugs at the bedside, including a pressor (eg adrenaline and/or phenylephrine), the right size intubating LMA, OPAs, NPAs and a ETT out on the airway trolley (have it there and you won’t need it, and it’s good practice for the team).

Monitoring was prepared including oximetry, BP set to go every 2.5 minutes and ECG.  Unfortunately we don’t use capnography due to cost for short procedural anaesthesia.

The patient was given 20mg of propofol and 20mg of ketamine IV. Also known as ketafol.



I had been wary of giving ketamine to a patient with tachycardia but Cliff Reid and others on Twitter have convinced me it won’t make the patient more tachycardic.  The ketamine is a great analgesic, maintains BP and airway reflexes but tends to make people puke and have bad trips.  The propofol is a great anaesthetic, tends to prevent nausea and bad trips but tends to drop BP.

We cranked the nasal prongs up to 10L a minute once she was dozing off.

The defib was set to 150J, maybe could have used less on a skinny old lady, and synchronised.  With one shock (remember to hold the shock button down for a while, it doesn’t fire straight away in synch mode) she was back to sinus rhythm.

The patient breathed spontaneously through out.  Her BP dipped to 88 systolic.  Her saturations stayed at 100%.  She did not remember being shocked.  She did have some vivid but not unpleasant dreams.

It was early evening.  We possibly could have got her home that night but her ECG was a little abnormal when she reverted (ST elevation in V1 and V2, probably just due to incomplete LBBB, but we had no old ECGs to compare with) and her family were understandably a little nervous about taking her home.  She was discharge from ED without incident the next morning.

So we can get away with tiny doses of anaesthetics, especially a combination of propofol and ketamine in the elderly with good results.

Remember the arm brain time is slower in the elderly.  Give it at least a minute before you start thinking about giving another bolus of anaesthetic.

Cautionary tale

Some colleagues of mine in a hospital far, far away, somewhere near the centre of Australia, had an elderly person with conscious VT and they rightly wanted to cardiovert her.  Unfortunately her veins were crap and they could only get a line in her foot.  They gave propofol, then more propofol, then a little bit more propofol and finally she went to sleep.  Then all the propofol finally made it to her heart and brain -> PEA.

They had the good sense to cardiovert her to sinus rhythm and do CPR until the propofol was metabolised and the patient woke up with no adverse effect.

Just remember that it can take a long time for drugs to get from a foot to the target organs, especially in a compromised elderly person.

Alternative anaesthetics

Mean while back in 2014 most junior doctors or paramedics are not allowed to give propofol unsupervised.  I’m sure this will change in time. In the mean time I would give one mg of midazolam, wait a few minutes and see if you needed another milligram.  When the patient is midly sedated give 20mg of ketamine as analgesia.  The combination should give excellent anaesthesia for a cardioversion, the patient will just take a bit longer to wake up from the midazolam than from propofol.

Another anaesthetic option is to use etomidate alone or etomidate and ketamine, though again etomidate usually requires supervision by a senior doctor.  Make sure you give an antiemetic as etomidate makes people puke too.


Ketafol image from:








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Oxy morons. Avoid prescribing oxycodone

It has been interesting moon-lighting at another hospital to see how much oxycodone (common brands names: oxynorm and oxycontin) was being used professionally and recreationally.

I was out with a friend who told me he had been given 1 1/2 oxycontin tabs by an acquaintance a while ago and had been high as a kite for a couple of days.  Interestingly he said there was no “come down”.  Sounds like a very desirable drug of abuse.

In the ED everyone was prescribing oxycodone to everybody, from the ED reg to the ENT reg to the ortho house officer.

“… we are looking at a disaster in the making. We have been complacent about the warnings from the rest of the western world, with harms arising from pharmaceutical opioids overtaking those from heroin. This has reached epic proportions in the United States, with oxycodone particularly over-represented. Pharmaceutical opioids in the United States now kill more people than firearms or road traffic accidents, and more than the combined death rates from heroin and cocaine overdoses. This is shocking and shameful …” Dr Jeremy McMinn* 

Oxycodone is more addictive and more expensive than morphine.

Oxycodone is no safer in renal failure than morphine.

Most people with morphine “allergy” were just given too much  and developed nausea, vomiting, dysphoria or an itchy rash from the histamine release caused by morphine.  It may be worth try a test dose of IV morphine to see if they can tolerate it, check with a senior first.

Generally in ED for analgesia we use paracetamol/acetaminophen and a NSAID such as ibuprofen.  For severe pain we will use a fast acting IV or IN opioid such as fentanyl to control the pain.  Once the pain is controlled if ongoing strong pain relief is required we will move to oral morphine (or IV if unable to take oral).  Oral morphine is available in fast acting and slow release forms.

In our hospital we have made oxycodone only able to be prescribed by order of a consultant, and I’m trying to have oxcodone removed from our ED.

As an aside, at the other hospital, as always, there was a granny who had bounced back into hospital because she had been discharged from the ortho ward on oxycodone, prescribed a bulk forming laxative but no stimulant laxative, and hadn’t crapped for a week and felt rotten.

It’s a shame that the resident who discharged her wasn’t working that weekend.  It would have been a good educational experience for him/her to come down, give the enema and readmit the patient.

This is a problem with all opioids, not just oxycodone.  Always prescribe a stimulant laxative when prescribing more than a few doses of opioids eg something with sennosides in it.  By the way sennosides are Category A (considered safe) in pregnancy.  Shame the resident wasn’t on that weekend.


*Dr Jeremy McMinn is a consultant psychiatrist and addiction specialist at Capital & Coast DHB. He is also the Co-Chair of the National Association of Opioid Treatment Providers and the New Zealand Branch Chair of the Australasian Chapter of Addiction Medicine






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