Justin Morgenstern

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

Don't get BiTEn by bispecific T-cell engagers

This novel class of oncology drugs has 2 time sensitive, life threatening complications that emergency clinicians must know #FOAMed

Research Roundup – January 2026 The big paper of the month: ketamine vs etomidate for RSI Casey JD, Seitz KP, Driver BE, et al. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2025 Dec 9. doi: 10.1056/NEJMoa2511420. Epub ahead of print. PMID: 41369227 On its face, this is a fairly simple pragmatic RCT comparing etomidate to ketamine as the induction agent in critically ill adults.

Research Roundup – January 2026

The big paper of the month: ketamine vs etomidate for RSI Casey JD, Seitz KP, Driver BE, et al. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2025 Dec 9. doi: 10.1056/NEJMoa2511420. Epub ahead of print. PMID: 41369227 On its…

Vernakalant: shockingly fast without the shock? There are many different approaches to stable patients with atrial fibrillation who present to the emergency department. Personally, I have leaned towards electrical cardioversion over chemical cardioversion in patients in whom cardioversion is appropriate. In the places I work, it is usually faster and easier to get a patient sedated and electrically cardioverted than to wait for drugs to work. However, that is largely because procainamide (the best current best option) is not actually that effective, and is well known for its adverse effects.

Vernakalant: shockingly fast without the shock?

There are many different approaches to stable patients with atrial fibrillation who present to the emergency department. Personally, I have leaned towards electrical cardioversion over chemical cardioversion in patients in whom cardioversion is…

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

Calciphylaxis

In the Rapid Review series, I briefly review the key points of a clinical review paper (which often extends to multiple papers because I can’t help myself). The topic this time: Calciphylaxis The papers: Nigwekar SU, Thadhani R, Brandenburg VM. Calciphylaxis. N Engl J Med. 2018 May…

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

Has etomidate been killing people?
Does ketamine cause cardiovascular collapse?
Does the RSI trial settle these questions??
#FOAMed

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

Does coffee lead to atrial fibrillation | The DECAF trial

You are at a conference. You had 1 glass of wine too many last night, so you had to add an extra coffee to get moving this morning. Then you feel a slight flutter in your chest. Caffeine is a stimulant, right? Could it be causing atrial…

Every day until Christmas, we're sharing a newly coined word from @drmattmorgan.bsky.social's medical lexicon

Some are thoughtful. Some are quietly humorous.

Today's word is Hospibrew: The distinctive hospital smell of equal parts reheated food and human waste
www.bmj.com/content/391/...

Research Roundup – December 2025

The December 2025 FIrst10EM Research Roundup
Get your #FOAMed #EBM fix with septic shock, bad data, contrast allergies, and even some rhinoceros pulmonary physiology

Under Trump, America is committing war crimes. But under Biden, there were irritating student protests at a college I did not attend. I have never felt more politically homeless.

BroomeDocs podcast December 2025 YouTube video by First10EM

The BroomeDocs First10EM JournalClub is out now on YouTube
www.youtube.com/watch?v=tk3o... @broomedocs.bsky.social

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

Sweet’s Syndrome (aka acute febrile neutrophilic dermatosis)

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

Thank goodness for noise cancelling headphones and Rage Against the Machine

When the parents in your kid's drama class strike up a conversation:
"We don't do flu shots"
"I found someone who will sell me homeopathic pellets"
"When I took an extra Tylenol, I got liver pain, so I know this is safer"
"Like, I don't know much about homeopathy, but it definitely works"

would not start antihypertensives.

would discharge home immediately (it doesn’t seem like this admission is even indicated?)

outpatient followup

honestly this guy needs good outpatient management, not a fancy hospitalization that will be super expensive

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

I predict this will not be enough to convince some people:

285 studies
132 million people in real-world data
157,414 in randomized trials
~80% reduction in cervical cancer when given before age 16
No increase in serious adverse events @drjengunter.bsky.social

www.eurekalert.org/news-release...

“I have been using a combination of cap refill and MAP since the original ANDROMEDA SHOCK paper”

Justin explores the many limitations of this trial but then admits that he does use CRT as a resus target.

I fundamentally agree.

Implementing imperfect data into practice is complicated. #EMIMCC

Not so fast with the capillary refill guided resuscitation (ANDROMEDA-SHOCK-2) As far as I can tell, despite talking about the paper widely at conferences, I never included a write up of the original ANDROMEDA-SHOCK trial on First10EM. (Hernández 2019) (There is a massive file of all the topics I want to cover, and would cover if this was a job rather than a hobby. I assume it just got lost in there.) As a reminder, that trial showed that clinical management of septic shock patients based on capillary refill time was not statistically different from management guided by trending lactates, although there was some optimism because the point estimate for all cause mortality was actually 9% better.

Not so fast with the capillary refill guided resuscitation (ANDROMEDA-SHOCK-2) #FOAMed

💯💯 From my viewpoint in critical care the primary risk of the steroid protocol is (as I think you stated) diagnostic delays

Every year we see several people who are seriously harmed by diagnostic failures 2/2 irrational fears of CT scans

If you're critically ill we really need to know why, ASAP

Agree
Decided not to be too critical of their math logic there, if it gets us to the point where we can abandon these steroid protocols
The NNT for benefit here is also probably just as made up

Contrast may cause anaphylacTOID reactions (not anaphyLAXIS)

(anaphylactoid rxns = angry mast cells spit out histamine; usually less severe than anaphylaxis)

Canadian guidelines: don't pre-treatment w/ steroid, give antihistamine

This makes physiological sense!

Thank you science! #1/3. #EMIMCC

Steroids are OUT for CT contrast allergy YouTube video by First10EM

Stop using steroids to pretreat CT contrast allergy
youtube.com/watch?v=h2Hv...

Stop using steroids to pretreat contrast allergy! (CAR/CSACI Practice Guidance for Contrast Media Hypersensitivity) I have spent a lot of time summarizing the evidence and trying to dispel myths when it comes to contrast and kidney injury. (Bottom line: we have massive amounts of evidence, and in controlled studies with modern contrast agents, we cannot find even the smallest hint of harm from contrast.) However, there is another persistent aggravation when it comes to ordering contrast CTs: allergies and arcane allergy protocols.

Stop using steroids to pretreat contrast allergy!
The CAR/CSACI Practice Guidance for Contrast Media Hypersensitivity #FOAMed

Research Roundup (October 2025) There are, I think, some very interesting papers this time around. Physicians vs AI: ECG edition 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.

Research Roundup (October 2025)

There are, I think, some very interesting papers this time around. Physicians vs AI: ECG edition 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.…

Antibiotics: less is more? Why do so many antibiotics get prescribed for a week? Is there something special about 7 days of therapy? Would we ever use the number 7 in any other context? The courses of antibiotics we prescribe are clearly not scientific, which has always made the lecture that patients receive about finishing their entire course of antibiotics sounds pretty stupid. Thankfully, a lot of attention has been paid to shortening antibiotic courses over the last few years.

Less is more when it comes to antibiotics. If you are still counselling your patients to take their full course, stop.

Amyloid-related imaging abnormalities: an emergency medicine nightmare? If you had asked me 5 years ago whether a disease modifying agent for Alzheimer’s disease would be developed, I would have laughed. “Moonshot; million to one; when pigs can fly”. Seems like I am as good at predicting the future as I am at hitting a golf ball. Although there is some debate about their true benefit, such therapies now exist, in the form of anti-amyloid monoclonal antibodies.

Amyloid-related imaging abnormalities: an emergency medicine nightmare?

If you had asked me 5 years ago whether a disease modifying agent for Alzheimer’s disease would be developed, I would have laughed. “Moonshot; million to one; when pigs can fly”. Seems like I am as good at predicting the…

The First10EM Research Roundup for September 2025 It has been a while since I have critically appraised. Life without medical journals is sort of nice, but I guess it just isn’t me, so I am back and nerdier than ever. That means there are some strange selections this time around, but there are bound to be at least a few people out there that find these papers as fascinating as I do.

The First10EM Research Roundup for September 2025

It has been a while since I have critically appraised. Life without medical journals is sort of nice, but I guess it just isn’t me, so I am back and nerdier than ever. That means there are some strange selections this time around, but there are…

The continuing quest to treat numbers, not patients (OPTRESS) Might elderly patients, with a higher risk of undiagnosed hypertension and higher rates of vascular disease, require higher blood pressure targets in sepsis? Or might this just be yet another example of medicine doing harm in the quest of better numbers on a monitor?

The continuing quest to treat numbers, not patients (OPTRESS) #FOAMed

In a beautiful park, by the ocean, on a sunny day, with my boy

Remember why you do what you do

The First10EM wrap-up for Spring 2025 The First10EM monthly wrap up is a place for me to share updates about the website, about my academic life, and also interesting content, such as books, podcasts, and other FOAMed, that I have encountered in the prior month. First, I have obviously been on a bit of a hiatus. I haven’t published anything since April, and I also took a pretty long break in January and February.

The First10EM wrap-up: Updates on the website, interesting media, good FOAMed, and random thoughts

If interested in ketamine for status, great debate emcrit.org/emcrit/ketam...
@first10em.bsky.social vs @emcrit.bsky.social #EMIMCC