SMACC and the power of FOAM

I have just had the pleasure of attending the SMACC (Social Media And Critical Care) conference in Sydney – wow!

Any thoughts that this conference was going to be the same as many college scientific meetings were rapidly dispelled when the (alleged) ‘welcome’ speaker, who was delivering a tedious stuttering analysis of statistical irreleventia was picked up and thrown from the stage (with his lectern) by a masked wrestler wearing the SMACC logo.


Another one bites the dust! Photo from

From the first sessions of the conference it became rapidly apparent that most of the audience were far more Twitter-literate than I was. At first I thought it was a sign of rudeness that over half the audience were tapping away on various mobile devices while speakers were delivering their talks; I then realized that most of the activity was people sending out ‘tweets’.

Each person was tweeting to several hundred people at once.

Tweets contained the speaker’s key ‘take home messages’ and pearls of wisdom, complete with pictures, slides, and links to resources.

It dawned on me that this was instantaneous dissemination of cutting-edge medical information and ideas across oceans and borders.

(plus, of course, the presumably drunken tweet from the Gala Dinner: “F@#$ yeah! This vegan dinner is the s#!t!”)

AucklandHEMS in action: Chris Denny competing in Sonowars

AucklandHEMS in action: Chris Denny competing in Sonowars

The power of social media for medical use was brought home to me in a talk delivered by Minh Le Cong about airway management.

He played a video of a recent intubation he performed in the retrieval setting., involving a combative patient with a predicted difficult airway, hypoxia despite high flow oxygen via a non-rebreather, and bilateral pneumonia.

This is the sort of clinical scenario that gives acute care doctors and paramedics nightmares, but Minh navigated it successfully with a delayed sequence intubation (premedication with fentanyl allowing enough behavioral control to pre-oxygenate), pre-oxygenation with BiPAP instead of a traditional BVM, providing apneic ventilation with nasal cannulae during the period of paralysis, and placing a Fast-Track (an intubating LMA device) prior to passing a tube through it.

Some of the key elements of airway management listed above have been disseminated largely through social media over the last year. They have been blogged, tweeted, podcasted, vodcasted, and facebooked – not just the techniques themselves but people’s experiences, cautions, and refinements. The end result is that changes in practice have occurred in a timeframe that five years ago would not have been possible. Relying on traditional media (peer-reviewed journals and textbooks) places the timescale for changes in clinical practice into years.

Scott Weingart explains why patients drop their blood pressure once anaesthetised

Scott Weingart explains why patients drop their blood pressure once anaesthetised

Clearly there are risks associated with this sort of process. The internet represents pure anarchy when it comes to information dissemination, and it would be very easy for dangerous misinformation to be presented as gospel, aided by slick-looking multimedia pieces (have a look at some of the NZ anti-immunization websites if you want to see misinformation presented in a nice-looking pseudo-scientific form!). A considerable proportion of the conference involved discussions around ways dealing with the uncontrolled nature of FOAM (free open-access meducation) via social media – whether regulation and oversight is needed, how to deal with disputes and misinformation, and how academic colleges (which rely heavily on  preset curriculums and traditional media).

The answers to these questions are far from clear.

Having spent the SMACC conference observing the power of social media (specifically for FOAM), I came to the following conclusions:

1)   Social media for FOAM is tremendously powerful, and it is here to stay. We should embrace it as a teaching tool.

2) The power of FOAM lies in the ability to transmit not just medical information, but EXPERIENCE – i.e valuable lessons that you would otherwise learn the hard way in resus or on the road.

3)   Although there are risks in using FOAM, the benefits vastly outweigh them.

4)   There is a moral (but possibly not legal) responsibility on the part of someone producing/disseminating FOAM material to ensure that it is as accurate as possible.

5)   The legal responsibility for translating FOAM material into clinical care ultimately lies with the clinician who provides care to the patient

Conclusion 5 is potentially vexatious for clinicians – how do we know what is valid/safe and what is not? Stating “I got this technique from a blog’ is not a defence in the setting of a medicolegal disaster.

The way I have reconciled this is that before applying FOAM material in clinical care, I must make a judgement as to the safety of information, the validity (or otherwise), how and whether it applies to the patient in front of me, how to manage the risk, what the accepted standard of care (and the supporting evidence) is in similar situations, and whether my decision would be defensible in the event of a poor outcome.

Sounds like a complicated and risky process, doesn’t it?

It’s called the Art of Emergency Care, and whether FOAM is involved or not, we are ALREADY doing it every day.

FOAMing at the mouth

(an introduction to FOAM, for people who have no idea what I’m talking about)


The rise of the internet over the last 20 years has had a profound impact on both practice and education in medicine. Working in the ED, there is not a shift that goes by without my consulting The Oracle to look something up (usually something that I once knew but have long since forgotten).

Medical material on the internet previously consisted mostly of static web pages and images akin to online reference texts (quality variable!) Now, with widespread access to high speed internet services and newer internet-based forms of communication and information dissemination (twitter, facebook, youtube, podcasts….), the store of medical information on the internet has expanded rapidly. More importantly however, multiple means of communicating online AROUND medical information have led to an international explosion of collaboration on knowledge and ideas. This phenomenon has become known as FOAM (free open-access meducation).

The term FOAM was apparently coined over a pint of Guinness in Dublin in 2012. Surprisingly the people who came up with the idea managed to remember it until the morning, and FOAM has become the term that ties together multiple online sources of medical education. Life In The Fast Lane have a great page describing FOAM here, and describe it thus:

FOAM resources are sophisticated, cutting edge learning resources that enable clinicians and students to update their knowledge and improve their understanding in a fun, motivating and time efficient way. It is all free, and can be accessed by anyone, at anytime, anywhere. We believe that together with asynchronous learning and the flipped classroom, FOAM is the future of medical education and lifelong learning

I am a relative neophyte when it comes to FOAM, having heard the term only since setting up this site (late 2012) and scouring the internet looking for resources that may be helpful for our service.

What has struck me about FOAM is how powerful it is at rapidly promoting, refining, and disseminating knowledge that changes practice.

This landmark paper by Richard Levitan and Scott Weingart was published in the Annals of Emergency Medicine in 2012. It provides a superb review of evidence around preventing desaturation during ED airway management, and contains multiple practical (and evidence-based) tips, as well as introducing some lesser known but highly effective concepts like apnoeic ventilation.

While changes in practice would be expected to result from the publication of a landmark paper in a respected and widely circulated journal, FOAM allows even faster dissemination    of knowledge worldwide. Scott Weingart’s podcast, for example, is downloaded by over 100000 people per episode! The techniques described in the paper above are already being used on a daily basis in the Auckland ED, and are equally relevant to our pre-hospital airway management.

Such a rapid evolution in clinical practice would not be possible without FOAM. Changes of practice that rely on textbooks and journals require a timeframe of years rather than weeks or months. FOAM allows people to learn in a time and manner of their choosing.

FOAM also allows people to add their own personal perspectives and stories to medical educational material. Much of the training performed by Auckland HEMS involves airways (RSI being arguably the most important technical skill the addition of doctors to the helicopter has provided). As such I have read, listened to, and scrounged a lot of FOAM resources regarding airway management for this site. With surgical airways in particular, FOAM has provided me with the following pearls that I would probably never have found in a text or journal:

  • announcing loudly “I can’t intubate, I, cant ventilate, I am doing a surgical airway” is a great technique for honing the focus of the team and getting everyone ‘on the same page’ (and it sounds a but more professional than ‘F$@#’)
  • there is a lot of bleeding during a surgical cricothyroidotomy – so much so that some people have abandoned the procedure! Be prepared for this
  • when performing a needle cricothyroidotomy, setups involving syringes/3 way taps/ETT connectors are not necessary – have a look at this!

Snippets of information like these could make the difference between a good outcome and  death in the event of a failed airway – and yet the chances of finding them outside a FOAM format are probably pretty small. Many thanks to Minh Le Cong and Scott Weingart!

To quote Joe Lex (a highly respected emergency medicine educator):

“If you want to know how we practiced medicine 5 years ago, read a textbook.

If you want to know how we practiced medicine 2 years ago, read a journal.

If you want to know how we practice medicine now, go to a conference.

If you want to know how we will practice medicine in the future, listen in the hallways and use FOAM.”

If you wish to learn more about FOAM, this page is a great place to start.

This is a talk about FOAM by Mike Cadogan at ICEM in 2012:

Plus, of course, SMACC is less than a month away…