FOAMcast - An Emergency Medicine Podcast
256 episodes - English - Latest episode: 2 months ago - ★★★★★ - 222 ratingsWe believe in the educational merits of Free Open Access Medical education (FOAM), which includes podcasts, blogs, articles on PubMed Central, conferences streamed for free and more. As a result, we would like to encourage others to move beyond quoting podcasts and into the realm of tying “cutting edge” FOAM to the core content. We’ll provide some review and references for listeners to go read. Why, indeed, should we FOAM it alone when FOAM can inspire us to go, read, think, and be excellent?
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Episodes
COVIDcast: Surviving Sepsis SCCM Guidelines (3.20.20)
March 20, 2020 23:15 - 22 minutes - 40.9 MBWe interrupt our normal FOAMcast episodes to bring you updates from COVID-19, as literature develops. *Things change frequently and this may be out of date in days/weeks. So, check us* In this episode, we cover the Society of Critical Care Medicine, Surviving Sepsis Guidelines for COVID-19 Show notes: FOAMcast.org Thanks for listening, Lauren Westafer and Jeremy Faust
COVIDcast: Pregnancy, Breastfeeding, and Investigational Treatments 93.19.20)
March 20, 2020 10:32 - 20 minutes - 37.4 MBWe interrupt our normal FOAMcast episodes to bring you updates from COVID-19, as literature develops. *Things change frequently and this may be out of date in days/weeks. In this episode we review: guidance for pregnant and breastfeeding patients and healthcare workers experimental treatments that are all the craze: remdesivir, chloroquine, hydroxychloroquine, lopinavir-ritonavir Show notes: FOAMcast.org Thanks for listening! Lauren Westafer and Jeremy Faust
COVIDcast: Co-infections, Pediatrics, and Ibuprofen
March 19, 2020 12:27 - 13 minutes - 25.2 MBWe are going to try to bring you updates regarding COVID-19 on a regular basis. These podcasts will likely be out of date in a few days, so check back for updates. This episode features: Co-infections (extended respiratory panel positive and positive for Sars-CoV-20 Epidemiology of pediatric infections Ibuprofen and ACE-inhibitor use Recorded 3.18.20 Thanks for listening, Lauren Westafer and Jeremy Faust
Community Acquired Pneumonia
March 08, 2020 20:39 - 25 minutes - 34.8 MBWe review the evaluation and management of Community-Acquired Pneumonia (CAP) as well as the Infectious Disease Society of America (IDSA) / American Thoracic Society (ATS) 2019 guidelines for CAP. Shownotes and references at FOAMcast.org Thanks for listening! Jeremy Faust and Lauren Westafer
Top 5 Articles of 2019
February 01, 2020 01:17 - 27 minutes - 37.4 MBWe cover some top articles of 2019, including the following: Roc vs Sux: Guihard B et al. Effect of rocuronium vs succinylcholine on endotracheal intubation success rate among patients undergoing out-of-hospital rapid sequence intubation: A randomized clinical trial. JAMA 2019 Dec 17; 322:2303. (https://doi.org/10.1001/jama.2019.18254) Targeted Temperature Management after Cardiac Arrest: Lascarrou JB, Merdji H, Le gouge A, et al. Targeted Temperature Management for Cardiac Arrest with...
VITAMINS Trial - Vitamin C, Thiamine, and Hydrocortisone in Septic Shock
January 17, 2020 11:30 - 22 minutes - 30.4 MBThe VITAMINS trial by Fujii et al has been published in JAMA and provides insight into the performance of the "metabolic cocktail" (Vitamin C + thiamine + hydrocortisone) in ICU patients with septic shock. We review this trial in the context of prior literature. Show notes and references at FOAMcast.org Thanks for listening! Jeremy Faust and Lauren Westafer
ACEP Headache Clinical Policy
December 18, 2019 21:01 - 24 minutes - 34.2 MBWe review the American College of Emergency Physicians (ACEP) clinical policy on headache from June 2019, most of which revolves around the diagnosis of subarachnoid hemorrhage. Show notes and references at FOAMcast.org Thanks for listening! Jeremy Faust and Lauren Westafer
Olanzapine + Benzodiazepines - What is the FDA warning about?
October 29, 2019 11:10 - 21 minutes - 28.9 MBWe are at ACEP 2019 in Denver and do a deep dive on a topic introduced by Bryan Hayes (@PharmERToxGuy) in a talk on black boxed medications used in the ED. We review the data underlying the FDA warning for olanzapine and benzodiazepines. Thanks for listening! Jeremy Faust and Lauren Westafer
Black Box Warnings for Common ED Medications
October 29, 2019 02:49 - 8 minutes - 12.2 MBIn this episode covering the American College of Emergency Physicians (ACEP) 2019, we cover common black box warnings including fluoroquinolones midazolam droperidol NSAIDs and more Thanks for listening! Jeremy Faust and Lauren Westafer
Concussion and VP Shunts from ACEP 2019
October 27, 2019 23:36 - 18 minutes - 25.2 MBWe are at ACEP 2019 in Denver and cover pearls from interesting lectures. Today, that included concussion and VP shunts.
Vaping Associated Lung Injury (VALI)
October 11, 2019 18:31 - 22 minutes - 30.9 MBVaping associated lung injury (VALI) has become a frequent topic in the news in the United States (US). In this episode we review the epidemiology, presumed pathophysiology, and new recommendations from the Centers for Disease Control (CDC) in the US. Thanks for listening! Jeremy Faust and Lauren Westafer FOAMcast.org References: Morbidity and Mortality Weekly Report (MMWR). 2019; 68(40) Layden JE, Ghinai I, Pray I, et al. Pulmonary Illness Related to E-Cigarette Use in Illinois an...
Hyperkalemia Treatment - Insulin/Dextrose
September 30, 2019 13:08 - 24 minutes - 34.1 MBIn this episode we briefly review hyperkalemia and the principles of emergent treatment. Then we explore, in-depth, the role of insulin and dextrose including the incidence of hypoglycemia and pearls to reduce this side effect. Pearls: 10-20% of patients treated with insulin/dextrose for hyperkalemia get hypoglycemic Consider giving 5 units insulin instead of 10 units Check the glucose for hours (dextrose lasts <1 hr, insulin lasts ≥2 hours) Beware of insulin in patients with renal ...
Droperidol and Butyrophenones
September 01, 2019 15:55 - 23 minutes - 32.4 MBWe discuss the US Food & Drug Administration's black box warning for droperidol and the evidence behind this warning. We then discuss the use of butyrophenones such as droperidol and haloperidol for the treatment of agitation, headaches, nausea and vomiting, and gastroparesis/cannabinoid hyperemesis. Thanks for listening! Jeremy Faust and Lauren Westafer
Thromboelastography (TEG) Guided Resuscitation
July 31, 2019 21:13 - 22 minutes - 30.5 MBWe discuss the coagulation test thromboelastography (TEG) / Rotational Thromboelastometry (ROTEM), reviewing the evidence behind the use of the tests as well as the clinical implications. Show notes and graphics FOAMcast.org Thanks for listening! Jeremy Faust and Lauren Westafer
2019 Mid-Year Literature Review
July 09, 2019 15:02 - 26 minutes - 35.9 MBIn this episode, we discuss important and "hot" articles thus far in 2019. These articles include: Testing for pulmonary embolism in pregnant patients Van der pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 2019;380(12):1139-1149. Langlois E, Cusson-dufour C, Moumneh T, et al. Could the YEARS algorithm be used to exclude pulmonary embolism during pregnancy? Data from the CT-PE-pregnancy study. J Thro...
Psychogenic Non-epileptic Attacks (PNEA)
May 24, 2019 16:45 - 25 minutes - 34.4 MBWe review the entity formally known as pseudoseizures and psychogenic non-epileptic seizures (PNES), now referred to as psychogenic non-epileptic attacks (PNEA). We discuss the history of PNEA as well as relevant literature on the diagnosis and treatment of this entity. Thanks for listening! Jeremy Faust and Lauren Westafer
Emergent Issues in Sickle Cell Disease
April 30, 2019 18:26 - 27 minutes - 37.5 MBWe review myths and reality in the management of patients with Sickle Cell Disease (SCD) Are these patients typically opioid seeking? (No) If the patient appears comfortable I should withhold proper analgesia. (No). Should IV fluids be a routine part of the cocktail for vaso-occlusive pain episodes? (No) We also review common emergencies in sickle cell disease that include Infections Acute chest syndrome Anemia (Aplastic crisis, splenic sequestration) Ischemia Strokes Avas...
Mechanical CPR, Balloon Tamponade, and Advocacy
March 29, 2019 12:22 - 14 minutes - 25.9 MBWe are at #SMACC in Sydney, Australia, thanks to the Rosh Review, delivering updates from the conference to your earbuds. Advocacy in Emergency Medicine - Esther Choo and Hugh Montgomery Mechanical CPR vs Manual CPR - Ken Milne vs Salim Rezaie Super sick massive GI bleeds and balloon tamponade - Sara Gray Thanks for listening! Jeremy Faust and Lauren Westafer
Roc vs Sux, Bougie vs Stylet, The Crashing Asthmatic at #SMACC
March 28, 2019 06:51 - 16 minutes - 29.3 MBWe are at SMACC in Sydney, Australia, thanks to the Rosh Review, delivering updates from the conference to your earbuds. Today we cover resuscitation pearls. Bougie vs Standard Stylet in emergency department (ED) rapid sequence intubation (RSI) - Brian Driver vs Rich Levitan Rocuronium vs Succinylcholine Debate - Billy Mallon and Reuben Strayer The Crashing Asthmatic - Haney Mallemat Thanks for listening! Lauren Westafer and Jeremy Faust
anti-NMDA receptor encephalitis and communicating with patients at #smacc
March 27, 2019 08:32 - 10 minutes - 19 MBWe are at #smacc in Australia thanks to the Rosh Review! The opening session this morning was amazing and we can't do it justice on the podcast. Gill Hicks (@MadForPeace), a victim in the July 7, 2005 bombing attack on a London train spoke on how impactful everyone in the healthcare delivery system can be (from medics to detectives to nurses to physical therapists to physicians). Dr. Dara Kass delivered a powerful talk on vulnerability, responsibility, and lack of knowledge even in a super...
Emergency Medicine Updates - 2019
March 27, 2019 08:11 - 12 minutes - 23.1 MBWe co-hosted (with John Vassiliadis) the SMACC EM Updates half-day conference. We had amazing speakers. Salim Rezaie spoke on TXA for Everything, Ken Milne spoke on hot papers from 2018, and we learned about when ultrasound may be helpful in pediatric lumbar punctures. In addition, Jeremy spoke on what is usual care in sepsis and Lauren spoke on pulmonary embolism: the next generation. In this short podcast we highlight some of our other talks. Aidan Baron (@Aidan_Baron) on Prehospital Upd...
Supraventricular Tachycardia Treatment Controversies
February 18, 2019 07:16 - 28 minutes - 52.2 MBWe have previously podcasted on tachyarrythmias (Episode 34 Tachyarrhythmias), but in this episode, we focus specifically on the treatment of supraventricular tachycardia (SVT), specifically paroxysmal SVT. We discuss the treatment options of adenosine and calcium channel blockers, weighing in with the evidence, the guidelines, and some opinion. Thanks for listening! Lauren Westafer and Jeremy Faust Thanks to Figure 1 for supporting this episode. We do not make money off of thi...
Fluoroquinolones and Aortic Pathology
January 31, 2019 11:59 - 25 minutes - 47 MBThe US Food and Drug Administration (FDA) recently released another warning for fluoroquinolones, this time regarding aortic dissection and aneurysm. We review the evidence behind this warning, including the following studies: Lee CC Risk of Aortic Dissection and Aortic Aneurysm in Patients Taking Oral Fluoroquinolone. JAMA Intern Med. 2015;175(11):1839-47. Lee CC Oral Fluoroquinolone and the Risk of Aortic Dissection. J Am Coll Cardiol. 2018;72(12):1369-1378. Pasternak B Fluoroquino...
ACEP Non-ST Elevation Acute Coronary Syndrome Guidelines
December 27, 2018 19:12 - 31 minutes - 57.6 MBWe cover the clinical policy from the American College of Emergency Physicians - Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non–ST-Elevation Acute Coronary Syndromes In adult patients without evidence of ST-elevation acute coronary syndrome, can initial risk stratification be used to predict a low rate of 30-day major adverse cardiac events? Use HEART score ≤3 In adult patients with suspected acute non–ST-elevation a...
Medicated Assisted Treatment (MAT)
November 20, 2018 11:46 - 26 minutes - 49.2 MBWe discuss Medicated Assisted Treatment (MAT) for opioid use disorder (OUD) including buprenorphine initiated from the emergency department. This show was sponsored by Figure 1, a free open access application for providers using images and cases Thanks for listening! Jeremy Faust and Lauren Westafer References: Berg ML, Idrees U, Ding R, Nesbit SA, Liang HK, and McCarthy ML. Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department. Drug Alcohol Depend....
Magnesium
October 22, 2018 12:24 - 31 minutes - 57.6 MBThe Free Open Access Medical Education (FOAM) world is often obsessed with magnesium. In this show we address the use of magnesium for various applications. Magnesium for Acute Atrial Fibrillation with Rapid Ventricular Response (RVR) Bouida et al. LOw dose MAGnesium sulfate versus HIgh dose in the early management of rapid atrial fibrillation: randomised controlled double blind study. Acad Emerg Med. 2018 Jul 19. Ho KM, Sheridan DJ, Paterson T. Use of intravenous magnesium to treat ac...
2018 Literature Update
October 16, 2018 15:30 - 31 minutes - 57 MBIn this episode we highlight key articles in Emergency Medicine that came out, thus far, in 2018. D'souza et al. Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis Emerg Med J. 2018;35(5):325-331. Driver 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 Intuba...
Myths in imaging and pediatrics
October 03, 2018 21:14 - 11 minutes - 21.1 MBWe bring you pearls from the American College of Emergency Physicians (ACEP) 2018 Scientific Assembly in San Diego, CA. In this episode we highlight: Myths in diagnostic imaging Torsion ultrasound is insensitive CTPA for PE is not perfect. There are false positives AND false negatives Myths in pediatrics Response to antipyretics does NOT make viral infection more likely Juice in kids with gastroenteritis is a great way to rehydrate them Kids don't have to wait 24 hours on ant...
Errors in CYA Medicine and Biomarkers
October 03, 2018 00:07 - 15 minutes - 28.6 MBWe bring you pearls from the American College of Emergency Physicians (ACEP) 2018 Scientific Assembly in San Diego, CA. In this episode we highlight: Problems with CYA (Cover your a$$) medicine such as admissions Problems with lactate, procalcitonin, and other biomarkers Thanks for listening! Jeremy Faust and Lauren Westafer
severe pediatric head trauma, aortic dissection diagnostics, and chest tubes
October 01, 2018 22:15 - 17 minutes - 31.5 MBWe bring you pearls from the American College of Emergency Physicians (ACEP) 2018 Scientific Assembly in San Diego, CA. In this episode we highlight: Severe pediatric brain injury, tips for management and preventing badness Aortic dissection diagnostics Chest tube pearls Thanks for listening! Jeremy Faust and Lauren Westafer
Lyme (Borreliosis)
September 24, 2018 13:27 - 25 minutes - 45.8 MBWe cover a JAMA Clinical Reviews podcast on lyme disease, including some myth-busters. *Doxycycline can be used, safely, in kids < 8 years old *Testing for lyme is a mess because : (1) we test patients with ultra low probability of disease (2) we test patients who shouldn't be tested (i.e. have erythema migrans) (3) the tests are a pain to interpret *Lyme disease is spreading further south and west in the US, into Canada, and it's also increasingly found in Europe. We then delve into...
Penile Fracture and Priapism
August 27, 2018 19:31 - 25 minutes - 46.2 MBWe review the American Urological Association guidelines on penile fracture and priapism. We supplement this with core content from Tintinalli and Rosen's Emergency Medicine.
Corneal Emergencies
July 20, 2018 12:24 - 30 minutes - 55 MBWe review one of the editors top picks from Annals of Emergency Medicine, which are free for 6 months from issue release. The article covered in this podcast is Waldman et al, is a study of tetracaine in corneal abrasions. We also review commonly encountered corneal emergencies: Corneal abrasions Corneal ulcers and herpes keratoconjunctivitis. Thanks for listening! Jeremy Faust and Lauren Westafer
Clostridium difficile
June 18, 2018 06:32 - 24 minutes - 45.3 MBShow notes at FOAMcast.org We cover the 2017 IDSA/SHEA guidelines on clostridium difficile (c diff). We then review core content on c diff including risk stratification and treatment using Rosen's and Tintinalli as guides. Thanks for listening! Jeremy Faust and Lauren Westafer
ACEP Pulmonary Embolism Policy + Risk Stratifying PE
May 16, 2018 14:02 - 32 minutes - 59.4 MBWorkup for pulmonary embolism (PE) is common (perhaps too common) in the United States. The American College of Emergency Physicians has released a clinical policy on pulmonary embolism. We cover this policy as well as core content on PE risk stratification and "rule out" Thanks for listening, Jeremy Faust and Lauren Westafer
The Lactating Emergency Department Patient
May 01, 2018 01:30 - 20 minutes - 38 MBWe cover the emergency department care of lactating patients including Medications during breastfeeding - who should "pump and dump"? (spoiler: very few people, check LactMed or InfantRisk) Mastitis & Breast Abscesses Emergency Department Support Thanks for listening! Jeremy Faust and Lauren Westafer
The Faust-Westafer Central Theorem of Emergency MEdicine
April 01, 2018 04:00 - 12 minutes - 22 MBShow notes at FOAMcast.org We have a special April 1st show - the Faust-Westafer Central Theorem of Emergency Medicine. Listen for details Thanks for listening! Jeremy Faust and Lauren Westafer
Literature Update - 2017
March 21, 2018 22:36 - 28 minutes - 39.6 MBWe review select articles from 2017 that are important or that got people talking including: Sadeghirad B et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ. 2017;358:j3887. Barniol et al.Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial. Ann Emerg Med. 2018;71(1):125-131.e1 Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, ...
Episode 78 - Influenza
February 24, 2018 08:58 - 24 minutes - 33.4 MBWe tackle some free open access medical education from the CDC on the flu vaccine, including: Recommendations that individuals with any severity of egg allergy (including anaphylaxis) receive the flu vaccine. The only modification that needs to occur is patients with a history of true anaphylaxis to eggs should be given the flu shot in a setting where they can be monitored by a healthcare professional if needed (i.e. a doctor's office). It is very unlikely that the flu vaccine causes Guil...
Episode 77 - Alcohol Withdrawal
January 14, 2018 13:28 - 24 minutes - 34 MBOver at the Pulmcrit blog, Dr. Josh Farkas has proposed the use of phenobarbital monotherapy for the treatment of ethanol withdrawal and we cover this protocol. We then dive into core content alcohol withdrawal using Rosen’s Emergency Medicine (9th ed) Chapter 142 , Tintinalli’s Emergency Medicine (8th ed) Chapter 292, and Goldfrank's Toxicologic Emergencies (10th ed) Chapter 81 as guides. Thanks for listening, Lauren Westafer and Jeremy Faust
Episode 76 - Pneumoperitoneum, Gastritis, PUD
December 05, 2017 14:21 - 22 minutes - 30.4 MBWe discuss ultrasound diagnosis of pneumoperitoneum using a podcast from 5MinSono. Then we delve into core content on gastritis, PUD, and helicobacter pylori using Rosen's Ch 78 and Tintinalli's Ch 79 as guides. Thank for listening! Jeremy Faust and Lauren Westafer
Episode 75 - Mass Casualty Incidents
November 20, 2017 06:56 - 22 minutes - 30.5 MBWe cover Free Open Access Medical Education (FOAM) on mass casualty incidents, an unfortunate reality in the current United States climate (and elsewhere). There is a must read (truly, emergency providers really should read this) in EP Monthly by Dr.Kevin Menes, “How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass Shooting in U.S. History”. He details his process in running the Emergency Department that evening. We cover pearls from other great resources include a post on th...
ACEP 2017 - In flight emergencies, CT scans, and peds
November 04, 2017 17:48 - 14 minutes - 19.6 MBWe bring you pearls from the American College of Emergency Physicians (ACEP) 2017 Scientific Assembly. We cover in-flight emergencies, need for contrast enhanced CT scans, bronchiolitis and sucrose for infants Thanks for listening! Jeremy Faust and Lauren Westafer
ACEP 2017 - H. Pylori, Tox, and Zika
October 30, 2017 22:02 - 13 minutes - 18.1 MBWe bring you pearls from the American College of Emergency Physicians (ACEP) 2017 Scientific Assembly. Pearls on H. Pylori from: It's Alimentary - Poo-Pourri of Conditions From the Mouth to Rectum - Dr. Adebayo, Dr. Batra, Dr. Bavokek Emerging Infections: Zika and Its Friends - Dr. Joan Noelker High Yield Toxicology - Dr Erickson, Dr Traub, Dr. Perrone
ACEP 2017 - Critical Care Updates and Pediatric Pitfalls
October 30, 2017 02:37 - 12 minutes - 17.7 MBWe cover top pearl from the American College of Emergency Physicians (ACEP) Scientific Assembly 2017. Dr. Michael Winters - Critical Care Updates Dr. Tim Horeczko - Pediatric Pitfalls Thanks for listening! Jeremy Faust and Lauren Westafer
The Cutting Edge - PEs, Steroids, Pus, and more
October 08, 2017 20:45 - 25 minutes - 35 MBWe cover some high yield, important, or frequently discussed recent articles. Antibiotics and abscesses - Daum et al FAST in hemodynamically stable patients - Holmes et al Haloperidol in gastroparesis - Roldan et al and Ramirez et al Ignoring PERC - Buchanan et al Steroids in non-asthma/COPD lower respiratory tract infections - Hay et al Gender pay gap persists in academic EM (and it's not due to hours, rank, or roles) - Madsen et al
Episode 74 - Physostigmine and Anticholinergic Toxidrome
September 15, 2017 19:24 - 21 minutes - 29.2 MBWe review this blog post by Bryan Hayes, an ED pharmacist (@PharmERToxGuy), on the use of physostigmine in anticholinergic toxicity. We then review anticholinergic toxidrome using Rosen's, Tintinalli's, and Goldfrank's as a guide. Thanks for listening! Lauren Westafer and Jeremy Faust
Episode 73 - Gastroparesis & Biliary Pathology
September 01, 2017 00:52 - 23 minutes - 32.9 MBWe review gastroparesis treatment with haloperidol including a recent study by Ramirez and colleagues. This study had significant methodologic limitations but provides some interesting insight into a practice that many providers have adopted - using haloperidol for gastroparesis. A tiny RCT by Roldan and colleagues also looked at this practice and found promising results, although the study was very small. Haloperidol has also been used in cannabinoid hyperemesis but literature on this is l...
Episode 72 - Hypertension
August 18, 2017 09:57 - 21 minutes - 29.7 MBWe review recent discussions on the accuracy of cuff blood pressures including a meta-analysis Picone et al published in the Journal of the American College of Cardiology discussing the accuracy of cuff blood pressures. We cover core content on hypertensive emergencies and asymptomatic markedly elevated blood pressure using the ACEP clinical policy on hypertension, Rosen's (9th ed) Chapter 74 "Hypertension," and Tintinalli (8th ed), Chapter 57 “Systemic Hypertension” Chapter 59 “Aortic D...
Episode 71 - Opioids
July 31, 2017 16:12 - 28 minutes - 39.1 MBWe cover Free Open Access Medical Education on opioids. The Poison Review podcast reviews papers on the opioid epidemic, including a paper by Rudd et al demonstrating an increase in opioid-related deaths over the past five years as well as the following paper by Shah and colleagues. The Dantastic Mr. Tox and Howard, a new podcast on the scene, also covers multiple topics on opioids, including common misconceptions of tramadol. Then we cover core content on opioid overdose and withdrawal...