Dr David McCreary Emergency FellowA 26-year-old female represents to the ED 24 hours after an initial assessment for lower abdominal pain which was attributed to likely pelvic inflammatory disease (PID), for which antibiotics had been commenced by GP and bolstered to an eTG-happy regimen in ED before being discharged. On representation, the patient was reporting increasing lower back and abdominal pain. PV and speculum exam on the second presentation showed purulent discharge from the cervix and right adnexal tenderness. WCC was normal on both presentations. CRP was 155 on first presentation and had increased to 205 the following day. The concern at this point was for tubo-ovarian abscess (TOA) and so a pelvic ultrasound was performed quicker than you could say "fill your bladder” and was reported as: Conclusion: Moderate volume free fluid in the pelvis which is mildly complex, with possible dilated right fallopian tube. This area was mobile, and non-tender. No collection, abscess or features of appendicitis. At which point the patient was discussed with our friendly neighbourhood gyanecologists, who were happy to continue her investigation and management under their care as a likely tubo-ovarian abscess. So, what can we learn from this case? Well, first let’s talk a little about TOA… It’s a complex infectious mass of the adnexa that forms as a sequela of PID. Classically, lower abdominal-pelvic pain ± PV discharge, fever, ↑ WCC and an adnexal mass on PV exam. While this is the textbook presentation, a study in 1983(1) reported 35% patients were afebrile, 23% had normal WCC, only 50% complained of fevers/chills, 28% PV discharge, 265 with nausea and 21% with abnormal vaginal bleeding. Mucopurulent discharge and cervical motion tenderness → PID Add uterine or adnexal tenderness and you’re thinking TOA. Sexually active Multiple partners IUD insertion Previous history of PIDAll the usual suspects: Appendicitis Diverticulitis IBD PID Torsion Ectopic Ruptured ovarian cyst Pyelonephritis CystitisAside from the usual (bloods, HCG etc), options are US (sensitivity 75-82%) or CT (sensitivity up to 100%). Though for obvious reasons we’re usually choosing US as first line in these patients, knowing that CT is there if you have ongoing diagnostic uncertainty. Hell yes. If it ruptures the resulting intra-abdominal sepsis can be life threatening and then we're in strife. As you would expect - Chlamydia and Gonorrhoea are on there. But so are E.Coli, Bacteroides, Peptococcus and Peptostreptococcus. Actinomyces can be associated with presence of IUD. From us: Ceftriaxone 2g daily as per eTG (empirical treatment for severe PID) From our specialty friends: Percutaneous draining by radiology will suffice for most Alternatively, laparoscopic drainage or laparotomy may be needed if things are really badSo, let’s talk utility of pelvic exams… We had a bit of spirited discussion during our grand round on this case as to when we should be performing pelvic examinations on female patients presenting with lower abdominal pain. The text book answer is always. Why? You can assess for cervical motion tenderness, adnexal tenderness, purulent discharge, and you can take a high vaginal swab. But in the uncomplicated patient where you are already past the pre-test probability where you have decided to treat them - does it need to be performed on every patient? Well, I’ll be the first to put my hand up and admit that I don’t perform pelvic examination on every female patient whom I treat for pelvic inflammatory disease, though it’s thoroughly on a case-by-case basis and I have to be pretty convinced that it is uncomplicated PID.  So, I cannot stress enough that the following argument is not for patients with abdominal tenderness, abnormal vital signs or a stonking high CRP (as was the case in the patient). But as I love a bit of EBM, let’s look at what I was on about. There is a little bit of evidence for this approach with a study in the Annals of Emergency Medicine 2018(2). You can see my summary of the paper, and listen to my RCEMLearning podcast segment on it here(3). This was a study of 288 female patients aged 14-20 years with lower abdominal pain and/or PV discharge and normal vital signs. All patients had urine testing for chlamydia, gonorrhoea and trichomonas. Following standardised history to assess for cervicitis/PID, the clinicians recorded their likelihood of disease on a VAS. The same clinician then performed pelvic exam and again recorded their likelihood of PID with the additional information gained. They looked at the VAS before and after examination for both STI +ve and STI -ve patients. They also looked at how many cases where the examination would have changed management (by moving the VAS across the half way mark that they had decided was diagnostic).  They then worked out the test characteristics of pelvic exam using the urine results as the standard. What did they find? History alone had a sensitivity of 54.5% and specificity of 59.8% for cervicitis/PID. History plus pelvic exam had a sensitivity of 48.1% and specificity of 60.7%. So, no difference. The information the clinicians gained from the pelvic examination changed their management in 71 cases. Of those, 35 actually had a STI and 36 didn’t…so it was a coin flip. They concluded "For young female patients with suspected cervicitis or PID, the pelvic examination does not increase the sensitivity of diagnosis of chlamydia, gonorrhoea, trichomonas compared with taking a history alone.  Test characteristics for pelvic examination are not adequate, its routine performance should be reconsidered." Why does it matter? Well, that’s a valid question. It is the textbook work up for a reason. Despite this study, I don’t think diagnostically you’re ever going to be worse off for doing an examination. However, as the authors point out: pelvic exam is uncomfortable and emotionally distressing for most women, particularly teenage girls - so are the not less likely to engage in health care if the think they are routinely going to have to undergo an intimate exam? It’s the same argument for not doing ABGs on asthmatics or diabetics if you don’t have to. Caveat, disclaimer, “don’t blame me” closing statement… Remember this study, and my argument is entirely for uncomplicated PID presentations. If there’s a sniff of unwell or not quite right then this is not the paper for you. References: Landers DV, Sweet RL. Tubo-ovarian abscess: contemporary approach to management. Rev Infect Dis. 1983 Oct;5(5):876–84. Farrukh S, Sivitz AB, Onogul B, Patel K, Tejani C. The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease. Ann Emerg Med. 2018;7 McCreary D, Neill A. Pelvic Exam for PID. (RCEMLearning Podcast). December 2018. Available from: https://www.rcemlearning.co.uk/foamed/december-2018/ Kairys N, Roepke C. Tubo-Ovarian Abscess. . In: StatPearls . Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Dave is an Emergency Physician who completed training between the UK and Australia and completed an MSc in Trauma Science with QMUL. His clinical interests include trauma, critical care, evidence based medicine and human factors. Dave is a regular contributor the RCEMLearning podcast and is a FOAMed editor for RCEMLearning. He dislikes coriander, decaff coffee and dermatology.

Dr Emma Bellenger Emergency Registrar Peer Reviewer: DR David McCreary Redback spiders Good ol’ Australia Creepy crawlers galore Spiders and snakes And plenty more The red-back spider is one to know about As her bites you will see In Emergency no doubt When someone presents With a bite on their skin How can you tell That a red-back did the sin? Ouch! They may scream As It hurts like hell Their hairs will stand up And they won’t feel well The sweat starts to pour Their heart starts to race If their blood pressure rises They'll go red in the face They might get a surprise If they are a gent To find that they have “Pitched the tent!!” Despite all this The news isn’t all bad For the venom won’t kill Which is pretty rad The mainstay of treatment Is to manage the pain Consider anti-venom But be aware the risk versus gain So next time you see A red-back spider bite Don’t run away Everything will be alright By Emma Bellenger (The ED poet) The BLUF Red-back spider envenomation hurts, but won’t kill you Keep red-back spider bites in the back of your mind for non-specific presentations To anti-venom or not to anti-venom? Weigh up the risks vs benefits Female red-backs are boss ladies, but spiders in general are gross I am terrified of spiders. Last week a patient presented to ED with a spider in a jar, asking for a doctor to identify it. NO, THANKS! Thankfully, managing spider bites is much less scary. In fact, in Australia only one spider can actually kill you – the funnel web. But that’s for another day. Today we are going to delve in to red-back spider bites. The red-back spider is an Australian Icon. Many young Aussies grew up checking under their toilet seats religiously for red-backs, thanks to the Aussie song hit “There’s a red-back on the toilet seat” (or was that just me?). It’s probably worth the look because red-back spider bites are frequent, particularly in summer months, where they thrive in dry, sheltered areas. Only the female red-back is dangerous, and she can be identified by her characteristic red stripe on her round pea-sized black body. A redback spider (Latrodectus hasseltii) female, found in suburban Sydney, NSW, Australia. (By Toby Hudson - Own work, CC BY-SA 3.0, Wikimedia) The red-back spider is worthy of it’s own song, and although not deadly, is certainly worthy of knowing how to identify the symptoms and management of this boss lady’s bite. First things first - Do thousands of baby spiders really ever hatch out from a bite?? Literally my worst fear. Fortunately, this is a MYTH. The red-back spider venom contains alpha-latrotoxin which causes activation of the sympathetic nervous system. It does NOT cause thousands of eggs to hatch and baby spiders to emerge from the skin. PHEW! Now that we’ve cleared that up… How does a red-back spider bite present? The envenomation syndrome caused by red-back spiders is called ‘latrodectism’. The classic triad of symptoms is: Intense pain at the bite site – usually radiating proximally Sweating – sometimes only on the affected limb Piloerection Systemic envenomation may occur and cause further autonomic symptoms such as hypertension and tachycardia. Priapism may also occur in young males, so with any presentation of priapism red-back spider bites should always be a differential. But did you die? Contrary to common belief, red-back spider envenomation is not life threatening. Tricks for young players Like most things in medicine, the textbook presentation of syndromes is rarely as straight forward as it seems. Red-back spider bites can present with non-specific features such as generalised pain, headache, nausea and vomiting. In young children the only symptom may be inconsolable crying. So, keep red-back spider bites in the back of your mind at all times (get ready for the impending nightmares). 🤓   Ed:" in="in" my="my" (limited)="(limited)" experience="experience" of="of" having="having" seen="seen" a="a" few="few" these,="these," the="the" systemic="systemic" symptoms="symptoms" envenomation="envenomation" didn’t="didn’t" occur="occur" until="until" hours="hours" or="or" so="so" after="after" bite,="bite," which="which" could="could" make="make" it="it" harder="harder" to="to" think="think" diagnosis.="diagnosis."> How to fix it The mainstay of treatment is pain relief. Apply ice to the area and give simple analgesia to begin with. If pain is non-remitting then opiates may be necessary. Symptoms will usually reside within 3-5 days. Anti-venom is a debated topic in the management of red-back spider bites. It should be considered when pain is severe and not responding to analgesia. Time to RAVE on about anti venom To give or not to given anti-venom? Spoiler alert – there’s no correct answer. Why would you give it? Anti-venom should be considered when pain is severe and non-remitting. Why wouldn’t you give it? There are considerable side effects to giving anti-venom, the main two being anaphylaxis and serum sickness, experienced in approximately 5% and 16% of patients respectively. RAVE 2(1) concluded there is no significant clinical benefit of anti-venom above standard analgesia for pain management in red-back spider bites. Multicentre randomised placebo controlled trial P: 224 patients ≥ 7 years with RBS bite & severe pain (+/- systemic effects) I: RBS antivenom C: Placebo (saline) O: Clinically significant reduction in pain at 2 hours 2nd 1* outcome: subgroup with systemic features resolution of systemic symptoms at 2 hours 🤔  two primary outcomes Conclusion: The addition of antivenom to standardised analgesia in patients with latrodectism did no significantly improve pain or systemic effects Editor’s thoughts: Sample size was for difference of 20% in pain improvement and 30% in systemic effects 30% seems high for reduction in systemic symptoms Didn't reach their sample size (short by 16 patients - 7% of their target of 240) The trend in the results is toward benefit from anti-venom (CI -1.1-22.6%), so while the effect probably isn't as much as the 20% they were looking for, there probably is benefit and they were underpowered to find it. Though as they discuss, even if the difference is 10% (a NNT of 10 for pain relief), that would be an unacceptable efficacy in the context of the potential risk of hypersensitivity reaction (4% or NNH 25) Much the same for their second primary endpoint. Underpowered to show that benefit. Clinical bottom line: As with everything, this paper doesn’t give a definitive answer for the treatment of ‘all-comers’, but it does suggest there is no benefit (vs the harm) for the routine treatment of latrodectism. I have used it in the past (on tox advice and a shared decision with the patient) for a patient with significant systemic symptoms. They felt great within about an hour. In that study of n=1 it was great. Why won’t you just tell me what to do?! Unfortunately, there’s no one case fits all answer, which usually means it’s time to float some buzz words: “shared decision making” “patient centred care” “risk vs benefit” You also have your local poisons hotline for advice and wisdom! Go! Check under your toilet seat So there you have it. Red-back spider bites. Ouchies! Definitely wouldn’t want a bite on my bottom, so I hope you’ll all join me in checking under the toilet seat forever onwards. "There was a red-back on the toilet seat When I was there last night, I didn't see him in the dark, But boy! I felt his bite! And now I'm here in hospital, A sad and sorry plight, And I curse that red-back spider On the toilet seat last night." - Not by Emma the ED poet, but by Slim Newton, “The Red-back on the Toilet Seat” References Isbister GK, Page CB, Buckley NA, Fatovich DM, Pascu O, MacDonald SPJ, et al. Randomized controlled trial of intravenous antivenom versus placebo for latrodectism: the second Redback Antivenom Evaluation (RAVE-II) study. Ann Emerg Med. 2014 Dec;64(6):620-628.e2. DOI: 10.1016/j.annemergmed.2014.06.006. PMID: 24999282 Austin Clinical Toxicology Service. Redback Spider (RBS) bite – Latrodectus hasselti. Version 2. Austin Health. August 2020. Austin Clinical Toxicology Service. Redback Spider Antivenom (RBS AV). Version 1. Austin Health. January 2019. Piloerection image by Ildar Sagdejev (Specious) - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=4277167 Dr Emma Bellenger is an Emergency Registrar at the Alfred Hospital with a passion for life long learning, quality of life and efficiency. Alongside her role in ED she dabbles in sports medicine working with various football teams. Pre-pandemic Emma enjoyed doing hikes around the world, but of recent times has found solace in the simple things in life such as trail running, cuddling her cats and LEGO.

Musings on hypertension in pregnancy Dr Mike Khoury Senior Registrar Sure, that pun makes no sense. If you can think of something better (help with HELLP?), I’d like to hear from you. There are plenty of resources out there about managing these conditions, both in the community and in hospitals. They vary somewhat but there’s a general consensus about keeping systolic blood pressure below 140mmHg, preventing seizures, and delivering babies safely and emergently if you can’t do both of those things. If you want to know, and you should, check out RANZCOG’s official recommendation. But I wanted to speak on some of the more quizzical parts of the syndrome. Things I would sit there pondering for hours on end in a fellowship study session, fully knowing everyone else is thinking the same thing but is too embarrassed to ask. What does “eclampsia” mean? You’d be right to think you’ve never seen another word that looks remotely like this in medicine. It’s modern Latin by way of medieval French who in turn borrowed it from the Ancient Greeks. It’s initial form, “eklampein” meant to “shine.” It eventually came to be “eklampsis,” which was their word for “sudden light” (aka lightning) - and gradually became applied to the sudden onset convulsions seen in pregnant women. Take home message, it’s the Greek word for lightning. I presume that pre-eclampsia is therefore the Greek word for “thunder” - but only if the storm is moving away from you, I guess. Why is magnesium sulfate measured in grams instead of millimoles like in every other treatment regime? A ten millimole vial of magnesium sulfate is roughly equivalent to 2.5 grams. The MAGPIE trial, conducted in England in 2002, used 5g ampoules of the stuff. That’s simply how the drug company decided to package it. They used ⅘ of it (4g) in the trial but that’s how it came out of the box. I’ve asked six obstetricians about this - five said it never crossed their minds, and the sixth said that the 10mmol is used for replacement therapy whereas the higher-dose “gram” ampoules (henceforth known as “grampoules”) are resuscitative. It’s worth noting that the vials do state both units on them. Maybe this isn’t super important, but this is how my mind works. What did the MAGPIE study show, anyway? Magpies are horrible. According to www.magpiealert.com, which is a completely real website, 68% of swooping victims are cyclists. According to an unsourced ABC article from October 2020, 60 eye-related magpie injuries presented to Victorian hospitals in 2020. But I digress. The MAGPIE study(1) recruited 10,141 women across 33 countries, at greater than twenty weeks gestation, with systolic blood pressure greater than 140mmHg and another clinical feature of pre-eclampsia (usually proteinuria). Women allocated magnesium sulphate had a 58% lower risk of eclampsia than those allocated placebo. A follow up study determined that the intervention posed no risk to the foetus. Multi-centre, international, randomised, placebo controlled trial P: Women with pre-eclampsia in whom there was uncertainty about whether to use magnesium sulphate Included regardless of whether they had received another anti-convulsive therapy I: IV Magnesium Sulphate 4g loading dose followed by 24 hour maintenance at 1g/hr (or 5g IM into each buttock followed by 5g IM q4h x24h) C: Placebo (normal saline) O: Eclampsia (and, if randomised before delivery, death of baby before hospital discharge) Powered to find 50% decrease in risk of convulsions and 15% reduction in baby mortality (Target n = 10800-12750) Results: 10141 patients randomised → 10110 kept to analysis Less eclamptic seizures in treatment group - 0.8% vs 1.6% or 11 fewer eclampsia per 1000 patients (95% CI 7-16, p <0.0001). 58% (CI 40-71%) lower RR giving a NNT of 91 (CI 63-143) In patients with severe pre-eclampsia NNT 63 | Non-severe NNT 109 No difference in baby mortality (12.7% for intervention vs 12.4% for placebo) Methyldopa? Pre-eclampsia can be treated in the community in low-risk, closer-to-twenty-weeks patients provided close monitoring is possible. More specifically, these patients have “pregnancy-induced hypertension” - effectively the same thing but without the additional symptoms (proteinuria, clonus, headaches, and so on). These patients can be treated with everyone’s favourite slow-release dihydropiridine calcium channel blocker, nifedipine. But some hospitals advocate for methyldopa, which sounds like a nu-metal band from a small town in Indiana and seems, honestly, just as obscure. So, I went hunting for some evidence. A paper published in the AHA’s Hypertension journal in 2008 by Podymow and August entitled “Update on the Use of Antihypertensive Drugs in Pregnancy” summed it up fantastically. Methyldopa, 0.5 to 3 grams per day (in two doses) has an excellent safety profile to the foetus. Nifedipine, as you may recall, can inhibit labour. That’s all I’ve got for today. If you came here looking for a management flow chart, Queensland Health has already perfected it, so have a look here. References Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. The Lancet. 2002 Jun;359(9321):1877–90. Mike is a senior registrar at the Alfred currently sitting his fellowship exams. He is apologetically Canadian - sorry. His medical interests are junior teaching, environmental medicine and retrieval. Outside of medicine, he likes to repeat his own jokes - sorry.

Congratulations to Lemeki Lenoa a pre-hospital emergency care and major incident management specialist, and Navy Search & Rescue who received an Order of Fiji from His Excellency, the President Major-General (Ret’d) Jioji Konusi Konrote on 24th November 2020. The Order of Fiji is awarded for eminent achievement and merit of the highest degree in service to Fiji or to humanity at large. President Konrote said today’s Investiture Ceremony is another important milestone in the history of the Order whereby Government and Fijians, continue to acknowledge, but more importantly, honour and reward those deserving members of our society for their selfless contributions to Nation Building and for acts of bravery during extreme and dangerous situations. “The Recipients of today’s awards, in my humble opinion may be referred to as ‘extraordinary individuals’ who should be justifiably proud of their individual or collective actions in serving humanity either here at home or overseas.”

APPROACH TO THE SHOCK TRAUMA PATIENT Session one of our regional registrar teaching uses a case study of an acutely unwell shock-trauma patient to initiate a discussion of the initial interventions and the management of the severely head injured patient. Our panellists include A/Prof Joseph Mathew, Dr Eleanor Junckerstorrf, Dr Mike Noonan, Dr David Stark and Dr Dani Bersin. The session is Facilitated by Dr Luke Phillips. Recorded on October 21, 2020 HIGH PERFORMING TEAMS, COMMUNCIATION AND HUMAN FACTORS Session two of our regional registrar teaching contains an overview of team leadership and management in the shock-trauma patient, a discussion about a recent surgical airway case and a discussion on stress management when managing complex resuscitations. We finalise the session with a review of our hot debriefing after clinical events project that has been implemented within our department. Our panelists include Dr Helen Stergiou, Dr Chris Groombridge, Dr Luke Phillips, Dr Rob Melvin, Dr Shearne Wilkie and Dr Amelia Law. The session is Facilitated by Dr Eleanor Junckerstorff Recorded on October 21, 2020

Monash School of Public Health and Preventive Medicine researchers have just published data from Emergency Department (ED) attendances in Victoria and Tasmania during the beginning of the “second wave” throughout July – the largest study yet of patients attending EDs with suspected COVID-19. The study revealed that contact with a positive case of COVID-19 or a loss of smell or taste are good predictors of someone with the virus. The COVID-19 Emergency Department (COVED) Quality Improvement Project is a world-first program developed by Monash University researchers to help hospital emergency departments rapidly identify and predict the outcomes of patients with COVID-19 infection. The project, led by Monash researcher and emergency physician at the Alfred Hospital, Associate Professor Gerard O’Reilly, has just published its latest data in the journal, Emergency Medicine Australasia. Read more

Compassion has emerged as a prominent subject in the context of the Corona-virus pandemic. Loved ones have been unable to spend time with patients who are hospitalised with COVID-19, family members in the community have been isolated from one another, and there is a constant stream of news and information concerning the tragedy that is changing the world irrevocably. Yet, under these circumstances, compassion has perhaps been demonstrated; to a greater degree for marginalised cohorts, such as government funding a mass effort to shelter homeless persons in the context of COVID-19. The Compassion is Care webinar series aims to highlight the many facets of compassion as experienced in clinical care and community. The three themed sessions will highlight the criticality of compassion to the provision of high-quality care and clinician well-being, and consider how the notion informs practice both at the local and the health and social policy level. REPLAY: COMPASSION IN CARE – THE CLINICIAN EXPERIENCE FILMED ON 22 SEPTEMBER 2020 Speakers will discuss the positive and negative aspects of providing compassionate care in the increasingly complex context of healthcare. The session reveals how individuals, teams and healthcare leaders can be empowered to generate an environment that is conducive to compassionate care, and how such a environment benefits patients, healthcare professionals, and the wider community. https://vimeo.com/460765999 REPLAY: COMPASSION IS CARE – THE PATIENT EXPERIENCE FILMED ON TUESDAY, 29 SEPTEMBER 2020 While compassion is a felt emotion, it is also a serious clinical mechanism that promotes healing and mitigates against harm. Moreover, compassion is underscored by the ethos of treating others as we would like to be treated ourselves. In this session a patient advocate and a clinician share stories of their experience in healthcare. Their stories invite us to ‘walk in their shoes’, as we share in what compassionate care looks and feels like for a patient, and why it matters to the people who matter most: our patients. COMPASSION AND QUALITY AND SAFETY STANDARDS IN CARE FILMED ON TUESDAY, 6 OCTOBER 2020 Healthcare professionals experience first-hand the suffering of patients, their families, and their communities. Beyond the clinical setting there are factors that promote or impinge upon the ability to provide compassionate care. This session features speakers who have expertise in informing policy and strategy in healthcare. Speakers will highlight the imperative of compassion as a core value in healthcare, irrespective of the context of care-giving. The three themed sessions will highlight the criticality of compassion to the provision of high-quality care and clinician well-being, and consider how the notion informs practice both at the local and the health and social policy level. https://vimeo.com/465574883

In the summer of 2010, Emergency Physicians International (EPI) published its first edition in Singapore, in partnership with the International Conference on Emergency Medicine. In that issue, Logan Plaster interviewed Drs. Peter Cameron and Gautam Bodiwala, former heads of the International Federation for Emergency Medicine (IFEM), to get a high-level view of the present and future of global emergency medicine. A decade on, we decided to revisit this interview, and give the good physicians a chance to review and annotate their answers. Here’s what they said the second time around. Read more...

The International Emergency Medicine Education Project (iEM) has been providing free emergency medicine educational resources for medical students since June 2018. Content produced by 175 contributors from 27 countries has already reached thousands of students from 197 countries around the globe. COVID-19 has impacted many aspects of our lives and education is no exception. Because of the pandemic precautions, many medical students are missing their normal course of education. iEM has been working rapidly to find a solution to help students and educators and have launched an e-learning platform (www.iem-course.org) designed to provide free online emergency medicine courses for medical students around the world. Emergency Medicine Core Content Course This course is designed according to undergraduate emergency medicine curriculum recommendations of the International Federation for Emergency Medicine and the Society for Academic Emergency Medicine (SAEM). All students around the world are free to register and use the resources provided in this course. The course consists of 11 main lessons covering 37 topics. Each topic has video and reading assignments to reach the expected knowledge foundation. Videos are provided by Lecturio. Chapters were chosen from iEM Education Project 2018 eBook and SAEM CDEM Curriculum website. The iEM’s image and video archives, and other available FOAM resources were also used where appropriate. It is a 4-week (28 days) course. Studying an average of 5 – 7 hours each week will be enough to cover video and reading assignments. After enrolment, the course content will be available for 35 days. For more information and to register visit: https://iem-course.org/courses/emergency-medicine-cc/ Other iEM project resources include: iem-student.org is the main hub of the iEM Education project. Students can reach 2018 eBook chapters, blog posts, video, image, audio archives through this website. Flickr image archive contains images and short videos provided by iEM contributors. All photos and short videos are free to download. These items can be used in presentations and exams. YouTube video archive is where clinical videos and interviews with world-renowned experts are shared. SoundCloud audio archive contains iEM 2018 eBook chapters recorded in audio so students can download and listen anytime and anywhere. All iEM resources are cost and copyright free for all medical students and educators.