Overheard In The Emergency Room

Dr Adrian Cois MD
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I'm an emergency physician. I take what I see in the ED and turn it into what you actually need to know to stay out of one. Overheard in the Emergency Room is a show about the evidence behind the advice. Full episodes break a topic down from the ground up. Quick Hits answer your questions in about ten minutes. Overheard Journal Club takes a single paper apart for clinicians and trainees. Whether you're a patient trying to make a real decision about your own health, a student or resident learning to read a paper properly, or a colleague who has been looking after everyone except yourself, there's something here for you. Every case is deidentified. Every claim has a source. No affiliate links, anywhere, ever. New episodes every Friday. Companion blogs, references, and free resources: https://drcois.com Let's chase less bad days and more good decades together.

  1. Oct 16

    Why Your Vegan Doctor Says It's Okay to Eat Meat!

    Can a vegan doctor tell you it's okay to eat meat? In Episode 39, Dr Cois takes you from the boundary line of a premiership-winning Aussie Rules club, to a rural Australian birth suite at 3 a.m., to an American Emergency Department, and explains how each room shaped the Two-Tier Blueprint. Then he gets to your plate. The 2025 EAT-Lancet Commission's Planetary Health Diet, built on health evidence alone, suggests about 1 serving of red meat a week and could prevent about 15 million premature deaths a year. Health care is itself a significant polluter, and prevention is climate action. You'll hear what the diet looks like, three common objections prebunked, including the protein question, and one practical swap to make this week. Key takeawaysYou don't need to go vegan: the Planetary Health Diet allows about 1 serving of red meat a week.Fundamentals beat gadgets, on the sports field and in your health.A primary care physician is the closest thing most people have to a performance team.Health care has a large carbon footprint, and prevention shrinks it.Your one thing: swap one red meat meal for a legume meal this week. DisclaimerEducational purposes only. This podcast does not provide medical advice and does not establish a physician-patient relationship. Talk to your own clinician before changing your diet or medications.

  2. Oct 2 ·  Bonus

    The Chest X-Ray Misses 1 in 4 Pneumonias [Journal Club]

    You think your patient has pneumonia, so you order a chest X-ray. Checked against CT, that film misses about 1 in 4 pneumonias. The ultrasound probe beside the bed, in trained hands, catches roughly 9 in 10. In this Overheard Journal Club, Dr Adrian Cois, an Emergency Physician, appraises Chavez and colleagues' 2014 meta-analysis in Respiratory Research: 10 studies, 1,172 adults, 94% sensitivity and 96% specificity. Then he looks under the hood at one study of 32 patients that became 384 data points, a rule-in that wobbles while the rule-out holds, the patients who were excluded, and a 2025 head-to-head update that used CT for everyone. Key takeaways: • A negative scan is lung ultrasound's most trustworthy result:a 30% pretest drops to about 3 to 5% • The 2014 numbers are a ceiling. In the 2025 CT-referencedupdate, ultrasound was 90% sensitive and 91% specific, against 73% and 82% forthe X-ray • B-lines alone are not pneumonia. Look for consolidation, theshred sign, and the dynamic air bronchogram • It all depends on training, and nobody yet knows how much isenough Companion blog, visual walkthrough of every finding, and fullreferences at DrCois.com. Educational purposes only. Not medical advice. No financialrelationships with any ultrasound manufacturer. Let's chase less bad days and more good decades together.

    The Chest X-Ray Misses 1 in 4 Pneumonias [Journal Club]

  3. Sep 25

    Why Your Doctor Will Not Order a Fasting Insulin Test

    A man in his 40s came to my emergency department on a Sunday morning with an abscess. We drained it, checked his blood sugar because of where the abscess was, and it came back at 440. He went home with antibiotics, metformin, and a diagnosis of type 2 diabetes he had no idea he had. A number like that takes years to arrive. For most of those years, a routine blood test would have looked normal. This episode is about why that happens, and about the one test on your panel that does not care what you had for breakfast. This is episode 2 of Lab Results Explained, the reference series in Overheard in the Emergency Room. I walk through the physiology of insulin and the two very different ways it fails, the 3 tests used to diagnose diabetes and what each one physically measures, the exact diagnostic thresholds, and where the US Preventive Services Task Force and the American Diabetes Association agree and differ on who should be screened. I also take on the loudest claim in online metabolic health, which is that your doctor is deliberately withholding a fasting insulin test that would have caught this years earlier. The biology behind that claim is correct. The conclusion is not, and I explain exactly why using the assay standardization data. And then the part I actually made this episode for: the personal fat threshold, the DiRECT trial, and what remission really means for a condition most people are told is permanent. KEY TAKEAWAYS • An A1c reflects roughly 3 months of blood sugar,because red blood cells live about 120 days. It does not require fasting. • Diabetes thresholds: fasting glucose 126 mg/dL orhigher, A1c 6.5 percent or higher, or a 2-hour glucose of 200 or higher. Prediabetes: 100 to 125, 5.7 to 6.4 percent, or 140 to 199. • Unless the hyperglycemia is unequivocal, a diagnosis needs a confirmatory test. One abnormal number is a reason to test again, not to panic. • The USPSTF recommends screening adults 35 to 70 withoverweight or obesity. The ADA screens everyone from 45, and earlier with risk factors. • Anemia, kidney failure, pregnancy, recent transfusion, and hemoglobin variants can all make an A1c unreliable. Use glucose criteria instead. • Fasting insulin is a real physiological quantity and a legitimate research tool, but assay variation between labs ran from 12 to 66 percent, no society has ratified a diagnostic cutoff, and HOMA-IR is not recommended outside research. • In DiRECT, 46 percent of the intervention group were in remission at 12 months versus 4 percent of controls, and 86 percent of those who lost 15 kg or more went into remission. • The highest-yield action for most listeners is not atest at all. It is having a primary care physician who is looking. DISCLAIMER This episode is for educational purposes only. It does not provide medical advice or establish a physician-patient relationship. The case discussed has been deidentified. If you have symptoms concerning for a medical condition, please seek care from a qualified clinician. All sources are available at DrCois.com, with no affiliate links.

    Why Your Doctor Will Not Order a Fasting Insulin Test

  4. Sep 18

    Stroke or Not? The 6 Signs You Cannot Wait On

    A 66-year-old woman wakes up to find her right arm weak and heavy. Not paralyzed, just not quite hers. She decides she slept on it funny. Three hours later, it gets better, almost completely, and that is exactly what convinces her she is fine. She came in later anyway. Her MRI showed a small stroke that had already happened. This is the second episode in the "ER or Wait?" series, and it is about the version of stroke that does not look like the version in your head. I give you the answer first, then the physiology behind it: what BE FAST is and why the two extra letters matter, what to do in the first 5 minutes, what the treatment windows actually are in the 2026 AHA/ASA guideline, and the honest numbers on clot-busting drugs, including the bleeding risk. I also want to take away the most common reason people wait: not denial. It is embarrassing. Roughly 1 in 3 of the people we scramble the whole stroke team for turn out not to be having a stroke. That is not the system failing. That is the system working exactly as designed. Let's chase less bad days and more good decades together. Educational purposes only. This episode does not provide medical advice and does not establish a physician-patient relationship. The case described is deidentified. Key takeaways ● Stroke symptoms that resolve completely are not anall-clear. Very often, they are a TIA, which the American Stroke Association calls a warning stroke. ● FAST misses about 1 in 7 ischemic strokes. BE FAST,which adds Balance and Eyes, cuts that to about 1 in 23. ● The single most valuable thing you can tell a stroketeam is the last moment the person was seen completely normal. ● Call 911 rather than driving. The assessment, thepre-notification, and the routing decision all start earlier. ● Do not give aspirin for suspected stroke. About 1 in 7Strokes are a bleed. ● Roughly 1 in 3 stroke activations turns out to be amimic. That is a deliberate design choice, not a failure. ● Nothing we do undoes the stroke you already had. Everything we do is about the next one, which is why the follow-up appointment matters more than it should.

    Stroke or Not? The 6 Signs You Cannot Wait On

  5. Sep 11

    GLP-1 Drugs: What an ER Doctor Wants You to Know

    A patient came into my emergency room vomiting 10 times a day, two days after a semaglutide injection. They had just increased their dose. When I asked why, they did not know. It was what the app told them to do. Ozempic, Wegovy, Mounjaro and the rest of the GLP-1 family are the biggest story in medicine right now, and the conversation around them has collapsed into two camps. Half the internet calls them a miracle. The other half calls them poison. Neither is being straight with you. So this episode runs them through the same framework I use for every medication. We start with the physiology, because not all GLP-1s are created equal and the difference between a GLP-1 agonist and a dual GIP and GLP-1 agonist actually matters when you are reading about them online. Then question one, what is the real benefit? Split by condition, because these are not just weight loss drugs. There is the head-to-head diabetes data on blood sugar control. There is a trial of 17,604 people with cardiovascular disease but no diabetes, where the rate of cardiovascular death, heart attack or stroke dropped meaningfully. And there is the tirzepatide weight data, which approaches surgical territory. Then question two, what are the real risks? I give you the actual discontinuation number from a large trial rather than a vague warning about nausea, and we cover the rarer risks worth screening for. And then the part I care about most, because it is my world and it is being badly undercommunicated. These drugs slow gastric emptying. That is the mechanism, not a side effect. Which means when you fast before a procedure, your stomach may not be empty. There is an ultrasound study on exactly this, and the number should change how you prepare for surgery. We finish with muscle, fiber, what actually happens when you stop, and the specific hazard with compounded and app-directed prescribing. I am Dr Adrian Cois, an Emergency Medicine physician and Assistant Professor. Companion guide and the full reference list at drcois.com. Let's chase less bad days and more good decades together. Key takeaways ● The benefit is real and goes well beyond weight loss,with a demonstrated reduction in cardiovascular death, heart attack and strokein people without diabetes. ● These drugs were built for type 2 diabetes. The weight loss was a happy side effect, and the diabetes evidence base is still the largest one. ● The most common side effects are gastrointestinal, and in one large trial roughly one in six people stopped the drug permanently because of adverse effects. ● Slowed gastric emptying is the mechanism, not a side effect, which is why it cannot simply be avoided. ● Tell every clinician on your care team that you take a GLP-1, especially before any procedure. Do not assume it is in the chart. ● Protein, resistance training and fiber matter more onthese drugs, not less. ● Weight tends to return when you stop, which is also true after any diet. That makes this chronic disease management, not a short course. ● Dosing errors from compounded and app-directed prescribing are what land people in the emergency department.

    GLP-1 Drugs: What an ER Doctor Wants You to Know

  6. Sep 4

    Forget 'Good' and 'Bad' Cholesterol. Here's What Matters

    Cardiovascular disease is the number one killer in the US and in Australia, and cholesterol is the most misunderstood set of numbers in medicine. On one side you have people insisting it does not matter at all. On the other you have people selling you a supplement to fix it. In this episode I take you through a standard lipid panel line by line. What each number actually measures, what the evidence really shows, and what your numbers mean for you rather than for a reference range on a page. I am Dr Adrian Cois, an Emergency Medicine physician and Assistant Professor. I met the consequence of 20 years of unexplained cholesterol at 2 a.m. in my emergency department, and that case opens this episode. In this episode: ● How an LDL particle physically gets into your arterywall, and why ApoB is the part that causes the damage ● Why LDL cholesterol is a surrogate for particle countrather than a direct measure of it ● Why HDL got called the good cholesterol, and why thedrugs that raised it failed ● What moderately high triglycerides are quietly tellingyou about your metabolic health ● How to calculate your non-HDL cholesterol from numbersyou already have ● When ApoB and lipoprotein(a) are worth asking yourdoctor about ● Why oxidized LDL, LDL particle size, and thetriglyceride to HDL ratio do not get you off the hook ● Whether you actually need to fast before a lipid panel Resources and links ● Companionguide and printable summary: https://drcois.com/blog ● Listenon Spotify: https://open.spotify.com/show/5wKvs7CY1WKWJciPFq9H9U ● Subscribeon YouTube: https://www.youtube.com/@dr_cois ● Watchfirst, the Lab Results Explained framework episode: https://music.youtube.com/watch?v=ow7G1Dr0PPE&si=aJID3iI0opnLEZic ● Book mentioned in the outro: Cholesterol Truths by Dr Mohammed Alo, written with Dr Thomas Dayspring. I have no financial relationship with the authors or publisher and receive nothing from this mention. Key papers ● Ference BA, et al. Low-density lipoproteins cause atherosclerotic cardiovasculardisease. Eur Heart J. 2017;38(32):2459-2472.https://doi.org/10.1093/eurheartj/ehx144 ● Blumenthal RS, et al. 2026 ACC/AHA/Multisociety Guideline on the Management ofDyslipidemia. Circulation. 2026;153(17):e1154-e1276.https://doi.org/10.1161/CIR.0000000000001423 ● Baigent C, et al. Efficacy and safety of cholesterol-lowering treatment: 90,056participants in 14 randomised trials of statins. Lancet.2005;366(9493):1267-1278. https://doi.org/10.1016/S0140-6736(05)67394-1 ● Voight BF, et al. Plasma HDL cholesterol and risk of myocardial infarction: amendelian randomisation study. Lancet. 2012;380(9841):572-580.https://doi.org/10.1016/S0140-6736(12)60312-2 Disclosures I have no financial relationship with any product, company, laboratory, book, or author mentioned in this episode. No affiliate links are used anywhere on this channel or at drcois.com. Disclaimer This video is for educational purposes only. It does not provide medical advice or establish a physician-patient relationship. Always consult a qualified clinician about your own health.

    Forget 'Good' and 'Bad' Cholesterol. Here's What Matters

  7. Aug 28 ·  Bonus

    Kidney Stone: No Needle, No CT? What 2 Trials Show [Journal Club]

    A patient is writhing on the bed, unable to lie still, pale with the pain. It is the textbook picture of renal colic, and the classic reflex is an IV in the arm, intravenous pain medication, and a trip down the hall for a CT. But what if the typical patient does not need all of that? This is Overheard Journal Club, where I take a paper I love, break it down, and tell you how it makes me think about the way I practice. This episode breaks the usual format and pairs twocomplementary trials, because together they sketch something more interesting than either does alone. We cover both in full PICO, walk through the results, and then get honest about the limitations, including why one trial was allocated by calendar date rather than truly randomized, why a bedside scan that is only 72 percent sensitive cannot rule out a stone, and where the evidence stops and clinical extrapolation begins. Key takeaways • Leading with bedside ultrasound cut emergencydepartment length of stay by 62 minutes and about 60 dollars per patient, withno increase in missed diagnoses or 30-day complications • The time was won by reaching CT faster rather than byavoiding it, since every patient in that trial was scanned • Intranasal ketorolac matched intravenous ketorolac for severe renal colic pain by 60 minutes, with the same safety profile and no needle • Both trials are small and single-center, so this is asignal worth acting on thoughtfully rather than a mandate • For the right patient, consider the scan-and-spray pathway, and reserve the CT for those who do not settle, look infected, or have a complicated history Disclaimer Educational purposes only. This podcast does not provide medical advice and does not establish a physician-patient relationship. Cases are deidentified and altered. Always discuss management decisions with a qualified clinician. Links Companion blog and full reference list: https://drcois.com/blog

    Kidney Stone: No Needle, No CT? What 2 Trials Show [Journal Club]

  8. Aug 21

    Is This Chest Pain a Heart Attack? (ER Doctor Explains)

    A man in his fifties sat at his kitchen table one night, certain he had bad indigestion. He took an antacid and went to bed. By the time he came to the Emergency Department several hours later, his ECG told a very different story, and those hours had cost him heart muscle we could never get back. Here is the uncomfortable truth at the center of that story. The person least able to tell whether chest pain is a heart attack is the person having it. So in this episode, Dr Adrian Cois walks through the warning signs emergency physicians actually look for, including the quiet ones that show up in women, older adults, and people with diabetes. He covers why roughly one in three confirmed heart attacks in a registry of more than 400,000 patients arrived with no chest pain at all, and why those patients did so much worse. He explains why a heart attack and a panic attack cannot be reliably told apart by symptoms alone, and what actually raises the stakes enough to call for help. And he gives you the exact plan for the first 10 minutes, including where aspirin fits and the one thing you should never do. This is Spoke 1 of the “ER or Wait?” cluster. If you have not heard the framework episode yet, start there. Key takeaways • Chest discomfort with pressure, sweating,breathlessness, or pain spreading to the arm or jaw is an emergency, notsomething to sleep on. • A heart attack does not always bring dramatic pain,especially in women, older adults, and people with diabetes. • You cannot reliably separate a heart attack from apanic attack at home, so when in doubt, you call. • In the first minutes: stop, call, do not driveyourself, and take aspirin only if the dispatcher advises it. • The Tier 1 version of this episode is a primary care physician who knows your blood pressure, cholesterol, blood sugar, and family history. Links • Companion blog post and full reference list:https://drcois.com/blog • Watch on YouTube: https://www.youtube.com/@dr_cois • More from Dr Cois: https://drcois.com Disclaimer Educational purposes only. This episode does not provide medical advice and does not establish a physician-patient relationship. If you think you may be having an emergency, call your local emergency number immediately. Always consult aqualified clinician for personal health questions. No financial relationship with any product, company, or service mentioned.

    Is This Chest Pain a Heart Attack? (ER Doctor Explains)
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About

I'm an emergency physician. I take what I see in the ED and turn it into what you actually need to know to stay out of one. Overheard in the Emergency Room is a show about the evidence behind the advice. Full episodes break a topic down from the ground up. Quick Hits answer your questions in about ten minutes. Overheard Journal Club takes a single paper apart for clinicians and trainees. Whether you're a patient trying to make a real decision about your own health, a student or resident learning to read a paper properly, or a colleague who has been looking after everyone except yourself, there's something here for you. Every case is deidentified. Every claim has a source. No affiliate links, anywhere, ever. New episodes every Friday. Companion blogs, references, and free resources: https://drcois.com Let's chase less bad days and more good decades together.

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