Free Open Access Medical Education (FOAM or #FOAMed) has always had a bit of a rebellious streak. The prototypical FOAMite enjoys ostentatiously taking on unproven dogma (ie, “received wisdom”), skeptically appraising seemingly sacred literature, and vociferously bragging about being an early adaptor. Now, however, some prominent FOAMites are going mainstream and showing up in some of medicine’s top peer-reviewed journals. At least some FOAMites are making the transition from health care influencers to health care innovators.

The first famous example of this precedes even the coining of the term FOAM. Back in 2011, Richard Levitan, MD, FACEP (@airwaycam), and Scott Weingart, MD, FCCM (@emcrit), published their review of the concept of apneic oxygenation during preparation for endotracheal intubation, which they cleverly named NODESAT (nasal oxygen during efforts securing a tube), in Annals of Emergency Medicine. By the time the article was finally published, bloggers and online learners were well aware of its contents and were lauding the protocol as a simple, inexpensive, and effective intervention. However, this wasn’t a randomized, controlled trial.

This fall, an active FOAMite on Twitter became the first person to be first author in two separate prospective randomized controlled trials in two of medicine’s top journals: The New England Journal of Medicine (NEJM) and JAMA. The NEJM was the so-called HEAT Trial, “Acetaminophen for Fever in Critically Ill Patients with Suspected Infection.” This study showed that dosing ICU patients with 1 gram of acetaminophen when a fever >38°C was present did not change the number of days a patient avoided an ICU or mortality.

The JAMA trial, “Effect of a Buffered Crystalloid Solution vs. Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial,” showed no difference in the incidence of renal replacement therapy (ie, dialysis) or mortality over 90 days in ICU patients who received moderate amounts of fluid (approximately 2 liters) regardless of whether that fluid was normal saline or buffered crystalloid.

Amazingly, both studies had the same first author, New Zealand intensive care physician Paul Young, BSc, MB ChB. Dr. Young, equally known for his presence on Twitter (@DogICUma), his informative contributions to the emergency medicine mega-blog LifeintheFastlane.com, and his well-attended lectures this past June at the Social Media and Critical Care Conference in Chicago (#SMACCus), has set the bar high for budding FOAMites-researchers. Within hours of online publication, Twitter was abuzz with these new trials.

In case you are wondering whether receiving social media attention increases a paper’s influence, consider that in just the first few hours, the HEAT trial received some of the most Twitter attention in the history of the NEJM’s account. Is this isolated? Apparently not. At least two studies have shown that articles that receive online attention are more likely to be influential than those that do not (another study found otherwise). This is a possible early indication of the death knell for the dominance of Journal Impact Factor as the primary arbiter of prestige in research. Back in 2005, Brody et al published data in the Journal of the American Society for Information Science and Technology showing that a higher number of downloads of a paper correlated to future citations of that article. Later, in 2011, Gunther Eysenbach, MD, MPH (@eysenbach), published findings in the Journal of Medical Internet Research suggesting that mere Twitter attention in the first few days after publication predicated which articles would go on to become highly cited in future literature. More recently, proprietary products such as Altmetric have moved to monetize the idea that a combination of page views, downloads, tweets, and other forms of social media and online attention may more accurately reflect the impact of a particular peer-reviewed publication than previous metrics such as impact factor.

This comes as no surprise to me. At #ACEP13, Dr. Weingart informally polled his audience. How many people, he asked, routinely performed apneic oxygenation as part of their preintubation procedure because of his and Dr. Levitan’s NODESAT paper? The vast majority of hands immediately went up. While this was clearly a select audience, the point was made. How often could papers published even by the top peer-reviewed journal of our field, Annals of Emergency Medicine, expect to enjoy such wide and brisk translation from print to practice in the first two years after publication? The answer is very few. The fact that Dr. Weingart’s EMCrit podcast is downloaded approximately 300,000 times per month and that he and Dr. Levitan combine for more than 26,000 Twitter followers may have something to do with that.

The ethos of FOAM continues to develop. While I hope it never sheds its freedom-fighter posture, it is a welcome development that FOAMites are becoming true thought leaders in emergency medicine and critical care.