For years we’ve been transfusing red cells in the ED to patients who don’t actually need them. A study looking at trends in transfusion practice in the ED found that about 1/3 of transfusions given were deemed totally inappropriate. As we explained in previous EM Cases episodes, there have been a whole slew of articles in the literature over the years that have shown that morbidity and mortality outcomes with lower hemoglobin thresholds, like 70g/L for transfusing ICU patients (TRICC trial), patients in septic shock (TRISS trial), and patients with GI bleeds are similar to outcomes with traditional higher hemoglobin thresholds of 90 or 100g/L. We’re simply transfusing blood way too much! The American Association of Blood Banks in conjunction with the American Board of Internal Medicine’s Choosing Wisely campaign, as one of its 5 statements on overuse of procedures, stated, “don’t transfuse iron deficiency without hemodynamic instability”. So, in this episode with the help of Transfusion specialist, researcher and co-author of the American Association of Blood Banks transfusion guidelines Dr. Jeannie Callum, Transfusion specialist and researcher Dr. Yulia Lin, and 'the walking encyclopedia of EM' Dr. Walter Himmel, we give you an understanding of why it’s important to avoid red cell transfusions in certain situations, why IV iron is sometimes a better option in a significant subset of anemic patients in the ED, and the practicalities of exactly how to administer IV iron.