Always On EM - Mayo Clinic Emergency Medicine

Drs. Alex Finch and Venk Bellamkonda talk through tick related infectious diseases including Lyme Disease, Rocky Mountain Spotted Fever, Ehrlichiosis, Babesiosis and more! Tick related illnesses are prevalent this time of year, so take a moment to brush up on how to manage them. CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - [email protected] REFERENCES & LINKS Society guidelines: United States CDC Tickborne diseases of the US Anaplasmosis - information for healthcare providers Babesiosis - resources for healthcare professionals Ehrlichiosis Lyme Disease RMSF A reference manual for healthcare providers 2017 American Academy of Pediatrics has several publications on babesiosis, borrelia infections other than Lyme, Ehrlichia, anaplasma, Lyme itself, RMSF Infectious Disease society of America Clinical practice guideline on diagnosis and management of babesiosis 2020 Canada Canadian pediatric society Practice point on Lyme disease in Canada - focus on children 2021 Society of OB / Gyn of Canada Committee opinion for management of tick bites and Lyme disease during pregnancy 2020 Australia - New Zealand Australian government department of health released An Australian guideline on the diagnosis of overseas - acquired Lyme disease / borreliosis in 2015 Japan choosing wisely Japan - Lyme disease 2018 India Department of health research - Indian council of medical research (ICMR) - guidelines for diagnosis and management of rickettsial diseases in India in 2015 UK National institute for health and care Excellence (NICE) quality standards on Lyme disease 2019 Guideline on Lyme disease 2018 British Infection Association (BIA)

Dr. Kharmene Sunga, Mayo Clinic emergency medicine consultant physician, specializing in simulation, diversity equity and inclusion, and education shares a guide for how to communicate (both through listening and speaking) most effectively when it counts. TEASER There's no place like the Emergency Department. Patients are in pain, scared, and anxious. Staff are distracted, fatigued, frustrated - and sometimes, well, also scared and anxious. How can Emergency Physicians speak to rise above the fray, to best care for patients, lead a team, and ensure that everyone feels heard? Join Dr. Kharmene Sunga as she discusses insights from sources ranging from medicine to business and even child psychology to cut through the proverbial noise. CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - [email protected]

Ms Lisa Beck, assistant professor of nursing and a clinical nurse specialist in the department of physical medicine and rehabilitation, shares her experiences over a career in caring for persons with intrathecal baclofen pumps for managing spinal cord injury related spasticity. Baclofen related complications such as withdrawal and overdose can both be fatal and pump specific complications as well require timely expertise from the emergency care team – but not often discussed in emergency medicine. Check out the episode to learn more! CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - [email protected] REFERENCES & LINKS Singh NK, Agarwal A, Salazar L, Henkle JQ. Osborn waves in hypothermia induced by baclofen overdose. BMJ Case Rep 2009; 2009. Sullivan R, Hodgman MJ, Kao L, Tormoehlen LM. Baclofen overdose mimicking brain death. Clin Toxicol (Phila) 2012;50:141 Alden TD, Lytle RA, Park TS, et al. Intrathecal baclofen withdrawal: a case report and review of the literature. Childs Nerv Syst 2002;18:522

This is really two separate episodes put together - Dr. Walker delivered grand rounds on network science applications to emergency medicine and it was inspiring. Though because it was such a visual talk, Alex and I had a conversation with her and Dr. Kohler to better understand the topic and present it in a more easily digestable state for you. Both experiences are presented here for your interest.

Dr. Mark Mannenbach, emeritus pediatric emergency medicine faculty of Mayo Clinic and former chairperson of the division of pediatric emergency medicine sits down with Alex and Venk to talk about pediatric diabetic ketoacidosis. We review tips and tricks from a lifetime of caring for sick kids, discuss our Mayo Clinic practice guideline, cerebral edema diagnosis and management, compare the care of pediatric DKA with that of adult DKA and more - Check out this ultra-sweet chapter! CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - [email protected] REFERENCES & LINKS Wolfsdorf JI, Allgrove J, Craig M, et al. Hyperglycemic crises in pediatric patients with diabetes; a consensus statement from the International Society for Pediatric and Adolescent Diabetes. Pediatr Diabetes. 2014;15(S20):154-179. Neu A, Hofer SE, Karges B, et al. Ketoacidosis at diabetes onset is still frequent in children and adolescents. Diabetes Care. 2009;32:1647-1648. doi: 10.2337/dc09-0553. Epub 2009 Jun 23. PMID: 19549730. Kuppermann N, Ghetti S, Schunk JE, et al. Clinical trial of fluid infusion rates for pediatric diabetic ketoacidosis. N Engl J Med. 2018;378:2275-2287 Long B. Lentz S, Koyfman A, Gottlieb M. Euglycemic diabetic ketoacidosis: etiologies, evaluation and management. Am J Emerg Med. 2021 Jun;44:157-160 Glaser N, Barnett P, McCaslin I. Risk factors for cerebral edema in children with diabetic ketoacidosis: The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. 2001;344:264-269. Soto-Rivera CL, Asaro LA, Agus MSD, DeCourcey DD. Suspected cerebral edema in diabetic ketoacidosis: Is there still a role for head CT in treatment decisions? Pediatr Crit Care Med. 2017 Mar;18(3):207-212 Wilkinson K, Sanghamitra S, Nair P, Sanchez J, Ambati S. Utility of head CT scan in treatment decisions for suspected cerebral edema in children with DKA. J Pediatr Endocrinol Metab. 2022 Sep 29;35(10):1257-1263

This is a recording of Dr. Kyle Hess, emergency medicine pharmacy resident, speaking at grand rounds on the utility of high-dose insulin therapy for selected cardiac medication overdoses. CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - [email protected]

Rheumatoid arthritis is a challenging disease with variable presentations and complex medications that can make providing emergency care challenging. Dr. John Davis, Vice Chair of Division of Rheumatology at Mayo Clinic sits down with us to help us move easier through RA for our patients. CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - [email protected] REFERENCES & LINKS Kaeley et al. The importance of ultrasound in identifying and differentiating patients with early inflammatory arthritis: a narrative review. Arthritis Research & Therapy. 2020;22:1 Horton SC, Tan AL, Wakefield RJ, et al. Ultrasound-detectable grey scale synovitis predicts future fulfillment of the 2010 ACR/EULAR RA classification criteria in patients with new onset undifferentiated arthritis. RMD Open 2017;3:e000394 https://youtu.be/7YqGIl6Oqbk - industry sponsored video on POCUS for rheumatoid arthritis. I recommend jumping to the 20 minute mark and watch this area for examples of ultrasounds and the use of the grey scale evaluation for synovitis.

Dr. Alyson McGregor is an emergency physician and champion for health equity with regards to sex and gender. She gave an important and incredible talk to our department about the importance of recognizing the differences between sexes and genders and how that can and should impact our clinical care and research. CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda; @McGregorMD Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - [email protected] Dr. McGregor’s website: www.alysonmcgregormd.com

Possibly the first ever podcast dedicated to optimizing the experience of lactating persons in the ED, Alex and Venk sit down with Dr. Sarah Dodd, assistant professor of anesthesiology at Mayo Clinic and passionate champion for optimizing the care of lactating persons throughout healthcare. Lengthy ED visits have the potential to begin a cascade that hastens the end of milk production, and is a significant source of stress for lactating persons and families. We have an opportunity to do better. Learn how to navigate medications, procedural sedation, long ED length-of-stay and more! CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - [email protected]

Dr. Laura Burke is a health sciences researcher and assistant professor of emergency medicine at Harvard Medical School. She gave a reaffirming grand rounds talk to us, packed full of evidence to support the concept that emergency medicine and emergency physicians provide an incredible quality of service and value to the healthcare system overall. Listen in! Articles she references throughout are listed below in chronological order. CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda; @LauraBurke20 Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - [email protected] REFERENCES & LINKS Li G, Lau JT, McCarthy M, Schull MJ, Vermeulen M, Kelen GD. Emergency Department Utilization in the United States and Ontario, Canada. Acad Emerg Med June 2007, Vol 14, No. 6 Papanicolas I, Woskie LR, Jha AK. Health Care Spending in the United States and Other High-Income Countries. JAMA. 2018;319(10):1024-1039 Papanicolas I, Woskie LR, Orlander D, Orav EJ, Jha AK. The Relationship between health spending and social spending in high-income countries: How does the US compare? Health Aff (Millwood). 2019 Sep;38(9):1567-1575 Zhou RA, Baicker K, Taubman S, Finkelstein AN. The uninsured do not use the emergency department more – they use other care less. Health Affairs (Millwood). 2017 Dec;36(12):2115-2122 Smulowitz PB, Lipton R, Wharam JF, Adelman L, Weiner SG, Burke L, Baugh CW, Schuur JD, Liu SH, McGrath ME, Liu B, Sayah A, Burke MC, Pope JH, Landon BE. Emergency department utilization after the implementation of Massachussetts health reform. Annals of Emergency Medicine. 2011 Sep;58(3):225-234 Singer AJ, Thode HC, Pines JM. US Emergency Department visits and hospital discharges among uninsured patients before and after implementation of the Affordable Care Act. JAMA Network Open. 2019 Apr 5;2(4):e192662 Brook, Robert H., Emmett B. Keeler, Kathleen N. Lohr, Joseph P. Newhouse, John E. Ware, William H. Rogers, Allyson Ross Davies, Cathy D. Sherbourne, George A. Goldberg, Patricia Camp, Caren Kamberg, Arleen Leibowitz, Joan Keesey, and David Reboussin, The Health Insurance Experiment: A Classic RAND Study Speaks to the Current Health Care Reform Debate. Santa Monica, CA: RAND Corporation, 2006. https://www.rand.org/pubs/research_briefs/RB9174.html. Vogel JA, Rising KL, Jones J, Bowden ML, Ginde AA, Havranek EP. Reasons patients choose the emergency department over primary care: A qualitative metasynthesis. J Gen Intern Med. 2019 Nov; 34(11):2610-2619 Chou SC, Gondi S, Baker O, Venkatesh AK, Schuur JD. Analysis of a commercial insurance policy to deny coverage for emergency department visits with nonemergent diagnoses. JAMA network Open. 2018 Oct 5;1(6):e183731 Raven MC, Lowe RA, Maselli J, Hsia RY. Comparison of presenting complaint vs discharge diagnosis for identifying nonemergency emergency department visits. JAMA. 2013 Mar 20;309(11):1145-53 Arnetz BB, Goetz C, vanSchagen J, Baer W, Smith S, Arnetz JE. Patient-reported factors associated with avoidance of in-person care during the COVID-19 pandemic: Results from a national survey. PLoS One. 2022 Aug 5;17(8):e0272609 Sharma M, Lioutas VA, Madsen T, Clark J, O’Sullivan J, Elkind MSV, Willey JZ, Marshall RS, Selim MH, Greer D, Tirschwell DL, Burton T, Boehme A, Aparicio HJ. Decline in stroke alerts and hospitalisations during the COVID-19 pandemic. Stroke Vascular Neurology. 2020 Dec;5(4):403-405 Bradley CJ, Neumark D, Walker LS. The effect of primary care visits on other health care utilization: A randomized controlled trial of cash incentives offered to low income, uninsured adults in Virginia. J Health Economics. 2018 Nov;62:121-133 Peikes D, Dale S, Ghosh A, Taylor EF, Swankoski K, O’Malley AS, Day TJ, Duda N, Singh P, Anglin G, Sessums LL, Brown RS. The comprehensive primary care initiative: effects on spending, quality, patients and physicians. Health Affairs (Millwood). 2018 Jun;37(6):890-899 Song Z, Gondi S. Will increasing primary care spending alone save money? JAMA. 2019 Oct 8;322(14)1349-1350 Weinik RM, Burns RM, Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics. Health Affairs (millwood). 2010 Sep;29(9):1630-6 Wang B, Mehrotra A, Friedman AB. Urgent care centers deter some emergency department visits but, on net, increase spending. Health Affairs (Millwood). 2021 Apr;40(4):587-595 Pitts SR, Pines JM, Handrigan MT, Kellermann AL. National trends in emergency department occupancy, 2001-2008:effect of inpatient admissions versus emergency department practice intensity. Annals of Emergency Medicine. 2012 Dec;60(6):679-686 Burke LG, Wild RC, Orav EJ, Hsia RY. Are trends in billing for high-intensity emergency care explained by changes in services provided in the emergency department? An observational study among US Medicare beneficiaries. BMJ Open. 2018 Jan 30;8(1):e019357 Schuur JD, Venkatesh AK. The growing role of emergency departments in hospital admissions. NEJM. 2012 Aug 2;367(5):391-3 Chou SC, Bake

Dr. Justin Kreuter, Transfusion Medicine attending at Mayo Clinic, joins Alex and Venk on the podcast to talk about transfusion in its many dimensions. We talk through a model of evaluation for patients with life threatening bleeding, how to interpret tests, the science behind the 1:1:1 ratio of trauma transfusion practice and much much more! CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda; @KreuterMD Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch; @KreuterMD Email - [email protected] REFERENCES & LINKS Lab medicine rounds podcast link: https://news.mayocliniclabs.com/homepage/podcasts-2/lab-medicine-rounds/ Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, plaeteles, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma – the PROPPR Randomized Clinical Trial. JAMA. 2015; 313(5):471-482 Holcomb JB, Del Junco DJ, Fox EE, et al. The prospective observational multicenter major trauma transfusion (PROMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013 Feb;148(2):127-136 J-Y Borg et al. FEIBA in the treatment of acquired hemophilia A: results from the prospective multicentre French ‘FEIBA dans l’hemophilie A acquise’ (FEIBHAC) registry. Haemophilia. 2015 May;21(3):330-337 Sharp G, Young CJ. Point of care viscoelastic assay devices (rotational thromboelastometry and thromboelastography): a primer or surgeons. Anz J Surg. 2019 Apr;89(4):291-295 Hospital Liaison Committee for Jehovah’s Witnesses: https://www.jw.org/en/medical-library/strategies-downloads/hospital-liaison-committees-jehovahs-witnesses/

In this episode, Alex and Venk give the virtual stage to Dr. Amy Zeidan from Emory University. She is an experienced and passionate advocate for helping those most in need - particularly immigrants to the United States. She gave Grand Rounds to our department January 24, 2023 and we share that with you here. Summary The United States immigration system is exceedingly complex and results in barriers to care for structurally vulnerable immigrant populations. Immigration status alone is a social determinant of health with historical, economic, social and political implications related to healthcare 'access'. As a result, the emergency department may be one of the most reliable and safe points of entry into the health system for immigrant populations, as 'access' to routine care may seem unattainable. EM physicians are well positioned to provide high quality and structurally competent care to immigrant populations seeking care in the ED, as well as facilitating community-academic partnerships to address external barriers to care. Doctor Zeidan will provide an overview of the US immigration system, how it impacts health seeking behaviors, and discuss strategies and considerations for care delivery for immigrant populations. Objectives: 1) Explore the structure and context of the US immigration system and how this impacts the health of immigrants 2) Discuss the barriers to care faced by immigrants that impact health seeking behaviors (both inside and outside of the hospital) 3) Consider the role of EM physicians in supporting the health rights of immigrants on shift and beyond the hospital Contacts: TWITTER - @AlwaysOnEM; @VenkBellamkonda; @Amyjwal INSTAGRAM – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch EMAIL - [email protected]

Dr. Abhishek Deshmukh, Cardiologist specializing in electrophysiology at Mayo Clinic, joins Alex and Venk on the podcast to talk about Wolff Parkinson White Syndrome and other supraventricular tachycardias. We will review the underlying pathophysiology, and how the specific electrical conduction pathway should determine how you treat your patient. He brings a pragmatic approach to this complex topic that you will be able to implement on your very next shift. Contacts: TWITTER - @AlwaysOnEM; @VenkBellamkonda; @Abhishek_mbbs INSTAGRAM – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch EMAIL - [email protected]

Exceptional individuals display five common traits according to former FBI agent, Joe Navarro, an expert in non-verbal communication. These include: self-mastery, observation, communication, action, and psychological comfort. Most clinicians would agree that the therapeutic effect we have on patients has little to do with the medication we provide, but more what is communicated verbally and nonverbally during the interaction. But, how do we hone these skills? And importantly, how do we become masters of the art of medicine, so we can provide comfort and healing in the most complex of encounters - to the geriatric patient in acute crisis. Join Dr. Liz Goldberg in this Mayo Clinic Emergency Medicine Grand Rounds, titled, The 5 Traits of Exceptional People & How to Use Them to Master the Geriatric Patient Encounter, to learn how to adopt and further develop these five traits through case studies in geriatric emergency medicine. Upon conclusion of this activity participants should be able to: - List the five traits of exceptional individuals - Discuss strategies to improve care for geriatric patients in the ED - Recognize ways to grow your impact through scholarship Contacts: TWITTER - @AlwaysOnEM; @VenkBellamkonda; @LizGoldbergMD INSTAGRAM – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch; @LizGoldbergMD EMAIL - [email protected]

Alex and Venk sit down with Dr. Jim Gregoire, Mayo Clinic Nephrology, to talk through a variety of emergency nephrology topics. We talk through dialysis related issues including the different types of peritoneal dialysis and their complications. Following that we talk through acute kidney injury with a focus on how we should approach this as emergency practitioners. Finally, we talk through some electrolyte issues that are not commonly discussed in our specialty.

Dr. Sergey Motov, gave this presentation on acute pain management to the Mayo EM Grand Rounds audience in the fall of 2022. Pain is the most common reason for people to seek care in the Emergency Department. The current laws and regulations have significantly affected ED Clinician’s ability to provide effective, efficient and safe pain relief by worsening opiophobia, by repurposing non-analgesic medications for pain control and by proliferation of dangerous drug-drug combinations. This talks is set to discuss the current state of ED analgesia when it comes to acute pain management with a primary focus on what works and what does not. Contacts: TWITTER - @AlwaysOnEM; @VenkBellamkonda; @PainFreeED INSTAGRAM – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch EMAIL - [email protected]

Dr. Ben Sandefur, Emergency Medicine attending at Mayo Clinic, joins Alex and Venk on the podcast to talk about angioedema and awake tracheal intubation. He reviews the different types of angioedema in a format designed to assist the emergency department practitioner with decision making and prognostication. This is followed by a description of how to prepare for and lead a team and patient through awake tracheal intubation using fiberoptic and video laryngoscopy techniques. Contacts TWITTER - @AlwaysOnEM; @VenkBellamkonda INSTAGRAM – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch EMAIL - [email protected] References Rosenbaum S, Wilkerson RG, Winters ME, Vilke GM, Wu MYC. Clinical Practice Statement: What is the Emergency Department Management of Patients with Angioedema Secondary to an ACE-Inhibitor? J Emerg Med. 2021 Jul;61(1):105-112 [from the American Academy of Emergency Medicine] https://pubmed.ncbi.nlm.nih.gov/34006418/ Moellman JJ, Bernstein JA, et al. A consensus parameter for the evaluation and management of angioedema in the emergency department. Acad Emerg Med. 2014 Apr;21(4):469-84 [from the American College of Allergy, Asthma & Immunology (ACAAI) and the Society for Academic Emergency Medicine (SAEM)] https://pubmed.ncbi.nlm.nih.gov/24730413/ Carrillo-Martin I, Gonzalez-Estrada A, Funni SA, Sandefur BJ, Jeffery MM, Campbell RL. Angioedema - related emergency department visits in the United States: Epidemiology and time trends, 2006-2015. J Allergy Clin Immunol Pract. 2020 Jul-Aug;8(7):2442-2444. https://pubmed.ncbi.nlm.nih.gov/32302784/ Ishoo E, Shah UK, Grillone GA, Stram JR, Fuleihan NS. Predicting airway risk in angioedema: staging system based on presentation. Otolaryngol Head Neck Surg. 1999 Sep;121(3):263-8 https://pubmed.ncbi.nlm.nih.gov/10471868/ Arthur J, Caro D, Topp S, Chadwick S, Driver B, Henson M, Norse A, Spencer H, Godwin SA, Guirgis F. Clinical predictors of endotracheal intubation in patients presenting to the emergency department with angioedema. Am J Emerg Med. 2022 Oct 19;63:44-49 https://pubmed.ncbi.nlm.nih.gov/36327748/ Sandefur BJ, Liu XW, Kaji AH, Campbell RL, Driver BE, Walls RM, Carlson JN, Brown CA. Emergency Department Intubations in Patients with Angioedema: A Report from the National Emergency Airway Registry. J Emerg Med. 2021 Nov;61(5):481-488 https://pubmed.ncbi.nlm.nih.gov/34479750/ Sandefur BJ, Oliveira Silva L, Lohse CM, Goyal KA, Barbara DW, Castaneda-Guarderas A, Liu XW, Campbell RL. Clinical features and outcomes associated with angioedema in the emergency department. West J Emerg Med. 2019 Aug 6;20(5):760-769 https://pubmed.ncbi.nlm.nih.gov/31539333/ Additional Resources Wilkerson RG, Moellman JJ. Hereditary Angioedema. Emerg Med Clin North Am. 2022 Feb;40(1):99-118 https://pubmed.ncbi.nlm.nih.gov/34782094/ Wilkerson RG, Winters ME. Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema. Emerg Med Clin North Am. 2022 Feb;40(1):79-98 https://pubmed.ncbi.nlm.nih.gov/34782093/

This is a recording of Dr. Victor Montori's grand rounds presentation to Mayo Clinic Emergency Medicine challenging us to rethink the care we provide to our patients and the community as a whole. He will be discussing the movement toward careful and kind care he calls the Patient Revolution. This movement seeks to turn away from industrialized healthcare – a form of healthcare in which the care of patients is a means to an end, in which patients are processed, and in which cruelty happens routinely and care by happy accident. He challenges us to turn toward careful and kind care. Careful care is unhurried, evidence-based, safe, and sensible. It is responsive to the needs and situation of this patient rather than patients like this. Careful care, as he describes, requires that clinicians see patients in high definition, notice their problems in their biology and biography, and respond with compassion and competence by co-creating plans of care that make intellectual, emotional and practical sense to each patient. Kind care recognizes each patient as a fellow human, one of us rather than one of them. It calls for minimizing the demands healthcare makes on patients’ scarce time, energy, and attention which patients rather use to fulfill their obligations, pursue their loves, and flourish. Based on solidarity and love, health care must support the work of people who come together to give and receive care. Beyond healthcare, we need to advocate for common care and for the care of our environment. He is challenging us to create a movement for care. Contacts: TWITTER - @AlwaysOnEM; @VenkBellamkonda; @VMontori INSTAGRAM – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch EMAIL - [email protected] References: 1. Why we revolt, authored by Dr. Victor Montori, published October 2017 2. www.PatientRevolution.org, organization cofounded by Dr. Victor Montori

Dr. Uma Thanarajasingam, Rheumatology attending at Mayo Clinic, joins Alex and Venk on the podcast to talk about how to approach patients with symptoms that span multiple organ systems and we are considering Lupus or when the patient has known Lupus when they present. We talk about Catastrophic Antiphospholipid antibody syndrome, immunochemistry and much more! Contacts: TWITTER - @AlwaysOnEM; @VenkBellamkonda INSTAGRAM – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch EMAIL - [email protected]

SPEAKER: Brian Patterson, MD, University of Wisconsin He discusses the experience at UW conceiving, designing, and implementing a program, which incorporates a machine-learning algorithm for real-time calculation of fall risk for all older adults who visit the ED. The talk will include the rationale for using automation to improve public health referrals from the ED, techniques used to create the intervention, and issues surrounding the design and governance of similar interventions. TWITTER @BPatterson; @AlwaysOnEM; @VenkBellamkonda INSTAGRAM @AlwaysOnEM EMAIL [email protected]

Dr. Doug Brown is an emergency physician and expert in wilderness medicine and mountain rescue with a special career focus on hypothermic cardiac arrest. He has been instrumental in building the rescue and resuscitation practices in Vancouver region of Canada and has published his work in the New England Journal of Medicine. Dr. Brown talks with Alex and Venk about a bunch of very COOL topics! Contacts: TWITTER - @AlwaysOnEM; @VenkBellamkonda INSTAGRAM – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch EMAIL - [email protected] References: 1. Brown DJ, Brugger H, Boyd J, Paal P. Accidental Hypothermia. N Engl J Med. 2012 Nov 15, 367(20):1930-8 2. Paal P, Brown DJ, Brugger H, Boyd J. In hypothermic major trauma patients the appropriate hospital for damage control and rewarming may be life saving. Injury. 2013 Nov;44(11):1665 3. Wanscher M, et al. Outcome of accidental hypothermia with or without circulatory arrest experience from the Danish Praesto Fjord boating accident. Resuscitation. 2012 Sep;83(9):1078-84

SPEAKER: Sara Crager, MD, UCLA Emergency Medicine When it comes to shock, we have developed a blood pressure addiction. Our propensity for a laser-like focus on blood pressure frequently hobbles our ability to promptly diagnose and optimally manage shock patients. This lecture aims to facilitate a more naunced approach to shock through an expanded mental model of shock pathophysiology combined with an iterative hypothesis testing strategy for clinical problem solving TWITTER @SaraCrager; @AlwaysOnEM; @VenkBellamkonda INSTAGRAM @AlwaysOnEM EMAIL [email protected]

There has been discussion nationally about the potential for a mismatch in the needs of the United States and the emergency physician workforce. Alex and Venk talk with Dr. Christopher Bennett, from Stanford Emergency Medicine about what he has learned and how he perceives the situation moving forward after spending a significant amount of time researching the EM workforce. TWITTER: @AlwaysOnEM; @VenkBellamkonda; @CLeeBennett INSTAGRAM: @Always On EM; @Venk_like_vancomycin; @ASFinch GMAIL: [email protected] References: 1. Bennett CL, et al. National Study of the Emergency Physician Workforce, 2020. Annals of Emerg Med. Dec 2020 2. Marco CA, et al. The Emergency Medicine Physician Workforce: Projections for 2030. Annals of Emerg Med. Dec 2021

Dr. Pritish Tosh, Infectious Disease attending at Mayo Clinic, joins Alex and Venk on the podcast to talk about Monkeypox, especially how it compares and contrasts to Smallpox and Chickenpox. Stick around to the end where an addendum is added to discuss the July 2022 New England Journal of Medicine case series on Monkeypox. Contacts: @AlwaysOnEM - TWITTER [email protected] @VenkBellamkonda - TWITTER References: 1. Thornhill JP, et al. Monkeypox Virus Infection in Humans across 16 countries - April-June 2022. N Engl J Med. 2022 Jul 21. doi: 10.1056/NEJMoa2207323. Online ahead of print. 2. WHO Director-General's statement at the press conference following IHR Emergency Committee regarding the multi-country outbreak of monkeypox - 23 July 2022; read July 24, 2022; weblink: https://www.who.int/director-general/speeches/detail/who-director-general-s-statement-on-the-press-conference-following-IHR-emergency-committee-regarding-the-multi--country-outbreak-of-monkeypox--23-july-2022 3. Second meeting of the International Health Regulations (2005)(IHR) Emergency Committee regarding the multi-country outbreak of monkeypox - 23 July 2022; read July 24, 2022; weblink: https://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-health-regulations-(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox

Dr. Lyell Jones, award winning neurologist educator, joins us on the podcast to talk about Myasthenia Gravis, Guillain-Barre Syndrome and neuromuscular weakness.

Alex and Venk talk with Dr. Nandan Anavekar, cardiac intensivist, about wide complex tachycardias - antitachycardia pacing, balloon pumps, dual sequential cardioversion, vasopressors, beta blockers and more! SHOW: @AlwaysOnEM | @VenkBellamkonda | EMBlog.mayo.edu | [email protected] GUEST: @NandanAnavekar | @MayoCVFellows | @MayoClinicCV

The Always On crew is joined by Dr. Jessica Schoen who is a world expert in medical simulation who shares perspectives on simulation fellowship as well how to uplift community emergency medicine practice through simulation.

Dr. Lauren Southerland, president of ACEP and former president of SAEM geriatric EM sections and Associate Professor of Emergency Medicine at Ohio State University, joins the show and truly inspires us to think differently about how we approach the care of older patients. She talks us through four models for providing geriatric emergency care, what does an ideal setup for older patients look like, what should we be doing to train future geriatrics-capable emergency physicians and much more! Please listen and check out the companion piece in the Mayo Clinic EM Blog. Tweet Dr. Southerland @LSGeriatricEM Tweet Dr. Bellamkonda @VenkBellamkonda Tweet Always on EM Podcast @AlwaysonEM

Left ventricular assist devices (LVADs) can feel incredibly complex and these patients can inspire fear or trepidation in many healthcare providers. In this episode, we talk through the basics of LVADs from taking vital signs, to managing alarms, and evaluating common issues all with the experience and insights of our wonderful guest, Sarah Schettle, PA-C in Cardiovascular Surgery at Mayo Clinic. She is an incredible educator and breaks this topic down into really digestable and applicable pieces. Check out a summary on the Mayo Clinic EM Blog

This is a challenge for us to think about the model of healthcare delivery differently by Dr. John Schupbach, resident, Mayo Clinic Emergency Medicine.

This is a recording of Drs. Ankel and Cabrera, renowned educators presenting grand rounds to the departments of emergency medicine at Mayo Clinic. They make a bold prediction for how the practice of emergency medicine will evolve and how the next generation of physicians will be challenged to practice differently.

In this episode, we talk through a systematic way for determining if a person has capacity to make a decision in the emergency department. We also talk through special circumstances such as when a person has consumed alcohol, etc.

Guest speaker, Dr. Jim Homme talks through the role of Nitrous Oxide in emergency medicine practice

As we get started on this podcast journey, we want you to know who we are, where we coming from, and where we hope to go with the podcast.