Always On EM - Mayo Clinic Emergency Medicine

Ischemic heart disease is a leading cause of morbidity and mortality. While atherosclerotic coronary artery disease (CAD) is the focus of most outpatient and inpatient evaluations for cardiovascular symptoms, up to two thirds of patients suffer from myocardial ischemia with non-obstructive coronary arteries (INOCA). Patients with INOCA have unique symptoms and are more likely to have functional limitation and repeat presentations for cardiovascular evaluation. While there has been increasing recognition of INOCA there is no specific functional status measure, limiting our ability to evaluate the course of illness or effectiveness of therapies. In this presentation, Dr. Samit Shah, interventional cardiologist at Yale New Haven Hospital who recently gave grand rounds recently to the Mayo Clinic Department of Emergency Medicine, reviews the causes of ischemic heart disease, challenges with current symptom assessment, and proposes a new path for better diagnosis and treatment of heart disease.   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda; @SamitShahMD YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com

Dr. Adela Cope breaks down pelvic inflammatory disease, tubo-ovarian abscess, ovarian torsion, ectopic pregnancy and more in this densely packed chapter of Always on EM. Tune in as Alex and Venk also try to figure out which one has the correct mental model of PID and who will ask the first stupid question.    CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com   LEARN MORE ABOUT RESIDENCY: https://youtu.be/gCQ0zimhhhY?si=NpsyTruGM9N_UpVM https://college.mayo.edu/academics/residencies-and-fellowships/emergency-medicine-residency-minnesota/   REFERENCES: Williams T, Mortada R, Porter S. Diagnosis and Treatment of Polycystic Ovary Syndrome. Am Fam Physician. 2016;94(2):106-113 Rutz M, Boulger C. Early Pregnancy. Sonoguide - American College of Emergency Physicians. Accessed 8/20/2024 (https://www.acep.org/sonoguide/basic/early-pregnancy)  Rodgers SK, et al. A lexicon for first-trimester US: Society of radiologists in ultrasound consensus conference recommendations. Radiology. 2024; 312(2):e240122 Kreisel K, Flagg EW, Torrone E. Trends in pelic inflammatory disease emergnecy department visits, United STates, 2006-2013. Am J Obstet Gynecol 2018;218:117e1-e10 Adhikari S, Blaivas M, Lyon M. Role of bedside transvaginal ultrasonography in the diagnosis of tubo-ovarian abscess in the emergency department. JEM 2008. 34(4):429-433 Mohseni M, Simon LV, Sheele JM. Epidemiologic and clinical characteristics of tubo-ovarian abscess, hydrosalpinx, pyosalpinx, and oophoritis in emergency department patients. Cureus. 2020;12(11):e11647 CDC sexually transmitted infections treatment guidelines, 2021 - Pelvic Inflammatory Disease (PID) accessed 8-20-24 Linden JA. et al. Is the pelvic examination still crucial in patients presenting to the emergency department with vaginal bleeding or abdominal pain when an intrauterine pregnancy is identified on ultrasonography? A randomized tli. Annals of Emerg Med 2017(70):825-834 Stein JC, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: A Meta-Analysis. Annals of Emerg Med. 2010;56:674-683 Robertson JJ, Long B, Koyfman A. Emergency Medicine Myths: Ectopic pregnancy, evaluation, risk factors, and presentation. JEM. 2017(53)6819-828 Brown J, Fleming R, Aristizabal J, Rocksolana G. Does pelvic exam in the emergency department add useful information? West J Emerg Med. 2011;12(2):208-212 Lee R, Dupuis C, Chen B, Smith A, Kim YH. Diagnosing ectopic pregnancy in the emergency setting. Ultrasonography. 2018;37:78-87  

This past winter, Dr. Rich Griffey, healthcare quality leader from Washington University School of Medicine and Emergency Medicine, came to present grand rounds on a new way to care for patients with mild to moderate DKA, which they call the SQuID protocol. This talk serves to inspire us to look even at some of our well established conditions and see what we could do differently, as well as appreciate the value that healthcare quality improvement integrated with research methods and implementation science thinking can do when they all come together for the improvement of patient care. Come be inspired with us! CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com   WANT TO WORK AT MAYO? EM Physicians: https://jobs.mayoclinic.org/emergencymedicine EM NP PAs: https://jobs.mayoclinic.org/em-nppa-jobs   Nursing/Techs/PAC: https://jobs.mayoclinic.org/Nursing-Emergency-Medicine EMTs/Paramedics: https://jobs.mayoclinic.org/ambulanceservice All groups above combined into one link: https://jobs.mayoclinic.org/EM-Jobs  

Dr. Ronna Campbell, professor of emergency medicine, and passionate anaphylaxis researcher schools Alex and Venk on several issues related to contrast-related anaphylaxis. She helps clarify an approach to managing ED situations where a contrasted CT is desired yet the patient has documented anaphylaxis to iodine, or how to treat a patient who returns with unexpected reaction after receiving contrasted imaging. Can you be allergic to Iodine? What is the relationship between shellfish allergy history and contrast? What is the role of steroids in anaphylaxis management? These are just some of the questions that we answer in this discussion.    CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com   WANT TO WORK AT MAYO? EM Physicians: https://jobs.mayoclinic.org/emergencymedicine EM NP PAs: https://jobs.mayoclinic.org/em-nppa-jobs   Nursing/Techs/PAC: https://jobs.mayoclinic.org/Nursing-Emergency-Medicine EMTs/Paramedics: https://jobs.mayoclinic.org/ambulanceservice All groups above combined into one link: https://jobs.mayoclinic.org/EM-Jobs

Dr. Ken Milne presents his talk entitled, “Old Fashioned Doctors,” to Mayo Clinic Emergency Medicine as our keynote speaker for our annual research day. In this talk, he goes through 10 ideas that were proposed in an article by Dr. Herbert Fred as potential ways that old-fashioned doctors may practice medicine more effectively or more palatably than younger counterparts. In this talk, he challenges those ten ideas while offering insights and reflections founded from his experiences before that can help guide or shape the way people can practice tomorrow. This is all done through the use of story and humor as he does in all of his other public speaking opportunities.   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda; @KenMilne4234 Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch TikTok - @Dr_Venk Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Skeptics guide to emergency medicine: https://thesgem.com/  Ken Milne’s Youtube video of his presentation: https://youtu.be/f18FmFci-BI?si=jqJ-53HMLTI-uwLy Herbert L Fred M.D. (1998) Old-Fashioned Doctors, Hospital Practice, 33:12, 15-15, DOI: 10.1080/21548331.1998.11443787   WANT TO WORK AT MAYO? EM Physicians: https://jobs.mayoclinic.org/emergencymedicine EM NP PAs: https://jobs.mayoclinic.org/em-nppa-jobs   Nursing/Techs/PAC: https://jobs.mayoclinic.org/Nursing-Emergency-Medicine EMTs/Paramedics: https://jobs.mayoclinic.org/ambulanceservice All groups above combined into one link: https://jobs.mayoclinic.org/EM-Jobs

Dr. Lacey Shiue, emergency ultrasound faculty, sits down with Alex and Venk to talk through ultrasound guided nerve blocks and plane blocks. We talk through key differences in commonly used medications, how to manage toxicity from those medications as well as a detailed discussion of several different specific blocks including: Erector Spinae Plane Block, Fascia Iliaca Compartment Block, Supraclavicular Block, Interscalene Block among others. In addition, she discusses the keys to advancing an emergency regional anesthesia program.   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com   RESOURCES FOR PRACTICE: MDCALC for anesthetic dose calculation: https://www.mdcalc.com/calc/10205/local-anesthetic-dosing-calculator  Safe Local app for anesthetic dose calculation: https://apps.apple.com/us/app/safelocal/id1440999841  New York School of Regional Anesthesia: https://www.nysora.com/filter-topics/  Highland County Emergency Medicine Website: https://highlandultrasound.com/  ASRA - American Society of Regional Anesthesia - Checklist for treatment of LAST: https://www.asra.com/news-publications/asra-updates/blog-landing/guidelines/2020/11/01/checklist-for-treatment-of-local-anesthetic-systemic-toxicity    REFERENCES: American College of Emergency Physicians Policy Statements: Ultrasound-Guided Nerve Blocks, published April 2021. Document accessed June 20, 2024 via: https://www.acep.org/patient-care/policy-statements/ultrasound-guided-nerve-blocks American College of Emergency Physicians Policy Statements: Guideline for ultrasound transducer cleaning and disinfection, approved April 2021. Document accessed June 20, 2024 via: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.acep.org/siteassets/new-pdfs/policy-statements/guideline-for-ultrasound-transducer-cleaning-and-disinfection.pdf  Disinfection of Ultrasound Transducers Used for Percutaneous Procedures: Intersocietal Position Statement. J Ultrasound Med. 2020; online before print. https://doi.org/10.1002/jum.15653  Ramesh S, Ayyan SM, Rath DP,Sadanandan DM. Efficacy and safety of ultrasound-guidederector spinae plane block compared to sham procedure inadult patients with rib fractures presenting to the emergencydepartment: A randomized controlled trial. Acad Emerg Med.2024;31:316-325. doi:10.1111/acem.14820 New York School of Regional Anesthesia: Ultrasound-guided fascia iliaca nerve block. Accessed June 21, 2024 via: https://www.nysora.com/techniques/lower-extremity/ultrasound-guided-fascia-iliaca-block/  Downs T, Jacquet J, Disch J, Kolodychuk N, Talmage L, Krizo J, Simon EL, Meehan A, Stenberg R. Large Scale implementation of fascia iliaca compartment blocks in an emergency department. West J Emerg Med. 2023 May 3;24(3):384-389 Makkar JK, Singh NP, Bhatia N, Samra T, Singh PM. Fascia iliaca block for hip fractures in the emergency department: meta-analysis with trial sequential analysis. Am J Emerg Med. 2021 Dec:50:654-660 Rukerd MRZ, Erfaniparsa L, Movahedi M, et al. Ultrasound-guided femoral nerve block versus fascia iliaca compartment block for femoral fractures in emergency department: a randomized controlled trial. Acute Med Surg. 2024 Mar 6;11(1):e936 Beaudoin FL, Haran JP, Liebmann O. A comparison of ultrasound-guided three-in one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial. Acad Emerg Med. 2013 Jun;20(6):584-91 Reavley P, Montgomery AA, Smith JE, Binks S, Edwards J, Elder G, Benger J. Randomised trial of the fascia iliaca block versus the 3-in-1 block for femoral neck fractures in the emergency department. Emerg Med J. 2015;32:685-689 Schulte SS, Fernandez I, Van Tienderen R, Reich MS, Adler A, Nguyen MP. Impact of the fascia iliaca block on pain, opioid consumption, and ambulation for patients with hip fractures: a prospective, randomized study. J Orthop Trauma. 2020 Oct;34(10):533-538   WANT TO WORK AT MAYO? EM Physicians: https://jobs.mayoclinic.org/emergencymedicine EM NP PAs: https://jobs.mayoclinic.org/em-nppa-jobs   Nursing/Techs/PAC: https://jobs.mayoclinic.org/Nursing-Emergency-Medicine EMTs/Paramedics: https://jobs.mayoclinic.org/ambulanceservice All groups above combined into one link: https://jobs.mayoclinic.org/EM-Jobs  

In this final chapter of the academic year 2023-2024, we celebrate our graduating EM class of residents by spotlighting a senior capstone presentation by Dr. Matthew Hamilton covering the intersection of homosexuality and medicine. In this presentation, he aims for the learner to be able to recognize pivotal movements in LGBTQ+ history and civil rights; describe structural mechanisms that excluded gay people from medicine for over 150 years; and to be able to recognize and mitigate ongoing threats to the health and wellbeing of LGBTQ+ people. Please tune in to learn more from one the great graduating senior emergency medicine resident physicians at Mayo Clinic! CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com  

Alex and Venk talk through the medicolegal aspects of practicing emergency medicine with emergency physician and attorney, Dr. Rachel Lindor. She is previous chair of research for Mayo Clinic Emergency Medicine in Scottsdale Arizona and holds both MD & JD degrees. She outlines how the most commonly litigated conditions (MI, orthopedics etc) still only accounts for about 1/5 of medicolegal cases in the United States and the importance of certain key behaviors in our practice to maintaining legal safety. Check it out!   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com   REFERENCES & LINKS Heaton HA, Campbell RL, Thompson KM, Sadosty AT. In support of the medical apology: the nonlegal arguments. Journal of Emergency Medicine 2016. 51(5)605-609 Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and Physicians’ attitudes regarding the disclosure of medical errors. JAMA 2003;289:1001-7 Carlson JN, et al. Provider and Practice Factors associated with emergency physicians being named in a malpractice claim. Ann Emerg Med. 2018;71:157-164 Sachs. Malpractice claims: It’s a crapshoot-Time to stop the self-blame and ask different questions. Ann Emerg Med. 2018;71(2):165-167 Weinstock & Jolliff.  High-Risk Medicolegal Conditions in Pediatric Emergency Medicine. Emerg Med Clin N Am. 39(2021) 479-491 Selbst, et al. Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and urgent care centers.  Pediatr. Emerg Care. 2005 Mar;21(3):165-9 Wong, et al. Emergency Department and Urgent Care Malpractice Claims 2001-2015. West JEM. 2021. 22(2): 333-8  

Dr. John Wilson, consultant in the division of infectious diseases at Mayo Clinic, and professor of medicine, director of Tuberculosis consultations at Mayo Clinic presents updates in Tuberculosis for Mayo Clinic Emergency Medicine Grand Rounds back in February.    CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com  

Dr. Dagny Anderson, a specialist in the division of pulmonary and critical care medicine at Mayo Clinic, joins Alex and Venk to talk about both life threatening hemoptysis and non-lifethreatening hemoptysis. In this chapter we review what we need to be doing in the emergency department, while also shedding light on what our teammates in other specialties can offer the patients downstream. Join for this colorful journey of how to manage the situation when no one likes what is coming out of the patient's mouth.   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com   REFERENCES Gopinath B, et al. Nebulized vs IV Tranexamic Acid for Hemoptysis - A pilot randomized controlled trial. Chest 2023;163(5):1176-1184 Wand O, Guber E, Guber A, Epstein Schochet G, Israeli-Shani L, Shitrit D. Inhaled Tranexamic Acid for Hempotysis Treatment: A randomized controlled trial. Chest 2018;154(6):1379 Ibrahim WH. Massive Hemoptysis:The definition should be revised. Eur Respir J. 2008 Oct;32(4):1131-2