Always On EM - Mayo Clinic Emergency Medicine

In this chapter, Dr. Dougie Moss, final year EM resident presents his Capstone presentation on best charting practices to match reimbursement to the care we deliver. Take a listen to better understand the new billing expectations of our documentation.   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com

Alex and Venk talk through a previous case where they care for a young person with meningococcemia on a night shift. We review the disease, what to watch for, how to treat it, and go over some of the residue after being part of a case like this. We also review some of the considerations regarding ECMO for severe sepsis.   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Heckenberg SG, et al. Clinical features, outcome and meningococcal genotype in 258 adults with meningococcal meningitis: a prospective cohort study. Medicine (Baltimore) 2008. 87(4):185 Brechot N, Hajage D, et al. Venoarterial extracorporeal membrane oxygenation to rescue sepsis-induced cardiogenic shock: a retrospective, multicentre, international cohort study. Lancet 2020. 396(10250)545-552 Ling RR, Ramanathan K, et al. Venoarterial extracorporeal membrane oxygenation as mechanical circulatory support in adult septic shock: a systematic review and meta-analysis with individual participant data meta-regression analysis. Crit Care 2021. Jul 14;25(1):246   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

It is no surprise that outcomes are poor for patients who already meet one definition for 'death' even before the point of their first medical contact. But for nearly half of certain patients with out-of-hospital cardiac arrest, good neurologic outcomes can be achieved. And while patients with in-hospital cardiac arrest are also very likely to suffer a poor outcome, there is some reason to believe that some out-of-hospital cardiac arrest patients might have a better chance of survival. During this discussion, we will discuss why this might be, while also challenging assumptions about topics including epinephrine, airway management, and the risks and benefits of transporting patients in cardiac arrest. We will also look to future directions in cardiac arrest management.   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com

This chapter we talk with Dr. Henry Schiller, trauma surgeon and professor of surgery at Mayo Clinic, about a variety of hematomas including Morel Lavellee lesions, retroperitoneal hematomas, rectus sheath and more! Alex even gets to ask a question about REBOA that he has been hoping to do for a long time.  CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Nickerson TP, Zielinski MD, Jenkins DH, Schiller HJ. The Mayo Clinic Experience with Morel-Lavallee lesions: Establishment of a practice management guideline. J Trauma Acute Care Surg. 2012. Vol 76, Number 2 493-497 Demetriades D, Chan LS, Velmahos G, Berne TV, Cornwell III EE, Belzberg H, Asensio JA, Murray J, Berne J, Shoemaker W. TRISS methodology in trauma: the need for alternatives. British Journal of Surgery 1998, 85,379-384 Meyer DM, Jessen ME, Grayburn PA. Use of echocardiography to detect occult cardiac injury after penetrating thoracic trauma: A prospective study. J Trauma. 1995 Nov;39(5):902-7      

In this episode, Dr. Heather Murray, from Queen's University Department of Emergency Medicine presents the landscape of diagnostic errors in emergency medicine from the perspective of why they might occur, what can be done when they happen, and how we might minimize them in the future.    CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com   REFERENCES ARHQ report and responses: December 2022, AHRQ (Agency for Healthcare Research and Quality) released a systematic review on diagnostic error in the ED. https://effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-258-diagnostic-errors.pdf Letter from many ED organizations: Multi-Organizational Letter Regarding AHRQ Report on Diagnostic Errors in the Emergency Department December 14, 2022 Published critical appraisal of report: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10121120/pdf/ms120_p0114.pdf JAMA commentary Feb 2023 “Misdiagnosis in the ED: Time for a System Solution” Misdiagnosis in the Emergency Department: Time for a System Solution | Health Care Safety | JAMA Recovering from error: ARHQ summary on recovery after error Second Victims: Support for Clinicians Involved in Errors and Adverse Events | PSNet ARHQ Commentary – after error:How Do Providers Recover From Errors? | PSNet Clinician Peer Support Program after adverse events – implementation Supporting Clinicians after Adverse Events: Development of a Clinician Peer Support Program - PMC Scott SD, Hirschinger LE, Cox KR, McCoig M, Hahn-Cover K, Epperly KM, Phillips EC, Hall LW. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010 May;36(5):233-40. Caring for our own: deploying a systemwide second victim rapid response team   General resources on Diagnostic Error: Schiff JAMA Network Open 2021Characteristics of Disease-Specific and Generic Diagnostic Pitfalls: A Qualitative Study | Health Policy | JAMA Network Open Monteiro et al. 2020 Review “The enduring myth of generalisable skills.” https://asmepublications.onlinelibrary.wiley.com/doi/full/10.1111/medu.13872 Book – Improving Diagnosis in Health Care (chapter 9) The Path to Improve Diagnosis and Reduce Diagnostic Error   Cognitive biases: MDs were asked to reflect on a serious error and given some education on cognitive biases: Watari, T.; Tokuda, Y.; Amano, Y.; Onigata, K.; Kanda, H. Cognitive Bias and Diagnostic Errors among Physicians in Japan: A Self Reflection Survey. Int. J. Environ. Res. Public Health 2022, 19, 4645. Cognitive Bias and Diagnostic Errors among Physicians in Japan: A Self-Reflection Survey Anchoring Bias and strategies for overcoming: Anchoring Bias With Critical Implications | PSNet "Give me a break!" A systematic review and meta-analysis on the efficacy of micro-breaks for increasing well-being and performance: Albulescu P, Macsinga I, Rusu A, Sulea C, Bodnaru A, et al. (2022) "Give me a break!" A systematic review and meta-analysis on the efficacy of micro-breaks for increasing well-being and performance. PLOS ONE 17(8): e0272460. "Give me a break!" A systematic review and meta-analysis on the efficacy of micro-breaks for increasing well-being and performance | PLOS ONE   Better teams in EM: Purdy E, Borchert L, El-Bitar A et al “Psychological safety and Emergency Medicine team performance: a mixed methods review.” EM Australasia 2023;35:456-465 Psychological safety and emergency department team performance: A mixed‐methods study - Purdy Ottawa M+M rounds framework: Enhancing the Quality of Morbidity and Mortality Rounds: The Ottawa M&M Model - Calder - 2014 - Academic Emergency Medicine - Wiley Online Library   Selected references for artificial intelligence in medicine: AI chatbot in JAMA Internal Medicine Comparing Physician and Artificial Intelligence Chatbot Responses to Patient Questions Posted to a Public Social Media Forum | Health Informatics | JAMA Internal Medicine AI in Health Care NEJM podcast Is Medicine Ready for AI? — ITT Episode 6 | NEJM AI clinical prediction (systematic review 2022) Artificial Intelligence for the Prediction of In-Hospital Clinical Deterioration: A Systematic Review - PMC Lee P, Bubeck S, Petro J. Benefits, limits and risks of GPT-4 as an AI chatbot for medicine. NEJM 2023;388:1233-1239 Benefits, Limits, and Risks of GPT-4 as an AI Chatbot for Medicine | NEJM  

Neonatal fever can raise the temperature of the entire clinical pod along with the baby, but it doesnt have to. Join as Dr. Meghan Cain, chair of the division of pediatric and adolescent emergency medicine at Mayo Clinic, talks through the nuances of evaluating fever concerns in neonates of different ages and risk profiles and empowers you to be cool as a cucumber in these situations. CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Pantell RH, Roberts KB, Adams WG, Dreyer BP, Kuppermann N, O’Leary ST, Okechukwu K, Woods Jr CR. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics. 2021 Aug;148(2):e2021052228 Powell EC, Mahajan PV, Roosevelt G, Hoyle Jr JD, Gattu R, Cruz AT, Rogers AJ, Atabaki S, Jaffe DM, Casper TC, Ramilo O, Kuppermann N. Epidemiology of bacteremia in febrile infants aged 60 days and younger. Ann Emerg Med. 2018 Feb;71(2):211-216 Mahajan P, Browne LR, Levine DA, Cohen DM, Gattu R, Linaki JG, Anders J, Borgialli D, Vitale M, Dayan PS, Casper TC, Ramilo O, Kuppermann N. Risk of bacterial coinfections in febrile infants 60 days and younger with documented viral infections. J Pediatr. 2018 Dec:203:86-91.e2

So many people come to emergency departments with unexplained recurrent pains, fatigues, gastrointestinal symptoms and more - when there seems like no way we can help them, Dr. Mohabbat offers us some insight into what might be happening and how we can help be a positive experience in these patient's and family's lives. Listen to this grand rounds on Central Sensitization and be a better doctor for this large segment of the population. CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com  

Dr. Katie Young, co-director of the cardioobstetrics clinic here at Mayo Clinic sits down to talk about peripartum cardiomyopathy. This is something we will likely consider many times in our careers for patients with shortness of breath in and around late pregnancy. Find out what interventions are key, what patients are most likely to suffer a bad outcome and more. CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Gierula J, et al. Prospective evaluation and long-term follow up of patients referred to secondary care based upon natriuretic peptide levels in primary care. European Heart Journal – Quality of Care and Clinical Outcomes. 2019. 5, 218-224 Bay M, et al. NT-proBNP: A new diagnostic screening tool to differentiate between patients with normal and reduced left ventricular systolic function. Heart. 2003. 89,150-154 Dockree S, et al. Pregnancy reference intervals for BNP and NT-pro BNP – changes in natriuretic peptides related to pregnancy. Journal of Endocrine society. 2021. 5(7)1-9 Mueller C, et al. Heart failure association of the European society of cardiology practical guidance on the use of natriuretic peptide concentrations. European Journal of Heart Failure. 2019. 21, 715-731 Ravichandran J, et al. High-sensitivity cardiac troponin I levels in normal and hypertensive pregnany. American J of Medicine. 2019. 132,362-366 High sensitivity troponin T and I among pregnant women in the US – the National Health and Nutrition Examination Survey. JAMA Cardiology. 2023. 8(4)406-408 Tweet MS, et al. Spontenaoues Cardic Artey Dissection associated with pregnancy. Journal of the American College of Cardiology. 2017. 70,426-435 Baggish AL, et al. The differential diagnosis of an elevated amino-terminal Pro-B-Type Natriuretic Peptide level. Am J Cardiol. 2008. 101,43A-48A Lichtenstein DA, Meziere GA. Relevance of lung ultrasound in the diagnosis of acute Respiratory Failure – the Blue Protocol. Chest. 2008. 134,117-125 Smit MR, et al. Comparison of linear and sector array probe for handheld lung ultrasound in invasively ventilated ICU patients. Ultrasound in Med & Biol. 2020. 46(12)3249-3256 Haller EP, Nestler DM, Campbell RL, Bellamkond VA. Point-of-care ultrasound findings of acute pulmonary embolism: McConnell sign in the emergency medicine. JEM. 2014. 47(1)e19-e24 Halpern DG, et al. Use of medication for cardiovascular disease during pregnancy:JACC State of the Art Review. J Am Coll Cardiol. 2019. Feb, 73(4)457-476 Loyanga-Rendon RY, et al. Outcomes of patients with peripartum cardiomyopathy who received mechanical circulatory support. 2014. Circ Heart Failure. 7,300-309 Adedinsewo DA, et al. Detecting cardiomyopathies in pregnancy and the postpartum period with an electrocardiogram-based deep learning model. European Heart Journal – Digital Health. 2021. 2,586-596 Zieleskiewicz L., et al. Lung ultrasound-guided management of acute breathlessness during pregnancy. Anesthesia. 2013. 68,97-101 Balaceanu A. B-type natriuretic peptides in pregnant women with normal heart or cardiac disorders. Medical Hypotheses. 2018. 121,149-151

In this chapter, Dr. Alex Niven, renowned critical care physician and educator, provides a mirror for us to see our current state of emergency airway management - for its opportunities for improvement, innovations and best practices. This evidence fueled presentation is a must-listen for any emergency healthcare physician or provider. CONTACTS Youtube -https://www.youtube.com/@AlwaysonEM  X - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com

Dr. Nayantara Coelho-Prabhu, Mayo Clinic gastroenterologist specializing in the care of patients with gastrointestinal bleeding and endoscopy, talks through many aspects of acute GI bleeding. She helps to clarify the prioritization of medications, when to incorporate imaging, broadens our differentials for upper and lower GI bleeding, gives mindblowing advice on stool guiac testing and SO much more in this over-stuffed (or should we say constipated) chapter of Always on EM. There is also a special cameo from Dr. Luke Wood going over how to insert a Minnesota tube (esophageal balloon tamponade device)!   CONTACTS X - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com   RECOMMENDATION: Dieulafoy lesion video from New England Journal of Medicine: https://youtu.be/tzJQDen1nug?si=zOmywZ1VN3VvA004    REFERENCES: Drescher MJ, Stapleton S, Britstone Z, Fried J, Smally AJ. A call for reconsideration of the use of fecal occult blood testing in emergency medicine. Journal of Emerg Med. 2020. 58(1)54-58 Mathews BK, Ratcliffe T, Sehgal R, Abraham JM, Monash B. Fecal Occult Blood testing in hospitalized patients with upper gastrointestinal bleeding. Journal of Hospital Medicine. 2017. 12(7)567-569 Harewood GC, McConnell JP, Harrington JJ, Mahoney DW, Ahlquist DA. Detection of occult upper gastrointestinal bleeding: performance in fecal occult blood tests. Mayo Clin Proc. 2002 Jan;77(1):23-28 Blatchford O, et al. A risk score to predict need for treatment for upper gastrointestinal haemorrhage. Lancet 2000. Oct 14;356(9238):1318-21 Blatchford O, Davidson LA, Murray WR, Blatchford M, Pell J. Acute upper gastrointestinal haemorrhage in west of scotland: case ascertainment study. BMJ 1997. Aug 30;315(7107):510-4 Chen IC, Hung MS, Chiu TF, Chen JC, Hsiao CT. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding. Am J Emerg Med. 2007 Sep;25(7):774-9 Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021 May 1;116(5):899-917 Roberts I, Shakur-STill H, Afolabi A, et al. Effects of High-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 2020. 395(10241):1927-1936 Aziz M, Haghbin H, Gangwani MK, Weissman S, Patel AR, Randhawa MK, Samikanu LB, Alyousif ZA, Lee-Smith W, Kamal F, Nawras A, Howden CW. Erythromycin improves the quality of esophagogastroduodenoscopy in upper gastrointestinal bleeding: a network meta-analysis. Dig Dis Sci 2023. Apr;68(4):1435-1446 Abraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol 2022;00:1-17 Vigano GL, Mannucci PM, Lattuada A, Harris A, Remuzzi G. Subcutaneous desmopressin (DDAVP) shortens the bleeding time in uremia. Am J Hematol 1989. May;31(1):32-5 Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FL, Soares-Weiser K, Uribe M. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev 2010. Sep 8;2010(9):CD002907 Gao Y, Qian B, Zhang X, Liu H, Han T. Prophylactic antibiotics on patients with cirrhosis and upper gastrointestinal bleeding: A meta-analysis. PLoS One 2022. Dec 22;17(12):e0279496 Steffen R, Knapp J, Hanggi M, Iten M. Use of the REBOA catheter for uncontrollable upper gastrointestinal bleeding with hemorrhagic shock. Anaesthesiologie 2023. May;72(5):332-337 Sato M, Kuriyama A. Countering hemorrhagic shock due to duodenal variceal rupture with resuscitative endovascular balloon occlusion of the aorta. Am J Emerg Med 2023. Feb;64:204.e1-204.e3