Always On EM - Mayo Clinic Emergency Medicine

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 - AlwaysOnEM@gmail.com 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 - AlwaysOnEM@gmail.com

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 - AlwaysOnEM@gmail.com 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 - AlwaysOnEM@gmail.com 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 - AlwaysOnEM@gmail.com

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 - AlwaysOnEM@gmail.com 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, Baker O, Schuur JD. Changes in Emergency Department Care Intensity from 2007-16: Analysis of the National Hospital Ambulatory Medical Care Survey. Western Journal of Emergency Medicine. 2020 Feb 21;21(2):209-216 Janke AT, Gettel C, Vacirca RK, Lin MP, Kocher KE, Venkatesh AK. Trends in treat and release emergency care visits with high-intensity billing in the US, 2006-19. Health Affairs (Millwood). 2022 Dec;41(12)1772-1780 Gani F, Canner JK, Pawlik TM. Assessing coding practices for gastrointestinal surgery over time in the United States. Surgery. 2018 Sep;164(3):530-538 Schonberger RB, Dutton RP, Dai F. Is there evidence for systematic upcoding of ASA physical status coincident with payer incentives? A regression discontinuity analysis of the national anesthesia clinical outcomes registry. Anesthesia Analgesia. 2016 Jan;122(1):243-50 Rajkumar CA, Suh WM, Francis DP. Upcoding of clinical information to meet appropriate use criteria for percutaneous coronary intervention. Circulation: Cardiovascular Quality and Outcomes. 2019 Mar;12(3):e005025 Smulowitz PB, Honigman L, Landon BE. A novel approach to identifying targets for cost reduction in the emergency department. Annals of Emergency Medicine. 2013 Mar;61(3):293-300 Burke LG, Burke RC, Epstein SK, Orav EJ, Jha AK. Trends in costs of care for Medicare beneficiaries treated in the emergency department from 2011 to 2016. JAMA Network Open. 2020 Aug 3;3(8):e208229 Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save medicare money and bolster episode-based payment models. Health Affairs (Millwood). 2016 Sep 1;35(9):1681-9 Lin MP, Baker O, Richardson LD, Schuur JD. Trends in emergency department visits and admission rates among US acute care hospitals. JAMA Intern Med. 2018 Dec 1;178(12):1708-1710 Pomerantz A, Burke R, Friedman A, Burke L, Wolfe R, Smulowitz P. The influence of Medicare for all on reimbursement for emergency care treat-and-release visits. Annals of Emergency Medicine. 2020 Oct;76(4):454-458 Obermeyer Z, Cohn B, Wilson M, Jena AB, Cutler DM. Early death after discharge from emergency departments: analysis of national US insurance claims data. BMJ. 2017 Feb 1;356:j239 Burke LG, Epstein SK, Burke RC, Orav EJ, Jha AK. Trends in mortality for medicaire beneficiaries treated in the emergency department from 2009 to 2016. JAMA Internal Medicine. 2020 Jan 1;180(1):80-88 Marco CA, Courtney DM, Ling LJ, Salsberg E, Reisdorff EJ, Gallahue FE, Suter RE, Muelleman R, Chappell B, Evans DD, Vafaie N, Richwine C. The emergency medicine physician workforce: projections for 2030. Annals of Emergency Medicine. 2021 Dec;78(6):726-737 Paul Genberg. The Value of Being a Generalist. Forbes. June 3, 2021

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 - AlwaysOnEM@gmail.com 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 - AlwaysOnEM@gmail.com  

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 - AlwaysOnEM@gmail.com