Always On EM - Mayo Clinic Emergency Medicine

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 - AlwaysOnEM@gmail.com

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 - AlwaysOnEM@gmail.com

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

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 AlwaysOnEM@Gmail.com

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 - AlwaysOnEM@gmail.com   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 AlwaysOnEM@Gmail.com

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: AlwaysOnEM@gmail.com   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