Always On EM - Mayo Clinic Emergency Medicine

Chapter 44 - Withdrawal warriors battle with barbs! Phenobarbital as a treatment for alcohol withdrawal

Is it possible that the cutting edge therapy for alcohol withdrawal care is one of the older tools in our bag? Possibly! In this chapter, one of the rising stars, Dr. Brandy Hernandez, Emergency Pharmacist, discusses the case for phenobarbital for helping patients for with their acute alcohol withdrawal symptoms. Find out when it may be preferable, what we don’t know yet, what the pitfalls are, and more!

 

Grand Rounds - Dr Fiterman Molinari - Cardiac Arrest: when Standard Care is Not Enough

In this grand rounds, Dr. Daniel Fiterman Molinari challenges the status quo of cardiac arrest care with thought provoking takes on the literature. Take a listen to his Capstone presentation and find yourself pondering whether you agree or disagree, and whether you need to go revisit the literature yourself. You may find your own heart skips a beat in this great episode.

Chapter 43 - Code Brown: When the runs run the room! - Management of Acute Diarrheal Emergencies

Diarrhea is one of the more common concerns in emergency medicine worldwide and in the United States, yet we often do not spend enough time understanding the breadth of causes and considerations for this syndrome. Do you know which patients benefit from Zinc? Would you like to review HUS? Can you mixup Oral Rehydration Solution if you needed to? We cover all of this and more in this “code brown” of a chapter! So come, get dirty with Alex and Venk in this truly crappy chapter of Always on EM!

 

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com

REFERENCES & LINKS

• Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K, Langley JM, Wanke C, Warren CA, Cheng AC, Cantey J, Pickering LK. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis. 2017 Nov 29;65(12):e45-e80. doi: 10.1093/cid/cix669. PMID: 29053792; PMCID: PMC5850553.
• Gore JI, Surawicz C. Severe acute diarrhea. Gastroenterol Clin North Am. 2003 Dec;32(4):1249-67. doi: 10.1016/s0889-8553(03)00100-6. PMID: 14696306; PMCID: PMC7127018.
• Freedman SB, van de Kar NCAJ, Tarr PI. Shiga Toxin–Producing Escherichia coli and the Hemolytic–Uremic Syndrome. The New England Journal of Medicine. 2023;389(15):1402-1414. doi:10.1056/NEJMra2108739.
• Logan C, Beadsworth MB, Beeching NJ. HIV and diarrhoea: what is new? Curr Opin Infect Dis. 2016 Oct;29(5):486-94. doi: 10.1097/QCO.0000000000000305. PMID: 27472290.
• Chassany O, Michaux A, Bergmann JF. Drug-induced diarrhoea. Drug Saf. 2000 Jan;22(1):53-72. doi: 10.2165/00002018-200022010-00005. PMID: 10647976.
• Schiller LR. Secretory diarrhea. Curr Gastroenterol Rep. 1999 Oct;1(5):389-97. doi: 10.1007/s11894-999-0020-8. PMID: 10980977.
• Gong Z, Wang Y. Immune Checkpoint Inhibitor-Mediated Diarrhea and Colitis: A Clinical Review. JCO Oncol Pract. 2020 Aug;16(8):453-461. doi: 10.1200/OP.20.00002. Epub 2020 Jun 25. PMID: 32584703.
• Do C, Evans GJ, DeAguero J, Escobar GP, Lin HC, Wagner B. Dysnatremia in Gastrointestinal Disorders. Front Med (Lausanne). 2022 May 13;9:892265. doi: 10.3389/fmed.2022.892265. PMID: 35646996; PMCID: PMC9136014.
• Expert Panel on Gastrointestinal Imaging; Chang KJ, Marin D, Kim DH, Fowler KJ, Camacho MA, Cash BD, Garcia EM, Hatten BW, Kambadakone AR, Levy AD, Liu PS, Moreno C, Peterson CM, Pietryga JA, Siegel A, Weinstein S, Carucci LR. ACR Appropriateness Criteria® Suspected Small-Bowel Obstruction. J Am Coll Radiol. 2020 May;17(5S):S305-S314. doi: 10.1016/j.jacr.2020.01.025. PMID: 32370974.
• Rami Reddy SR, Cappell MS. A Systematic Review of the Clinical Presentation, Diagnosis, and Treatment of Small Bowel Obstruction. Curr Gastroenterol Rep. 2017 Jun;19(6):28. doi: 10.1007/s11894-017-0566-9. PMID: 28439845.
• Modahl L, Digumarthy SR, Rhea JT, Conn AK, Saini S, Lee SI. Emergency department abdominal computed tomography for nontraumatic abdominal pain: optimizing utilization. J Am Coll Radiol. 2006 Nov;3(11):860-6. doi: 10.1016/j.jacr.2006.05.011. PMID: 17412185.
• Scheirey CD, Fowler KJ, Therrien JA, et al. ACR Appropriateness Criteria Acute Nonlocalized Abdominal Pain. Journal of the American College of Radiology : JACR. 2018;15(11S):S217-S231. doi:10.1016/j.jacr.2018.09.010.
• Atia AN, Buchman AL. Oral rehydration solutions in non-cholera diarrhea: a review. Am J Gastroenterol. 2009 Oct;104(10):2596-604; quiz 2605. doi: 10.1038/ajg.2009.329. Epub 2009 Jun 23. PMID: 19550407.
• Musekiwa A, Volmink J. Oral rehydration salt solution for treating cholera: ≤ 270 mOsm/L solutions vs ≥ 310 mOsm/L solutions. Cochrane Database Syst Rev. 2011 Dec 7;2011(12):CD003754. doi: 10.1002/14651858.CD003754.pub3. PMID: 22161381; PMCID: PMC6532622.
• Centers for Disease Control and Prevention (CDC). Scombroid fish poisoning associated with tuna steaks--Louisiana and Tennessee, 2006. MMWR Morb Mortal Wkly Rep. 2007 Aug 17;56(32):817-9. PMID: 17703171.
• Résière D, Florentin J, Mehdaoui H, Mahi Z, Gueye P, Hommel D, Pujo J, NKontcho F, Portecop P, Nevière R, Kallel H, Mégarbane B. Clinical Characteristics of Ciguatera Poisoning in Martinique, French West Indies-A Case Series. Toxins (Basel). 2022 Aug 3;14(8):535. doi: 10.3390/toxins14080535. PMID: 36006197; PMCID: PMC9415704.
• Centers for Disease Control and Prevention (CDC). Ciguatera fish poisoning--Texas, 1998, and South Carolina, 2004. MMWR Morb Mortal Wkly Rep. 2006 Sep 1;55(34):935-7. PMID: 16943762.
• Thyroid Inferno EM Blog: https://emblog.mayo.edu/2014/11/01/thyroid-inferno/ 
• Lazzerini M, Wanzira H. Oral zinc for treating diarrhoea in children. Cochrane Database Syst Rev. 2016 Dec 20;12(12):CD005436. doi: 10.1002/14651858.CD005436.pub5. PMID: 27996088; PMCID: PMC5450879.
• Dhingra U, Kisenge R, Sudfeld CR, Dhingra P, Somji S, Dutta A, Bakari M, Deb S, Devi P, Liu E, Chauhan A, Kumar J, Semwal OP, Aboud S, Bahl R, Ashorn P, Simon J, Duggan CP, Sazawal S, Manji K. Lower-Dose Zinc for Childhood Diarrhea - A Randomized, Multicenter Trial. N Engl J Med. 2020 Sep 24;383(13):1231-1241. doi: 10.1056/NEJMoa1915905. PMID: 32966722; PMCID: PMC7466932.
• Dalfa RA, El Aish KIA, El Raai M, El Gazaly N, Shatat A. Oral zinc supplementation for children with acute diarrhoea: a quasi-experimental study. Lancet. 2018 Feb 21;391 Suppl 2:S36. doi: 10.1016/S0140-6736(18)30402-1. Epub 2018 Feb 21. PMID: 29553435.

 

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

Grand Rounds - Dr. Lauren Chernick - Designing Digital Interventions to Improve Adolescent Sexual Health

The rapid evolution of digital health is transforming emergency care, but how do we design and implement technologies that truly meet patient needs? This session will explore the landscape of digital health tools and unpack how user-centered design ensures their effectiveness. Using a phased approach to development, Dr. Lauren Chernick from Columbia emergency medicine will discuss key strategies for integrating technology into engaging mobile health interventions. She will also share insights from three real-world sexual health interventions designed for adolescents in the ED—highlighting both successes and challenges. Join us for a discussion on digital health in emergency medicine and its potential to enhance patient care.

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com

 

Chapter 42 - Yes, I can help - Feeling empowered to help with in-flight emergencies

Alex and Venk discuss the fundamental differences of caring for people during an in-flight emergency: what changes with oxygen and pressure, what is available to you, what are the expectations, and more. Both have been teaching about this scenario to others and have been present for several such encounters. They bring their expertise and the available literature to establish this level-setting chapter of the Always on EM Podcast. By the end of this, hopefully, you'll have zero hesitation standing with confidence that you can provide assistance in any event that arises and be as well prepared as anyone to do it. So, buckle up, put your seatbacks up, stow your laptops, and tune in to this high-flying chapter of Always on EM!

 

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com

REFERENCES & LINKS

• Kim Y, Bae SC, Song YS. Exploring the potential of telehealth in-flight medical emergencies. Digit Health. 2025 Mar 13;11:20552076251326666. doi: 10.1177/20552076251326666. PMID: 40093698; PMCID: PMC11907535.
• Hawati SM, Binobaid F, Alsaeigh A, Alameer W, Al Ajmi AM, Alghamdi MK, Alqarni AA, Al-Harthi SN, Almelaifi A, Al Shehri AA. Assessing Emergency Medicine, Family Medicine, and ICU Doctors' Knowledge, Confidence, and Attitude in Managing In-Flight Medical Emergencies in the Kingdom of Saudi Arabia Hospitals: A Cross-Sectional Study. Cureus. 2025 Feb 1;17(2):e78359. doi: 10.7759/cureus.78359. PMID: 40046350; PMCID: PMC11880637.
• Hu JS, Smith JK. In-flight Medical Emergencies. Am Fam Physician. 2021 May 1;103(9):547-552. PMID: 33929167.
• Martin-Gill C, Doyle TJ, Yealy DM. In-Flight Medical Emergencies: A Review. JAMA. 2018 Dec 25;320(24):2580-2590. doi: 10.1001/jama.2018.19842. PMID: 30575886.

Grand Rounds - Dr. Alexander Ginsburg - Integrating Palliative Care in the ED: Streamlined Solutions to Minimize Provider Burden

In this Grand Rounds chapter, Dr. Alex Ginsburg, board certified in both emergency medicine and palliative care, and physician leader practicing in both specialties at Mayo Clinic in Rochester, Minnesota discusses a pragmatic way to incorporate palliative care into a busy and complicated emergency medicine practice. Beginning with why this is important and highlighting the challenges and barriers to making this happen, Dr. Ginsburg then proceeds to talk through approaches that are patient-centric while simultaneously feasible for a busy emergency physician. He will call out specific patients and scenarios that would benefit from consulting palliative care if possible and then cover optimal practices in how to clarify the goals of care of your patient. Tune in for this incredibly important Mayo Clinic Emergency Medicine Grand Rounds!

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com

Chapter 41 - Conversations toward cohesive practice - Optimizing the emergency physician and APP interface

The variety of practice models in the United States emergency healthcare system is numerous and most of them involve both physicians as well as advanced practice providers (physician assistants and nurse practitioners). Yet, the preparation for how to supervise an APP from a physician perspective, or what to expect from a physician colleague from the APP perspective is not standardized. In this chapter, we sit down with Dr. Eric Boie who is the current medical director for the APP practice at Mayo Clinic in Rochester, Minnesota, as well as Mr. Jeff Wood, PA-C who has been the supervisor of the APPs both in our health system as well in Rochester for nearly a decade until just recently - to discuss our current model of practice, how it supports resident education, how to support APPs autonomy and optimize patient care, how to handle when things don't go as planned and more. 

 

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com

 

RELATED READING

• Clark A, Amanti C, Sheng AY. Supervision of Advanced Practice Providers. Emerg Med Clin North Am. 2020 May;38(2):353-361. doi: 10.1016/j.emc.2020.02.007. PMID: 32336330.
• Rainer R, Bambach K. Navigating Supervision of Advanced Practice Providers. Emerg Med Clin North Am. 2025 Feb;43(1):131-138. doi: 10.1016/j.emc.2024.05.030. Epub 2024 Aug 1. PMID: 39515936.
• Lowery B, Scott E, Swanson M. Nurse practitioner perceptions of the impact of physician oversight on quality and safety of nurse practitioner practice. J Am Assoc Nurse Pract. 2016 Aug;28(8):436-45. doi: 10.1002/2327-6924.12336. Epub 2015 Dec 29. PMID: 26712306.
• Haslam-Larmer L, Krassikova A, Wojtowicz E, Vellani S, Feldman S, Katz P, Robert B, Heer C, Martin-Misener R, May K, McGilton KS. Nurse Practitioner and Physician Collaboration in the Long-Term Care Setting: Secondary Analysis of a Scoping Review. J Am Med Dir Assoc. 2025 Feb;26(2):105418. doi: 10.1016/j.jamda.2024.105418. Epub 2024 Dec 27. PMID: 39701552.
• McGilton KS, Haslam-Larmer L, Wills A, Krassikova A, Babineau J, Robert B, Heer C, McAiney C, Dobell G, Bethell J, Kay K, Keatings M, Kaasalainen S, Feldman S, Sidani S, Martin-Misener R. Nurse practitioner/physician collaborative models of care: a scoping review protocol. BMC Geriatr. 2023 Feb 16;23(1):98. doi: 10.1186/s12877-023-03798-1. PMID: 36797669; PMCID: PMC9934505.
• Guidelines Regarding the Role of Physician Assistants and Nurse Practitioners in the Emergency Department. American College of Emergency Physicians Policy Statement Approved June 2023. 

Grand Rounds - Dr. Brit Long - Choose your own adventure - High risk diseases in the emergency department

Legendary emergency medicine educator, Dr. Brit Long, gave grand rounds in Rochester in a highly interactive experience covering high risk, yet low frequency conditions that we need to watch for on shift. He uses an engaging style filled with cases to drill home key points related to these conditions. Enjoy this Valentine's Day chapter of Always on EM-Grand Rounds for a fun and engaging reminder of what our specialty is all about!

 

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda; @Long_Brit

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com

Chapter 40 - The Full Bird and Fumar de Cystica - an EM guide to the gallbladder

Dr. Henry Schiller, Professor of Surgery, Liutenant Colonel in the US Army Reserve, and Mayo Clinic Teaching Hall of Fame inductee rejoins the show to talk about gallbladders. We review the distinction between the evaluation and management of cholelithiasis, choledocolithiasis, the role of different imaging modalities, and much more in this awesome chapter of the show - dont miss this!

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com

REFERENCES & LINKS & ADDITIONAL READING 

• Childs DD, Lalwani N, Craven T, Arif H, Morgan M, Anderson M, Fulcher A. A meta-analysis of the performance of ultrasound, hepatobiliary scintigraphy, CT and MRI in the diagnosis of acute cholecystitis. Abdom Radiol (NY). 2024 Feb;49(2):384-398. doi: 10.1007/s00261-023-04059-w. Epub 2023 Nov 20. PMID: 37982832.
• de Oliveira GS, Torri GB, Gandolfi FE, Dias AB, Tse JR, Francisco MZ, Hochhegger B, Altmayer S. Computed tomography versus ultrasound for the diagnosis of acute cholecystitis: a systematic review and meta-analysis. Eur Radiol. 2024 Nov;34(11):6967-6979. doi: 10.1007/s00330-024-10783-8. Epub 2024 May 17. PMID: 38758253.

 

Grand Rounds - Dr. Lekshmi Kumar - Response to Recovery; Elevating trauma care with prehospital blood transfusions

Dr. Lekshmi Kumar, Associate Professor of Emergency Medicine at Emory University / Grady Hospital system in Atlanta, Georgia and the EMS director or the city of Atlanta presents grand rounds to kick off the 2025 calendar year! She talks about their collaborative work to create a prehospital blood transfusion program to uplift the trauma care in their region. Tune in to learn about the method for handling the change, the specifics for implementation and to learn the difference that this is making for their patients. 

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com