Always On EM - Mayo Clinic Emergency Medicine

Grand Rounds - Dr. Matthew Hamilton - The History of Homosexuality and Medicine

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

 

Chapter 31 - Legal landmines and lifeboats: Understanding legal risk in emergency medicine

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

 

Grand Rounds - Dr. John Wilson - Updates in Tuberculosis "The gift that keeps on giving"

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

 

Chapter 30 - Two minutes to midnight: Critical overview of hemoptysis

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

Grand Rounds - Dr. Michael Wilson - What your psychiatrist isn't telling you about suicide prevention in the ED

Whether or not emergency physicians believe that patients with thoughts of self-harm belong in the ED, they are coming to your ED anyway. According to the Centers for Disease Control, ED visit rates for nonfatal self-harm increased 42% among persons 10 years or older, and visits for suicidal ideation, self-directed violence, or both increased 25.5% from 2017-2018. That’s an increase of more than 1% per month pre-COVID. This solutions-oriented talk will discuss some of the science behind suicide prevention in the ED, and will present techniques that you can use to reduce risk in your ED.

 

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com

Chapter 29 - How to save a life - A primer on ECPR and ED ECMO

Dr. Suraj Yalamuri, Mayo Clinic Anesthesiology Critical Care and Cardiovascular Medicine Consultant, joins Alex and Finch to talk about the fundamentals of ECMO and ECPR. This is a great way to get caught up on this emerging science so that you'll be ready to provide the best resuscitative care for your patients when your system is ready too. 

Grand Rounds - Dr. Rebecca Leff - Fit for Purpose: Emergency Medicine Physicians and Humanitarian Response in Complex Emergencies

Dr. Leff shares, in her senior resident capstone presentation, a primer on humanitarian efforts, what are basic principles of aid, how to identify the key health needs of populations affected by crises and how EM clinicians can respond to those needs with the greatest impact. She will discuss how to engage responsibly and to anticipate how humanitarianism will develop and adapt in the future to improve responsiveness. 

Chapter 28 - Cant stop the bleeding - Mastering epistaxis

Dr. Mike Olson, former EM PA and now ENT attending sits down to talk about epistaxis with Alex and Venk. We go through a pragmatic approach to epistaxis, discuss some nuance cases including telangiectasia, hypertension, and anticoagulation. 

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

• Ingason AB, et al. Warfarin is associated with higher rates of epistaxis compared to direct oral anticoagulants: a nationwide propensity score-weighted study. J Intern Med. 2022 Sep;292(3):501-511
• Thomg JF, et al. A prospective comparative study to examine the effects of oral diazepam on blood pressure and anxiety levels in patients with acute epistaxis. Journal of Laryng & Otol. 2007. (121)124-129
• Terakura M et al. Relationship between blood pressure and persistent epistaxis at the emergency department: a retrospective study. J Am Soc Hypertens. 2012 Jul(4):291-295
• Lee CJ, et al. Evaluation of the relationship between blood pressure control and epistaxis resource after achieving effective hemostasis in the emergency department. J Acute Med. 2020 mar 1;10(1)27-39

 

Chapter 27.5 - Unbundling the bundle - Part two of sepsis

Dr. Casey Clements spent two hours breaking down the history and influences in sepsis care over the past three decades and going through the best practices in today's emergency medicine. This is the second part of the two part series.

Do you know how Sepsis is defined currently? What is the difference between SEP - 1 and surviving sepsis campaign? What is the role of steroids or vitamin C? Can you resuscitate these patients with albumin? These and so many more questions will be answered in this two part series. We review the PROCESS, PROMISE, and ARISE trials and provide pragmatic approach to your septic patients. 

So join Venk like vancomycin, and Alex (aka Zosyn) and Casey "not-cidal" Clements in these amazing episodes.

 

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com

REFERENCES & LINKS

Intravascular volume assessment

• Azadian M, Win S, Abdipour A, et al. Mortality benefit from the passive leg raise maneuver in guiding resuscitation of septic shock patients: A systematic review and meta-analysis of randomized trials. J Intensive Care Med. 2022 May;37(5):611-617
• Spiliotaki E, Saranteas T, Moschovaki N, et al. Inferior vena cava ultrasonography in the assessment of intravascular volume status and fluid responsiveness in the emergency department and intensive care unit: a critical analysis review. J Clin Ultrasound. 2022 Jun;50(5):733-744

 

Chest radiography paper referenced

• Poku JK, Bellamkonda-Athmaram VR, Bellolio F, Nestler DM, Stiell IG, Hess EP. Failure of prospective validation and derivation of a refined clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome. Acad Emerg Med. 2012 Sep;19(9):E1004-10

 

Albumin

• Caironi P, Tognoni G, Masson S, Fumagalli R, Presenti A, Romero M, Fanizza C, Caspani L, Faenza S, Grasselli G, Iapichino G, Antonelli M, Parrini V, Fiore G, Latini R, Gattinoni L, ALBIOS Study Investigators. Albumin Replacement in patients with severe sepsis or septic shock. NEJM. 2014;370(15):1412
• Xu JY, Chen QH, Xie JF, Pan C, Liu SQ, Huang LW, Yang CS, Liu L, Huang YZ, Guo FM, Yang Y, Qiu HB. Comparison of the effects of albumin and cyrstalloid on mortality in adult patients with severe sepsis and septic shock: a meta-analysis of randomized clinical trials. Crit Care. 2014;18(6):702
• Jiang L, Jiang S, Zhang M, Zheng Z, Ma Y. Albumin versus other fluids for fluid resuscitation in patients with sepsis: A meta-analysis. PloS One. 2014;9(12):e114666

 

Unbundling studies

• ProCESS Trial: ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, PIke F, Terndrup T, Wang HE, Hou PC, LoVecchio F, Filbin MR, Shapiro NI, Angus DC. A randomized trial of protocol based care for early septic shock. NEJM  2014;370(18):1683
• ProMISE Trial: Mouncey PR, Osborn ™, Power GS, Harrison DA, Sadique MZ, Grieve RD, Jahan R, Harvey SE, Bell D, Bion JF, Coats TJ, Singer M, Young JD, Rowan KM, ProMISe Trial Investigators. Trial of early, goal directed resuscitation for septic shock. NEJM 2015;372(14):1301
• ARISE Trial: ARISE investigators, ANZICS Clinical Trials Group, Peake SL, Delaney A, Bailey M, Bellomo R, Cameron PA, Cameron PA, Cooper DJ, Higgins AM, Holdgate A, Howe BD, WEbb SA, Williams P. Goal-directed resuscitation for patients with early septic shock. NEJM 2014;371(16):1496
• Angus DC, Barnato AE, Bell D, Bellomo R, Chong CR, Coats TJ, Davies A, Delaney A, Harrison DA, Holdgate A, Howe B, Huang DT, Iwashyna T, Kellum JA, Peake SL, Pike F, Reade MC, Rowan KM, Singer M, Webb SA, Weissfeld LA, Yealy DM, Young JD. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS, and ProMISE investigators. Intensive Care Med. 2015 SEp;41(9):1549-60
• PRISM Investigators. Early Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis. NEJM 2017
• Lu Y, Zhang H, Teng F, Xia WJ, SUn GX, Wen AQ. Early goal-directed therapy in severe sepsis and septic shock: A meta-analysis and Trial sequential analysis of randomized controlled trials. J Intensive Care Med. 2018;33(5):296

 

Vitamin C

• Sevransky JE, et al. Effect of vitamin C, thiamine, and hydrocortisone on ventilator- and vasopressor-free days in patients with sepsis: The VICTAS randomized clinical trial. JAMA. 2021 Feb 23;325(8):742-750

 

Chapter 27 - Machiavelli's Hectic Fever - Part one of sepsis

Dr. Casey Clements spent two hours breaking down the history and influences in sepsis care over the past three decades and going through the best practices in today's emergency medicine. Do you know how Sepsis is defined currently? What is the difference between SEP - 1 and surviving sepsis campaign? What is the role of steroids or vitamin C? Can you resuscitate these patients with albumin? These and so many more questions will be answered in this two part series. So join Venk like vancomycin, and Alex (aka Zosyn) and Casey "not-cidal" Clements in these amazing episodes.

 

CONTACTS

X - @AlwaysOnEM; @VenkBellamkonda

YouTube - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com

REFERENCES & LINKS

SOFA Score:

• Vincent JL, MOreno R, Takala J, et al. The SOFA (Sepsis-related organ failure assessment) score to describe organ dysfunction / failure. On Behalf of the working group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996 Jul;22(7):707-10
• Vincent JL, de Mendonca A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ dysfunction / failure in intensive care units: results of a multicenter, prospective study. Working group on ‘sepsis-related problems’ of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26(11):1793-1800
• Ferreira FL, Bota DP, Bross A, Merlot C, Vincent JL. Serial evaluation of the SOFA score to predict outcomes in critically ill patients. JAMA. 2001 Oct 10;286(14):1754-8
• Cardenas-Turanzas M, Ensor J, Wakefield C, Zhang K, Wallace SK, Price KJ, Nates JL. Cross-validation of a sequential organ failure assessment score-based model to predict mortality in patients with cancer admitted to the intensive care unit. J Crit Care. 2012 Dec;27(6):673-80

qSOFA score

• Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):762-774
• Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a new definition and assessing new clinical criteria for septic shock: For the Third International Consensus Definitions for Sepsis and SEptic Shock (Sepsis-3). JAMA. 2016;315(8):775-787
• Freund Y, Lemachatti N, Krastinova E, et al. Prognostic accuracy of Sepsis-3 Criteria for in-hospital mortality among patients with suspected infection presenting to the emergency department. JAMA. 2017;317(3):301-308
• Raith EP, Udy AA, Bailey M, et al. Prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit. JAMA. 2017;317(3):290-300

Comparing Prognostic scores

• Henning DJ, Puskarich MA, Self WH, Howell MD, Donnino MW, Yealy DM, Jones AE, Shapiro NI. An Emergency Department validation of the SEP-3 Sepsis and Septic Shock definitions and comparison with 1992 consensus definitions. Ann Emerg Med. 2017 Oct;70(4):544-552

IDSA concern

• Rhee C, Chiotos K, Cosgrove SE, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Strich JR, Winslow DL, Klompas M. Infectious diseases society of america position paper: Recommended revisions to the National Severe Sepsis and Septic Shock early management bundle (SEP-1) Sepsis Quality Measure. Clin Infect Dis. 2021 Feb 16;72(4):541-552

About Barcelona Declaration

• Slade E, Tamber PS, Vincent JL. The Surviving Sepsis Campaign: raising awareness to reduce mortality. Crit Care. 2003;7:1-2

1- hour surviving sepsis bundle guidance

• Freund Y, Khoury A, Mockel M, et al. European Society of Emergency Medicine position paper on the 1-hour sepsis bundle of the Surviving Sepsis Campaign: expression of concern. Eur J Emerg Med. 2019 Aug;26(4):232-233

Early Goal Directed Therapy

• Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM. 2001 Nov 8;345(19):1368-77

SEP - 1 Quality Measure

• National Quality Forum Measure submission and evaluation worksheet 5.0 for NQF #0500 Severe Sepsis and Septic Shock: Management Bundle, last updated Date: Oct 05, 2012. Website link Accessed 01-31-2024: https://www.qualityforum.org/Projects/i-m/Infectious_Disease_Endorsement_Maintenance_2012/0500.aspx 
• National Quality Forum: NQF Revises Sepsis Measure. Website link accessed 01-31-2024: https://www.qualityforum.org/NQF_Revises_Sepsis_Measure.aspx 
• Faust JS, Weingart SD. The Past, Present, and Future of the Centers for Medicare and Medicaid Services Quality Measure SEP-1 - the early management bundle for severe sepsis / septic shock. Emerg Med Clin N Am. 2017; 35:219-231

Affordable care act

• Patient Protection and Affordable Care Act, Public Law 148, U.S. Statutes at Large 124 (2010):119-1024. Website link accessed 01-31-2024: https://www.govinfo.gov/app/details/STATUTE-124/STATUTE-124-Pg119/summary. 

Fluids for sepsis in concerning populations

• Pence M, Tran QK, Shesser R, Payette C, Pourmand A. Outcomes of CMS-mandated fluid administration among fluid-overloaded patients with sepsis: A systematic review and meta-analysis. Am J Emerg Med. 2022 May:55:157-166
• Zadeh AV, Wong A, Crawford AC, Collado E, Larned JM. Guideline-based and restricted fluid resuscitation strategy in sepsis patients with heart failure: A systematic review and meta-analysis. Am J Emerg Med. 2023 Nov:73:34-39

 

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