Always On EM - Mayo Clinic Emergency Medicine

Chapter 21 - Chickity Check Yo’ Self Before Yo’ Wreck Yo Self! Tick borne infections

Drs. Alex Finch and Venk Bellamkonda talk through tick related infectious diseases including Lyme Disease, Rocky Mountain Spotted Fever, Ehrlichiosis, Babesiosis and more! Tick related illnesses are prevalent this time of year, so take a moment to brush up on how to manage them.

CONTACTS

Twitter - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com

REFERENCES & LINKS

Society guidelines:

• United States
  • CDC
    • Tickborne diseases of the US
    • Anaplasmosis - information for healthcare providers
    • Babesiosis - resources for healthcare professionals
    • Ehrlichiosis
    • Lyme Disease
    • RMSF
    • A reference manual for healthcare providers 2017
  • American Academy of Pediatrics has several publications on babesiosis, borrelia infections other than Lyme, Ehrlichia, anaplasma, Lyme itself, RMSF
  • Infectious Disease society of America
    • Clinical practice guideline on diagnosis and management of babesiosis 2020
  • Canada
    • Canadian pediatric society 
      • Practice point on Lyme disease in Canada - focus on children 2021
    • Society of OB / Gyn of Canada
      • Committee opinion for management of tick bites and Lyme disease during pregnancy 2020
    • Australia - New Zealand
      • Australian government department of health released An Australian guideline on the diagnosis of overseas - acquired Lyme disease / borreliosis in 2015
    • Japan 
      • choosing wisely Japan - Lyme disease 2018
    • India
      • Department of health research - Indian council of medical research (ICMR) - guidelines for diagnosis and management of rickettsial diseases in India in 2015
    • UK
      • National institute for health and care Excellence (NICE) 
        • quality standards on Lyme disease 2019
        • Guideline on Lyme disease 2018
      • British Infection Association (BIA)

Grand Rounds - Dr. Kharmene Sunga - Can You Hear Me Now? How To Speak Like An Emergency Physician

Dr. Kharmene Sunga, Mayo Clinic emergency medicine consultant physician, specializing in simulation, diversity equity and inclusion, and education shares a guide for how to communicate (both through listening and speaking) most effectively when it counts. 

 

TEASER

There's no place like the Emergency Department. Patients are in pain, scared, and anxious. Staff are distracted, fatigued, frustrated - and sometimes, well, also scared and anxious. How can Emergency Physicians speak to rise above the fray, to best care for patients, lead a team, and ensure that everyone feels heard? Join Dr. Kharmene Sunga as she discusses insights from sources ranging from medicine to business and even child psychology to cut through the proverbial noise.

 

CONTACTS

Twitter - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com

 

Chapter 20 - Relaxin to the maxin - Intrathecal baclofen pumps in the ED

Ms Lisa Beck, assistant professor of nursing and a clinical nurse specialist in the department of physical medicine and rehabilitation, shares her experiences over a career in caring for persons with intrathecal baclofen pumps for managing spinal cord injury related spasticity. Baclofen related complications such as withdrawal and overdose can both be fatal and pump specific complications as well require timely expertise from the emergency care team – but not often discussed in emergency medicine. Check out the episode to learn more!

CONTACTS

Twitter - @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email - AlwaysOnEM@gmail.com

REFERENCES & LINKS

1. Singh NK, Agarwal A, Salazar L, Henkle JQ. Osborn waves in hypothermia induced by baclofen overdose. BMJ Case Rep 2009; 2009.
2. Sullivan R, Hodgman MJ, Kao L, Tormoehlen LM. Baclofen overdose mimicking brain death. Clin Toxicol (Phila) 2012;50:141
3. Alden TD, Lytle RA, Park TS, et al. Intrathecal baclofen withdrawal: a case report and review of the literature. Childs Nerv Syst 2002;18:522

Grand Rounds - Dr. Laura Walker & Dr. Katharina Kohler - Network Science Applied to Healthcare

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.

Chapter 19 - Sugar, we’re goin down swinging! - Pediatric diabetic ketoacidosis

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

1. 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.
2. 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.
3. 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
4. Long B. Lentz S, Koyfman A, Gottlieb M. Euglycemic diabetic ketoacidosis: etiologies, evaluation and management. Am J Emerg Med. 2021 Jun;44:157-160
5. 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.
6. 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
7. 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

Grand Rounds - Kyle Hess, PharmD - High Dose Insulin therapy for calcium channel and beta blocker overdose

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

Chapter 18 - a Joint Venture - A guided tour of Rheumatoid Arthritis

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

1. 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
2. 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
3. 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.

 

 

Grand Rounds - Dr. Alyson McGregor - How sex and gender based research impacts the delivery of emergency care

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

Chapter 17 - LactatED: A stat consult on optimizing lactation in the ED

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

Grand Rounds - Dr. Laura Burke - Emergency Physicians as leaders of high-value healthcare

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