Volume 1: Issue 3

"Tox Talks"

Chloroquine Conundrum or One Poisoned Mosquito

Chloroquine is a classic antiplasmodial agent used in malaria prophylaxis in regions that have not developed resistance such as Central America, the Caribbean and a few additional countries. 500mg are taken every week for this purpose. The drug has a very small toxic-to-therapeutic margin, with severe toxicity being seen in patients who have ingested as little as 5 grams. In the pediatric population, this translates into toxicity with as little as one or two 500mg pills.

Toxicity typically presents 1-3 hours after ingestion with QRS prolongation, atrioventricular block, ST abnormalities and QTc prolongation. These are accompanied by vasodilation and hypotension. Visual disturbances are a side effect of therapeutic dosages, but are not a major hallmark of toxicity. Treatment consists of epinephrine for hypotension/vasodilation, activated charcoal if recent ingestion and patient protecting airway, sodium bicarbonate for prolonged QRS segment, and diazepam for both its cardio protective effects and sedation.

In summary:

  • Toxicity with as few as 10 pills (5 grams) in adults, or 1-2 pills (pediatric).
  • Presentation largely one of cardiovascular failure.
  • Treatment with epinephrine, diazepam and sodium bicarbonate if prolonged QRS.
  • Hemodialysis not effective secondary to large volume of distribution, extensive binding.

Critical Care Pearl

In the acute eye injury, the most important thing to determine is the visual acuity. Because the surrounding tissues can swell up quickly, sometimes the emergency physician might be the only person to get an exam before the eye swells shut. The best way to open the eye is not to pull the lids, but rather, put your fingers just below the superior orbital ridge and the inferior orbital ridge, and roll your fingers away from the eye. Once open, if you don't have an eye chart handy, have the patient read something, anything (clock, name tag, etc.). Your ophthalmologist consultant can convert the distance and size of the letters into a more familiar 20/x acuity. If they cannot read anything, try counting fingers or determining light perception, as this is still important prognostic information.

Journal Club
The Taser Comes of Age

A large number of articles have been published this past spring and summer in emergency medicine literature on tasers and their effects. Now that the taser has finally arrived, what do we need to know about it?

To start off, tasers are a hand-held weapon that, when activated, launches two compressed gas powered barbs at its target. These barbs remain attached to the taser via thin metallic wire. Once they embed into the target, they deliver a five second long set of intermittent electrical pulses which result in muscular tetany. The incapacitation of the tetany typically lasts for thirty seconds. Now to the literature.

The publication of a large multicenter study of the effects on tasers appears in the April issue of Annals of Emergency Medicine. Over 36 months, six United States law enforcement agencies prospectively collected records from over 1,100 usages of tasers on criminal suspects in the field. Of this cohort, 462 injuries were minor; of those, 408 were superficial puncture wounds as a direct result of the taser barbs, and 62 suffered mild injuries from blunt head trauma.

Five subjects suffered major consequences: three with significant injuries and two who died. Of the significant injuries, two were closed head injuries from their fall, and the third suffered rhabdomyalosis. Of the subjects that died, one died approximately 20 minutes after being tased. He had cocaine in his bloodstream and dilated cardiomyopathy. The second subject died five minutes after being tased. His autopsy did not determine an anatomic cause for his death. The medical examiner did not conclude electrical conduction was causal in either of the fatalities. The remaining subset of tased suspects did not suffer any recorded injury from the event.

A second study from Academic Emergency Medicine was published in August 2009, and looked retrospectively at several cases of sudden death shortly after exposure to taser conducted electrical weapons. Of the 200 deaths reviewed, 118 of the subjects collapsed within 15 minutes of being tased, and 56 had a recorded presenting rhythm. Four of those presenting rhythms were ventricular fibrillation, and 52 were bradycardia-asystole or pulseless electrical activity.

The vast majority of the arrhythmias were not ventricular fibrillation. The study was unable to conclude that taser-induced ventricular fibrillation is a common cause of taser-induced sudden cardiac death. The study also remarked that a similar rate of fatality is also known to occur in subjects of a similar demographic who are apprehended using means other than taser. The study, however, did not report a probable cause of those deaths.

In summary, this year the data really began to roll in on the safety of taser-conducted electrical weapons. A leading cause of significant injury from conducted electric weapons appears to be head injury from fall. There is a small, but significant, subset of the population who suffer a sudden cardiac death within the first hour of being tased. However, the relationship between the effect of the conducted electrical weapon and their sudden death has yet to be fully elucidated. Undoubtedly, more research will follow.

3rd Annual AAEM/RSA
Midwest Medical Student Symposium a Success!

Jeff Pinnow, MD
AAEM/RSA Board of Directors
AAEM/RSA Education Committee Chair

The 3rd Annual Midwest Medical Student Symposium at Loyola University Chicago Stritch School of Medicine on August 22nd was, once again, a huge success. Medical students from across the Midwest attended the AAEM/RSA conference to gain knowledge about the emergency medicine residency process, as well as learn valuable skills for use during their ED rotations.

Dr. Tom Scaletta, AAEM Immediate Past President, gave an entertaining and educational talk about what makes emergency medicine a unique specialty, and also explained the role AAEM plays in the lives of emergency physicians. Dr. Scaletta discussed the unique attributes that emergency physicians must possess to be successful in the ED and what types of opportunities exist once they finish training and enter the workforce. He also described the role AAEM plays in advocating for fair contracts and proper board certification amongst emergency physicians and within EM groups.

Dr. Edward Callahan, Program Director and Education Fellowship Director at the Medical College of Wisconsin, gave the second lecture of the morning. Dr. Callahan outlined the process of applying to a residency program and described how his program evaluates the ERAS application. Two brave medical students volunteered to have their applications reviewed and scored by Dr. Callahan for all to witness. This demonstration provided the students with a perspective they normally would not realize and proved to be a valuable experience.

Following the lectures, the students had the chance to have their questions answered during the resident and program director panels. The residency panel consisted of Dr. Alicia Pilarski, AAEM/RSA Vice President and Chief Resident at University of Nevada, Las Vegas; Dr. Dan Bartgen, 1st year resident from Advocate Christ Medical Center; Dr. Daniel Gromis, 1st year resident at Advocate Christ Medical Center; and Dr. Jeff Pinnow, AAEM/RSA board member and Chief Resident at York Hospital. During the resident panel, students inquired about resident lifestyles, personal strategies used in applying for positions, and how competitive each resident felt he/she was when using Dr. Callahan's scoring system. This gave the attendees an opportunity to compare themselves with those who have successfully navigated the Match.

The program director panel was, once again, the highlight of the morning. Students eagerly asked questions of those on the panel. This year's panel consisted of Dr. David Overton, Program Director from the Michigan State University Kalamazoo Center for Medical Studies; Dr. Robert Harwood, Program Director from Advocate Christ Medical Center; Dr. Nicole Colucci, faculty from Resurrection Medical Center; and Dr. Edward Callahan, Program Director from the Medical College of Wisconsin. Discussions ranged from board scores to ways of handling difficult questions during the interview process. The students took full advantage of having four leaders in emergency medicine answer their questions to help them better prepare for obtaining a highly competitive EM residency spot.

During lunch, medical students were able to personally solicit advice from the program directors and residents. They provided the medical students with business cards, email addresses and phone numbers for further questions and potential mentoring. The relaxed nature of the lunch allowed the medical students to be themselves and have a good time getting to know some of the amazing people who have shaped our field. It helped match faces with the names that the program directors will be seeing on applications in years to come, giving those in attendance an advantage when application season approaches.

New to this year's Symposium were workshops aimed at helping students become more successful and productive during their EM rotations. An ultrasound workshop was conducted by Dr. Brent Becker, 3rd year and Chief Resident at the York Hospital Program in York, PA. During his workshops, students received hands-on training in performing FAST exams on one another, as well as performing ultrasounds of the aorta looking for possible aortic aneurysms. These skills have become indispensible for EM physicians, and this early training, along with additional practice during their rotations, will help the students to make a positive impression on those residents and attendings working with them.

A suturing workshop was also conducted by Drs. Bartgen and Gromis. This workshop included teaching the 1st and 2nd year students the basics of suturing, including proper anesthetizing techniques. For the 3rd and 4th year students, complex lacerations were addressed, and students were taught more complex techniques such as purse string sutures and mattress sutures. Knowledge of these techniques will help students shine on their future EM rotations.

Dr. Pilarski also gave a workshop to the 3rd and 4th years students covering ways of maximizing their experience on their EM rotations and giving valuable tips on the application process. Dr. Pinnow spoke with the 1st and 2nd year students, providing pearls on what they should do during their pre-clinical years to help them obtain experience and exposure to emergency medicine in preparation for the years to come.

Overall, the day proved be a huge success, and participants had nothing but positive things to say, expressing their thanks to AAEM/RSA for organizing such a high-quality educational event. Of course, the day could only be considered a success because of the hard work and dedication of the people involved. AAEM/RSA would like to thank all of the speakers who took time out of their lives to help enrich this experience for those medical students in attendance. Our resident members, despite the rigors of residency training, also deserve special thanks for finding the time to educate those who will follow in the coming years.

Our gratitude is also extended to Loyola University Chicago Stritch School of Medicine for allowing AAEM/RSA to use their outstanding venue for the event. Additionally, many thanks are owed to Jody Bath, AAEM/RSA Program Manager, and Lauren Pandolfe, AAEM/RSA Midwest Regional Representative, for their critical roles in planning and executing the event.

We look forward to another great Midwest Medical Student Symposium next year. If you would like to be involved with this event or any other AAEM/RSA activity, please contact jbath@aaem.org.

AAEM/RSA's Exclusive - A Must Have!

Emergency Medicine:
A Focused Review of the Core Curriculum

22 chapters, 225 board-style questions, 79 images...one way to excel! Here's a sneak peek:

A 45-year old man is brought by ambulance from a restaurant with the feeling that he has a piece of steak stuck in his throat. He is hemodynamically stable and his airway is patent. Of the therapies listed below, the one most likely to be effective is:

  1. Nifedipine
  2. Meat tenderizer
  3. Glucagon
  4. Diazepam
  5. Nitroglycerin

To purchase this incredible new resource, visit https://ssl18.pair.com/aaemorg/aaemrsa/book_store/index.php for your member discount!

Answer: The correct answer is C. Glucagon is helpful in approximately 50% of meat impactions at the lower esophageal sphincter. Nitroglycerin and nifedipine are limited by their side effects and are less efficacious than glucagon. Benzodiazepines are ineffective. Meat tenderizer has fallen out of favor.

Emergency Medicine in the Popular Press

The Washington Post publishes daily updates to their "Health-Care Reform 2009." Learn more about where we are, and more importantly, where we are going at http://voices.washingtonpost.com/health-care-reform/.

A few articles of particular interest:

"Health-Care Spending - France, which has national health insurance, spends less on health care per capita than the United States."

"How Significant Is the Malpractice Problem?"


New ACGME Accredited Emergency Medicine Residency at Southern Illinois University

We are pleased to announce the approval of a new ACGME Accredited EM Residency at Southern Illinois University in Springfield, Illinois.

The residency has received a 3-year accreditation from the ACGME and will participate in the 2009-2010 NRMP. The residency is now accepting applications through ERAS.

Program Overview:

Primary Sites: Memorial Medical Center, St. John's Hospital. Both are regional tertiary care facilities.

Annual ED Census: Approximately 120,000 patients per year between our two primary sites.

Trauma Status: The Level I Southern Illinois Trauma Center rotates on an annual basis between our two training sites.

School Affiliation: The SIUEM Residency is affiliated with Southern Illinois University School of Medicine. There are residents training at both of our sites in 15 specialties.

Contact Information:

Residency Coordinator:
Linda Schneider
SIU School of Medicine
Emergency Medicine Residency
P.O. Box 19638
Springfield, IL 62794-9638
217-545-3518 - voice
217-545-2711 - fax

Please see http://www.aaem.org/secure/repository/files/AAEMRSA/1254328107-SIUEM_Residency_Description.doc for full program details.


Emergency Medicine Physician Billing and Reimbursement Seminars

Beyond Basics is a 2-day small group seminar solely focused on billing and reimbursement training for emergency physicians, coders, administrators and other emergency department staff.

The next seminars:
November 12-13 - Providence, RI
January 18-19 - New Orleans, LA
February 11-12 - Seattle, WA

"...Do not finish residency without attending this seminar. Your future practice depends on it."

* Refer to this ad and receive a 50% discount!


Save the Date

Mark your calendar, and book your travel! This year's Scientific Assembly will be held at Caesars Palace in Las Vegas, NV, February 15-17, 2010. Join us for a resident track, student track and social! Consider entering the Journal of Emergency Medicine research or photo contest! For more information, go to http://www.aaem.org/education/scientificassembly/.

Call for Abstracts: AAEM/JEM Resident and Student Research Competition.

Deadline: November 6, 2009

For more information, go to http://www.aaem.org/UserFiles/Call%20for%20Papers%20brochure.pdf


Your Leadership

We welcome your comments and suggestions. Feel free to get in touch with your elected leaders:

Michael Ybarra, MD

Vice President
Alicia Pilarski, DO

Immediate Past-President
Megan Boysen, MD

Cyrus Shahpar, MD MPH MBA

At-large Board Members
Heather Jimenez, MD
Jennifer Kanapicki, MD
Jeff Pinnow, MD
Ryan Shanahan, MD
Sandra Thomasian, MD

Medical Student Council President
Jamie "Akiva" Kahn

Modern Resident Contributors

Copy Editor: Teresa Matejovsky, MD

This month's Journal Club, Tox Talk and Critical Care Pearl written by Robert Katzer, MD

Interested in writing?

E-mail submissions to: info@aaemrsa.org

Please submit articles by November 15th for the December/January edition.

In the subject line please indicate: "Tox Talk", "Critical Care Pearl", "Board Review", "Journal Club", "Image of the Month", or submit any new articles you would like us to consider!