Trevonne M. Thompson

Fentanyl epidemic in Chicago, Illinois and surrounding Cook County

Introduction. Epidemics related to illicit fentanyl abuse have been reported and the potential exists for a national epidemic associated with high mortality. This report describes emergency department visits for opioid toxicity and a recent outbreak of illicit fentanyl fatalities in Chicago, Illinois and surrounding Cook County. Methods. Retrospective chart review of opioid-related overdoses seen in our emergency department and a retrospective review of data from the Cook County Medical Examiners Office Fentanyl Fatality Database from April 2005 through December 2006. Results. Our emergency department treated 43 patients with a total of 55 emergency department visits during this time. Paramedic transport was utilized for 83.6% of the emergency department visits and naloxone was administered during 80.4% of transports. Naloxone was administered during 47.3% of emergency department visits witwh total doses ranging from 0.4 mg to 12 mg. Eighty percent of cases were treated and discharged from the emergency department. During this same time frame, the Medical Examiners office identified 342 fentanyl-related fatalities. In 2006, illicit fentanyl fatalities represented 6.9% of all Medical Examiner cases for that year. Approximately 80% of deaths occurred in Chicago. A peak in fentanyl-related deaths occurred in the spring of 2006 and again in the fall of 2006 while the number of emergency department visits peaked during May of 2006. Conclusion. Chicago and surrounding Cook County experienced an outbreak of 342 fentanyl-related deaths between April 2005 and December 2006. The experience demonstrated a clear need for an interdisciplinary approach to identifying, communicating, and managing an outbreak.

The general approach to the poisoned patient

The poisoned patient can present many challenges to the healthcare practitioner. An organized and thoughtful approach to the poisoned patient is necessary. Understanding the nuances of a toxicological history and physical examination can aid in the management of these patients. Supportive care with attention to the body systems at risk from the poisoning is the mainstay of therapy. Consultation with a medical toxicologist or regional poison control center can positively impact diagnosis, management, and disposition of poisoned patients.

Computerized N-acetylcysteine physician order entry by template protocol for acetaminophen toxicity

Some medication dosing protocols are logistically complex for traditional physician ordering. The use of computerized physician order entry (CPOE) with templates, or order sets, may be useful to reduce medication administration errors. This study evaluated the rate of medication administration errors using CPOE order sets for N-acetylcysteine (NAC) use in treating acetaminophen poisoning. An 18-month retrospective review of computerized inpatient pharmacy records for NAC use was performed. All patients who received NAC for the treatment of acetaminophen poisoning were included. Each record was analyzed to determine the form of NAC given and whether an administration error occurred. In the 82 cases of acetaminophen poisoning in which NAC was given, no medication administration errors were identified. Oral NAC was given in 31 (38%) cases; intravenous NAC was given in 51 (62%) cases. In this retrospective analysis of N-acetylcysteine administration using computerized physician order entry and order sets, no medication administration errors occurred. CPOE is an effective tool in safely executing complicated protocols in an inpatient setting.

Case Files of the Toxikon Medical Toxicology Fellowship in Chicago: The Poisoned Anesthesiologist

ConclusionSuicide attempts by health care workers are very serious because these patients have the knowledge of and access to potentially lethal substances. Our patient presented with hypotension and hemodynamic instablility. He was treated with multiple-dose activated charcoal and 2 rounds of hemodialysis. While there was rapid toxicokinetic improvement and extubation on day 2 of his hospital stay, he had prolonged altered mental status, illustrating the long-acting effects of phenobarbital. It remains unclear exactly how our medical treatment regimens alter the clinical course of phenobarbital poisoning. We are indebted to Clemmesen and Nilsson for their description of the Scandinavian Method and the resulting reduction in morbidity from sedative-hypnotic poisoning. Further research is needed to define the precise clinical benefit achieved from additional therapeutic modalities in treating such poisonings.

Salicylate Toxicity from Genital Exposure to a Methylsalicylate-Containing Rubefacient.

Methylsalicylate-containing rubefacients have been reported to cause salicylate poisoning after ingestion, topical application to abnormal skin, and inappropriate topical application to normal skin. Many over-the-counter products contain methylsalicylate. Topical salicylates rarely produce systemic toxicity when used appropriately; however, methylsaliclyate can be absorbed through intact skin. Scrotal skin can have up to 40-fold greater absorption compared to other dermal regions. We report a unique case of salicylate poisoning resulting from the use of a methylsalicylate-containing rubefacient to facilitate masturbation in a male teenager. Saliclyate toxicity has not previously been reported from the genital exposure to methylsaliclyate.

Lessons Learned from the Reimbursement Profile of a Mature Private Medical Toxicology Practice: Office-Based Practice Pays

We previously reported the financial data for the first 5xa0years of one of the author’s medical toxicology practice. The practice has matured; changes have been made. The practice is increasing its focus on office-based encounters and reducing hospital-based acute care encounters. We report the reimbursement rates and other financial metrics of the current practice. Financial records from October 2009 through September 2013 were reviewed. This is a period of 4 fiscal years and represents the currently available financial data. Charges, payments, and reimbursement rates were recorded according to the type and setting of the medical toxicology encounter: forensic consultations, outpatient clinic encounters, nonpsychiatric inpatient consultations, emergency department (ED) consultations, and inpatient psychiatric consultations. All patients were seen regardless of ability to pay or insurance status. The number of billed Current Procedural Terminology (CPT) codes for office-based encounters increased over the study period; the number of billed CPT codes for inpatient and ED consultations reduced. Office-based encounters demonstrate a higher reimbursement rate and higher payments. In the fiscal year (FY) of 2012, office-based revenue exceeded hospital-based acute care revenue by over

Diversity in medical toxicology: Why this is important.

140,000 despite a higher number of billed CPT encounters in acute care settings, and outpatient payments were 2.39 times higher than inpatient, inpatient psychiatry, observation unit, and ED payments combined. The average payment per CPT code was higher for outpatient clinic encounters than inpatient encounters for each fiscal year studied. There was an overall reduction in CPT billing volume between FY 2010 and FY 2013. Despite this, there was an increase in total practice revenue. There was no change in payor mix, practice logistics, or billing/collection service company. In this medical toxicology practice, office-based encounters demonstrate higher reimbursement rates and overall payments compared to inpatient and ED consultations. While consistent with our previous studies, these differences have been accentuated. This study demonstrates the results of changes to the practice—reduced inpatient/ED consultations and increased outpatient encounters. These practice changes resulted in higher overall revenue despite a lower patient volume. In this analysis, the office-based practice of medical toxicology has higher reimbursement rates, nearly 2.5 times higher, when compared to hospital-based acute care consultations.

Parenteral ophthalmic tropicamide or cyclopentolate protects rats from lethal organophosphate poisoning.

Medical toxicology is an avant-garde specialty. The care provided by medical toxicologists knows no boundary and encompasses all aspects of the practice of medicine. Medical toxicologists have responded to world disasters, testified before federal regulators regarding medication safety, performed research on novel antidotes, and even alerted authorities to the presence of serial poisoning. Yet in 2013, there is a toxicologic health disparity in the USA. In 2002, the Institute of Medicine released a report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. This report stated that “Evidence of racial and ethnic disparities in healthcare is, with few exceptions, remarkably consistent across a range of illnesses and healthcare services” [1]. The racial and ethnic health and health-care disparity is evident in our field. n nEnvironmental injustice is a term that describes the disproportionately heavy exposure of vulnerable populations to toxic chemicals, contaminated water, unsafe workplaces, and other environmental hazards [2]. The concept of environmental injustice was developed in the 1980s when studies found that waste sites in the Southeastern United States were located in poor counties inhabited, in large part, by African-Americans and Native Americans [2]. Similar waste site distributions were found elsewhere in the USA [2, 3]. Waste sites are not the only sources of environmental injustice, and disproportionate exposure to intoxicants has consequences. African-American children consistently are documented to have higher rates of lead poisoning than white children [4–6]. Air pollution has been linked to increased cancer risk in certain African-American communities [7]. Migrant farm workers have been exposed to work conditions leading to pesticide toxicity in the fields and, in some cases, exposing their families in the home [8]. These are just a few examples of the many that illustrate the toxicologic health disparity. n nUnderserved populations, specifically racial and ethnic minorities, suffer disparities in the treatment of cardiovascular diseases, HIV, cancer, and diabetes, among other medical maladies [1, 9]. The same applies to toxicologic maladies as well. A consistent recommendation to combat racial and ethnic disparities in health care is to increase the proportion of underrepresented US racial and ethnic minorities among health professionals [1]. Within the fold of racial and ethnic minorities, there is the concept of physicians who are underrepresented in medicine. The Association of American Medical Colleges defines underrepresented in medicine as physicians whose numbers in medicine are disproportionally lower than in the US population [10]. This group has historically included African-Americans, Native Americans, Mexican Americans, and mainland Puerto Ricans; however, underrepresented in medicine is not limited to these groups. Racial and ethnic minority physicians are more likely to serve minority and underserved populations and can help health systems improve cultural competence and reduce linguistic barriers [9, 11]. Racial and ethnic minority patients report higher satisfaction when care is provided by minority health-care professionals [9, 11]. Diversity of faculty and staff in medical education and training has a positive impact on the education of all students [12, 13]. Racial and ethnic diversity among investigators would broaden the research agenda and increase the likelihood of conducting research within minority communities [12, 13]. When examining the data regarding diversity in medicine, there is no specific mention of the practice of medical toxicology. While these data apply to our specialty, it is conceivable that the young age of our specialty has precluded specific research by medical toxicologists in this direction. n nThe 2010 US Census Bureau data show that 13xa0% of the US population was identified as African-American or Black and 16xa0% were Hispanic [14]. A 2010 report from the AAMC shows that 5xa0% of emergency physicians, the specialty in which most medical toxicologists are trained primarily, are African-American and 5.3xa0% are Hispanic [15]. There are no racial and ethnic data available for medical toxicology as a specialty or within our specialty society, the American College of Medical Toxicology. n nThe strides medical toxicology has made in a short span of time—ACGME recognition for fellowship programs and board certification within the American Board of Medical Specialties, an active and engaged professional society—show that our field is comprised of energetic and innovative physicians. Within our field, however, increased attention should be given to the concepts of diversity in medicine and toxicologic health disparities and efforts should be made to address their consequences. We should actively recruit physicians of diverse backgrounds into our specialty. We should invite to our meetings and form collaborations with physicians and researchers of various specialties who are working to address issues related to environmental injustice and health disparities. As we are the leaders in all other aspects of medical toxicology, we should become leaders addressing the toxicologic health disparity in all of its facets.

Reviewing the Record: Medical Record Reviews for Medical Toxicology Research

We determine the efficacy of parenteral ophthalmic antimuscarinic agents (tropicamide ophthalmic 1% and cyclopentolate hydrochloride ophthalmic 1%) on survivability in a rat model of acute, lethal organophosphate pesticide (OP) poisoning. After obtaining an appropriate dose-response for study comparison, rodents were randomized to receive 1 of 4 intraperitoneal antidotes; (1) 0.3 mL normal saline, (2) atropine 10 mg/kg, (3) ophthalmic tropicamide 20 mg/kg, or (4) ophthalmic cyclopentolate 20 mg/kg. Five minutes after pretreatment, 15 mg/kg of dichlorvos was administered subcutaneously. Mortality rates and time to death were compared using Fisher exact test and the Kaplan-Meier method with log-rank test, respectively. If alive at 120 minutes, survival was assumed and the study was terminated. Survival in rats pretreated with atropine (10 mg/kg) was 90%. Survival in rats pretreated with tropicamide (20 mg/kg) and cyclopentolate (20 mg/kg) were 90% [P < 0.01; 95% confidence interval (CI) 0.71-1.09] and 90% (P < 0.01; 95% CI 0.71-1.09), respectively, compared with controls (10% survival; 95% CI 0.04-0.45). Time of death ranged between 6 and 13 minutes in nonsurvivors. Overall comparison of survival time revealed a statistically significant improvement in experimental groups compared with controls (P < 0.0001). Pretreatment with parenteral ophthalmic solutions (tropicamide or cyclopentolate) was equivalent to standard atropine in preventing lethality in this rat model of acute, lethal OP poisoning.

Emergency Department Patient Burden from an Electronic Dance Music Festival

Medical records are a treasure trove of data with tantalizing prospects for scientific advancement. In medical toxicology, medical records can provide detailed narratives of the clinical course and treatment of poisoned patients. These narratives identify nuances about exposures, provide insights into novel treatments, and stimulate ideas for future research. On the other hand, medical records often contain errors, omissions, and inconsistencies. Therefore, medical record review studies, also known as chart review studies, should be well-designed to contribute meaningfully to the medical literature. The randomized, double-blind, placebo-controlled study represents a high methodological standard for medical research [1, 2]. There are several reasons why this study design is not always practical or feasible, especially in medical toxicology. First, it is unethical to poison human subjects prospectively and simply describe the clinical course or provide therapy to only a subset of the cohort. Second, many poisonings are rare, and performing a sufficiently powered prospective study cannot be done in a reasonable timeframe. New knowledge in the field of medical toxicology usually occurs from novel exposures, unplanned events, and natural experiments. For these reasons, case reports, surveys, and medical record reviews each play an important role in advancing patient care. These each have limitations that can be mitigated through rigor in design and manuscript preparation. Methodological rigor, regardless of study type, can minimize bias while performing the investigation and improve the published product [3]. Here at the Journal of Medical Toxicology (JMT), we have previously published guidelines and best practices to help authors improve their case reports and survey studies [4, 5]. We believe the quality of case reports and surveys have improved since we published those guidelines. Since the majority of the research submitted to and published in our journal are retrospective medical chart reviews, our editors deliberated for several years how best to guide the authors of these submissions. Many experienced members of our editorial board frequently cite the 1996 guidelines proposed by Gilbert and the subsequent article in 2005 by Worster, both in the field of emergency medicine, when evaluating submitted manuscripts that rely on medical record reviews [6, 7]. Although many of the retrospective studies submitted to JMT include cases that originated in the emergency department, we recognize differences in the field of medical toxicology from that of emergency medicine. For these reasons we describe here the important elements of a medical chart review study that should be considered by investigators when planning their studies and by authors when drafting a submission to JMT. It is most important for all stakeholders to remember that the primary purpose of the medical record is not for research: instead, it is a document containing patient-focused medical information [6]. A medical record serves many roles—a communication tool between clinicians about patient care, an archive of a patient’s clinical course, a source for medical coders and insurance billing, and even as evidence in legal proceedings. Historically, William Osler and other pivotal physicians used patient care records for retrospective research studies [8]. Today’s medical chart would be unrecognizable to Osler; we also have a better understanding of the limitations of using a medical chart for research. The modern medical record includes multiple authors with different levels of training and different perspectives on patient care. The authors may be paramedics, nurses, pharmacists, medical students, and varying levels of physicians—residents, fellows, and attendings. What is asked of patients and what is examined varies by provider, and how that information is documented by the many different people involved in a single patient encounter * Jaiva Larsen jaiva.larsen@gmail.com