Emergency Medicine

Toxicology Fellowship Session Topics and Chapter Lists

  • Tox primer - toxidromes, antidotes, QRS/QT prolong (GF3,4) supportive care (GF12,16), basic acid/base (GF12)
  • GI decontamination (GF5/SC2,GFA1,GFA2)
  • Acetaminophen(GF33) / NAC(A3)
  • Salicylates(GF37) / sodium bicarbonate(A5)
  • NSAIDs(GF35)
  • Toxic Alcohols(GF106)/Fomepizole(A33)/Ethanol(A34)/(SC9)
  • Beta Blockers(GF59) / glucagon(A20)
  • CCB(GF60) /High dose insulin(A21)
  • Antipsychotics(GF67)/bromocriptine
  • Carbon monoxide(GF122) / HBO(GFA40)
  • Cyclic antidepressants(GF68)/sodium bicarbonate(A5)
  • Atypical antidepressants, SRIs (GF69)
  • Sedative/hypnotics(GF72)/flumazenil(A25)/GHB(GF80)(Rachel)
  • Withdrawal principles(GF14) & ethanol wd(GF77)(annette)
  • Lithium(GF70) & Monoamine oxidase inhibitors(GF71)(annette)
  • Cardioactive steroids(GF62)/digoxin-specific antibodies(A22)
  • Antiepileptics(GF48)/L-carnitine(A10)
  • Opioids(GF36)/Naloxone(A4)
  • Cardiologic principles(GF15), antidysrhythmics (GF57), magnesium(A16)(annette)
  • Snake envenomation(GF119), crotalid anti-venom(GFA39),non-native snake envenomation(GFSC10)
  • Iron(GF45)/deferoxamine(A7)(Rachel)
  • Antihistamines(GF49) / physostigmine(A11)(annette)
  • Caustic ingestions(GF103)
  • Hydrofluoric acid(GF104), calcium(A32)        
  • Pharmacokinetic principles/ Pharmacodynamics/ toxicodynamics (dose/concentration relationship to effect, receptor agonism/antagonism, receptor regulation, structure-activity relationship)(GF9) (DANA)
  • UDS primer - Workplace drug & alcohol testing (MRO, cutoffs, adult/dil/subst) (Matt Noble)
  • Drugs of Abuse primer + diluents, adulterants, contaminants(Rob)
  • Metals primer (As, Pb, Hg) (Annette)

Year 1:

  • Neurotransmitters and neuromodulators(GF 13)
    Physiology and neurotransmission
    Acetylcholine, muscarinic/nicotinic receptors, norepinephrine/epinephrine, alpha/beta receptors
    Dopamine and dopamine receptors
  • Neurotransmitters and neuromodulators(GF 13)
    Serotonin and 5HT receptors
    GABA and GABA channel
    GHB, Glycine, Adenosine
    Glutamate and NMDA receptor
  • Cyanide/hydrogen sulfide(GF123), antidotes(GFA41,A42)
  • Mushrooms(GF117) / silibinin
  • Insecticides: Organic phosphorous/carbamate(GF110)/ atropine(GFA35)/2-pam (A36)
  • Organic chlorines/ pyrethrins/pyrethroids(GF111)
  • Cocaine(GF75) & benzodiazepines(A26)
  • Hallucinogens(GF79)
  • Phencyclidine and ketamine(GF83)
  • Lead(GF93)/ BAL(GFA28) / EDTA(GFA30)
  • Mercury(GF95)
  • Arsenic(GF86) / DMSA(GFA28)
  • Inhalants(GF81)
  • Fungicides (SK102), EPA chapter
  • Herbicides(GF109)
  • Cannabis/Cannabinoids(GF74)
  • Methamphetamine and amphetamine(GF73)
  • Antimalarials(GF55)
  • Antituberculous drugs(GF56)/pyridoxine(A15)
  • Antibiotics, antifungals, antivirals(GF54)
  • Anti-migraine medications(GF52)
  • Methylxanthines and beta agonists(GF63)
  • Misc antihypertensives (ACE, ARB, vasodilators, alpha agents)(GF61)
  • Antidiabetics and hypoglycemic (GF47)/octreotide(A8,9)
  • Thyroid and anti-thyroid medications (GF53)
  • Anti-thrombotics(GF58)/PCC(A17)/vitamin K(A18)/protamine(A19)
  • Anesthetics-local(GF64) & lipid emulsion(A23)
  • Anesthetics-inhalational(GF65)
  • Chemotherapeutic agents(GF50,GF51), folinic acid(A12), glucarpidase(A13), Uridine triacetate(A14)
  • Methotrexate, 5-fluorouracil, capecitabine(GF51)
  • Pharmaceutical additives(GF46)
  • Dieting agents and regimens(GF40)
  • Pneumoconioses (SK 41)
  • Methemoglobin inducers(GF124), methylene blue(A43)
  • Marine envenomation(GF116)
  • Athletic performance enhancers(GF41)
  • Simple asphyxiants and pulmonary irritants(GF121)
  • Rodenticides (coumarin, inandiones, smfa, phosphide, as03, barium, tetramine, choloecalciferol, Bromethalin, antu, thallium, yellow phosphorus, strychnine)(GF case study 11, 107, 112, 113, 114)
  • Ophthalmologic(GF24) & Otolaryngologic principles(GF25)
  • Thermoregulatory principles(GF29) / dantrolene(A24)
  • Dermatologic principles(GF17),transdermal toxicology(GFSC3)
  • Gastrointestinal principles(GF18)
  • Hematologic principles(GF20)
  • Vitamins(GF44)

Year 2:

  • Dietary supplements(GF43)
  • Arthropods(GF115), spider antivenom(GFA37), scorpion antivenom(GFA38)
  • Colchicine, podophyllin, and vinca alkaloids(GF34)
  • Asbestos and MMFs (SK 111 & 112)
  • Disulfiram and disulfiram-like reactions(GF78)
  • Persistent Environ Chemicals (PCBs and dioxin) (Rom chapters)
  • Poison Center Admin/epidemiology/AAPCC(GF129,130)
  • Principles of epidemiology (GF137)
  • Adverse drug events (ADE, drug interactions, immunologic response, polymorphisms causing adverse events, and epigenetics)(GF134)
  • Chemical principles(GF10) & chemical structures
  • Solvents - Aliphatic, aromatic, halogenated (GF105)
  • Solvents - Aldehydes (SK95,96) & Ketones (SK107 just ketone section)
  • Neurologic principles(GF22)
  • Principles and techniques applied to enhance elimination(GF6)
  • Hepatic principles(GF21)
  • Renal principles(GF27)
  • Genitourinary principles(GF19)
  • Antiseptics, disinfectants, and sterilants(GF 101)
  • Chemical weapons(GF126)
  • Biological weapons(GF127)
  • Radiation (GF128) / SKI (GF A44) / DTPA (GF A45)
  • Internal concealment of xenobiotics(SC5)
  • Biochemical and metabolic principles(GF11)           
  • Reproductive and perinatal principle(GF30) (pharm of pregnancy, neonate, placental and breast milk transfer)
  • Food poisoning(GF39)
  • Botulism(GF38), botulinum antitoxin(GFA6)
  • Response to Hazmat incidents(decon, ICS, CZ, resources)(GF132) & clandestine drug labs(GB66)
  • Neuromuscular blockers(GF66)
  • Nicotine and tobacco(GF82)
  • Essential oils(GF42)
  • Intrathecal administration(SC7) & extravasation(SC8)
  • Occupational Health risk assessment (GF131)
  • Risk assessment & communication(GF133)

Additional:

  • Occupational asthma (ROM26)
  • Manganese (GF94)
  • Selenium (GF97)
  • Thallium (GF99) & prussian blue (GF A31)
  • PCBs (Rom 77)
  • Pulmonary function testing (Rom 15)
  • Carbon disulfide (Rom 79)

Every year

Professional Development:

  • Medical legal aspects of tox/expert witness lecture
  • Medical legal aspects of tox/expert witness report
  • Reviewing for journals 1- lecture
  • Reviewing for journals 2 - review

Occupational toxicology topics

  • Asynchronous – principles of occupational toxicology: diagnosis and control (GF131)
    • Industries -
      Construction(SK48) (carpentry(GB5), painting, welding(GB38))
      Chemical manufacturing(GB45) & Pharmaceutical industry
      Artists(GB2), Jewelers(GB20) & Cosmetology(GB19)
      Munitions/explosives manufacture & Law enforcement(GB30), combustion toxicology(SK50)
      Agricultural industry(SK52) (crop fumigation, pesticides, manure pits, silos)(GB15), fumigation(GF108), camphor/moth repellants(GF102)
      Aerospace(SK37,GB41) & Shipbuilding/breaking(GB52,SK46) & automotive manufacture (GB42) & Airbag manufacture (SK 36)
      Health care(GB9)
      Mining(GB46, SK40) & Smelting/metal refining/ reclamation(GB37,SK40)
      Petroleum/petrochemical industry (GB47, SK67-70)
      Plastics/Epoxy/Resin/Rubber manufacture(SK34,35,chart fr GB54)
      Timber/pulp/paper industry (GB49,SK44)
      Sanitation/sewer treatment(GB35), waste treatment(SK45), water treatment (SK51)
      Semiconductor industry(GB51, SK33)
      Textile industry (GB53) & Dry cleaning(GB11)
    • Environmental
      Intro to environmental toxicology (Precautionary princ, vuln pop)
      Food and drinking water toxicology
      Indoor air pollution (GB 56)
      Outdoor air pollution (GB 57)
      Soil and surface water pollution (Ladou48)
    • Forensic
      Forensic toxicology introduction
            Postmortem specimens, interpretation, redistribution
            Collection/storage/interpretation of specimens, different matrices (blood, saliva, breath) (GF140)
      Forensic opioids & cannabis
      Drug-facilitated sexual assault
      Forensic ethanol (GF76 & SC11)
    • Addiction tox
      Introduction to addiction toxicology
          Definitions (addiction, dependence, wd, tolerance, hyperalg)
          Treatment (Alc UD, opioid UD, behavioral int. buprenorphine, methadone, naltrexone, disulfiram
          Screening, assessment, and brief intervention

Every other year:

Esoteric tox –
Year 1:

  • Veterinary products
  • Household products
  • Chelation
  • Hazmat/skin decontamination
  • Minor metals, part 1
  • Minor metals, part 2
  • Metal and polymer fume fever
  • Role of federal agencies/regulatory bodies
  • Toxic alcohols (lesser known; DEG, EGBE)
  • Miscellaneous drugs lecture
  • Miscellaneous drugs 2 lecture
  • Abortifacients and teratogens

Year 2:

  • Population health, study design, statistics, & causation
  • Toxicologic Cancers (IARC, NTP, etc)
  • Toxicology associated with human milk/breastfeeding
  • Molecular mechanisms (ion channels and pumps, enzymes & transport proteins, glycolysis, ox phos, membranes)
  • Nonworkplace testing (etoh, nicotine, hair/mec/vitreous, CLIA)
  • Molluscides (oxidizers-chlorine, chloramine, bromine, h2o2, iron; and non-oxidizers-ammonium, aromatic, amine salts, niclosamide)
  • Mutagenesis / carcinogenesis /epigenetics
  • Airborne solids(silicosis/organic dust/coal dust, silica)
  • RADS/Occupational asthma
  • Environmental toxins (WTC cough, multi-chemical sensitivities)
     
  •  Added when possible:  Plants(GF118)

Possible additional lectures:

  • Chemical warfare (zane, rob, matt)
  • Tear gas (zane)

Orientation topics for the first day on campus:

  1. July Intro
    1. First day stuff
      1. Badge
      2. Key
      3. Computer
      4. Toxicall on your computer
      5. EPIC on your computer
      6. Phone - reimbursement
      7. Give pager and phone # to Rachel
      8. Copier
      9. Printers
    2. Fellowship Handbook
      1. Roles in the fellowship
        1. Faculty
        2. PC leadership
        3. Fellowship coordinator/EM staff
        4. EM administration
      2. Consultation service and consult requirements
        1. Consults 200
        2. Occupational/Environmental 25
        3. Pediatric 25
      3. Poison Center – Oregon, Alaska, Guam
      4. How to use:
        1. ToxIC registry/RedCap
        2. Toxicall
        3. Micromedix
        4. Outlook calendar
        5. Microsoft Teams
        6. OneDrive
        7. Library & OVID
        8. Shiftadmin
          1. How to request off/on ED shift
          2. Rules for requesting off/on ED shifts
          3. Conferences:  NACCT, ACMT, western fellows, ?others
      5. Merit award
      6. Wellness program
      7. ACMT & AACT
      8. CME
      9. Meals
      10. Policies and guidelines
        1. Vacation and PTO
        2. FMLA, dress, hand-offs, duty hours
        3. Moonlighting –
          1. Duty hours
          2. No more than 6 total shifts a month
          3. No PC call during shifts
        4. Wellness
          1. 1 day off a week
          2. Break each call day
        5. Graded responsibility
    3. What does July look like?
      1. Daily chapters
      2. Patient to see?
        1. 9a in person consults, led by on call
        2. Check OHSU tab on toxicall and text group
        3. Others will help document in room
        4. Try to share responsibilities of notes and redcap especially if multiple patients
        5. If no patients to see, plan for 10a. Fellow from day before typically leads sit rounds to review interesting cases (Thursdays this will be with Utah)
      3. Use your weekends to explore this month!
    4. Regular schedule in August
      1. Cases for Multicenter (WA) conference
      2. If on call:
        1. 7a-7a  pager vs cell phone
        2. Check OHSU tab on toxicall and text group
        3. Patient to see?
          1. 9a in person rounds, led by on call
          2. Others will help document in room
          3. Try to share responsibilities of notes and redcap especially if multiple patients
        4. If no patients to see, plan for 10a. Fellow from day before typically leads sit rounds to review interesting cases (Thursdays this will be with Utah)
        5. Make sure students/residents know if we are online/in person/watching a webinar/on another link like WA
      3. Consults:
        1. IP consult to Poison Center
        2. Billing rules
        3. .toxconsult    
        4. MedHub – documenting consults
      4. Being on call
        1. Interacting with SPIs
        2. Closing cases
        3. Staffing
        4. Take your hour!
        5. What to do if doc is on the line
      5. Be prepared for:
        1. Chapter every Wednesday
        2. Q4 minor tox
        3. Journal club on Thursdays
      6. Daily schedule
        1. Monday
          1. 10a Resident topics/student cases
          2. 1p usually attending led
          3. 1p WAPC Monthly
        2. Tuesday
          1. 10a Resident topics/student cases
          2. 11a Chapter review (see list)
          3. 1p usually attending led
        3. Wed: Fellow Day (no other learners)
          1. 10a Resident topics/student cases
          2. 11a Rob – ‘fellow didactic’ and minor tox
            1. Fellow didactic
            2. Minor tox
        4. Thurs
          1. 10a Resident topics/student cases
            1. Round with Utah starting at 10a
          2. 1p Journal club
            1. Some other faculty attend
              1. Dana Bojorquez
              2. Alumni
        5. Friday
          1. 10a Resident topics/student cases
          2. 1p Student/resident disasters
    5. Resources to have on hand for call – how to access them
      1. Download our policies and read them
      2. Goldfrank
      3. Lange
      4. Micromedex
      5. Pubmed/OVID
  2. Requirements:
    1. Consults (200 total, 25 peds, 25 occupational/industrial)
    2. Research – (1st year-case or review, 2nd year-research project)
    3. QI project – on QI committee in 2nd year
    4. One occupational “site visit” per year
    5. Fellowship schedule
      1. Decide amongst fellows and enter into shiftadmin
      2. Poison Center Call
        1. 10/month first year; 5/month second year
        2. 1-2 shifts/mo can be day shifts, but avoid Tu, W & Th.
        3. Reduction of calls:
          1. Don’t take call at conferences
          2. If at conference or on vacation, reduce your call by the percentage of days that you are at conference/vacation. For example, if you do 10 calls/month and you are at a conference for 3d in September, then reduce your 10 calls/month by 3/30 (conference days/total days in month) = 0.1 x 10 = reduce calls by 1 call = 9 calls in Sept. If on vacation for 7d, then reduce calls by 7/30 x 10 = 2 calls reduction = 8 calls in Sept.
    6. Occupational Toxicology
      1. Brent Burton – email
      2. See our own patients through the PC
  3. Grants & awards
    1. ACMT, AACT, MTF, ACEP
  4. Primary care doctor and dentist
  5. Ongoing fellow/attending projects to get involved in
    1. Fentalog
    2. DEA Tox & PSCAN
      1. Who is Jordan, Roy and Steve
    3. FACT/DOTS
  6. Advice for fellowship:
    1. Have fun
    2. This is a time for doing things that you won’t do later
    3. Dive in deep into the information
    4. Develop all of the tools that you want for your career

Orientation topics for July and August

Topics for all faculty to discuss with new fellows:

  • Simulated difficult calls – review with fellows a difficult call
  • How to handle calls with:
    Limited info and doc on the line
    Physician who doesn’t want to take your advice
    Physician who says “I’ve never heard of that before” – HDI, IVLE, methylene blue
    Patient in small AK village with no medevac flying
  • How to handle a possible welfare check
  • How to write a good toxicology consultation note
  • Wellness
  • What can we monitor at home – BPs? Pulse? Cap refill? Fingerstick glucose? Pulse ox?
  • When to do advise SPIs to call back on pts at home or in hospital (e.g. tmax v half-life)
  • Advice on what to get out of/how to plan your fellowship
  • Discuss research opportunities or projects
  • Review geography of OR, AK, Guam, N. Marianas  
  • Career building:
    What jobs are available for a medical toxicologist?
    Building a medical toxicology CV
    Media training
    Intro to statistics, part 1 (Amber Lin)
    Intro to statistics, part 2 (Amber Lin)
    Intro to Medhub (Kim & Kiahna)
    Intro to Toxicall (Anne)
  • Invasive procedures:
    HBO – where are the chambers, and what are the rules
    Dialysis – who does it; general use of EXTRIP guidelines
    Endoscopy - for button battery removal in Kids Endoscopy – for caustic injury
    ECMO – who does it? Who will go to hook up the pt?
  • Lab Issues:
    Labs – Alaska toxic alcohols
    Labs – Oregon toxic alcohols
    Labs – Iron conc./ deferoxamine challenge test
    Labs – Heavy metals, what and when to send
    Labs – Novel psychoactive substances – (in studies/ UCSF/ NMS)
    Labs – fish poisoning
    Labs – acetylcholinesterase labs for pesticide exposure
    Labs – Botulism animal testing with local
    Labs – CDC – abrine and ricinine
    Labs – methotrexate concentrations
  • Unique resources:
    Using the pharmacy department for uncommon medication acquisition
    Mushroom identification and our mycologists
    Plant Identification and plant toxin concentration resources
    How to get exotic antivenoms (Miami FD)
    Botulism – how to call the CDC to get antitoxin
    Multi-casualty chemical event – OERS/ HAZMAT teams
    Oregon Emergency Response System(OERS)
    Mercury spills – cleanup and EPA involvement
    EPA Radiation antidotes – RE/ACTS
    Malignant Hyperthermia hotline
    Product Safety – role of CPSC
    Working with local Health Dept on emerging issues
    Medical Examiner’s office – role in fatality cases
    Veterinary issues - the Animal Poison Center and John Tegzes
    Vet Poison Control
    Button battery hotline
  • Poison Center:
    Alaska village health provider system
    Why do the CSPIs call me about this – threshold protocols (e.g. sal > 50)
    How to have a call reviewed for CQI
    When is it appropriate to close a case?
    Expectations of taking call – answer routine page w/in 10 min, emergent phone calls, what if I’m driving?
    When to call faculty? Or medical director?
    General overview of PC rules for accreditation and funding
    Roles in the PC – director, medical director, SPI, educator, etc
    Learning the guidelines (read them when we do a chapter; store them for easy access)
  • Fellowship Issues:
    Expectations when taking call (10 min response, when to call MBU, location)
    Professionalism
    Billing and reimbursement in toxicology
    Making your schedule
    Planning your fellowship
    The one hour off per day rule - making sure you contact the PC and faculty
    Fatigue Mitigation
    What are the milestones and why do I care?
    Duty hours & using medhub (Kim, Kiahna)
    Disclosing adverse events to patients and families
    Wellness, substance abuse, depression, burn out & institutional protocol for helping physicians
    Diversity & Inclusion
    Financial planning, 401b, etc
  • Simulated difficult calls, 4 sessions