Emergency Medicine

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,John)
  • 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) *
  • Drugs of Abuse primer + diluents, adulterants, contaminants(Rob)
  • Metals primer (As, Pb, Hg) (Annette, Matt)
  • Mushrooms(GF117) / silibinin **
  • Insecticides: Organic phosphorous/carbamate(GF110)/ atropine(GFA35)/2-pam (A36) *
  • Methemoglobin inducers(GF124), methylene blue(A43) *
  • Biochemical and metabolic principles(GF11) *       

Fellow conferences: * = questions on the chapter are written (** could use an update)

Year 1(37):

  • 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) *
  • Hallucinogens(GF79) *
  • Phencyclidine and ketamine(GF83) *
  • Lead(GF93)/ BAL(GFA28) / EDTA(GFA30) *
  • Mercury(GF95) *
  • Arsenic(GF86) / DMSA(GFA28) *
  • Inhalants(GF81) *
  • Fungicides (SK102), EPA chapter
     
  • Cocaine(GF75) & benzodiazepines(A26) *
  • Organic chlorines/ pyrethrins/pyrethroids(GF111) *
  • Herbicides(GF109) *
  • Cannabis/Cannabinoids(GF74) *
  • Methamphetamine and amphetamine(GF73) *
  • Antimalarials(GF55) *
  • Antituberculous drugs(GF56)/pyridoxine(A15) *
  • Antibiotics, antifungals, antivirals(GF54) *
  • Methylxanthines and beta agonists(GF63) *
  • Antidiabetics and hypoglycemic (GF47)/octreotide(A8,9) **
     
  • 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)
  • 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) *
  • Vitamins(GF44) *
  • Dietary supplements(GF43) *
  • Asbestos and MMFs (SK 111 & 112) *
  • Persistent Environ Chemicals (PCBs and dioxin) (Rom chapters)
  • Poison Center Admin/epidemiology/AAPCC(GF129,130) *
  • Neurologic principles(GF22) *
    ​​​​

Year 2(37):

  • Anti-migraine medications(GF52) *
  • Misc antihypertensives (ACE, ARB, vasodilators, alpha agents)(GF61) *
  • Thyroid and anti-thyroid medications (GF53) *
  • Anti-thrombotics(GF58)/PCC(A17)/vitamin K(A18)/protamine(A19) * Thermoregulatory principles(GF29) / dantrolene(A24) *
  • Dermatologic principles(GF17),transdermal toxicology(GFSC3)
  • Arthropods(GF115), spider antivenom(GFA37), scorpion antivenom(GFA38) *
  • Colchicine, podophyllin, and vinca alkaloids(GF34) *
  • Disulfiram and disulfiram-like reactions(GF78) *
  • Principles of epidemiology (GF137) *
     
  • Adverse drug events (ADE, drug interactions, immunologic response, polymorphisms causing adverse events, and epigenetics)(GF134) *
  • Solvents - Aldehydes (SK95,96) & Ketones (SK107 just ketone section)
  • 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)
  • 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)
  • Essential oils(GF42) *
  • Intrathecal administration(SC7) & extravasation(SC8) *
  • Occupational Health risk assessment (GF131)
  • Risk assessment & communication(GF133)
     
  • Pharmacokinetic principles/ Pharmacodynamics/ toxicodynamics (dose/concentration relationship to effect, receptor agonism/antagonism, receptor regulation, structure-activity relationship)(GF9) *
  • Nicotine and tobacco(GF82) *
  • Ophthalmologic(GF24) & Otolaryngologic principles(GF25) *
  • Gastrointestinal principles(GF18) *
  • Hematologic principles(GF20) *
  • Chemical principles(GF10) & chemical structures *
  • Solvents - Aliphatic, aromatic, halogenated (GF105) *

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)

Fellow didactic subjects: *=lecture written

Every year –

Professional Development:

Medical legal aspects of tox/expert witness lecture *
Reviewing for journals 1- lecture *
UDS primer - Workplace drug & alcohol testing (MRO, cutoffs, adult/dil/subst) (Matt Noble)

Occupational toxicology topics

  • Asynchronous – principles of occupational toxicology: diagnosis and control (GF131)

Industries - (11)

  • Construction(SK48) (carpentry(GB5), painting, welding(GB38))*
  • Chemical manufacturing(GB45) & Pharmaceutical industry*
  • Healthcare(GB9) & 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)*
  • Mining(GB46, SK40) & Smelting/metal refining/ reclamation(GB37,SK40)*
  • Petrochemical industry & plastic epoxy resin rubber manufacture (GB47, SK67-70, SK34)*
  • 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 & indoor air pollution (GB 56)*
  • Soil, surface water, food and drinking water toxicology (Ladou48)*
  • Outdoor air pollution (GB 57) *

Forensic –

  • Forensic toxicology introduction *
    Postmortem specimens, interpretation, redistribution
    Collection/storage/interpretation of specimens, different matrices (blood, saliva, breath) (GF140)
    Drug-facilitated sexual assault *
  • Forensic opioids & cannabis *
  • 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
  • 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
  • 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
        A. https://www.acmt.net/wp-content/uploads/2022/09/2022-Intro-to-ACMT-for-FITs-Webinar-_FINAL.pdf
        B. https://www.acmt.net/
        C. https://www.clintox.org/
      8. CME
      9. Available funding for:
        A. Education Scholar's Program (ESP)
        B. Tuition
        C. Conference of your choice - one per year
      10. Meals
      11. 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
          A. Chart review on the patient should be completed by 9am.
        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
      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
            Chart review should be done by 9am
          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
        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. Minor tox
        3. Journal club on Thursdays
      6. Daily schedule
        1. Monday
          1. 9a consults
          2. 10a Resident topics/student cases
          3. 1p attending or 2nd year fellow led lecture
          4. 1p WAPC twice a month
        2. Tuesday
          1. 9a consults
          2. 10a Resident topics/student cases
          3. 1p attending or 2nd year fellow led lecture
        3. Wed: 
          1. 9a consults
          2. 10a Fellow Rounds
          3. 11a Fellow Didactic
          4. 1p Minor Tox Topic & Chapter (see list)
        4. Thurs
          1. 9am consults
          2. 10a Resident topics/student cases/rounds
          3. 1p Journal Club/Review/Dogma Review
        5. Friday
          1. 9am consults
          2. 10a Resident topics/student cases/rounds
          3. 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/environmental)
    2. Research – (1st year-case or review, 2nd year-research project)
    3. Role of Chief Fellow:
      i. QI project – on QI committee in 2nd year
      ii. Journal Club
      iii. Fatality review
    4. 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 Wednesday and Thursday
        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.
    5. Occupational Toxicology
      1. Matt Correia – email
      2. See our own patients through the PC
  3. Grants & awards
    1. ACMT, AACT, MTF, ACEP
      i. https://www.acmt.net/research-funding/
      ii. https://www.clintox.org/grants
  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. DOTS
    4. RENDOR
  6. Fellowship issues:
    a. Expectations when taking call (10 min response, when to call MBU, location)
    b. Professionalism
    c. Fatigue Mitigation
    d. Disclosing adverse events to patients and families
    e. Fellowship policies & trainings:
               i. Wellness
              ii. Substance abuse, depression, burn-out
             iii.     Institutional protocol for helping physicians
             iv. Diversity & Inclusion
              v. Graded Responsibility
             vi. Cost effective clinical care
  7. 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

  • 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?
  • 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
  • HBO – where are the chambers, and what are the rules
  • Hemodialysis – 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?
  • Unique resources:
    HBO – where are the chambers, and what are the rules
    Endoscopy
    CMO
  • Identification:
    Mushroom identification and our mycologists
    Plant Identification
  • How to get exotic antivenoms (Miami FD)
  • Botulism – how to call the CDC to get antitoxin
  • Oregon Emergency Response System(OERS)/hazmat teams
  • Mercury spills – cleanup and EPA involvement
  • EPA Radiation antidotes – RE/ACTS
  • Malignant Hyperthermia hotline
  • Working with local Health Dept on emerging issues (e.g. PSP)
  • Veterinary issues - the Animal Poison Center
  • 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?
  • 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

PD will schedule and review with fellows on days through July and August

Career building:

  1. What jobs are available for a medical toxicologist?
  2. Building a medical toxicology CV
  3. Media training
  4. Intro to statistics, part 1 (Amber Lin)
  5. Intro to statistics, part 2 (Amber Lin)
  6. Intro to Medhub (Kim & Rebekkah)
  7. Intro to Toxicall (Anne)
  8. Introduction to OVID
  9. Financial planning, 401b, etc
  10. Planning your fellowship
  11. What are the milestones and why do I care?
  12. Billing and reimbursement in toxicology