Viva Germany & Goodbye Mr. Maradona

Germany knockout Agentina with a dreaming result: 4-0. It seems it is time for Maradona to rest now.

photo: foreign.peacefmonline.com

Where are we going to go?

The poster is in persian: "Kidney for sale O- and A+". It was outside of our hospital.

What did they do in the ED?

I see them in a night shift in our ED.
What did they do in the ED? What do you think?

Nightmare of any Clinical Toxicologist

Aluminium phosphide is an pesticide which now is the leading cause of death from poisoning in Iran. Nowadays in Loghman hospital -where I spend my toxicology course- there are 2-3 aluminium phosphide poisoning daily and unfortunately with a mortality rate of nearly 100 percent. My first encounter with this poison was in Rasht's Razi hospital where I spent my internship 3 years ago and there were same mortality.
Toxicity is known to be due to phophine gas which release from aluminium phosphide when encounter with water. The sign ad symptoms include profound GI symptoms (abdominal pain, nausea, vomiting, diarrhea), agitation, seizure and cardiovascular collapse. The most important lab finding is profound metabolic acidosis which is probably a poor prognostic factor. Patients are surprisingly well and be critically ill just in minutes. The victims have a distinct odor something like decayed rice and bleech together. Vomiting usually is white and often foamy too. Detoriation begins with increased agitation although patient is completely alert, patient usually tell the physician that he/she feels the death and plea the doctor to help him/her. Metabolic acidosis become worse and worse despite great effort to its correction and a resistant cardiogenc shock develops. In EKG there are at least two findings: QRS complexes become wide and QT intervals increase. Patients suddenly develop a deadly ventricular dysrythmia usually torsade points or vf and sometimes pulseless vt; and this is the time when death arrives.

Gastric lavage with N/S or water is somewhat contraindicated and lavage is done with sodium bicarbonate and potassium permanganate. Charcoal probably has no benefit and if containing water has harm too. Some clinicians gavage mineral or natural oil to patients. The corner stone of management is correction of metabolic acidosis with as much sodium bicarbonate as possible. Therapies such calcium gluconate, magnesium sulfate, n-acetyl cystein are recommended but none of them are effective in clinic. For correction of shock norepinephrine is superior to dopamine which usually fail to correct shock, however in most cases a combination of these two vasopressors are recommended. Ventricular dysrhythmias are refractory to defibrillation and any drug, consider over drive pacing for torsades de pointes . Early intubation of patients seems reasonable before profound shock make it difficult to RSI patient. Early intubation has the benefit to use hyperventilation for acidosis correction.

The Good, the Bad and the Ugly

The Good

Yesterday, we had an osce as a part of our annual evaluation. The exam had 12 stations (2 of them were rest). Stations included Research, ATLS, ACLS, Neurological Examination, EKGs, Slides (2 stations), Seizure, Drug Seeker Patient and Airway Management. Althogh the exam designing was good; but it seems the last year exam was better in content, designing and execution. The Good for the exam was its joint execution between our ED and Iran's.

 The Bad

The exam was a real pity for me. I did Bad in nearly all stations and the worst was EKGs.

The Ugly

It seems cheating is something in our blood and we can't live without it. In abstract some of us cheated yesterday. I think there were nothing more ugly than this.

* Pics: Corporate America's Good, Bad and the Ugly

a diasapointed one

Yesterday was my first shift in toxicology and quite disappointing.
Despite my expectations and hopes; there were an over crowded emergency without any educational benefit for me. Most of my patients were ingested benzodiazepines or intoxicated with ethanol and a smaller group were intoxicated with amphetamines, opioids etc. Since 10pm till 1am I had 22 patients, 3 of them comatose enough to be intubated. I just saw my patients, take a very brief history (Material? Amount? Time Taken? Emesis? Reason?) and a more brief Physical examinations (ABC + V/S + pupils + rarely neurologic examination) and write my orders rapidly. Not enough time to think, consult or even concentrate at my cases.
What make the shift harder was the act of EMS and other hospitals that send any addict patient with any presentation (mostly decreased LOC) to our ED.

My resume in this shift:
about 30-40 patients admitted
2 CPRs both with ROSC
5 Intubations

The educational note of my shif:
My compatriots are mostly addict or at least have someone addict in their family; interestingly Pour Methadon syroup or liqufied opium in refrigerator.

P.S. Tonight I'll be in my favorite ED again.

What an Abdominal Pain...

This 34 years old afghani worker came to ED with complaint of vague abdominal pain and constipation which were gradually developed in a week.
He didn't have any significant past history or drug history. His V/s was BP:130/90 PR:80 RR:26 OT:36.7 c.
In examination he has a soft abdomen without distension or tenderness, but found out that he has difficulty in walking or sitting. His neurologic examinations were normal except increased tone in all four extremities.
He was admitted in a non monitored ED bed.

my new blue scrub

After lots of delay we now have new scrubs in our ED.
Our new scrubs were supposed to be better than our olds but in my and many of my friends mind, they are not. Our main complaint is about the tight ugly colars, that are like female clothing.
Other problems include its color and the cloth itself (which contains a large amount of plastic fibers).

very HOT rumors

Yesterday I heard rumors about two residency exam preparing institute in Iran -Soroush-e-farzanegan and noandishan-e-arya- was shut down. The participants did not attend in classes yesterday and institutes declare that the situation will be cleared today.
Probably the shutting down is related to recent Iran's residency exam and the possibility of exam preparing institutes to cooperated with cheaters.

I searched the net but did not find anything about it yet.
I will glad to hear about it from anyone with more information.

Toxicology

 (pic: http://www.acmt.net/)

Today is my first day in toxicology service as a rotational resident. Toxicology was my favorite field for years and despite my favor is decreased recent years (as I get acquainted with a more interesting field -EM-), I really love it yet.

I'll spend my one month toxicology course in Loghman hospital, the main toxicology referral center in Iran, with EM residents from all over Iran. It has a nearly crowded ED; with toxicology cases that any EM resident wishes to see them.

This was my story; and what I have for you?

Here are useful toxicology & toxinology links:

emedicine- emergency medicine articles (toxics and toxins both involved)

Clinical Toxinology Resourses

TOXNET - Databases on toxicology, hazardous chemicals, environmental health, and toxic releases

any good link, you know? please comment me to add them