The impact of a medical toxicology fellowship on the training of future emergency medicine residents.

Abstract

What is the impact of a medical toxicology fellowship on the training of future emergency medicine residents? While I do realize that not all fellows come from an emergency medicine background, many medical toxicology fellowships are closely associated with an emergency medicine residency (also our boards fall under the American Board of Emergency Medicine as well as two other certifying organizations) [1]. No matter where the fellowship, a medical toxicology fellowship is very complicated. Aside from clinical duties including bedside consults to taking call, we also participate in research, learn to write, and also read copious amounts of journals to stay abreast of all the current literature [2, 3]. As I am now starting my second-year fellowship, I look back at all the times I have taken call and reminisce on some of the cases I have had. I will highlight two contrasting cases I had one night which reminds me of another important, but sometimes forgotten function of fellowship—education. The first case is one that stands out in my mind as a reminder of the importance of our role in the education of other health care providers. I remember receiving a call one night from a small local hospital that had a patient present with a benzodiazepine overdose. The patient was a young woman who got into a fight with her boyfriend and, in a rash gesture, overdosed on her lorazepam. She presented with “coma with normal vital signs”. The attending physician administered his version of the “coma cocktail” with 2 mg of naloxone followed with 2 mg of flumazenil. Soon after being administered flumazenil, the patient developed seizures refractory to benzodiazepines, requiring endotracheal intubation and the use of propofol. It was at this point that I received the call from the ED attending for guidance. Needless to say, the damage was done. The patient had a prolonged hospital course secondary to the complications of intubation and eventually was discharged. When I asked this particular health care provider at that time what was his rationale (in a non-judgmental tone of course) for administering both naloxone and flumazenil, his response was, “That was the way I was taught”. Later in the night, I received a call from a recent graduate of the same emergency medicine residency where I am doing my fellowship about a similar case involving a young patient who also overdosed on a sedative-hypnotic. This patient also had a classic benzodiazepine picture of “coma with normal vital signs”. This recent graduate called early in the patient’s course and, needless to say, I was on edge from the other case I mentioned above. He presented the case and described his management which consisted of supportive care. He stated that he did not feel strongly about using flumazenil. He reasoned that the benefit would not outweigh the risk of potentially inducing a withdrawal seizure in someone he felt was chronically on a benzodiazepine. I asked the recent graduate where he learned about the proper use of flumazenil. He mentioned that he remembered about the use of flumazenil from a lecture one of our fellows gave at grand rounds during his residency. Editor’s note: David H. Jang is a senior fellow-in-training (FIT) editorial board member at the New York City Poison Center and New York University. The opinions stated in this section are those of the author and do not necessarily reflect the opinions of the Journal of Medical Toxicology (JMT) or the American College of Medical Toxicology (ACMT).