Stopping by woods

Sitting and drinking coffee watching the snow fall. Did my 30 minutes on the rowing ergometer. Abs and obliques have been tuned. The old hound and I walked in the snow and he did his business (I scooped and dumped). Waiting for the snow to stop so I can shovel out. I am trying to remember why I never bought a snow blower.

The ER has been busy despite the frequent snow storms. Nothing keeps my patient from their ER visits. A disturbing trend has been an uptick in the number of overdoses both intentional and accidental. The quality of injectable opiates varies greatly. Just a slight increase in the purity of the heroin leads to a bump in OD's. The cynical and jaded would say that this is social Darwinism at work. I try to keep the thought in my mind that every junkie is someone's friend, son, daughter, parent, etc.

Straight opiate overdoses from oxycodone, hydrocodone, heroin, methadone and others respond rapidly to Narcan. This antidote may be injected into a vein or a muscle and rapidly reverses the sedating effect of the opiate. It has the deleterious side effect of inducing immediate opiate withdrawal. A gown, mask and shoe covers are recommended for the ER team as the addict often vomits like an open fire hydrant.

Cocaine is toxic in any dose. Snorted, shot or smoked the effects are immediate and protean. Chest pains, arrythmias, strokes, nose bleeds, lung damage are all possible presenting complaints for the cocaine user. The major weapon in the ER doc's bag of tricks is lorazepam. Sedation and lots of it is the standard of care. A high degree of vigilance is needed to assure a safe outcome for the patient and the ER staff.

The real challenge is an overdose involving medications and household or industrial chemicals. In my younger days, the assessment, decontamination and treatment of such ingestions or exposures was hit or miss. The concept of a centralized source of information for treating toxic ingestions or exposures began in Colorado with Dr Barry Rumack. The info was stored on microfiches. For the Google generation, a microfiche was a sheet of clear plastic that contained very small printing and was read with a special reader. Regional Poison Control centers are still available by phone 24/7. The internet is also a great source of info for ER staff.

Toxidromes are groups of symptoms associated with specific classes of medications. Every med student, PA and resident has learned the acronyms for these toxidromes. An example is MUDPILES. Many toxins and diseases can present with metabolic acidosis with a high anion gap. The pH of human blood is normally 7.4. When the pH goes lower that is acidosis. I will spare my nonmedical readers a boring dissertation on the Henderson-Hasselbalch equation. The acronym is an aid to remember the causes of this toxidrome and aid in a search for the agent or disease process and guide the treatment.

Acetaminophen (Tylenol and other brands), aspirin, ibuprofen (Advil, etc.), nonprescription sleep meds, cold meds, rubbing alcohol all can be dangerous and even lethal in high enough doses. Many young people take an overdose as a cry for help and/or attention. They are unaware of the toxicity of the common nonprescription medications they ingest.

Acetaminophen interferes with a metabolic process in the liver. As few as thirty 500 mg Tylenol tablets can lead to liver damage and death. The toxic dose is weight related and the time after ingestion guides the treatment. An effective treatment is available and effective if given before permanent liver damage has occurred. N-acetylcysteine is the antidote. There is an IV form of the chemical that makes treatment easy and rapid. The oral form of the chemical was noxious to the patient and the health care workers as it smells like rotten eggs. Thank goodness for progress.

Antihistamines (eg Benadryl) are found in sleep aids, cold and flu formulations and allergy medications. Although they are safe and effective when used in recommended doses, they can be very dangerous in large amounts. The mnemonic that I learned back in the dark ages was: mad as a hatter, hot as a hen, red as a beet, dry as a bone. The symptoms of anticholinergic poisoning include hallucinations, fever, flushing, and dry skin thus the mnemonic. Tachycardia, seizures and coma are also seen in OD's of antihistamines. Jimson weed (Datura stramonium) is smoked and made into a tea as a mild hallucinogen. Too much can cause anticholingeric toxic symptoms.

For parents of small children (or adventurous/suicidal adolescents and teens) the recommendation for home treatment has changed. Giving Ipecac to induce vomiting is no longer the treatment of choice. Activated charcoal is the best option. It binds most medications and therefore limits the amount of the drug that can be absorbed from the GI tract. Check your medicine cabinets. Safely dispose of any medication that you are not currently using. Use child-proof containers. Consider locks on medicine cabinets. As little a single pill of some prescription medications may be a fatal overdose in a toddler.

The snow is still coming down but it should end soon. Let the shovelling begin. I think tonight I will have Hiberian Cure-all, single malt scotch and ibuprofen.