Chemical Hand Warmer Packet Ingestion: A Case of Elemental Iron Exposure.

For individuals who work outdoors in the winter or play winter sports, chemical hand warmers are becoming increasingly more commonplace because of their convenience and effectiveness. A 32-year-old woman with a history of chronic pain and bipolar disorder presented to the emergency department complaining of a "warm sensation" in her mouth and epigastrium after reportedly ingesting the partial contents of a chemical hand warmer packet containing between 5 and 8 g of elemental iron. She had been complaining of abdominal pain for approximately 1 month and was prescribed unknown antibiotics the previous day. The patient denied ingestion of any other product or medication other than what was prescribed. A serum iron level obtained approximately 6 hours after ingestion measured 235 micrograms/dL (reference range 40-180 micrograms/dL). As the patient demonstrated no new abdominal complaints and no evidence of systemic iron toxicity, she was discharged uneventfully after education. However, the potential for significant iron toxicity exists depending on the extent of exposure to this or similar products. Treatment for severe iron toxicity may include fluid resuscitation, whole bowel irrigation, and iron chelation therapy with deferoxamine. Physicians should become aware of the toxicity associated with ingestion of commercially available hand warmers. Consultation with a medical toxicologist is recommended.

Using Milestones as Evaluation Metrics During an Emergency Medicine Clerkship.

BACKGROUND: The Accreditation Council for Graduate Medical Education's (ACGME) Milestones presumes graduating medical students will enter residency proficient at Milestone level 1 for 23 skills. The Next Accreditation System now includes Milestones for each postgraduate specialty, and it is unlikely that schools will document every emergency medicine (EM) applicant's EM-specific skills in their performance evaluation. OBJECTIVES: The goals of this research were to determine if assessment of the Milestones was feasible during a medical student clerkship and examine the proportion of medical students performing at Milestone level 1. METHODS: This study was conducted at a center with Liaison Committee on Medical Education-approved medical training and a 4-year EM residency. Using traditional clerkship, we studied the feasibility of an ACGME EM Milestones-based clerkship assessment. Data led to redesign of the clerkship and its evaluation process, including all level 1 anchor(s) to add "occasionally" (>60%), "usually" (>80%), and "always" (100%) on a Likert scale to on-shift assessment forms. RESULTS: During the feasibility phase (2013-14), 75 students rotated though the clerkship; 55 evaluations were issued and 50 contained the Milestone summary. Eight deficiencies were noted in Milestone 12 and three in Milestone 14. After changes, 49 students rotated under the new evaluation rubric. Of 575 completed on-shift evaluations, 16 Milestone deficiencies were noted. Of 41 institutional evaluations issued, only one student had deficiencies noted, all of which pertained to patient care. All evaluations in this second cohort contained each student's Milestone proficiency. CONCLUSIONS: Assessment of the Milestones is feasible. Communication of ACGME EM Milestone proficiency may identify students who require early observation or remediation. The majority of students meet the anchors for the Milestones, suggesting that clerkship assessment with the ACGME EM Milestones does not adequately differentiate students.

Unique obstacle race injuries at an extreme sports event: a case series.

Obstacle course endurance events are becoming more common. Appropriate preparedness for the volume and unique types of injury patterns, as well as the effect on public health these events may cause, has yet to be reported in emergency literature. We describe 5 patients who presented with diverse injuries to illustrate the variety of injuries sustained in this competitive event. In particular, 4 of the patients had a history of contact with electrical discharge, an obstacle distinctive to the Tough Mudder experience.