Fentanyl and a Novel Synthetic Opioid U-47700 Masquerading as Street "Norco" in Central California: A Case Report.

In 2013 and 2014, more than 700 deaths were attributed to fentanyl and fentanyl analogues in the United States. Of recent concern is the cluster of unintentional fentanyl overdoses because of tablets thought to be "Norco" purchased on the street in Northern California. U-47700 (trans-3,4-dichloro-N-[2-(dimethyl-amino)cyclohexyl]-N-methylbenz-amide) is a nonfentanyl-based synthetic opioid with 7.5 times the binding affinity of morphine to µ-opioid. We report a case of fentanyl and U-47700 intoxication from what was thought to be illicitly purchased Norco. A 41-year-old woman presented to the emergency department (ED) for altered mental status shortly after ingesting 3 beige Norco pills bearing a Watson imprint. She had pinpoint pupils and respiratory depression, which reversed after 0.4 mg naloxone administration intravenously. She had complete recovery and was discharged from the ED after a 4-hour observation period. Serum testing with liquid chromatography-quadrupole time-of-flight mass spectrometry (LC 1260 QTOF/MS 6550; Agilent, Santa Clara, CA) confirmed the presence of the medications the patient reported receiving, and additionally fentanyl (15.2 ng/mL) and U-47700 (7.6 ng/mL). In this case report, street Norco purchased in Central California resulted in altered mental status requiring naloxone reversal because of fentanyl and the novel synthetic opioid U-47700. Because these compounds are not detected by routine urine drug testing and physical examination findings are similar to those of a traditional opioid toxidrome, emergency providers should use the patient's history and other circumstantial details to aid in diagnosis. In cases with suspicion of opioid or opioid analogue cause, we recommend that emergency providers contact their local poison control center, medical toxicologist, or public health department to aid in the investigation.

Evaluating Violent Person Management Training for Medical Students in an Emergency Medicine Clerkship.

OBJECTIVES: Violence is a significant problem facing healthcare workers in the United States, particularly in emergency departments (EDs). Education is key to providing a safe environment for workers to ensure their ability to recognize and respond to violent patients and visitors. We studied the effects of a video podcast-based violence education program aimed at improving medical students' knowledge and confidence in identifying and responding to violence. METHODS: We provided a pretest and questionnaire about recognizing and responding to violence in the ED to 141 fourth-year medical students on the first day of their emergency medicine clerkship. Students were invited to view a video podcast addressing violent person management (VPM) in the ED and were then administered a posttest and questionnaire at the conclusion of the clerkship. We measured changes in knowledge and confidence in responding to violent situations of students who watched the video podcast and completed the pre- and posttests and questionnaires. In addition, we assessed student response to the video podcast format as well as quantified student exposure to violence during their clerkship. RESULTS: Of the 123 students who completed the pre- and posttests, 93 (75.6%) reported watching the video. These 93 students demonstrated a statistically significant improvement in exam score between the pre- and posttests and expressed increased confidence in responding to violence in the ED. A total of 66 (71.0%) agreed that the video lecture was an appropriate method to deliver the VPM material and 4 (4.3%) disagreed. Seventy-two (77.4%) students agreed the VPM content was professionally relevant to medical students during the emergency medicine clerkship and only 1 student (1.1%) disagreed. Almost half of the 141 students surveyed witnessed verbal or physical assault in the ED during their 4-week clerkship. CONCLUSIONS: An educational video podcast is an effective method to improve medical students' knowledge and confidence in responding to a potentially violent person or violent situation in the ED and may be useful in other healthcare settings.