Utility of Hypertonic Saline and Diazepam in COVID-19-Related Hydroxychloroquine Toxicity.

BACKGROUND: Hydroxychloroquine (HCQ) poisoning is a life-threatening but treatable toxic ingestion. The scale of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (COVID-19) and the controversial suggestion that HCQ is a treatment option have led to a significant increase in HCQ use. HCQ poisoning should be at the top-of-mind for emergency providers in cases of toxic ingestion. Treatment for HCQ poisoning includes sodium bicarbonate, epinephrine, and aggressive electrolyte repletion. We highlight the use of hypertonic saline and diazepam. CASE REPORT: We describe the case of a 37-year-old man who presented to the emergency department after the ingestion of approximately 16 g of HCQ tablets (initial serum concentration 4270 ng/mL). He was treated with an epinephrine infusion, hypertonic sodium chloride, high-dose diazepam, sodium bicarbonate, and aggressive potassium repletion. Persistent altered mental status necessitated intubation, and he was managed in the medical intensive care unit until his QRS widening and QTc prolongation resolved. After his mental status improved and it was confirmed that his ingestion was not with the intent to self-harm, he was discharged home with outpatient follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: For patients presenting with HCQ overdose and an unknown initial serum potassium level, high-dose diazepam and hypertonic sodium chloride should be started immediately for the patient with widened QRS. The choice of hypertonic sodium chloride instead of sodium bicarbonate is to avoid exacerbating underlying hypokalemia which may in turn potentiate unstable dysrhythmia. In addition, early intubation should be a priority in vomiting patients because both HCQ toxicity and high-dose diazepam cause profound sedation.

A Surgical View of Anatomy: Perspectives from Students and Instructors.

As curricular emphasis on anatomy in undergraduate medical education continues to evolve, new approaches to anatomical education are urgently needed to prepare medical students for residency. A surgical anatomy class was designed for third- and fourth-year medical students to explore important anatomical relationships by performing realistic surgical procedures on anatomical donors. Under the guidance of both surgeons and anatomists, students in this month-long elective course explored key anatomical relationships through performing surgical approaches, with the secondary benefit of practicing basic surgical techniques. Procedures, such as left nephrectomy, first rib resection for thoracic outlet syndrome, and carotid endarterectomy, were adapted from those used clinically by multiple surgical subspecialties. This viewpoint commentary highlights perspectives from students and instructors that suggest the value of a surgical approach to anatomical education for medical students preparing for procedure-oriented residencies, with the goals of: (1) describing the elective at the authors' institution, (2) promoting similar efforts across different institutions, and (3) encouraging future qualitative and quantitative studies of similar pedagogic efforts.

Anatomy as a Model Environment for Acquiring Professional Competencies in Medicine: Experiences at Harvard Medical School.

Anatomy education provides students with opportunities to learn structure and function of the human body, to acquire professional competencies such as teamwork, interpersonal skills, self-awareness, and to reflect on and practice medical ethics. The fulfillment of this wide potential can present challenges in courses that are part of an integrated curriculum and shorter than traditional courses. This new reality, together with students' increasing concern about the stresses within medical education, led to efforts at Harvard Medical School to implement practical steps toward an optimal learning environment in anatomy. These were based on core elements of ethical anatomy education and principles of trauma-informed care. Anatomy is conceptualized here as the "first clinical discipline," with relational interactions between anatomical educators, medical students, and body donors/patients. Essential prerequisites for the implementation of this work were support by the medical school leadership, open partnership between engaged students and faculty, faculty coordination, and peer-teaching. Specific interventions included pre-course faculty development on course philosophy and invitations to students to share their thoughts on anatomy. Student responses were integrated in course introductions, combined with a pre-dissection laboratory visit, an introductory guide, and a module on the history and ethics of anatomy. During the course, team-building activities were scheduled, and self-reflection encouraged, for example, through written exercises, and elective life-body drawing. Students' responses to the interventions were overall positive, but need further evaluation. This first attempt of a systematic implementation of an optimal learning environment in anatomy led to the identification of areas in need of adjustment.