TTUHSC Paul L. Foster School of Medicine
Emergency Medicine

Emergency Medicine

Medical Toxicology Fellowship Program

Overview

The Medical Toxicology Fellowship Program at Texas Tech University of Health Sciences Center at El Paso (TTUHSC-EP) gained the campus' first ACGME fellowship accreditation in 2010.  Located in El Paso, Texas, along the US/Mexico border, fellows are afforded an unparalleled experience to interface with an extensive array of toxicological issues distinctive of our bi-national region. In addition, our fellows are exposed to leading research being carried out at the TTUHSC-EP Paul L. Foster School of Medicine, the country's first and only American medical school along the US/Mexico border's 2,000 mile stretch.

The medical toxicology fellowship is a 24-month training program designed to leverage the vast breadth of pathology endemic to our international border. As such, fellows will be exposed to a broad curriculum, including active involvement in a state-of-the-art simulation center currently under development, where they will be trained to detect and manage a broad scope of chemical, biological and nuclear exposures. In addition, fellows will receive training in disaster preparedness, industrial hygiene and safety, occupational and environmental medicine,  substance abuse and substitution therapies and abstinence syndromes. Because El Paso's geographic location places it at a crossroads of both intentional and non-intentional importation of illicit drugs and other chemical and biological hazards, fellows will have the advantage of expanding their treatment skills to less traditional forms of toxicological pathologies.

The medical toxicology fellowship at TTUHSC-EP understands the negative effects that toxicological hazards place on our community's public health and the important role of cutting-edge research. Therefore, in addition to participating in current research activities, fellows will partake in educational opportunities offered by the two schools of public health located in El Paso.

Upon successful completion, fellows will be prepared to pursue, academic, clinical or administrative careers in Medical Toxicology. Those who meet all requirements may sit for the subspecialty exam of the American Board of Medical Subspecialties upon completion of this ACGME-approved fellowship.

Goals

The goals of the medical toxicology fellowship program include:

  1. Train medical toxicologists of the highest competency, prepared to evaluate and treat patients of all ages with exposures to pharmaceuticals, dietary supplements, hazardous chemicals, toxic plants and venomous animals.
  2. Introduce the fellows to the broad scope of medical toxicology through a comprehensive review of the core content of medical toxicology (Wax PM, Ford MD, Bond GR et al. The core content of medical toxicology. Ann Emerg Med 2004;43:209-214) via readings, lectures, case conferences and discussions.
  3. Develop expertise in pharmacology, pharmacokinetics, drug interactions and adverse reactions.
  4. Focus on the importance of preventive medicine in avoiding acute and chronic poisonings and disability in the home, in avocations and in the workplace.
  5. Develop a center of excellence in toxicological care at University Medical Center of El Paso that will serve the entire western area of Texas, southeastern New Mexico and northern Mexico through improved 24-hour bedside hospital consultation services, a toxicology referral clinic and regional consultation services.
  6. Provide optimal medical care of patients of all ages exposed acutely or chronically to harmful substances.
  7. Develop proficiency in the evaluation of occupational and environmental exposures, with understanding of recommended and regulatory exposure limits, standards, biological exposure indices and medical surveillance.
  8. Develop proficiency in the choice of analytical methods and interpretation of laboratory studies related to toxic exposures.
  9. Develop expertise in procedural sedation and management of delirium and abstinence syndromes.
  10. Develop proficiency in maintaining proper medical records and documentation.
  11. Develop effective consultation skills, spanning telephone consults, outpatient evaluations and bedside routine, emergency department and critical care evaluations.
  12. Enhance the services provided by the West Texas Regional Poison Center by education of Certified Specialists of Poison Information (CSPIs) and provision of improved medical toxicology consultative services.
  13. Develop administrative skills needed to manage a toxicology consulting service and/or a regional poison control center.
  14. Educate fellows, residents, nurses, students of medicine, pharmacy, and nursing and pre-hospital providers in recognition and management of poisoned patients.
  15. Prepare the fellow to manage the medical aspects of hazardous materials emergencies and to understand the incident command structure.
  16. Advance pre-hospital care related to the poisoned patient, including victims of hazardous materials incidents.
  17. Develop proficiency in the critical review of the medical toxicology literature and its application to patient care.
  18. Enhance the evidence base in medical toxicology through outstanding laboratory and clinical research and to share toxicological knowledge through peer-reviewed publication and presentations at local, regional, national and international scientific meetings.
  19. Prepare the fellow to appreciate important cultural differences among our patient population and to understand how these differences impact on exposure risks and medical care.
  20. Create a focus on international and, particularly, border health issues related to toxicology and to share knowledge with our neighbors in order to improve the care of poisoned patients.
  21. To prepare physicians to meet the qualifications for sub-board certification in Medical Toxicology under the American Board of Emergency Medicine, American Board of Pediatrics or American Board of Preventive Medicine.
Objectives

Fellows are expected to meet ACGME Core Competencies:

I. Patient Care

Appropriately assess patients for toxicant-related illness through a thorough exposure history and physical examination.

Develop appropriate differential diagnosis based on available diagnostic information.

Demonstrate proficiency in the choice of decontamination methods, supportive care, appropriate use of antidoted, and extracorporeal methods of toxicant removal in poisonings, based on both published literature and individual patient assessment.

Demonstrate the capacity to effectively perform diagnostic and therapeutic procedures and emergency stabilization of patients.

Implement effective patient care, including therapy, consultation, monitoring, disposition, patient education and follow-up.

II. Medical Knowledge

Perform effective use of printed and electronic resources for access to toxicological information.

Demonstrate progressive growth in their knowledge of the effects of toxins and toxicants, including drugs, industrial and household chemicals, environmental toxicants, natural products such as herbs, plant toxins and venomous animals, and agents of warfare and chemical terror as well as their diagnosis and management.

Develop skills in preventive medicine, including epidedmiology and biostatistics, investigation of outbreaks of illness, design of scientific studies, principles of primary, secondary and tertiary prevention of poisoning.

Demonstrate general understanding of analytical and forensic toxicology.

III. Practice-Based Learning

Perform self-assessment of skills and experience and to demonstrate improvement based on experience.

Seek out scientific evidence supporting patients' illnesses and their management in order to provide evidence-based care that improves over time.

Maintain and up-to-date library of scientific articles addressing poisoning and its management.

Utilize electronic data sources as a means of access to the latest peer-reviewed medical data.

Share knowledge through educating other professionals and by attending conferences and scientific congresses.

IV. Professionalism

Demonstrate punctuality and preparedness for work.

Dress appropriately and maintain good hygiene.

Accept assignments and consultations at any hour of the day or night, when on duty, with dignity and pleasant demeanor.

Give and receive appropriate patient sign-outs.

Practice patient advocacy.

Complete medical records and logs honestly and punctually.

Treat patients and their entourage with dignity, respect and candor.

Protect patient confidentiality.

Accept and offer constructive feedback from patients, families and colleagues and to act on this advice to self-improve.

Discuss  end-of-life options and death with honesty, compassion and sensitivity.

Treat colleagues with deference and patience, recalling that each of us has limitations.

V. Interpersonal Skills

Effectively communicate with patients, their families and professional healthcare team associates.

Show respect, compassion, and integrity and to maintain a professional demeanor at all times.

VI. System-Based Practice

Practice cost-effective patient care and carefully analyze risk and benefit in every patient for each therapy envisioned.

Develop awareness of available resources for patient care and referral, capacities and limitations of various systems of care and barriers to care.

Understand various practice models and delivery systems.

Understand the limitations of poison control centers with regard to self-reporting of exposures, frequent inability to confirm poisoning, imperfect understanding of capabilities of caregivers requesting advice and the general limitations of telephone advice.

Facilities

The University Medical Center of El Paso (UMC) has been designated as the primary teaching site for the Texas Tech Health Sciences Center at El Paso since 1973.  As the only Level-I Trauma Facility within a 250 mile radius of El Paso, UMC offers a Regional Referral Center for high-risk pregnant women and their neonates; a state-of-the-art Regional Laboratory;  the West Texas Regional Poison Center and affiliation agreements with over 50 of the region's educational institutions.

As El Paso's only not-for-profit community hospital, the Emergency Department sees over 60,000 visits per year.  While on rotation at UMC, medical toxicology fellows will provide consultations in the hospital and, serving as attending EM faculty 12 hours per week, will direct the management of multiple patients of varying complexity and degrees of illness presenting simultaneously and overtime.   Fellows will also partake in off-service rotations, such as Pediatric and Medical Intensive Care Unit rotations, to hone their skills in managing critically ill patients.

The West Texas Regional Poison Center (WTRPC) at University Medical Center of El Paso is the first 24-hour fully bilingual regional poison center certified by the American Association of Poison Control Centers (AAPC) in the entire United States. Located in El Paso, Texas, it is the only poison center situated along the 2,000 mile US/Mexico border. 

Compounding the threat of dangerous poison exposures touching our region is the significant influx of people crossing the El Paso -Juarez border, one of the world's busiest ports of entry.With a service region encompassing 36 counties and 1.4 million inhabitants, WTRPC is a pioneer in the development of poison center services and educational programs unique to the bi-national region.  WTRPC also serves as the call center for the Southwest Center for Pediatric Environmental Health in Tyler, TX.

WTRPC hosts a fully bilingual staff whom are trained to address the region's unique demographics via a 24-hour poison emergency hotline, vigorous case management and both professional and public outreach.  During a period of 7-8 months per year, our medical toxicology fellows will be housed in the poison center, under the supervision of the center's board-certified medical toxicologists, Drs. John Haynes, Medical Director and Stephen Borron, Associate Medical Director.  Fellows will field calls under the auspices of the Certified Specialists in Poison Information and the Managing Director, Leo Artalejo III, PharmD, as well as responding to requests for bedside consultations at University Medical Center of El Paso and the William Beaumont Army Medical Center.

Established in 1921, William Beaumont Army Medical Center (WBAMC) provides care for military personnel and their eligible family members, WBAMC specializes in complete medical care, hosts a medical education program, and serves as one of the only two trauma units in the El Paso area.  WBAMC has a capacity of 600 beds and serves all of the West Texas, New Mexico, Arizona and part of Southern California.

Although primarily assigned to University Medical Center of El Paso, fellows will take call for WBAMC to augment the quantity and types of toxic exposures seen.  Fellows will perform consultations under the aegis of both TTUHSC and Army Medical personnel.  Active duty military personnel provide a unique patient population, one example being the increased frequency of snake and spider bites due to field operations.  In addition to toxicology consultations, small and large animal research facilities are available to the fellows for laboratory toxicology research.

BannerHealth Good Samaritan Medical Center, a flagship hospital of BannerHealth, is located in downtown Phoenix.  Having provided care since 1911, the medical center operates more than 662 licensed patient care beds.  Banner Good Samaritan is a teaching hospital that trains more than 250 physicians annually, a Level I Trauma Center and a premier medical center in Arizona and the Southwest. BannerHealth Good Samaritan Medical Center is home to a Medical Toxicology Fellowship Program based in the Department of Medical Toxicology. The Department of Medical Toxicology operates one of the busiest in-patient medical toxicology services, admitting and consulting over 600 patients annually.  The medical toxicology  faculty at BannerHealth Good Samaritan Medical Center has strong research credentials and an outstanding didactic program.

TTUHSC-EP Fellows will travel to Phoenix and participate in a rotation through their Medical Toxicology Fellowship Program during the months of July (2nd year fellows) and August (1st year fellows).  The timing of rotations permits fellows to benefit from an intensive lecture series that takes place during these two months each year.  The toxicology fellows will receive a series of core lectures beginning with pharmacokinetics, drug metabolism, and receptor physiology and will then move on to basic toxicological mechanisms, basic biochemical mechanisms, and common poisonings.  Household products, envenomations, natural toxins and occupational toxins are covered in this overview.