Whipped Cream Charger Abuse: The Toxicologist Mindset

whipped cream chargerThe Toxicologist Mindset series features real-life cases from the San Francisco Division of the California Poison Control System.

Case: A 39-year-old man, with no significant past medical history, was brought to the emergency department by family members, over three consecutive days, for anxiety, confusion, and ataxia. In the first two visits, his laboratory work-up, including complete blood cell count, chemistry panel, liver function tests, urine drug screen, and non-contrast head CT, were unremarkable. On his third visit, he was profoundly encephalopathic with confusion and poor concentration. He had bilateral lower extremity weakness and ataxia. He was admitted to the neurology service for further work up. Additional history revealed that hundreds of empty canisters of whipped cream chargers were found in his house.

1. Why might this patient be abusing whipped cream chargers?

Whipped cream chargers, colloquially known as “whippits,” “whippets,” or “hippie crack,” is a steel cartridge filled with nitrous oxide (N2O) gas. In whipped cream cans, dissolved nitrous oxide gas from the cartridges helps the cream transform into a frothy, whipped state upon dispensing. Inhalation of N2O produces a state of analgesia, depersonalization, derealization, dizziness, euphoria, and sound distortion.1 Cartridges are generally easy to obtain, either on the internet, in head shops, or on the street.

2. What is the mechanism of myeloneuropathy by nitrous oxide?

Nitrous oxide produces irreversible oxidation of cobalt in vitamin B12, rendering the vitamin B12 molecule functionally inactive. The functional deficiency of vitamin B12 results in an inability to incorporate phospholipids into myelin sheaths, resulting in neuropathy.2 Patients typically present with complaints of numbness, paresthesias, or weakness, and physical exam findings show changes in gait or coordination, difficulty walking, and falls.1 Most case reports describe neurologic sequelae after “chronic” abuse of N2O; however, an exact amount and duration of usage conferring risk has not been well defined.

3. What psychiatric sequelae are associated with nitrous oxide abuse?

In a recent systematic review, 12% of cases of abuse presented with a wide range of psychiatric complaints.1 Symptoms ranged from delirium, confusion, bizarre behavior, agitation, and memory problems. While typical vitamin B12 deficiency is associated with a megaloblastic anemia and neuropsychiatric sequelae, psychiatric symptoms after N2O abuse are not necessarily associated with low mean corpuscular volume. In some cases, delirium may be secondary to concomitant use of illicit substances.1

4. What laboratory or imaging studies could help confirm the diagnosis of nitrous oxide abuse?

There is no formal screening tool for N2O abuse. A detailed patient history is often the key to making the diagnosis.

  • Vitamin B12 levels: May be normal or low
  • Methylmalonic acid (MMA) and/or total serum homocysteine levels (precursors in vitamin B12-dependent pathways): May be elevated
  • T2-weighted MRI images: There have been reports of hyperintense signals in the posterior and/or lateral spinal cord at the cervical and/or thoracic levels.

5. What are some treatment modalities that need to be considered?

The most important intervention is the discontinuation of N2O abuse. Intramuscular and oral vitamin B12 supplementation has also been described. Patients will also require supportive care including an evaluation for fall risks at home due to persistent ataxia. Complete resolution of neuropsychiatric symptoms is variable. In 59 cases of neurologic sequelae after N2O abuse:1

  • Recovered completely: 10/59 cases
  • Symptom improvement: 46/59 cases
  • Psychiatric sequelae
    • Complete resolution: 5/11 cases
    • Improved symptoms: 2/11 cases

Case Outcome

The patient’s mental status and ataxia improved over the course of 3 days. He endorsed using anywhere from 50-100 canisters of nitrous oxide per day. He was diagnosed with chronic nitrous oxide toxicity that was further confirmed by an elevated MMA acid level. He was started on vitamin B12 therapy.


This Toxicologist Mindset series features real-life cases from the San Francisco Division of the California Poison Control System. Some elements of the patient’s case may have been altered to help provide additional patient anonymity.

Image credit

Garakani A, Jaffe R, Savla D, et al. Neurologic, psychiatric, and other medical manifestations of nitrous oxide abuse: A systematic review of the case literature. Am J Addict. 2016;25(5):358-369. [PubMed]
Flippo T, Holder W. Neurologic degeneration associated with nitrous oxide anesthesia in patients with vitamin B12 deficiency. Arch Surg. 1993;128(12):1391-1395. [PubMed]

Author information

Kathy Vo, MD

Kathy Vo, MD

Toxicology Fellow
Department of Emergency Medicine
University of California, San Francisco

The post Whipped Cream Charger Abuse: The Toxicologist Mindset appeared first on ALiEM.

ALiEM Book Club: On The Move

Oliver Sacks On the Move“I am a storyteller, for better and for worse. I suspect that a feeling for stories, for narrative, is a universal human disposition, going with our powers of language, consciousness of self, and autobiographical memory.” —Oliver Sacks, On the Move

Oliver Sacks has been many things in his life—physician, writer, researcher, drug addict, power lifter, motorcycle lover. He writes about all of these experiences as they have arced across the course of his much varied life in his memoir, On the Move [Amazon]. In this colorful autobiography, Sacks bobs and weaves through his own life, at times focusing in on the smallest detail, and at others zooming back for the 10,000 foot benefit of hindsight. Parts of the book are starkly innocent, while others border on frank arrogance. He demonstrates a complexity of personal characteristics that is at once believable and larger-than-life.

Book Overview

On the Move opens with a description of his childhood in England and his early love affair with motorcycles. After many decades of sidestepping the question, here Sacks openly writes about his sexual orientation and his subsequently conflicted relationship with his mother. Shortly following his years of university and medical school, he travels across the Atlantic to Canada in order to avoid the draft. Once there, he spends the first three months traveling west and lands unexpectedly in San Francisco, where he suddenly feels as if he has finally arrived home. He spends much of the next few years of internship and his neurology residency riding his motorcycle back and forth across the country and becoming intensely involved in power lifting. He experiments with stimulants and hallucinogens and rapidly becomes dragged down into a cycle of drug addiction while continuing to maintain his clinical practices—and of course, to write.

Sacks peppers his story with anecdotes from his patient encounters that continue to haunt. One patient, Frank, a man who initially confounded Sacks with his degenerative neurologic disease, dies ominously in an accident and becomes available for autopsy shortly after Sacks wished that he could see into the patient’s brain. Sacks also tells us about the many friends and colleagues who touched his life, both famous and not so famous. He writes about his brother Michael, who suffered greatly from paranoid schizophrenia during an era prior to the widespread use of antipsychotic medications. He discloses his few brief and sometimes passionate love affairs. However, his most touching relationship is with his Aunt Lennie, who seems to have given him a confidence that his successful parents had failed to instill.

Following residency, Sacks moves to New York City to complete a fellowship in neurochemistry and neuropathology at Albert Einstein. His raging drug abuse follows him across the country, where it almost kills him until friends intervene and pull him back from the brink. He begins work as a neurologist and publishes his first book, Migrane. The next several years of his career in New York City are tumultuous by any standard. Sacks is fired from three different jobs and intersperse his paid and unpaid time with postencephalic patients, autistic patients, and those with Tourette’s syndrome. He begins to make a name for himself with the publication of Awakenings, A Leg to Stand On, and the Man Who Mistook his Wife for a Hat. His circle of acquaintances grows to include well-known names such as the writer Thom Gunn, Francis Crick, Robert DeNiro, and the Nobel laureate neuroscientist Gerald Edelman. Sack also deals with the deaths of both his mother and father back in England.

Sacks concludes his memoir with a final chapter entitled, “Home.” As readers, we finally experience a sense of rest—or at least contentment. Sacks admits to feeling guilty for leaving his home country so abruptly in his early years, never to return again to live, and the absolution given to him by the Queen of England in his later years. He writes about his declining health and mortality. He also writes about the unexpected joy of meeting his partner, Bill Hayes, after 35 years of celibacy. Finally he reflects upon the act of writing itself. “The act of writing, when it goes well, gives me a pleasure, a joy, unlike any other … Over a lifetime, I have written millions of words, but the act of writing seems as fresh, and as much fun, as when I started it nearly seventy years ago.”

Analysis and Clinical Application

“To clinicians, Sacks generally seems a very good writer, and to lay readers, he often seems a remarkable doctor, but the extent of his distinction in either area has been subject to question. His writing sometimes has a tinge of expose, and there is no evidence that his clinical skills outrank those of other neurologists. To dismiss him on these fronts, however, misses the central fact that translating between those two great arenas has great value of it’s own.”

—New York Times Sunday Book Review

Oliver Sacks may be a neurologist by training, but On the Move reads like he should have been an emergency physician. Passionate, restless, and intensely curious about the world, we can certainly relate to his perspective on medicine, patients, travel, love, family, and friendships. The book unfolds like one of the author’s well-known case studies—except that the subject here is Oliver Sacks himself. He seamlessly weaves in his own colorful story with that of his many patients over the years and captivates us within the first few pages. He touches on some of the fundamental personal challenges of our field. Sacks writes “I thought of in part as a need to have different selves for day and night,” in describing how to marry his perception of his work self and personal self when first starting his career as a physician, a relatable struggle for many physicians.  An avid motorcyclist, he initially saw this as inconsistent with a respectable physician which he later proves wrong with his successful career as an esteemed neurologist. However, those accolades did not come without trials and challenges.  Sacks delves into darker moments in his life, including his struggle with drug abuse and addiction. He lets us in on how drug use affected his relationships and his work and a struggle that historically is taboo to discuss openly.

Then he reminds us of why we are in the medical field. Amidst the twists and turns of his extra curricular travels and adventures, he describes those memorable cases that stick with you for years. Academically, his insatiable curiosity and passion for learning brings the cases he describes to life and illuminating the fascinating science behind it almost making you want to exchange Sacks’ book for a pathology text. Almost. But patients are not just cases. His compassion for patients is apparent, even in defiance with professional norms. Sacks described a patient, suffering with a terminal disease. Her last wish was to join him on his motorcycle for a ride. In this moment, his dual identities come together as he makes the dying wish of his patient come true. He returned to the hospital, however, to be scolded, his job threatened, for his empathetic and unconventional act. It is clear, for Dr. Sacks, his patients come first.

Sacks’ innate desire for knowledge expands beyond the bounds of his chosen field and at times, the reader needs reminding that he is a neurologist. Reading from the perspective of an emergency medicine physician, you almost wonder, would Oliver Sacks be an emergency physician were that a specialty at the time of his training? While we will never be able to answer that question, a sense of reassurance in our own field comes from reading of his fascination of disease and treatment in many forms, which our field allows us to study. Not only is his fascination with his field apparent, but his respect of the history of medicine is clear as well. He describes the frustration of his colleagues during residency who rolled their eyes at his desire to discuss historical cases. Perhaps at the next educational conference, we will listen with a kind ear to that one colleague known to chime in with the seemly irrelevant knowledge or historic study.

Throughout his autobiography, Sacks returns to the power of narrative and storytelling in his own life but also its application in the field of medicine. He realizes that the practice of medicine is not just science, but is the art of the human story. We are reminded that in order to truly heal, we must understand more than simple physical complaints. Every day as emergency physicians we listen to and recreate dozens of stories as told to us by our patients and their families. And even beyond patient stories, sharing our own personal struggles and triumphs lets us know that we’re not alone. Stories make us resilient. They bind us together. They connect us to the patients we serve. They keep us human and reaffirm our commitment to making a difference in the lives of others. In the telling of his personal struggles, tragedies and triumphs, Sacks not only lets us in to his life but gives us a model and a platform to tell our own stories, find confidence in our strengths and, more importantly, our weaknesses. Not only did he advance the field of neurology, Sacks has advanced and challenged the concept of the physician.

Discussion Questions

  1. Although it was “understood” that Sacks would eventually become a doctor, he certainly did not take the direct path to respectability as was expected by his family. Reflect on your own path to choosing emergency medicine.
  2. Sacks delves into many of the important relationships in his life. Thinking back, who were the most influential people in your own life?
  3. The author describes attempting to delve into bench research two separate times, both ending in perceived failure. When have you felt failure in your career in medicine? How did those instances contribute to the physician you are today?
  4. Out of curiosity, Sacks used recreational drugs which evolved into a chronic abuse. Have you or have you known someone within the medical field who has struggled with drug abuse or addition? Do you feel as though he or she was supported by colleagues in recovery? Do you feel that this continues to be a taboo topic to discuss in the medical field?
  5. What are the activities outside of medicine that bring you joy?

Author information

Arlene Chung, MD

Arlene Chung, MD

Chief Strategy Officer,

2016-17 ALiEM Wellness Think Tank
Assistant Professor of Emergency Medicine
Assistant Program Director
Mount Sinai Emergency Medicine Residency
Editor, AKOSMED (EM wellness blog)

The post ALiEM Book Club: On The Move appeared first on ALiEM.

Introducing CME for ALiEM via FOAMbase

foambase-aliem-logo-sml cmeEver wish you could get Continuing Medical Education (CME) credit for the Free Open Access Meducation (FOAM) you already consume? We are excited to announce that 10 ALiEM articles are now available for AMA PRA Category 1 CME. This is a pilot program in collaboration with FOAMbase and EB Medicine. There is great content on trauma, geriatrics, pediatrics, critical care, and more. We think CME for FOAM is going to be a great way to increase sustainability for FOAM authors while keeping FOAM 100% free and open access.


The Bottom Line

  • 10 high quality articles from ALiEM are now available for AMA PRA Category 1 CME (more to come if this pilot is successful)
  • CME units can be obtained via the FOAMbase platform.
  • Each blog post is equivalent to 0.25-0.50 CME units.
  • There is a nominal CME charge ($4-8 per blog post). The revenue is which is shared between EB Medicine (CME accreditation provider), FOAMbase (centralized CME service for blog posts), and ALiEM/authors. 
  • The blog content remains 100% free for anyone to read, if CME units are not desired.

Blog Posts Available for CME

ALiEM Blog Post Title Category Number of CME Units
5 tips for managing pain in older adults Geriatrics 0.25
Trick of the Trade: Pre-charge the defibrillator Critical Care 0.25
Highlights from the 2015 American Heart Association CPR and ECC guidelines Critical Care 0.25
Synthetic cannabinoid use reaches new heights Toxicology 0.25
Fentanyl: Adding fuel to the fire in the North American opioid epidemic Toxicology 0.5
Traumatic brain injuries in older adults Trauma, Geriatrics 0.5
PEM Pearls: The nonvisualized appendix quandary on ultrasound Pediatrics 0.25
PEM Pearls: Assessing radiation risk in children getting CT imaging Pediatrics 0.25
PEM Pearls: Cardiac causes of pediatric chest pain Pediatrics 0.5
Ultrasound For the Win! Case – 55-year-old man with chest pain Ultrasound 0.25


I remember attending a talk by Mel Herbert at the 2015 Society for Academic Emergency Medicine (SAEM) meeting where he said something that stuck:

“FOAM is not free.”

What he meant is that while FOAM is distributed for free and is a labor of love for the authors, there are costs associated with creating and distributing content. Authors spend unpaid time creating the material, there are web costs for hosting, podcasters need to buy hardware and software tools, etc.

We remember thinking, how can we keep FOAM free and high quality while increasing sustainability for the authors?

Fast forward to 2016 Council of EM Residency Directors (CORD) meeting to one of those fated hallway conversations with Michelle Lin (@M_Lin), Nupur Garg (@NupurGargMD), and myself. We asked ourselves, was there a way to provide CME for ALiEM content? We took up the challenge and built FOAMbase CME to address just that.


  1. We want FOAM to remain free. ALiEM blog posts will always be 100% free and open access to read and learn from. A fee only applies when obtaining CME credit.
  2. We hope revenue-sharing with the blog website and individual authors will help offset the time and material costs of producing high quality educational content.
  3. At the same time, it will give physicians a great new source of high quality CME, allowing them to obtain credit for content that they may already reading.


  1. Create a new user account at FOAMbase as an “Attending” physician. This will open CME options for you.
  2. Click on FOAM CME to view the list of available CME content, or click on the content-specific links in the table above.
  3. Click the “Get CME” icon next to the blog post. This will launch a guided process on reading and obtaining CME credit for that blog post.


  • FOAMbase is a human curated database of FOAM content. It was built to keep track of high quality FOAM content from around the world and cut down on the noise that exist with FOAM search engines like GoogleFOAM.
  • FOAMbase CME is a custom add-on to FOAMbase with features required for CME administration, including pre-post quizzes, activity survey, certificate issuance, learner tracking, and a CME dashboard.
  • We are working with EB Medicine as the CME accreditation body.


Please let use know what you think. All comments are much appreciated. Nupur Garg and I will be at ACEP16 in the InnovatED section demoing the project. Come visit us!


Author information

Benjamin Azan, MD

Benjamin Azan, MD

Emergency Physician
Lincoln Medical Center
Founder/Editor of foambase.org

The post Introducing CME for ALiEM via FOAMbase appeared first on ALiEM.

MEdIC: Case of Cognitive Overload – Expert Review and Curated Community Commentary

cognitive overloadThe Case of Cognitive Overload outlined a scenario of a junior resident dealing with the harsh realities of working in emergency medicine when she experiences the negative impacts of cognitive overload while caring for a sick patient. This month, the MEdIC team (Tamara McColl, Teresa Chan, Sarah Luckett-Gatopoulos, Eve Purdy, John Eicken, and Brent Thoma), hosted a discussion around this case with insights from the ALiEM community. We are proud to present to you the Curated Community Commentary and our 2 expert opinions. Thank-you to all participants for contributing to the very rich discussions surrounding this case!

MEdIC Series

This follow-up post includes:

  • Responses from our solicited experts:
    • Dr. Amy Walsh is an emergency physician as well as the Global Emergency Medicine Fellowship Director at Regions Hospital in St. Paul, MN.
    • Dr. Jimmie Leppink is a postdoctoral researcher in education and is also a statistician at the School of Health Professions Education, Maastricht University, the Netherlands.
  • A summary of insights from the ALiEM community derived from the Twitter and blog discussions
  • Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities
Expert Response 1: Cognitive Overload and Communication Breakdown (Dr. Amy Walsh)
Expert Response 2: Check, Communicate, and Check Again (Dr. Jimmie Leppink)
The Case of Cognitive Overload: Curated from the Community (Dr. Sarah Luckett-Gatopoulos)

Case and Responses for Download

Click here (or on the picture below) to download the case and responses as a PDF (882 kb).

Author information

Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba

The post MEdIC: Case of Cognitive Overload – Expert Review and Curated Community Commentary appeared first on ALiEM.

I am Dr. Alicia Pilarski – How I Promote Wellness in EM

Wellness is not the sole responsibility of each individual physician, rather it is something we have to foster as a community. Many if not most of the things that contribute to burnout or detract from wellness are systems-level problems. Therefore the solutions also need to be systems-based, which inspired us to launch this series on how to promote wellness in EM. The goal is to share ideas, practices, and programs that have worked at different institutions to promote wellness. Our hope is that in reading these posts, you will be inspired to take some of the ideas and implement them in your own program. In this way we can slowly change the system that has produced a 70% burnout rate among Emergency Physicians and start to build programs and systems that promote wellness, resiliency, and career longevity. In this post, Dr. Pilarski discusses how she founded the Medical College of Wisconsin Wellness Committee, the challenges she overcame, and what the committee has accomplished.

alicia-pilarski-pictureDr. Alicia Pilarski is the Associate Residency Director, and Assistant Professor at the Medical College of Wisconsin.  She has been interested in wellness and resilience since residency during which she was involved in the development of a Wellness Committee. That interest continued as faculty where she established a Wellness Committee for the MCW Emergency Medicine Residency Program.

Name: Alicia Pilarski, DO
Location: Milwaukee, Wisconsin
Current Job(s): Associate Program Director, Department of Emergency Medicine; Assistant Professor; Wellness Committee Faculty Chair; Mom
Resilience and Wellness Program/Initiative: Founded the Wellness Committee for the EM Residency and currently working on creating a Second Victim Peer Support Team for the EM Department and the Trauma Surgery Department
Length of Time: Our EM Residency Wellness Committee has been going strong for over 5 years!

How did you become interested in wellness and resilience?

When I was a chief resident back in Las Vegas, my Program Director at the time (Dr. Michael Epter), agreed to let us create subcommittees and one of those committees was Wellness. My co-residents benefited so much from having dedicated wellness activities and planned events as a group. It brought us closer as a group and positively impacted our work-life balance. Having a dedicated Wellness Committee that is consistently evaluating and adjusting to the needs of the program keeps residents’ well-being on the forefront of their training experience. It contributes to building resilience among the residents both on an individual level and as a group.

What resilience and wellness initiative have you started?

I founded the Medical College of Wisconsin Wellness Committee, and I serve as the Wellness Committee Faculty Chair. Our Wellness Committee is responsible for planning both the Fall and Spring Resident retreats (organizing the events, picking a location, etc), coordinating social events for recruitment season such as pre-interview dinners), organizing the Intern Welcome, which is typically an outing to the Brewer’s Game, hosting/organizing/recruiting for the Big Brothers Big Sister’s of Milwaukee “Medical Explorer Day” (our yearly community outreach event) and other community outreach events throughout the year. We also send out monthly to bi-monthly wellness-related articles and updates about events on campus related to wellness. These have included mindfulness sessions on campus, or articles about improving wellness/resiliency, etc.

All of these events and efforts have made our residents closer as a group and provide a balance for spending time with their colleagues outside of the hospital. Also, we have been able to make the retreats more meaningful and enjoyable since the Wellness Committee took over the planning. Not only do residents get involved, but we have included others from our department (nurses, techs, APPs, etc) to participate in social events and our community outreach events. This helps create a better sense of community within our department and has made a big difference in the workplace.

What hurdles have you had to overcome?

Faculty buy-in. Initially, it was looked at as a ‘social group’ and not very important to the department. However, year after year, the committee has grown in size and our activities now encompass retreat planning, social activities, community outreach, wellness initiatives, and organizing peer support groups as needed. Our committee was integral during a tragedy that occurred in our program. One of our 2nd year residents, Carrie Falk, passed away from melanoma within 6 months of her diagnosis. Her passing was extraordinarily difficulty for residents, faculty, nursing, administration, and other departments in the hospital who knew her. The Wellness Committee organized peer support sessions (both group and individual), a memorial service, and each year we participate as a team in the Block Melanoma 5K Run/3K Walk to help support the cause of finding a cure for melanoma and also in memory of her.

Where have you found support?

Our former Program Director, Dr. Ed Callahan, was extremely supportive of me in starting the Wellness Committee. We were able to find funding to improve our Fall Retreat and also to create a mid-year retreat for the residents. Our residents have been the backbone to the committee and continue to make it better year after year. Each year, our Resident Chair (a 3rd year resident) helps coordinate our various activities, and also adds their own unique spin on the committee. We have bi-monthly meetings where we discuss upcoming events and brainstorm on how to improve the well-being of our residents, faculty, nursing and staff in the ED.

How could others promote wellness at their programs?

I would recommend a program to have the following: Program Director and Chairperson support, a wellness champion (ideally a faculty member with Wellness as an interest and who has time to devote to creating and maintaining the committee), a senior resident wellness committee chair (who is NOT a chief resident), and involvement of the residents (volunteers who meet bi-monthly with the wellness faulty and resident chairs). Our committee has 14 members including the faculty and resident chairs, and we have 28 residents in our program, so there is adequate representation from each class.

Author information

Christina Shenvi, MD PhD

ALiEM Associate Editor
Assistant Professor
Assistant Residency Director
University of North Carolina

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