Case series: 9 patients with acute kidney injury after smoking a synthetic cannabinoid

orgazmo3.5 out of 5 stars

Acute kidney injury associated with smoking synthetic cannabinoid. Buser GL et a. Clin Toxicol 2014;52:663-673.


In the summer of 2012, two patients presented to emergency departments in western Oregon complaining of nausea, vomiting and flank pain that started shortly after smoking a synthetic cannabinoid product. Both patients had elevated serum creatinine levels and hypertension. Renal biopsy revealed acute tubular injury with inflammation in both patients. Extensive work-up did not reveal any other possible cause of renal disease.

A public health investigation identified seven other patients in the region who presented with acute kidney injury (AKI) within 2 weeks of smoking a synthetic cannabinoid. Some key features of these cases include:

  • Exposure to several synthetic cannabinoid products, including “Clown Loyal,” Johnny Clearwater” (caramel corn), “Lava,” and “Orgazmo” (pineapple).
  • The synthetic cannabinoid XLR-11 was detected in each of 2 involved products that were tested, as well as in clinical specimens from one of five patients tested.
  • All patients recovered, although received a short course of hemodialysis.

This article is a very complete and finely done description both of the clinical syndrome of AKI associated with use of synthetic cannabinoids, and the related public health investigation. [HT @DougBorys]

Related posts:

Four (really three) cases of acute kidney injury associated with us of synthetic cannabinoids

MMWR: synthetic pot suspect in cases of kidney failure

Blueberry “spice” in Wyoming linked to cases of renal failure

Low nurse to patient ratios results in up to 35% increase in stroke unit deaths.

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A large study ( of 56,666 patients) by Benjamin Bray et al from King’s College, London has found that the number of registered nurses on stroke units during weekends significantly affects patient mortality.

A clear relationship was demonstrated, with patients admitted to hospitals that had the lowest weekend ratios of registered nurses to patient beds having the highest mortality risk (up to a 35% increase in deaths), and those admitted to hospitals with the highest ratios having the lowest risk (up to a 20–30% reduced risk of death).

Their research has found that higher nurse to patient ratios may prevent one death in every 25 admissions.

The study also concluded that there was no correlation of specialist doctor staffing levels and increased mortality over the same weekend period.

There are already several studies that show a relationship between higher patient mortality and the reduced staffing levels (and I would include reduced service provision) over weekends. This has become known as the weekend effect, but this is one of the first to support such a strong relationship to nurse / patient ratios.

The authors conclude:

This study is one of the first in any healthcare setting to specifically examine the relationship between the organisation of care on weekends and mortality. Despite the fact that staff account for the great majority of healthcare spending (64% in the National Health Service), there remains very little research into the effect of clinical staffing levels on patient outcomes. Controlled studies of different models of physician and nursing staffing seem both feasible and important, given the potentially large impact on patient outcomes and the high costs to health systems of increasing staffing levels on weekends. In the meantime, these data support the provision of higher weekend registered nurse/bed ratios in [stroke units].

References: featured image via tedeytan

  1. PLOS Medicine: Associations between Stroke Mortality and Weekend Working by Stroke Specialist Physicians and Registered Nurses: Prospective Multicentre Cohort Study [Internet]. [cited 2014 Aug 22]. Available from:

Countdown to presenting at global disaster forum #IDRC2014

csm_idrc2014_6fe511616eWe’re counting down the days until we present on the world stage at the 5th International Disaster and Risk Conference (#IDRC2014) in Davos Switzerland on 27 August.

This conference is organised by the Global Risk Forum in cooperation with the United Nations Office for Disaster Reduction (UNISDR) and is the largest world gathering of key players in this field.

IDRC Davos 2014 (24-28 August) attempts to find solutions to today’s challenges by managing risks, reducing disasters and adapting to climate change.

Importantly, it is a powerful opportunity to influence world policy. As a speaker we will be making recommendations for the Post 2015 Disaster Risk Reduction Framework to be ratified at the UN World Conference WCDRR in Sendai Japan in 2015.

Our topic will be “The importance of a whole of community approach to using social media for disaster resilience and how the Emergency 2.0 Wiki can help.”

emergency2.0wiki_logo_colour_lowres (2)We believe that together we can help create a world where communities use social media to save not only their own lives in a disaster, but also the lives of others. A world where:

  • Emergency services use social media to issue alerts and warnings to save lives
  • Emergency agencies engage with the community as partners
  • The community is prepared, including people with a disability
  • Digital volunteers from across the globe provide ‘information aid’ during and after disasters
  • The community reaches out to help the community

We believe that social media can play a transformative role in making disaster resilience a social norm. Social media offers the potential to help create a level of resilience that ensures communities don’t just ‘bounce back’ after a disaster, but ‘bounce forward’, becoming stronger with increased social networks, social cohesion and social capital. This requires a ‘whole of community approach’ in which the community becomes partners in using social media for disaster resilience.

We will be showcasing how this can be done using best practice examples from around the world and sharing how the Emergency 2.0 Wiki, a free global resource for using social media and new technologies in disasters, can help.

With thanks to our Sponsor

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We would like to thank our major sponsor, Emergency Management Australia, part of the Australian Attorney General’s Department, for making our presence at #IDRC2014 possible.

A great development from Australia in recent years has been the Australian Emergency Management Knowledge Hub. The Knowledge Hub provides research, resources and news to assist evidence-based decision making for the emergency management community nationally and internationally. For a vast range of disaster related multimedia and historical information on events such as bushfires, heatwaves, floods, environmental incidents, cyclones, epidemics, earthquakes and landslides, visit the Knowledge Hub and follow them on Twitter on @AEMKH.

Eileen Culleton, Founder & CEO Emergency 2.0 Wiki, Social Media in Times of Crisis Forum

Eileen Culleton, Founder & CEO Emergency 2.0 Wiki, Social Media in Times of Crisis Forum

We are excited to have this opportunity to showcase the Emergency 2.0 Wiki on the world stage and share our message on how countries can build disaster resilience through a whole of community approach to using social media.

We also look forward to making strategic contacts to form alliances with international bodies.

Join the conversation on the conference via the hashtag #IDRC2014.

We’re now on Facebook

FB_FindUsOnFacebook-144 - Copy


We’re now on Facebook, so please like us and share with your networks!



Eileen Culleton, Founder & CEO (Voluntary role)

PS. Together we can make our world safer…

Image Credit: Social Media in Times of Crisis National Symposium, Eidos Institute Facebook. Photographer Fiona Muirhead.

ECG of the Week – 25th August 2014

This ECG is from a 45 yr old male presenting to the Emergency Department following an episode of chest pain. He was pain  free when this ECG was recorded.

Click to enlarge
VAQ Corner

A 45 yr old male presents to your Emergency Department following an episode of chest pain.
He has no significant past medical history. He is pain free during this ECG recording.

  • Describe & interpret his ECG

Wake Up America! It Costs One Million Dollars to Become a Doctor!

After my last post, I had a conversation with a friend of mine who practices law in New York. Our discussion focused on how much doctors are being paid compared to lawyers. My friend considers me lucky, as I had a scholarship that paid the tuition for my education. I am fortunate that this is true, but the majority of physicians take out substantial loans to pay for their education. So I decided to create a list of what it costs to be a pediatric emergency physician in the United States. Medical School Tuition: A 20-year loan anywhere between $219,000 and $287,000, with interest between 5.41% and 6.41% per annum Tuition Interest: $182,000 (calculated at the lower end of the spectrum) USMLE Exam fees: $2455 USMLE study aids/Courses: $700 (if utilizing only question banks) FCVS enrollment: $350 Residency Application: $350-$400 Fellowship Application: $350-$400 Pediatric Board Certification: $2265 Fellowship Board Certification: $2900 Maintenance of Certification (every 5 years): $1230-$1420 Initial License to practice (NY): $735 License renewal (NY)(every 2 years): $600 DEA registration (every 3 years): $731 PALS Certification (every 2 years): $250 ATLS Certification (every 4 years): $450 ACLS Certification (every 2 years): $250 AAP Membership including SOEM membership (yearly) (optional): $800 Loss of Income During Years of Training: Average residents and fellows get paid $50,000 per year. During six years of postgraduate training, we lose income of about $70,000 per year for comparative degrees. This puts the loss at $420,000.   Total Costs: $836,000 to $904,000 I did not include costs of travel for residency, fellowship and job interviews, as those vary according to the geographical distribution of locations the candidate applied. This calculation also does not include the extra costs of ECFMG for foreign graduates. Another cost I have not included is the living expenses during years of education. These costs could cause the total number to exceed the one-million-dollar mark. Pediatric Emergency physicians do make a slightly better income than pediatricians, yet they continue to be the least paid in the world of emergency medicine. Can pediatricians and PEM physicians survive these costs? Especially in an era of steadily inflating costs and stagnant salaries! How much more can we cut from a budget that is already stretched thin? If we want to reduce healthcare costs we need to have a less expensive method of creating healthcare workers! Are you experiencing the same? Please share your thoughts and comments!

Driving With A Foot Out The Window

Driving With Foot Out Window

I saw this while driving down the road recently. A person just tooling down a major road with their foot hanging out the window.

What possesses people do drive with their feet out the window? I see it every once in a while from both drivers and passengers. This time my daughter just happened to be in the car with me so she could catch this picture.

I did a quick search of the internet and of the medical literature and wasn’t able to find any specific literature on the potential downsides from driving like this.

I was, however, able to find other pictures/posts/comments …
calling a driver doing this a “jackass,”
noting that the practice was awkward and potentially dangerous,
stating that a person driving in this manner is “white trash skank,”
stating that driving this way is illegal in Delaware,
noting that a driver in Australia who was pictured with both feet out a window had been charged with “reckless conduct endangering life, failure to have proper control of a vehicle, careless driving, and limbs protruding from a vehicle,” and
a comment noting that the practice was something worthy of circus people.

So if driving with your feet out the window doesn’t hurt anyone and it feels nice to have a breeze blowing on your bare feet while traveling at 50 MPH, then why shouldn’t we do it?
Here are some of my thoughts.

First, you look like a freak when you drive with your foot out the window. It isn’t cool. It isn’t funny. It looks low class and smarmy. Yes I’m old and out of touch with the younger generation. You still look like a smarmy whippersnapper when you drive with your foot out the window.

Next, when you drive with your foot out the window, your foot and/or leg is blocking your view of the driver’s mirror. That makes you less able to see your surroundings and more prone to getting into an accident.

With your leg in that position, you are probably less able to shift your body to turn and look in your blind spot when changing lanes or making a turn. That makes you more likely to hit a vehicle approaching you on your driver’s side.

Finally, pretend for a moment that you get into an accident with your foot hanging out the window. Think of what will happen to your body …

If you rear-end someone and your air bag deploys, momentum will carry your body forward while the airbag forces your hanging leg into flexion and external rotation. Ever popped a chicken leg off a cooked chicken?
Your knee will probably hyperextend as well, so you’ll be in a position where you’ll potentially have no knee ligaments and no hip joint.
The anterior force on your driving leg combined with the posterior force on your leg out the window will cause a shearing force on your pelvis which may be enough to snap your pelvis like a pretzel. Pelvis fractures are potentially life threatening, tough to rehab, and carry multiple serious complications.

If you’re involved in a rollover accident, it’s even worse. You won’t have time to pull your foot back in the vehicle and the edge of the window will hold your foot in place as the several tons of car rolls on top of it, mangling your foot if you’re lucky and just ripping it from your leg if you’re not so lucky. If the roof collapses from the rollover impact, then your knee and lower leg will get caught up in the mangled metal – which may prevent you from getting out of the car.

Look at the bright side, though. If you survive a serious accident with your leg hanging out the window, at least they have a lot of advanced leg prosthetics you can choose from.

Anyone got any stories about trauma from drivers or passengers with their feet out the windows?