The Journal of Emergency Medicine 927

their complaint issues analyzed preset categories. Results: Therewere 114 complaints lodged in 2009–2010, out of an annual at-tendance of around 300,000. Demographics, residential area,and billing status of complainants are comparable with the gen-eral patient pattern in this ED. Most of the complaints arose dur-ing the night time when the manpower is thin in the ED. Forurgent cases, complaint validity is 86% (65% in 1990–1994);for non-urgent cases, validity is 78% (58% in 1990–1994). Inour data, 45% were diagnosis and treatment related (it was29% in 1990–1994). Fifty percent were related to missing diag-nosis and improper management. Around 30% were related toinadequacy of care. Nature of complaints: Access: 17% (longwaiting time and access block); Communication: 22% (staffmanner); Treatment and Diagnosis: 45%; Treatment and Diag-nosis Subgroup analysis: 83% of these complaints are substanti-ated; 38% of substantiated cases are Medical and Orthopedicspatients. Out of valid complaints, themajority (75%) can be rem-edied by further explanation and apology. Conclusions: This isa pilot review on the limited number of complaint cases lodgedin 2009 and 2010. Communication is an important ring to im-prove patient satisfaction. Important diagnostic challenge shouldbe emphasized repeatedly among staff. For better analysis,a larger-scale prospective study would be recommended.

, EFFECTIVENESS OF VIRTUAL LEARNING COM-PARED TO CLASSROOM EDUCATION IN APPROACHTO DIAGNOSIS OF BIOTERRORISM AND CHEMICALTERRORISM AMONG EMERGENCY PHYSICIANS.M. A. Moghaddam G. Molavi, Emergency Medicine, ImamHossein Hospital affiliated with Shahid Beheshti University ofMedical Sciences, Tehran, IRAN.

Objective: Emergency Physicians have an important role indetecting chemical and biological terrorist attacks. The presentstudy compared the effectiveness of virtual vs. classroomteaching methods among Emergency Physicians in detectingchemical andbiological terrorist attacks.Methods: The quasi-ex-perimental study was performed on Emergency Physicians witha convenient sampling method. Study samples were divided intotwo groups for virtual and classroom teaching. Teaching mate-rials were about six category A biological terrorism attacks (An-thrax, Plague, Tularemia, Viral Hemorrhagic Fever, Botulism,Smallpox) and five chemical terrorism attacks (Chlorine, Phos-gene, Mustard, Lewisit, Nerve Agents). This study was conduct-ed to assess knowledge before and after training. A questionnaireto determine the ability to diagnose chemical and biological ter-rorism was designed and confirmed by two educationalexperts. Results: Therewere 160 Emergency Physicians enrolledin the study. Ninety-six (60%) were men and 64 (40%) werewomen. Average age was 36.2 6 5.5 years. In the virtual teach-ing method, pretest correct diagnoses of diseases were 30.6%,and after the training, score improved to 81.6%. In the classroomteaching method, pretest correct diagnoses of diseases were41.9%, and after the training, score improved to 72.9%. Meanscore difference in virtual learning was 51%. Mean score differ-ence in the classroom education method was 31%. Difference inscore improvement between two learning methods was signifi-cant (p < 0.02). Conclusions: Based on the results of this study,it seems that virtual learning is more effective than classroom ed-

ucation in approach to diagnosis of chemical and biological ter-rorism among Emergency Physicians.

, CAN CONTEMPORANEOUS FEEDBACK USINGWEB 2.0 APPLICATION TWITTER PROVIDE MOREEFFECTIVE EVALUATIONS THAN TRADITIONALEND-OF-BLOCK EVALUATIONS? Bobby Desai,Emergency Medicine, University of Florida, Gainesville, FL.

Background: Inconsistencies in work schedules and facultysupervision are barriers to monthly emergency medicine (EM)resident evaluations. Direct and contemporaneous resident feed-back may be effective in providing specific details that deter-mine a resident’s evaluation. Objectives: To determinewhether Twitter, an easy-to-use Web 2.0 application that isavailable on smartphones and the Internet, can provide directand contemporaneous resident feedback that is easily accessibleand easy to store and refer back to. Methods: First- to third-yearEM residents were administered a survey to assess theirthoughts on the current monthly evaluation system. Subse-quently, residents obtained a Twitter account and were in-structed to follow one general faculty Twitter account for easein data collection. Following completion of an 8-week study pe-riod, a second survey was administered to assess residentthoughts on contemporaneous feedback and evaluations vs.the traditional form. Results: Of 24 EM residents, 13 were avail-able for study. A total of 220 ‘‘tweets’’ were provided by sevenfaculty to the residents, with a mean of 11 tweets (range 8–17)per resident. The 13 residents received a total of eight formalevaluations from 19 faculty. The second survey demonstratedthat this method provided more detailed evaluations and in-creased the volume of feedback. Conclusions: Contemporane-ous feedback and evaluation provides a greater volume offeedback that is more detailed than end-of-block evaluations.Twitter is an effective and easy means to provide this feedback.Limitations included the length of study time and the inability tohave all EM residents involved in the study.

, AN OUTBREAK OF METHEMOGLOBINEMIA AF-TER EATING NOODLES BOILED IN WATER CON-TAINING ANTIFREEZE. Y. J. Park, S. P. Kim, S. J. Kim,S. H. Cho, N. S. Cho, Emergency Medicine, ChosunUniversity Hospital, Gwangju, KOREA.

Objective: Sodium nitrite is used commercially as a coloringagent, a food preservative, and a corrosion inhibitor. Accidentalpoisoning usually results from the ingestion of contaminatedfood and water and causes gastrointestinal irritation, vasodilata-tion, and methemoglobinemia with subsequent tissue hypoxia.We describe an outbreak case of sodium nitrite-induced methe-moglobinemia following the ingestion of water contaminatedwith industrial antifreeze. Methods: Eight workers who ate thenoodles were hospitalized with severe stomachache. The eightworkers employed at a construction site had instant cup noodlesas a mid-morning snack 3 h earlier. They boiled and poured thewater containing antifreeze into the cups mistakenly. Workershad put antifreeze into a 120-L water drum a day earlier to pre-vent thewater from freezing over night.Without realizing it, theyboiled the contaminated water to cook instant noodles. One

928 Abstracts

worker ate all the noodles, while the eight others stopped, com-plaining about an unusual smell. One worker died on the scene,with the other workers immediately transferred to the Emer-gency Department. Results: They complained that the noodletasted ‘‘unpleasant’’ and soon afterwards experienced nausea,vomiting, dizziness, weakness, sweating, and diarrhea. Theynoted cyanosis and sinus tachycardia, hypotension. Subsequentinvestigation demonstrated a methemoglobin concentration of64.6%, which was corrected by the intravenous administrationof 1 mg/kg methylene blue 3 h after the onset of symptoms.The patients made a prompt, uncomplicated recovery and weredischarged home 4 days later. Conclusions: Antifreeze "ingredi-ents label" contains sodium nitrite 20%, surfactant 10%, silicondioxide 5%, water 60%, and others 5%. Accidental poisoning ofindustrial antifreeze causes methemoglobinemia, and its con-tinuing commercial availability necessitates that physiciansconsider the diagnosis and institute treatment with methyleneblue promptly to prevent a fatal outcome.

, A CLINICAL REVIEW OF ACUTE POISONING INGERIATRIC PATIENTS FROM RURAL GANWONPROVINCE. J. Y. Lee, Department of Emergency Medicine,Hallym University Chuncheon Sacred Heart Hospital, Seoul,KOREA.

Objective: Recently, there has been an increase in acute poi-sonings in the elderly, which may be associated with attempts atsuicide. The purpose of this study was to compare and analyzethe clinical aspects and outcomes of acute poisonings in aged in-dividuals with those of younger individuals. Methods: We per-formed a retrospective analysis of 207 patients seen in theEmergency Department (ED) with acute poisoning from Janu-ary 2009 to December 2010. Two groups were created, > 65years and < 65 years. The following were carefully compared:annual frequency, gender distribution, cause of poisoning, poi-soning substance, motive for suicide, past psychiatric history,psychiatric interview, psychiatric diagnosis, disposition afterED visit, disposition after admission, poisoning severity score(PSS), duration of hospitalization, intensive care unit admissionrate, and mortality. Results: The annual frequency was 0.1% inthe > 65 group and 0.3% in the < 65 group, 0.4% in total. Thecause of poisoning was accidental more often in those > 65years than in those < 65 years. As motive for suicide, healthproblem was cited more often in the older group (p = 0.000).The older group had fewer interviews with psychiatrists andwere more often diagnosed with depressive disorder(p = 0.010, p = 0.041, respectively). PSS and mortality werehigher in the older group (p = 0.002, p = 0.010,respectively). Conclusions: A better understanding for the causeof poisonings and the poisonous substance used in the aged pop-ulation is needed. And because of the more serious effects ofacute poisonings to the elderly patient, they should readily re-ceive regular comprehensive care including psychiatric care.

, A CASE OF TRANSIENT DIABETES INSIPIDUS AS-SOCIATED WITH TETRODOTOXIN POISONING.D. H. Wi, School of Medicine, Department of EmergencyMedicine, Wonkwang University, Iksan, KOREA; S. H. Kim,Emergency Medicine, Gunsan Medical Center, Gunsan,KOREA.

Objective: Ingestion of puffer fish can result in severe andpotentially lethal intoxication. Tetrodotoxin is a potent neuro-toxin well known for its ability to inhibit neuromuscularfunction. To our knowledge, the only previous report ondiabetes insipidus occurring in association with tetrodotoxin isone case in Singapore. Case Report: A married couple (69-year-old man and 57-year-old woman) ingested two greenrough-backed puffer fish (Lagocephalus lunaris). Results:They complained of paraesthesia of the perioral area and ex-tremity and developed not only grade IV intoxication but alsoan increased urine output (4455 mL/day, 5035 mL/day), ele-vated serum sodium (157.4 mEq/L, 166.7 mEq/L), and elevatedserum osmolality (324mosmol/kg, 339mosmol/kg), which sug-gested the development of diabetes insipidus. The administra-tion of desmopressin was successful in normalizing urinevolume. Conclusions: The patients were discharged the 20thand 18th hospital day without any complications.

, BRUGADA ELECTROCARDIOGRAPHIC PATTERNAND SEIZURE INDUCED BY PROPRANOLOL OVER-DOSE. P. S. Leung, C. Wan, S. Tsui, Accident and EmergencyDepartment, Queen Mary Hospital, Hong Kong, CHINA.

Objective: Since the first description of Brugada syndromein 1992, it has become the focus of interest among cardiologistsand Emergency Physicians. Apart from its inherited form asso-ciated with SCN5A gene mutation, the acquired or drug-in-duced form was a relatively new concept. Although manyagents had been implicated for manifestation of Brugada elec-trocardiographic pattern, it was not commonly described amongpatients with propranolol overdose. Case Report: We reporta 44-year-old Chinese woman with history of bipolar affectivedisorder and drug overdose being admitted to the Accidentand Emergency Department with generalized tonic-clonic con-vulsion after ingestion of around 500 mg propranolol. Initial as-sessment showed reduced consciousness, hypotension, andrepeated brief seizures. Electrocardiogram showed sinus brady-cardia, widened QRS complex, terminal R wave in aVR, normalcorrected QT interval, and right bundle branch pattern withcoved type ST-segment elevation > 2 mm with downward slop-ing over right precordial leads at conventional positions, whichwas consistent with ‘‘type one’’ pattern. Fluid boluses, sodiumbicarbonate solution, and glucagon were administered. Serumcardiac markers and biochemistry results were within normallimits. Neither her personal nor family histories revealed syn-cope, documented arrhythmia, aborted or complete sudden car-diac death. Results: Propranolol was well known for itsmembrane-stabilizing ability and high lipophilicity. It couldreadily cross the blood-brain barrier, reduce seizure threshold,and alter consciousness. There was significant correlation be-tween widened QRS complex and seizure. The sodium channelblocking effect in the context of propranolol overdose led toelectrical heterogeneity of epicardial and endocardial action po-tentials. Avoidance of the offending agent, installation of an im-plantable cardioverter-defibrillator, and quinidine therapy mightbe treatments of choice. Early referral to a cardiologist, riskstratification, and family screening might also help in suspectedcases. Conclusions: It was important to recognize the Brugadaelectrocardiographic pattern and ventricular arrhythmia as