I love toxicologists, but it’s time for someone to call them out. (I also love ranting. Let’s see if I can get myself cancelled by a group of physicians that are definitely smarter than me.)
I am sick of the anti-science rhetoric. Every time a toxicologist takes the stage at a conference, or grabs the microphone on a podcast, I hear them say something like: “We don’t have any evidence for this. This is based entirely on case studies.” That, in itself, doesn’t bother me. It is the follow-up that drives me nuts. Immediately after lamenting the lack of available science, they always say, “this is the best we are ever going to get. We are never going to have great science on this topic. Good studies are just too hard in toxicology.”
Excuse me? That is absolute nonsense.
Toxicology is by far the easiest area in all of emergency medicine to run randomized trials in critically ill patients. Toxicology is the only area of emergency medicine where essentially every single patient across the entire country gets a phone call to a centralized expert. Every hospital is connected to a centralized hub.
Although it is true that individual cases of massive acetaminophen overdose are rare, every single case of massive acetaminophen overdose gets reported to poison control. That isn’t true for severe asthma. That isn’t true for right heart failure. For all other pathologies, the cases remain isolated at the individual hospitals. But for toxicology, every single case gets reported to a centralized service. Research in toxicology would be far easier than in any other critical illness.
If we don’t know the correct NAC protocol for a massive acetaminophen overdose, we can randomize it at the level of the poison center. Don’t know which patients require intralipid? We can randomize the advice being given by the poison center.
The studies might not be perfect. The poison center can’t mandate care. They would be pragmatic studies, in which the advice given by the toxicologist was randomized. But I think that would be good enough. How many emergency physicians, when faced with a critically ill poisoned patient, ignore the advice of the toxicologist?
So I am sick of the excuses. I think it is time for toxicologists to embrace the need for science, and embrace the centralized position they hold that facilitates that science being conducted.
Morgenstern, J. Toxicology: the excuses must stop, First10EM, October 21, 2024. Available at:
https://doi.org/10.51684/FIRS.134887
4 thoughts on “Toxicology: the excuses must stop”
“But for toxicology, every single case gets reported to a centralized service. Research in toxicology would be far easier than in any other critical illness.”
Absolutely not true. Poisonings regularly go unreported to PCCs, even massive ones.
“How many emergency physicians, when faced with a critically ill poisoned patient, ignore the advice of the toxicologist?”
Tox advice is often ignored by EM docs, and regularly ignored or disregarded upstairs.
This latter point informs the former: the PCC may get a call, but the EM doc often doesn’t have all the information on first contact when they’re calling for advice, and so the PCC (and thus the NPDS) data is often full of holes from the jump. Resuscitation continues, patient gets admitted or transferred and no one calls the PCC back with updates that have trickled in. When the SPI calls to follow up the patient, the ED team has turned over or moved on and no one knows the story anymore, especially if the patient was shipped out. Even when the patients don’t leave and stay in house, the inpatient treatment team caring for the poisoned patient often don’t want to read off the pages of labs, vitals, EKGs, MARs to the SPIs necessary to complete the data set. It often cannot even be confirmed if the recommendations tox made were even followed in the first place.
I cannot speak to these issues relative to other data sets, and this doesn’t even account for the lack of confirmatory testing, polysubstance ingestion, great degrees of variability in timing to presentation which make research in this domain an absolute slog through mud.
Absolutely agree with these comments.
Well, I fundamentally disagree with this. I’d argue that there has never been a really good RCT in toxicology. To enroll patients reported to the regional poison center in a randomized treatment study would require at least buy-in from every individual hospital involved. Ain’t gonna happen. Retrospective data from poison center databases are severely limited because of the heterogeneous patient mix, eligibility based often on history without laboratory confirmation, an often unknown mix of coingestants and underlying medical conditions — among other factors. Giving treatment recommendations based on experimental protocols would destroy trust in regional poison centers. Sometimes embracing science means realizing the limitations of existing evidence as well as any evidence we’re likely to have in the future.
I (obviously) don’t agree at all. Randomizing advice doesn’t require buy in from everyone at every hospital. Hell, they probably don’t even need to know, depending on how the trial is set up. And it definitely wouldn’t degrade trust. We run massive RCTs all the time. They don’t degrade trust. Exactly the opposite. Instead, you degrade trust when you insist science is impossible, and so just “trust me” instead. Care is already randomized around the world based on the opinions of the individual toxicologists. How is that a better system?