Emergency Toxicology: From Database to Subspecialty

Toxicology in emergency medicine had a humble beginning.

It began as a database for emergency physicians treating patients who were suffering from poisonings, allergic reactions or drug overdoses.

Now it is one of the three subspecialties in emergency medicine, and one that emergency physicians say fits perfectly in the specialty.

"Emergency medicine was a natural for it," said Christian Tomaszewski, MD, director of the clinical toxicology fellowship at Carolinas Medical Center in Charlotte, N.C. "We're the first line of treatment, and we see especially the acute patients. We have a special body of knowledge needed to care for patients with poisonings and overdoses."

Emergency medicine toxicology fellowships have been around for years, but toxicology became a subspecialty in emergency medicine only about four years ago, said ACEP board member Robert Schafermeyer, MD, associate chairman and director of the education division at Carolinas.

"There were a fair number of emergency physicians who were practicing toxicology back then," he said. "But at the time it was more prevalent in internal medicine and pediatrics."

That eventually changed, said Tomaszewski, when emergency physicians started realizing that their special body of knowledge should be used to its advantage. There are now more than 20 fellowships in emergency medicine toxicology in 15 states.

That database of toxicology information has turned into a nationwide network of fellowships, spawning more and more specialists in emergency medicine. But the challenge is to get residents interested in the subspecialty in the first place, Tomaszewski said.

"We have to tell residents that although they'll be doing a fellowship for two years between their residency and professional practice, this type of experience creates a longevity for emergency physicians," he said. "And this subspecialty allows the emergency physician to work closely with many other specialties, such as pediatrics, and even hyperbaric medicine."

Tomaszewski developed his own interest in toxicology during his residency, when he was considering his future as an academician.

"I became very interested in it, and I thought it would be a perfect niche for me," he said.

Now he's doing what he has always wanted to do, being involved in the education of up-and-coming emergency physicians in toxicology. However, although toxicology in emergency medicine has come a long way, it still has a long way to go, he said.

"We're short on the science, so it's a wide open field," he said. "We need to continue to find the funds to do the research needed to advance the subspecialty."

There also needs to be a continued emphasis on funding poison control centers, where much of the information emergency physicians use is developed. And the databases emergency physicians still use need to be expanded and made more widely available to even the most remote, rural areas, Tomaszewski said.

"We don't even know all the drug interactions and many of the new poisonings until we see it in the emergency department," he said.

Emergency departments can play a vital role in tracking this new information and ensuring it reaches the hands of the physicians in the trenches, he added.

At the same time, emergency physicians in the United States can serve as mentors to developing countries that need such information as well, he said. Tomaszewski recently returned from sharing his knowledge with physicians in Ecuador.

"All these countries are going through the same growing pains that we did maybe 20 to 30 years ago," he said. "We can be there to educate them and provide the knowledge they need instead of their having to reinvent the wheel."

Public education about the risks of toxic reactions to drugs and poisons, and all other aspects of toxicology medicine, remains another challenge, Tomaszewski said, and again emergency physicians can be the front line of defense.

"The buzzword of the 90s is 'prevention,'" he said.

But with the help of researchers and emergency physicians specializing in toxicology, 'prevention' can become more than just a buzzword for toxicology...it can become an attainable goal.

For additional information on fellowships in toxicology, visit the Emergency Medicine Residents' Association web site at: www.emra.org and click on the fellowship button on the home page.

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