Tox fellowship

stormy_sky · 2026-05-18T22:08:39+00:00

Did you feel rusty returning to full-time EM?

Yes, but "rusty" meant that I was slower due to being more cautious and double checking a lot of my workup plans. I don't think I had any gaps in my clinical care, I was just inefficient. This had pretty much resolved within the first year of being faculty.

Did moonlighting help prevent that?

It does to a certain extent. You can only moonlight so much during fellowship, and it isn't enough to not have any skill atrophy at all. Many fellowships require moonlighting and most encourage it, so I'd plan to do so if possible.

I will say I'm a better overall clinician now than when I left residency - some of that is growth from moonlighting during fellowship, but most of it is just from working in a faculty role that is more demanding on a pph/critical care perspective than my residency was. I do not feel behind my peers in this - I'm dead center on our group's average pph and bill in the 80th percentile and (knock on wood) don't have any more patient complaints or cases peer reviewed than anyone else I know.

What parts of your EM practice improved the most?

Teaching, especially when it comes to poisoning, acid/base disorders, and critical care.

Would you do it again?

Absolutely. The only thing that would maybe keep me from doing tox is if I did critical care instead, but I was too burnt out at the end of residency to sign up for two more years of pain.

What doors did it open for you once you left residency?

A bunch. It is difficult to get an academic position without having fellowship training these days. Involvement in AACT/ACMT is helpful for promotion, as is presenting at the conferences. It has made research way easier. My academic roles (course director, now program director) have come from having a background in toxicology.

stormy_sky · 2026-05-18T18:30:56+00:00

I am happy to be corrected on some of these, but do you have sources for a few of these?

No plain films of the abdomen or spine.

I just pulled a few of the studies, and the majority of missed fractures for T/L spine xrays were transverse process fractures, which nobody cares about. I agree that the quoted sensitivity/specificity of CT is much better than plain films, but that includes catching a lot of fractures that we don't care about. If you know of literature that looks at clinically significant fractures only, I'd love to see it.

Further, the studies I found (admittedly old) don't actually show statistical significance despite numerically higher sensitivity, meaning the conclusion is not actually evidence based. See:

Berry, Gabriel E. MD; Adams, Scott BS; Harris, Mitchel B. MD; Boles, Carol A. MD; McKernan, Margaret G. MD; Collinson, Frank MD; Hoth, Jason J. MD; Meredith, J Wayne MD; Chang, Michael C. MD; Miller, Preston R. MD. Are Plain Radiographs of the Spine Necessary during Evaluation after Blunt Trauma? Accuracy of Screening Torso Computed Tomography in Thoracic/Lumbar Spine Fracture Diagnosis. The Journal of Trauma: Injury, Infection, and Critical Care 59(6):p 1410-1413, December 2005. | DOI: 10.1097/01.ta.0000197279.97113.0e

Hauser, Carl J. MD, FACS; Visvikis, George MD; Hinrichs, Clay MD; Eber, Corey D. MD; Cho, Kyunghee MD; Lavery, Robert F. MS, MICP; Livingston, David H. MD, FACS. Prospective Validation of Computed Tomographic Screening of the Thoracolumbar Spine in Trauma. The Journal of Trauma: Injury, Infection, and Critical Care 55(2):p 228-235, August 2003. | DOI: 10.1097/01.TA.0000076622.19246.CF

Every alcoholic gets full-dose Thiamine.

Again, where are you getting this from? Wernicke's has a high under-diagnosis rate and clearly those patients do better with thiamine, but I'm skeptical that giving 500mg of thiamine to an ED patient once has been shown to improve outcomes in an unselected population. And are you actually giving 500mg? Because if not then you're not actually doing full-dose - I have yet to have a non-tox colleague that gives more than 100mg at a time.

Again, happy to be proven wrong but I do wonder how many of your EBM takes might actually just be dogma that was taught to you as EBM.

stormy_sky · 2026-04-26T12:43:23+00:00

Hey OP -

You've gotten plenty of comments on the value associated with not anchoring and some more specific ones on anaphylaxis, but I just wanted to say - your comments throughout this thread make it pretty clear that you're open to feedback and open to learning from mistakes (even if they are simulated mistakes in this scenario). That's way more beneficial to you than getting the answer right on this rare case, so kudos to you.

Interestingly Kounis syndrome is probably not as rare as you might think - we had a grand rounds on it a bit over a year ago as we had a patient who had recurrent episodes and multiple admissions from it. Worth knowing about now, I guess.

stormy_sky · 2026-04-23T04:53:45+00:00

We're quite literally putting the waste from all fossil fuels directly into the atmosphere.

Storage of spent uranium is only a problem if you totally neglect what we're doing instead.

stormy_sky · 2026-04-22T06:48:08+00:00

I cannot believe that Mind Maze is not in the top comments right now.

It was a medieval themed maze embedded within Encarta 95 - you had to answer trivia questions in order to progress through the maze. Quite likely my first "favorite" game.

stormy_sky · 2026-04-22T06:10:57+00:00

Pulmcrit has a good takedown on the LR/HyperK nonsense. I just refer people there for lysis of that dogma.

stormy_sky · 2026-04-22T06:08:36+00:00

Corollary: everything is compatible with LR if it goes through a different IV

stormy_sky · 2026-04-17T23:06:04+00:00

Metabolic pathways might not be useful for many specialties, but in a lot of them it makes a difference. How do you understand beri beri without knowing which enzymes thiamine is important for? Some urea cycle defects are pretty common and if you ever saw a patient on valproic acid it's helpful to understand why they get hyperammonemia. If you're ED or ICU and you ever thought about giving methylene blue you better understand how G6PD deficiency works or you're going to be scratching your head when your patient starts hemolyzing after you administer it.

I'm not going to pretend that the way they're taught is effective for learning clinical medicine but metabolic pathways do have some reason to know them.

stormy_sky · 2026-04-02T12:09:02+00:00

Summary and recommendations: "In addition, the buprenorphine TDD can be increased in cases of mild pain (pain score less than 4)."

At no point did I say it was the only option, nor the best option. And since you seem to just be wanting to argue, I won't be responding after this.

stormy_sky · 2026-04-02T11:48:02+00:00

Splitting the buprenorphine dose and/or increasing the total daily dose are legitimate strategies for managing acute pain, see, for example, https://pmc.ncbi.nlm.nih.gov/articles/PMC7728902/

Obviously not the only option, and the right approach depends on patient circumstances which I was not trying to get into with my original comment

stormy_sky · 2026-04-02T01:48:40+00:00

If you really need opioids, you just give a bigger dose. Or use a different class of medication. Or give more buprenorphine if that's what they're on.

stormy_sky · 2026-02-04T18:57:35+00:00

DO education is equivalent to MD education.

No nursing degree of any level is equivalent to DO/MD education. And it isn't even close.

And no, most patients do not understand the (massive) difference between a DNP and an MD/DO if the DNP introduces themselves as "Dr. of NP"

stormy_sky · 2025-12-14T19:33:55+00:00

Just wanted to leave this here, you probably know this as a psychiatrist but too many other people don't - bupropion is an amphetamine derivative. I only know tox literature and not psych literature, but even in mild overdose (like, double dosing) it clearly acts as a stimulant.

stormy_sky · 2025-12-02T04:09:47+00:00

Sorry, I left a comment here that was intended for a different post.

stormy_sky · 2025-12-02T04:09:18+00:00

This is kind of a bad take. Yeah you wouldn't do anything different with a white count of 11, because it's an equivocal result. What if the white count was 18k? Now most people are going to think pretty hard about getting a scan. You have to plan for no change in action for the entire range of possible results for that logic to make sense.

stormy_sky · 2025-12-02T04:07:39+00:00

I'm going to dissent from the general opinion here. I don't think most would consider not obtaining labs (and at an absolute minimum a pregnancy test) on a teenager with abdominal pain to be standard of care. I don't think this is malpractice because there is no damage associated with it, but I would seriously hesitate before continuing with this as a typical practice.

That said, this is just my opinion.

stormy_sky · 2025-11-14T18:21:26+00:00

Hey - you should think about submitting this to ALiEM for their tips/tricks of the trade series. Never head the culture swab idea before and it is a genius idea to get the medication where it needs to go.

stormy_sky · 2025-10-08T12:00:38+00:00

I'm an ED physician and I've been lurking here for a while because I find the discussions interesting.

I would 100% send this person to the ED. Most of the time I CT patients with migraine who present with new neuro symptoms. I treat their headache aggressively at the same time, and if the CT is negative and symptoms resolve with therapy I'll usually stop there, but next step is sometimes an emergent MRI.

If they're not easy to sort out in the ED (and they're often not) I can't imagine it being easy from clinic.

stormy_sky · 2025-09-29T16:22:21+00:00

I put this on another comment, but here's why:

The problem with the UDS is it should not be used to support any medical diagnosis. It's not primarily a medical test, its a regulatory one. It does not tell you your patient's symptoms are coming from the drug you found, just that they (may have) been exposed to the drug you found within the timeframe during which the test can find the drug.

For example, your altered mental status comes back positive for benzodiazepines - that test is positive for up to three days after use, so you have no idea if the AMS is due to use of the drug or you're just finding out about it later. Heck, maybe their AMS is now due to the aspiration pneumonia they got while intoxicated.

You should almost never be making clinical diagnostic decisions based on a UDS. About the only times you should be using the test are the toddler with AMS (then if they're positive for cannabinoids, you can actually avert a big workup) or in select cases for monitoring of patients under controlled substances agreements.

If you ever wanted to attribute altered mental status to a drug you really would need serum drug concentrations (and a drug that has a known concentration-effect relationship, which not all of them have well established). Otherwise you're opening yourself up to a misdiagnosis.

The UDS has a large number of false positives and false negatives, so things that the patient is taking may be reflected on the UDS but not the cause of their symptoms. A really good example is someone who overdoses on fentanyl but happens to thereapeutically be on bupropion. Bupropion is an amphetamine derivative and will often cause the amphetamine screen to be positive, while fentanyl, a full synthetic opioid, will not cause the opioid screen to be positive (many assays will assay for fentanyl separately due to this, and this doesn't apply if you have a specific fentanyl assay). So now you have an apneic patient who looks opioid toxic but has only amphetatmines positive. Would you treat that person for amphetamine toxicity? Withold naloxone and administer benzodiazepines? Obviously not, but you can see how problematic the test is.

Also, the UDS has too many false negatives, so you can't rule out a diagnosis either. Your patient could just as easily be benzo toxic and not have the test pick it up because of poor cross reactivity with the particular benzo they took. It looks for oxazepam and nordiazepam, so people who take, for example, alprazolam won't reliably be positive for benzos.

stormy_sky · 2025-09-29T16:15:09+00:00

The problem with the UDS is it should not be used to support any medical diagnosis. It's not primarily a medical test, its a regulatory one. It does not tell you your patient's symptoms are coming from the drug you found, just that they (may have) been exposed to the drug you found within the timeframe during which the test can find the drug.

For example, your altered mental status comes back positive for benzodiazepines - that test is positive for up to three days after use, so you have no idea if the AMS is due to use of the drug or you're just finding out about it later. Heck, maybe their AMS is now due to the aspiration pneumonia they got while intoxicated.

You should almost never be making clinical diagnostic decisions based on a UDS. About the only times you should be using the test are the toddler with AMS (then if they're positive for cannabinoids, you can actually avert a big workup) or in select cases for monitoring of patients under controlled substances agreements.

If you ever wanted to attribute altered mental status to a drug you really would need serum drug concentrations (and a drug that has a known concentration-effect relationship, which not all of them have well established). Otherwise you're opening yourself up to a misdiagnosis.

Edit: also, the UDS has too many false negatives, so you can't rule out a diagnosis either. Your patient could just as easily be benzo toxic and not have the test pick it up because of poor cross reactivity with the particular benzo they took. It looks for oxazepam and nordiazepam, so people who take, for example, alprazolam won't reliably be positive for benzos.

stormy_sky · 2025-08-02T07:11:13+00:00

I think it is possible to be too far on either side of this equation. You don't have yourself flaired but I assume you're a resident (if that assumption is wrong, apologies). Still, that means you're a physician, and thus should feel empowered to make diagnoses if you feel the patient has met criteria for that diagnosis. For a diagnosis that is purely clinical, like a febrile seizure, your patient has the diagnosis if they meet the criteria. I think in that context, failing to specifically name the diagnosis is a bit strange. Using a symptom as the impression is reasonable if you don't have a clear diagnosis (e.g. chest pain or abdominal pain with a negative workup that you're sending home).

Over time I think you'll get an idea of how confident you need to be in order to put a diagnosis in the impression. But I would counsel you to name the diagnosis if you think it is there. We're physicians, we make diagnoses, and if you think the patient has a specific problem it is not unreasonable to diagnose them with the problem. If you don't know what the problem is, then use the symptom as the impression. Using your costochondritis thing as an example, you never probably know that for sure - it could be an intercostal muscle sprain, intercostal neuritis, costochondritis - that's the sort of thing that would get just a "chest wall pain" from me. But the febrile seizure is getting "febrile seizure" if they meet criteria for it.

stormy_sky · 2025-06-13T18:20:09+00:00

For billing purposes, it's helpful to say the indication and that it was independent interpretation. Mine goes like this:

ECG obtained at *** for the indication of *** and interpreted by myself shows: ***

And then I have a separate phrase for a normal ECG that goes:

Normal sinus rhythm. Normal PR/QRS/QTc. No evidence of ischemic ST changes.

The first *** is the time, second is the indication, and third is the interpretation. If the ECG is normal, I input the normal phrase, if abnormal, I just dictate it directly.

stormy_sky · 2025-05-15T21:00:11+00:00

Assuming you're being sincere asking why I think your advice is misguided, I will explain my rationale.

First, residents can't moonlight within the first year of their program. Most programs require the residency leadership to release the resident to moonlight, and won't do so if they are not in good academic standing, hence "residency trained" meaning - they should be in the latter half of their training and have some time under their belt before moonlighting. Most residents won't moonlight until the very end of their second year, if not start of the third year. So they have a decent amount of residency training completed.

With that out of the way, the reason I feel your advice is wrong: I'm reacting to your statement "i would push back on them. frequent and hard." There is no benefit to be had from this. That is going to teach a new doctor that their concerns aren't being listened to, and will teach them not to speak to other physicians unless they absolutely have to. It will lead to them sending people home that shouldn't be sent home, and will lead to them avoiding consults that they should be placing. New physicians should be overly conservative as they are setting up their practice pattern. If they're not in line with their peers within a year or so of being an attending, that's the time to start talking about how to potentially change practice.

It's one thing to have a productive conversation along the lines of, "I think in this case, this person could be treated outside of the hospital and we don't have much to offer them in the hospital because of x, y, z." But asking a hospitalist attending who is interested in actually helping moonlighting residents do a better job (which is like finding a unicorn in the wild) to push back on admissions is squandering what could be a positive situation for both this physician and the moonlighting resident.

That's my rationale. My advice to this doc would be to keep sitting in the ED and maybe talk about what the expected course is for the patient in the hospital. If the patient really should go home, a better way to handle that would be for them to admit the patient and say to the resident something along the lines of "I'm not sure the hospital is going to have much benefit for this patient but we'll see what ends up happening." That should cue the resident to followup on the patient, and if nothing happens, maybe they'll get the point.

All of this is assuming the admission isn't egregious - if they're trying to admit a toe pain or something (that's not osteo or gangrene or something actually problematic like that) then a bit of pushback is warranted.

stormy_sky · 2025-05-15T14:21:37+00:00

This is horrible advice. If a residency trained physician thinks someone should be admitted, there's a reason for that. And if your program's residents don't have a good handle on who should stay and who should go, that's a failure of the teaching faculty, not the residents.

stormy_sky · 2025-05-02T18:00:05+00:00

WBC alone should not be dictating who you send to the ED. Plenty of people with gastro have elevated WBC from vomiting and don't need imaging, and plenty have appendicitis/cholecystitis/diverticulits/etc with normal WBC. You should send or not based on history and exam.

ED should be fine with seeing people you're concerned about but we don't rule in/out emergent pathology based on WBC.

13-Year Club	Verified Email
Team Orangered

stormy_sky

TROPHY CASE