When should you consult a medical toxicologist?

For the last month you have been more tired than usual despite sleeping well with diarrhea and abdominal pain. You went to your primary physician who found no cause after a physical exam, bloodwork, an EKG, a chest X-ray and CT scan. He asked you to follow up in 6 months. You wonder if it could be a reaction to a medication you started 2 months ago, or the supplement you started 3 months ago.

When should I see a medical toxicologist?

Consult a medical toxicologist if you are experiencing symptoms that you are concerned come from exposure to a poison or poisons or arise from a medication-medication interaction or medication-supplement interaction. Medical toxicology is the specialty dedicated to the prevention, evaluation, and treatment of injury and illness from exposures. A medical toxicologist is a physician with specialized training in the diagnosis, management, and prevention of poisoning, medication toxicity, adverse drug reactions, environmental exposures, and occupational exposures.

What symptoms should prompt me to consult a medical toxicologist?

There are many symptoms of poisoning because anything can be a poison. The symptoms depend on the particular substance, pattern of exposure, timing, and individual factors. The most sensitive indicator a poisoning is identifying the sequence of an exposure followed by symptoms. For example, if you took a medication and then developed symptoms, that sequence should prompt you to consider the possibility of a poisoning. But identifying an exposure is not enough evidence on its ownw. Not all symptoms after an exposure are caused by poisoning, and not all symptoms have a toxicologic explanation. A medical toxicologist helps evaluate whether an exposure is likely to explain a patient’s symptoms.

If you are experiencing symptoms that you think are life-threatening, go to an Emergency Department for evaluation immediately.

What problems can a medical toxicologist evaluate?

Medical toxicologists commonly evaluate:

• medication adverse effects
• medication interactions
• supplement and botanical reactions
• heavy metal concerns
• environmental exposures
• occupational exposures
• abnormal toxicology laboratory tests
• poisoning and overdose concerns
• unexplained symptoms potentially related to exposure

We also evaluate concerns related to heavy metals such as mercury, lead, arsenic, and other environmental toxicants.

What is the difference between a poisoning, exposure, and an adverse drug reaction?

The most general term is "exposure". An exposure is any contact with a substance. A poisoning is an exposure that causes symptoms and is synonymous with the phrase "symptomatic exposure". An adverse drug reaction is a poisoning that occurs from a medication taken at the recommended dose. For toxicologists the word poisoning has no legal connotation. Unlike the popular use of the term, we use it merely to refer to the degree of harm from an exposure.

Us toxicologists often quote Paracelsus: "All things are poison, and nothing is without poison; only the dose makes a thing not a poison."
Any substance can be harmful if consumed in excessive amounts.

How does the general public consult a medical toxicologist?

If you are experiencing symptoms that you think are life-threatening, go to an Emergency Department for evaluation immediately. As part of evaluating a possible poisoning, the Emergency Physician may consult a medical toxicologist. The Emergency Physician will page the on-call toxicologist if the hospital has that service in-house or calling the regional poison control call center (PCC).

For non-emergent situations, ask your primary care physician for a referral. A few medical toxicologists have outpatient clinics. Some health systems have the option for an "interprofessional consult", where one physician presents the case to another and asks the second physician's opinion. In interprofessional consults, the consulted physician does not personally evaluate the patient I created Chary Toxicology because despite growing demand there are few outpatient toxicologists, yet outpatient medical toxicology services remain limited in many regions of the United States. For example, there are no outpatient toxicology clinics run by medical toxicologists in New Jersey, New York, or Connecticut, nor virtual options with a licensed physician.

Situations where a medical toxicologist may be helpful:

• medication interactions
• adverse effects from medications
• supplement reactions
• abnormal toxicology tests
• environmental concerns
• occupational exposures
• complex medication interactions

How can my doctor consult a medical toxicologist, outside of sending me to the Emergency Department?

If you are admitted to a hospital, some hospitals have medical toxicologists on staff who see admitted patients. Depending on the healthcare system an interprofessional consult or a referral may be possible. Chary Toxicology provides interprofessional consults to physicians with no geographic restrictions.

Should my doctor just call Poison Control?

Anyone can call Poison Control. The universal toll-free number 1 (800) 222-1222 will forward your call to the nearest call center based on the area code of your phone. Your doctor can call Poison Control and ask to speak to the supervising toxicologist. However, the primary function of Poison Control is to provide triage advice. Not all toxicologists have experience in outpatient management beyond that required in training.

How do Poison Control Call Centers differ from Medical Toxicologists?

Poison Control Centers (PCCs) are regional call centers staffed by specially trained nurses and pharmacists operating under the supervision of a medical toxicologist. PCCs provide free, confidential advice 24/7 to the public and healthcare professionals. They predate the specialty of medical toxicology. PCCs were established in response to growing number of kids being exposed to household cleaning products in the 1950s. Poison Control Centers are designed primarily to provide immediate triage guidance and emergency exposure management. Some medical toxicologists also provide longitudinal outpatient consultation and interpretation beyond acute triage.

What about online triage tools?

In the modern era, there are digital tools that can provide limited triage advice. Two examples are Poison Help and webPOISONCONTROL. Currently, these tools are designed to provide immediate triage advice for one-time exposure to one substance in healthy individuals. They are not designed to provide advice for ongoing symptoms, multiple exposures, underlying medical conditions, or complex medication interactions.

Disclaimer: I am the co-Director of webPOISONCONTROL.

For more information, see:

• Mercury testing and heavy metal exposure
• Supplement safety and adverse effects
• Medication interactions

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This article is for educational purposes only and does not establish a physician-patient relationship.