Poison Control required consult in your ED?

[inspirationmd]

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One of my pet peeves is the statement "oh you are required to do this or that" due to ED or hospital protocol, etc. But then you ask to see the policy and it ends up being bull**** that has just been passed down from generation to generation despite it not making sense.

The ED Nurse Manager just told me that when things like mushroom ingestion, envenomation from snakes or other animals, etc comes in that we are required to call poison control which I have always known not to be true and personally do not allow to happen. I called it out and she's like we have to have a standard. I stated that practicing Emergency Medicine since its a subspecialty of the specialty should allow for some management just by being a physician (ie. Tylenol, TCA overdose) and I was told that not everyone is EM board certified in this ED. Regardless of training, I liken a policy this to a mandatory consult despite possible physician comfort which I feel is inappropriate. What happens if I disagree with poison control which is really just a tech reading from an algorithm 95% of the time?

What is the policy in your ED or hospital? Is this state dependent or just a cultural thing like I suspect?

 

[Rekt]

One of my pet peeves is the statement "oh you are required to do this or that" due to ED or hospital protocol, etc. But then you ask to see the policy and it ends up being bull**** that has just been passed down from generation to generation despite it not making sense.

The ED Nurse Manager just told me that when things like mushroom ingestion, envenomation from snakes or other animals, etc comes in that we are required to call poison control which I have always known not to be true and personally do not allow to happen. I called it out and she's like we have to have a standard. I stated that practicing Emergency Medicine since its a subspecialty of the specialty should allow for some management just by being a physician (ie. Tylenol, TCA overdose) and I was told that not everyone is EM board certified in this ED. Regardless of training, I liken a policy this to a mandatory consult despite possible physician comfort which I feel is inappropriate. What happens if I disagree with poison control which is really just a tech reading from an algorithm 95% of the time?

What is the policy in your ED or hospital? Is this state dependent or just a cultural thing like I suspect?

Every place I have been, it has always been a "courtesy" call to them in order to support them. To be honest I don't see the point in getting upset about it. If it helps keep them funded, the data shows they do a keep a bunch of nonsense ingestions out of the ED.

 

[Dr Mantis Toboggan]

Our poison center wants labs on all snake bites initially and after 6 hours. This is regardless of whether there is any evidence whatsoever of envenomination (locally or systemically) or even if not the snake is not venomous (typically brought in dead in a bucket with the patient). Learned that one the hard way.

One of my pet peeves is the statement "oh you are required to do this or that" due to ED or hospital protocol, etc. But then you ask to see the policy and it ends up being bull**** that has just been passed down from generation to generation despite it not making sense.

The ED Nurse Manager just told me that when things like mushroom ingestion, envenomation from snakes or other animals, etc comes in that we are required to call poison control which I have always known not to be true and personally do not allow to happen. I called it out and she's like we have to have a standard. I stated that practicing Emergency Medicine since its a subspecialty of the specialty should allow for some management just by being a physician (ie. Tylenol, TCA overdose) and I was told that not everyone is EM board certified in this ED. Regardless of training, I liken a policy this to a mandatory consult despite possible physician comfort which I feel is inappropriate. What happens if I disagree with poison control which is really just a tech reading from an algorithm 95% of the time?

What is the policy in your ED or hospital? Is this state dependent or just a cultural thing like I suspect?

Our poison center is great but inflexible when it comes to some things. For example, any snake bite they want labs initial and 6 hours out, regardless if the snake was killed by the patient and brought in or the patient clearly has no evidence of envenomination locally or otherwise whatsoever

One of my pet peeves is the statement "oh you are required to do this or that" due to ED or hospital protocol, etc. But then you ask to see the policy and it ends up being bull**** that has just been passed down from generation to generation despite it not making sense.

The ED Nurse Manager just told me that when things like mushroom ingestion, envenomation from snakes or other animals, etc comes in that we are required to call poison control which I have always known not to be true and personally do not allow to happen. I called it out and she's like we have to have a standard. I stated that practicing Emergency Medicine since its a subspecialty of the specialty should allow for some management just by being a physician (ie. Tylenol, TCA overdose) and I was told that not everyone is EM board certified in this ED. Regardless of training, I liken a policy this to a mandatory consult despite possible physician comfort which I feel is inappropriate. What happens if I disagree with poison control which is really just a tech reading from an algorithm 95% of the time?

What is the policy in your ED or hospital? Is this state dependent or just a cultural thing like I suspect?

 

[Rendar5]

They are consultants, not the treating physician. They can give recommendations, and you can decide if you want to follow recommendations or not. If they have recommendation you don’t understand, I might suggest you ask to speak with the toxicologist on call to find out the reasoning behind the recommendation because they may know something that you don’t. That said, if you are confident of your care, you can thank them for the consult, and then treat the patient as you feel the need to be treated.

 

[Rendar5]

And that is one request for a nursing manager that is not unreasonable. You’re doing the poison control center a favor by giving them data to work with and it takes about a minute of your time. There are many other things that they say are required per policy that is really not written down that I would get upset over or try and make a stand.

 

[GonnaBeADoc2222]

I usually just ignore whatever it is theyre telling me to do.

 

[inspirationmd]

And that is one request for a nursing manager that is not unreasonable. You’re doing the poison control center a favor by giving them data to work with and it takes about a minute of your time. There are many other things that they say are required per policy that is really not written down that I would get upset over or try and make a stand.

Fair enough. From a data acquisition standpoint I can see the point. I also suppose it helps the Tox fellows get their experience in those poison centers that work with fellowships. The nurses call anyway so I guess its whatever. My feeling is just that its just another thing that is cumbersome to have to deal with particularly if its advice that can be not as good as that off up to date or some other source. And you're right...many other things to fight back against. It just rubbed me the wrong way for some reason this morning

 

[NYEMMED]

Fair enough. From a data acquisition standpoint I can see the point. I also suppose it helps the Tox fellows get their experience in those poison centers that work with fellowships. The nurses call anyway so I guess its whatever. My feeling is just that its just another thing that is cumbersome to have to deal with particularly if its advice that can be not as good as that off up to date or some other source. And you're right...many other things to fight back against. It just rubbed me the wrong way for some reason this morning

Looks good in your chart if something does happen...

“Poison control consulted, advised 6 hour obs and cleared from Tox standpoint if stable”

Plaintiff attorney:
Doctor, was a poison control center available that you could have called for expert advice for my client. Why did you not? Why did you think a available expert should not be called?
Are the injuries sustained a direct result of your gross negligence to not call a poison control expert?

Mic drop, jury award

Always CYA

 

[Groove]

We don't have a policy for the physicians. Personally, I call them about 50% of the time depending on the ingestion more as a courtesy for the inpatient team since most of the time they have no idea how to handle it and I can assuage their anxiety in letting them know I've talked to poison control and can leave the instructions in my note. It's a quick phone call, buff's the chart for any medicolegal ramifications and keeps the lights on for them.

That being said, no... I don't think you should be required by policy to call them as an ABEM physician. Envenomations, poisonings, ingestions are well within your expert training and that would really rub me the wrong way as it implies you don't know how to treat the patient without expert guidance. Most of us manned these phones during residency and fielded statewide calls for poison control as a routine rotation. The problem lies in that most of us work with non boarded EM docs and for them, calling poison control is probably more common.

So, is it a good idea? Sure. Should it be required by blanket policy? Absolutely not.

A perfect example would be tylenol OD. Are you seriously going to be required by your ED policy to call poison control to treat an acetaminophen overdose every time one comes in? This is an example of nursing admin going rampant with policies in the guise of "patient care" that directly influence how you practice. No nurse should ever be able to tell you how to practice medicine. If they want to make it a formal nursing policy where the nurses call and obtain instructions for documentation purposes..fine, but making the physicians do it 100% of the time? Please.

 

[Groove]

The thing that really bothers me is the proliferation of nursing policies and protocols that directly impact or constrain physician care. All under the banner of "patient safety". Nurses obtaining lactates and initiating sepsis bundles. Triage protocol order sets. Stroke alert protocols for diabetic neuropathy pt's. Physicians ordered to call poison control for any ingestion. What's next? Death and subjugation by nursing protocols. What did we go to med school for again? Someone remind me.

 

[RuralEDDoc]

1. The “policy” may not exist. Ask for it in writing
2. I call poison control on any serious ingestion (even Tylenol which I know how to treat) for medical legal reasons. These are high risk patients - they are often suicidal, resistant to treatment plans, and have bad outcomes. Load the boat with appropriate consultants who may have something to offer.

 

[GonnaBeADoc2222]

Looks good in your chart if something does happen...

“Poison control consulted, advised 6 hour obs and cleared from Tox standpoint if stable”

Plaintiff attorney:
Doctor, was a poison control center available that you could have called for expert advice for my client. Why did you not? Why did you think a available expert should not be called?
Are the injuries sustained a direct result of your gross negligence to not call a poison control expert?

Mic drop, jury award

Always CYA

That's like saying cardiology has to be called for every chest pain. We are boarded EM physicians. We don't need a nurse reading off up to date.

 

[Groove]

I'd have absolutely no problem being an expert witness defending a doc who appropriately managed tylenol OD and got sued. Surely most of you wouldn't feel the need to testify that the standard of care is to call poison control for acetaminophen ingestions? What did we go to residency for in emergency medicine? These questions are on our board exams for crying out loud.

 

[RuralEDDoc]

I'd have absolutely no problem being an expert witness defending a doc who appropriately managed tylenol OD and got sued. Surely most of you wouldn't feel the need to testify that the standard of care is to call poison control for acetaminophen ingestions? What did we go to residency for in emergency medicine? These questions are on our board exams for crying out loud.

Depends. Tylenol ingestion with no toxic levels? No, tox consult not standard of care. Ingestion with toxic level? Absolutely, tox consult is standard of care, at least where I practice.

 

[Groove]

Depends. Tylenol ingestion with no toxic levels? No, tox consult not standard of care. Ingestion with toxic level? Absolutely, tox consult is standard of care, at least where I practice.

Weird. It's not down here. Bread and butter EM. That's one of the few ingestions I don't need to fire any neurons to manage. If you ran into a hairy case, you'd have better luck consulting a hepatologist before calling a nurse/NP/tech at poison control who's regurgitating a micromedex search. Most of the times when I'm calling them, it's simply so they can keep track of statewide poisonings for reporting purposes, not to get any real assistance with management of the patient.

 

[Zebra Hunter]

Weird. It's not down here. Bread and butter EM. That's one of the few ingestions I don't need to fire any neurons to manage. If you ran into a hairy case, you'd have better luck consulting a hepatologist before calling a nurse/NP/tech at poison control who's regurgitating a micromedex search.

100% this. It’s rare that I ever truly need a poison control consult. I usually consult for weird ingestions or for very sick patients, but that is typically CYA rather than absolute necessity. My nurses are going to call regardless. While I actually do usually personally call for Tylenol ODs that I am admitting, I would absolutely go to bat for another EM doc that decided to manage it on their own, as long as their care was seemingly appropriate. This is bread and butter EM that we should all know how to manage in our sleep.

 

[thegenius]

I think this is really a non-issue overall. First...I’d say that 80% of the time for toxic ingestions (maybe more than 4/5 actually...) our RN has already called poison control and they come to me and say “Poison control recommended x, y, z” and I thank them. Most of the time it’s what I expected, occasionally I’ll learn something new. No work has been transitioned to me.

Second...it so happens that many of these ingestions have concomitant psychiatric emergencies. So once they are medically cleared they are sent to psych. We all know that psych always demands unreasonable stuff (e.g. the patients creatinine is 1.3, it was 1.15 in the past, we will take them once it’s 1.15). They never listen to us, and while fighting with them sometimes gives you a Pyrrhic victory, it’s often not worth it. So that’s why I think it’s better to have a tox consult in the chart to back your decision not to repeat a falling Tylenol level that was never in the treatment range in the first place. Like first it’s 55, second one is 35....your done. No more checking is needed especially if the LFTs are normal.

I do agree with those that are pissed off with the ever increasing marginalization of physicians at the expense of nursing protocols and admin protocols. Why did we go med school? To be ordered around by admin and nursing.

It’s funny there are things that really get to me...but this isn’t one of them. Maybe because I think tox is kind of boring and I don’t really care about it, and I should probably care more about it, but don’t because 98% I think it’s just supportive care.

 

[DeadCactus]

1. I'm against mandatory just about anything in the ED, consults included.

2. The PCC is staffed by a nurse or pharmacist with about 2 years of training in answering those calls and generally has years to decades of experience providing that service. You're the physician and the patient is physically in front of you and medicine is full of differing opinions so by all means disagree. I find disparaging them to be in the same kind of nonsense as the cardiologists who disregard our ability to interpret an EKG or surgeons who blow off our diagnosis of appendicitis. The fact that there is a free service to get 24/7 advice on a medical issue from a trained professional is ridiculously amazing; toxicologists really shot themselves in the foot. Imagine the job market if they just left those people to call some nurse hotlines.

3. Calling poison control is not a toxicology consult. The poison center is great at triaging people away from a hospital and helping with relatively common cases but it's not a toxicologist.

 

[southerndoc]

We have a tox consult service with a resident rotator. We rarely - if ever - call the poison center. We talk to one of our toxicologists. If the patient is admitted, they will see them. They sometimes come to the ER to see them (or if one is working a clinical shift he will come see them).

 

[MechEDoc]

I'd have absolutely no problem being an expert witness defending a doc who appropriately managed tylenol OD and got sued. Surely most of you wouldn't feel the need to testify that the standard of care is to call poison control for acetaminophen ingestions? What did we go to residency for in emergency medicine? These questions are on our board exams for crying out loud.

I personally went into emergency medicine so that every person who vaguely stated some idea about self harm could get a licensed clinical social worker consult placed by nursing at 11 pm on Friday while there is a full waiting room. My favorite is having someone come up to me with their plan and recommendations (never consulted, nor really interested in "their" plan) after I discharged the patient!

 

[GeneralVeers]

When nurses ask me if they should call poison control I always say: "Sure". Their recommendations are always, EKG, labs and observe 4 hours. For the minor non-psych related ingestions I rarely observe for 4 hours unless sleepy or abnormal vital signs. It's seriously stupid, but it gives the nurses something to do, doesn't make any more work for me, and makes them feel like they are helping.

 

[DO3]

Some states have state mandated reporting. Just need to figure out if you state is one of them.

 

[deleted109597]

On the one hand, the number of times I've gotten useful information from PCC is exactly zero.
On the other, I know that there are a lot of people out there who aren't as keen on tox and depend on that service. So I call to keep the funding alive.

That being said, I quit a job where the charge nurse came to me and told me that I wasn't supposed to call PCC, because that was the nurse's job.

 

[thegenius]

Looks good in your chart if something does happen...

“Poison control consulted, advised 6 hour obs and cleared from Tox standpoint if stable”

Plaintiff attorney:
Doctor, was a poison control center available that you could have called for expert advice for my client. Why did you not? Why did you think a available expert should not be called?
Are the injuries sustained a direct result of your gross negligence to not call a poison control expert?

Mic drop, jury award

Always CYA

Prime example that lawyers have won. They have us all by the balls. It's striking how much extra crap we do so we don't get sued.

 

[RoyBasch]

Consulting poison control is not required. You are not 'Required' to consult any physician. That being said it may be a good idea. As a matter of course I always call them for any ingestion that is more than trivial. I think it strengthens the chart medicolegally, and they are always available and helpful without the run-around of other consults. Also, the toxicologists sometimes know things we don't. I have been surprised about some of their recommendations even for toxidromes I think I know well.

 

[BoardingDoc]

Depends. Tylenol ingestion with no toxic levels? No, tox consult not standard of care. Ingestion with toxic level? Absolutely, tox consult is standard of care, at least where I practice.

Late to the party, but that's bonkers. There is literally no reason to call poison control unless the doc doesn't know when/how to treat a tylenol OD, in which case I would not be questioning the need to call poison control, but rather why that person is practicing emergency medicine.

 

[RustedFox]

In general I near-always "consult poison control" (have the nurse call) in cases like this, if only so I can say to the family "I have my team in contact with poison control and we will have their input." Makes them feel better.

This is not the hill to die on.

 

[wolverine10k]

Agree with RF. At my facility the nurse taking care of the patient calls poison control and I throw it into my chart that they were consulted. I only call them myself if I need their help.

 

[deleted109597]

I only call them myself if I need their help.

I call them because I can't trust the nurses to give the proper history, pertinent physical exam findings, or literally anything else not algorithmic.
Also, evidence is always changing, so I like to hear what they say. And if I have an issue, I personally can ask for the toxicologist to call me, as opposed to having the nurses essentially refuse. "We already called"

 

[Groove]

Well, if any of you guys get hung out to dry by a malpractice attorney suing you for not calling poison control to handle something you were trained to do, you just send ol Dr. Groove a PM and I'll happily be your expert witness. Plus, I look fabulous in a suit.

 

[DeadCactus]

 

[thegenius]

Well, if any of you guys get hung out to dry by a malpractice attorney suing you for not calling poison control to handle something you were trained to do, you just send ol Dr. Groove a PM and I'll happily be your expert witness. Plus, I look fabulous in a suit.

Just don't charge $5,000/hr though you will never get hired!

 

[GonnaBeADoc2222]

Whatever. Don't think you're ever going to lose a suit because of this. Much more likely to get hit for the 3 yo you sent home for viral syndrome that turned out to be myocarditis.

 

[emergentmd]

I have never worked at any ERs where calling poison control is mandatory. I always call them for any intentional OD just to buff my chart. Takes 1 min, covers my A$$, they are usually very nice. They always recommend 4-6 hour obs on everything but I just typically err on the 4 hrs which is about how long it takes to get brought back, labs, D/C anyhow.

I care more about the sepsis crap where they are carpet bombing them with pan labs and antibiotics before I even see the pt.

 

[deuist]

Have the nurse call. It saves you time, yet fulfills any requirement your hospital may have regarding poison control consultations.