DocWalken

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Lowly MS0 here.

I just wanted to know if anyone has info about toxicology, either regarding the fellowship itself or work as an attending. I remember there used to be a forum or something on this, but I can't seem to find it now.

I really liked the EM that I've been exposed to so far and I've always been really interested in things that (I imagine to be at least) are related to what a toxicologist does (venoms, poisonings, etc.).

Are jobs in toxicology hard to come across besides in areas where someone would commonly see snakebites, etc? Are they rare in general? How does the pay/hours compare with regular EM? What I mean is, well I find the field potentially interesting, I don't have any particular desire to travel to remote jungles or live in the middle of nowhere.

Any info would be great. Thanks.
 

kungfufishing

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toxicology is a subspecialty which requires a fellowship after residency. A good working knowledge of common tox problems is fundamental to EM. The actual number of docs pursuing the fellowship is small and the number working exclusively in tox even smaller.
 

BADMD

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Are jobs in toxicology hard to come across besides in areas where someone would commonly see snakebites, etc?
There are lots of Toxicologic issues out there besides snake bites and overdoses. There is a significant amount of industrial/occupational toxicology. Can't forget product evaluations, legal work, and chronic exposures (such as heavy metals) and overseas work. Every Poison Control Center needs a medical director (although there aren't enough centers for every grad to be a director).

There is a move to start moving toxicology out of the Poison Centers and be more clinical. Many Toxicologists want to more than Poison Center work and consults. Dedicated toxicology units as regional poison referral centers are are starting to pop up, although there are difficult to start.

How does the pay/hours compare with regular EM?
It is less on face, but it doesn't have to be that way. EM has established payers, billing and attracts its own patients. If you can see 8-10 outpatients in a day for cash (and that is possible), you will quickly prove your worth. If you just do a few consult a week and take phone based call, you won't make that much and have to rely on EM for the bulk of your check. Although having a Tox board makes it easier to get an academic job and the associated pay benefits.

What I mean is, well I find the field potentially interesting, I don't have any particular desire to travel to remote jungles or live in the middle of nowhere.
You certainly don't have to. But keep in mind that the more desirable areas to live probably already have a number of people with your particular expertise, no matter what field you go into.
 
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My third and fourth year of med-school was in Las Vegas. I never saw a bite. My residency was in a place where there were rattlers as well. I never saw a bite in 3 years of residency. I have worked in an area where rattlers are prevalent for 6 months months now and haven't seen a bite.

Nevada has a fair number of rattlers in the wild. About 7 people are bitten per year. I would guess that given a population of 2,000,000, that there are around 500,000 ER visits per year in that state. That would give you as an ER doctor there, about a 1/100,000 chance per year of seeing a snake bite.

A whole lot more bites happen in California, but I would imagine the vast majority of ER physicians go their whole careers and never see one.

When I was on toxicology, there was one snake bite that we consulted over the phone about in a month.

The vast majority of consults that toxicologists get are for stupidly low amounts of fairly benign drugs. People that are really serious about killing themselves don't take a few handfuls of drugs, and then go tell someone, they drive to the middle of nowhere and do it right. Most overdoses are weak cries for help.

If you like obsessing about QTc intervals, QRS intervals, potassium, phosphorus, and urinary alkalinization, then toxicology is for you.

Just like the practice of Emergency Medicine, most things aren't really emergencies, or even very interesting. But once in a while, you get interesting cases that utilize your unique skill set, and make you glad you did an Emergency Medicine residency. In a similar fashion, toxicology is mostly boring, with a rare case that is rather interesting. There where 3 toxicologists at my residency. 2 did mostly clinical shifts, then covered call in the poison center. They had a lot more research and publishing work than other attendings and were a lot more busy between their various duties that their obligation to the poison center laid on them, in addition to their clinical shifts in the ER.

In general, poison centers don't generate any revenue. They are a public service funded by governmental grants and whatever private donations they can scrounge together. As a result, most toxicologists pull clinical shifts as well.
 

Apollyon

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I saw 2 bites in residency (in NC - one copperhead and one timber rattler). In the past year, in upstate SC, I've seen 3 bites - all copperheads.

(I don't call poison control for bites.)
 

WilcoWorld

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I've seen 2 bites in 5 months here in New Mexico - I also don't call Poison Control for bites, as there are very well-established protocols. I call them for plenty of other stuff, however.
 

southerndoc

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During medical school, a neighboring county had rattlesnake roundups. The county has the highest number of rattlesnakes per acre. A Georgian playing rattlesnake roundup is never a good thing. Needless to say, we would get 5 or 6 bites every year during the roundups and quite a few yearround.

http://www.claxtonevanschamber.com/rrhist.php
 

njac

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I've seen 2 bites in 5 months here in New Mexico - I also don't call Poison Control for bites, as there are very well-established protocols. I call them for plenty of other stuff, however.
only 2?! you're working the wrong nights. I've seen that many on the same individual in the same time period!
 

AmoryBlaine

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I think the most common job for a toxicology trained EM doc is to "be the toxicologist" on faculty at a residency program.
 

dchristismi

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You also never know when you're going to see a good tox case...

For example, just a few hours ago, I had a 40-something Hispanic woman delivered by "homeboy ambulance" to my ED- dropped off, no history... (you know, I could write this as a new post and make ya'll figure it out...) practically comatose. But, I won't.

Couldn't quite tell if she was faking it, and of course, the dude who dropped her off left. Did mention something about that she had been at work... very very vague.

Something was a bit fishy. On a hunch, I asked for an ABG. Note that I really don't use ABGs all that much - venous gases are almost as good, but what the hell. She didn't flinch.

Carboxyhemoglobin 16.7%. Oxygen applied (actually, I put it on before getting the gas). Pt started to wake up. Apparently, she and, oh, 40 coworkers were in a poorly ventilated cooler building with forklifts. And obviously something happened to the lot of them. (Later, pt's son arrives and volunteers that he works with her, and had a headache too, but it's better now.)

See, toxicology happens all the time! :)

(Don't even get me started on the dude who ate the Angel Trumpet last month.)
 
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