Traditionally, when a patient arrives at the BWH Emergency Department (ED) with a possible poisoning or overdose, the care team calls the Regional Center for Poison Control and Prevention based at Boston Children’s Hospital. A clinical toxicologist – a health care professional with specialized knowledge of the adverse effects of drugs and other chemicals – provides guidelines and advice to the care team on how to best treat the patient.
This year, the Brigham will bring its own medical toxicologists directly to the bedside to share their expertise and care for patients facing adverse effects from medications, drug overdoses and substance abuse issues, thanks to a new division recently launched within the Department of Emergency Medicine: the Division of Medical Toxicology.
“Toxicology has been a well-known subspecialty for 20 years or more,” said Michael VanRooyen, MD, MPH, Emergency Medicine chair. “We’re taking a new twist on it through the addition of biotechnology, oncology toxicity and opioid abuse research. The division will provide an innovative and unique way of looking at emergency toxicology.”
BWH emergency medicine physician, educator and medical toxicologist Susan Farrell, MD, EdM, is part of the new division, as well as medical toxicologists Edward W. Boyer, MD, PhD, and Peter Chai, MD, MMS, who both recently joined BWH from UMass Medical School in Worcester. Their expertise includes adverse drug events, toxicity, drug interaction and poisoning, and drug overdose. Medical toxicologist Timothy Erickson, MD, who joined BWH last September, serves as division chief, with areas of interest including the study of environmental toxins, venoms and the development of poison control centers in low-resource settings globally.
Division members will also provide staffing for the Regional Center for Poison Control and Prevention at Boston Children’s Hospital and collaborate with toxicologists at MGH and Beth Israel Deaconess Medical Center, sharing knowledge, training practices and the latest research in the field.
“At BWH and across Partners, we have the opportunity to take the field to a new level,” said Erickson. “There are incredible people here doing great work, and we’re excited to join forces with them.”
The field of medical toxicology
With roughly 500 board-certified medical toxicologists in the U.S., medical toxicology is one of the smallest medical specialties. BWH is the fourth hospital in Massachusetts to establish its own bedside toxicology consult service. (Boston Children’s Hospital, UMass Memorial Medical Center and Beth Israel Deaconess Medical Center are the three others.)
Toxicology itself spans many fields and disciplines, from botany and chemistry to forensics and the environment. Though clinical and medical toxicology are similar, medical toxicology training requires a fellowship only available to physicians.
“Medical toxicology is not a new field per se, as toxicology and poisoning go way back in history,” said Erickson, who has practiced in the field for 25 years. The formal education, fellowship training and board certification are all relatively new components of the field, he says.
Traditionally, medical toxicology has been practiced under the umbrella of emergency and critical care medicine since most of the specialty’s patients come to the hospital by way of an emergency department with urgent medical issues, such as a poisoning or overdose. Medical toxicologists also commonly practice in pediatric settings, where they often help to reverse children’s accidental ingestion of toxic substances – such as a bottle of sugar-coated iron pills that look like candy or cleaning solutions stored under the kitchen sink.
Chai, who joined BWH in February after completing his medical toxicology fellowship at UMass Medical School, always knew he wanted to pursue emergency medicine and toxicology.
“Most of my mentors were medical toxicologists,” said Chai. “I noticed from working in the ED that patients who have substance abuse problems are often very removed from care. It is important to me to connect with and try to help these patients.”
Caring for patients at the bedside
Once the new clinical service is up and running, medical toxicologists will not only care for ED patients who have overdosed, been poisoned or experienced an adverse reaction to a medication, but they will also be consulted on toxicologic issues for inpatients and outpatients and follow and discuss the management of these patients over time.
The team will help to reduce length of stay and decrease costs. Two examples of how medical toxicologists can achieve this: identifying which patients need to be observed, as opposed to admitted, and recognizing a poisoning early enough to provide an effective antidote.
Medical toxicology also encompasses opioid abuse, and clinicians have an important role to play in combating the opioid epidemic, says Boyer.
“In general, we have to be much more cognizant of how we prescribe medications,” said Boyer. “Research shows that writing somebody an extra handful of medications can have downstream effects on patients and families for decades. Understanding how patients use medications and the ways in which they take them has become ever more important in last few years.”
It’s also equally important to converse with patients about their expectations of pain, he says.
“No one wants to be in pain, but pain is a ubiquitous human experience,” Boyer said. “It’s unrealistic to say there will be no pain when it comes to illness and injury, so we need to have an open, honest dialogue with our patients from the outset.”
The expansion of Emergency Medicine into toxicology also includes plans to support cancer patients who are dealing with toxicity issues from chemotherapy and other medications. The initiative, which is expected to launch next year, will provide emergency care for cancer patients, as well as care coordination and palliative care for all cancer patients with toxicologic issues.
“We have a personal mission to help cancer patients, and our relationship with the Dana-Farber Cancer Institute puts BWH at the cutting edge of how to care for them quickly and compassionately,” said Erickson.
Educating the next generation of medical toxicologists
The division will continue Farrell’s integral work in educating clinical teams, trainees and Harvard Medical School (HMS) students. She has been teaching a toxicology and pharmacology course to HMS students for the past four years, as well as training Emergency Medicine residents in the ED as part of their core curriculum.
“The new division brings together a cadre of toxicologists who have the ability to cover a variety of services and answer a variety of questions about potential toxic ingestions and exposures, as well as expand our teaching and research efforts,” said Farrell.
VanRooyen says he looks forward to additional collaboration with Boston Children’s Hospital in the area of teaching.
“As we continue to develop a partnership with Children’s Hospital in this area, we’d like to build a more unified toxicology training program, in which the two hospitals can share fellowships and educational opportunities,” he said.
Growing the research pipeline
In addition to providing direct clinical care and training, the new division members will also pursue a variety of toxicology research, including the study of biotechnology that can share insights on medication compliance.
Chai will focus on technology and new innovations like Google Glass, drones and traceable medications. The latter rely on ingestible biosensors – electronic pills that trigger a remote response when they interact with stomach acid – to monitor medication intake.
“You can determine if patients are complying with their medications, and through a biometric sensor, you can see the physiological effects of the medication, including when patients become habituated,” said VanRooyen. “There is interesting work to be done here, including how to minimize our patients’ use of opiates.”
As director of Academic Development for Emergency Medicine, Boyer – who is the first emergency medicine physician to receive NIH funding under a mentoring-related grant – is charged with growing the academic pipeline of new research in the department, toxicology-related and otherwise.
“I’m excited to be working with extremely smart and highly motivated young faculty members to accelerate their academic careers,” said Boyer.