Episode Transcript
[00:00:13] Speaker A: Hello. Welcome back to another episode of the code 321 podcast. I'm here with Doctor Kennedy. Thank you for joining me today. I appreciate you having me over.
[00:00:20] Speaker B: Yeah, my pleasure.
[00:00:21] Speaker A: So, if you don't mind, if you want to tell the listeners just a little bit about how you found your way to toxicology and then a little bit about what you're doing now, that would be awesome.
[00:00:30] Speaker B: Yeah, that's a, that's a great start. So my. My path to toxicology, um, started in emergency medicine, and. And most toxicologists, not all come from an EM background. Um, there's a handful that come from internal medicine or from pediatrics, uh, occupational medicine as well. So it is a good collection of subspecialists that are not all from, you know, the. The emergency background, but, uh, you know, a sizable chunk of us are. And I had a mentor in residency, a fantastic guy, Tim Erickson, who's still down at the Brigham, Brigham and women's hospital, as an attending there. And I just thought he was one of the best doctors I'd ever met. Sharp as a tack, but just really, really witty. Took real good care of patients, and there was so much about toxicology that I think just made him and makes most toxicologists better emergency doctors. And I thought it would be a really cool career path. And, you know, Tim and several other folks were pretty instrumental in helping me, you know, realize I could pursue a fellowship. And so I ended up traveling, spent a couple of years out at Cook County Hospital and the University of Illinois in Chicago, completing training, and then moved back here to Vermont. And so that's kind of how I ended up here, how I ended up in my kitchen with you today? Yes.
[00:01:47] Speaker A: Did you go through residency as an EM resident and then do a fellowship in toxicology?
[00:01:52] Speaker B: Yeah. So within emergency medicine residencies, there are a handful of required and elective rotations, and one of them is toxicology. So, as residents, we spent time at the Massachusetts and Rhode island poison Center.
It's a really fun part of the job is getting kind of like with EMS ride alongs. We got to sit kind of in the den where all the pharmacists and nurses are manning the phones and answering phone calls at poison control. And, you know, it's a lot like any call center, but, you know, when you're exposed to hearing the calls firsthand, it's completely different than being in the emergency department where somebody's been triaged and you have more information.
You have these folks at poison center who are really just fielding sometimes phone calls from really exasperated, exasperated folks and if they need help, if they need backup, they go to a medical toxicologist, which is what I am. That's the kind of physician, or usually a pharmacist with really advanced training.
We're the backup for those really sick, critically, critically ill patients.
[00:02:56] Speaker A: I've definitely told everyone that will listen how much of a fan I am of the poison control hotline, because when I first started in this career field as like an EMT and an AEMT, I always assumed it was like some sort of national one eight eight, where you call and you get a menu and you push a button and you do this and you do that, and you kind of get generic responses. And so I never really access it. And then I had a complicated overdose patient on prescription medication that wasn't familiar with, and I called and it was like, are you a healthcare provider? So, yep. So I press one, and, and it was phenomenal. And ever since then, I, anytime I have any overdose of any kind, anytime I was precepting or working by myself or whatever, I always called them, because it's phenomenal. It's like talking to somebody like you on the phone.
[00:03:41] Speaker B: Oh, you'll learn something every time. The other thing that's really important is the kind of continuity of care that happens. And so I'm thrilled to be on the podcast, but kind of a special interest of mine is trying to reach any, really, any pre hospital or inter facility provider EMT to maybe even just a police officer who's at the roadside at the initiation of a case. But we've had calls, we get calls from everywhere. And so much of the information that I need as a toxicologist is about the scene and the ingestion. Right. What did it look like? What bottles did you find?
Anything you can do to gather information? And sometimes I've had a couple of cases just cracked wide open because a very thoughtful medic took a quick photo of this product. That was one example that sticks in my mind. This product, one four butane diol, which is. It used to be labeled or sold as a printer cleaner, a VHS cleaner, just illicitly, but it basically is metabolized to GHB. So just gets people very pleasantly inebriated and high. But you can buy this stuff in industrial bottles. And EMS picked up a guy with, he was just abundant, not even sternal rub, like completely a reflexic, intubated without meds, type of unresponsive, and the medic snapped a photo of this solution, and that was the only data we had to guide or help us figure out what was going on. Any chance I can get to get in touch with people, like, you know, the second they show up or even en route is really helpful. So we love those calls. Keep them coming. Evan.
[00:05:16] Speaker A: Definitely no, and theyre so helpful. I used to kind of joke that a lot of my patients with these crazy ingestions and seizure activity, they tend to recommend, like, benzodiazepines a lot, which is something that we actually do carry, that we give frequently. I know, which is good. And one of the things that I remember specifically as I called, and this patient, you know, had ingested something, and one of the people on the poison control lines, like, they're going to stop breathing in the next 15 minutes or so, so you should be ready for that. And sure enough, ended up intubating the patient about 20 minutes later, pre hospitally. And it was so helpful to know that because I never would have been able to look at that medication and made that correlation and to have them be like, you should. Do you have intubation equipment? Yeah. You should get that.
[00:05:57] Speaker B: Right?
[00:05:57] Speaker A: Yeah, that was really helpful.
[00:05:58] Speaker B: There are sometimes you kind of know for certain. Um, a call I took care of, you know, took the other day was a small critical access hospital in New Hampshire, and it was a woman who initially had, she drank a lot of alcohol, but took kind of a grab bag of antidepressants and ingested them. And I was going through the list with the doc at this facility, and one of them was bupropion, which, among everything else, the kind of Alphabet soup of SSRi's and other ones, that's when I really worry about, you know, I told the doc, I said, if that bottle is empty and her vitals are, you know, she was tachycardic and getting a little sleepy. I said, she's going to have a seizure. I, you know, I can't guarantee it, but it's going to happen, okay. And I know she's, she's stable now, but, like, things are going to get worse, and I promise you they're going to get worse, and you don't want to be alone. So start making phone calls, thinking about transfer.
Let the transport team know to have, you know, anti seizure medications. And so that's a lot of what we do is trying to forecast and plan and prepare for the worst. It's kind of, you know, just a. More of an extension of what we do naturally anyways. And, you know, in ems and em in general.
[00:07:09] Speaker A: Yeah, no, that's. That's really fascinating. I've always been interested in toxicology because there's just. It's like, it feels like it's the blend between like biology and chemistry and like environmental things and like all these crazy cases and there's so many podcasts and movies and, you know, things like that, you know, where people have these crazy experiences and get ingestions of various things and its just so fascinating. So can you share with me a little bit about, lets say im a paramedic or an EMT and I go to a patient and lets just use like the term, the broad term of altered mental status, a patient whos not acting appropriately and they roll in. Is there any kind of standardized approach that you start with? Just some basic ground balls about how to start figuring out maybe whats going on? Is this tox, is this medical? Like, how do you approach a patient thats, lets say, not able to tell you their name? Maybe they're a little bit uptunded and they're difficult to communicate with.
[00:08:01] Speaker B: Yeah, that's a. Well, that's already a lot of good information to start with there.
It's funny, I'm one of, one of my pet peeves is probably the term altered mental status in general. And I've kind of been on a crusade to try and just. Are there ways to think about refining that term a bit? Right, because it's often used as a triage term or a check in or something like that. But there's so much more to it. People who are hyperactive, right. They have kind of an agitated, you know, presentation sometimes. Sometimes they're just hyperactive but in a really good mood. And that's a whole separate type. Sometimes they're really sleepy, right? Yeah, they're sleepy. There's kind of like, okay, you know, they're. They're laying there, they're not interfering with care. Yeah, that's the type that generally most people are happy with. But, you know, then it borders on, okay, you're not breathing or you are just like we talked about earlier, a big baclofen overdose or GHB. Some of these agents that just. They will render people essentially brain dead for better or worse. But I don't know my 62nd approach, right. When I get to the head of the bed or foot of the bed, wherever you're standing, as an Ed doc and as a toxicologist, I'll generally look first like anyone else. What's the respiratory effort? And I want to know that because my first intervention would probably be thinking about what are immediately reversible things? Or more importantly, what can I do to support somebody who's really sick and not actively breathing. And oftentimes it comes down to just being quick enough to think about BVM, bad cough mask rescue, and even before there's such a kind of knee jerk reaction in many situations to just give naloxone, given the opioid epidemic we're dealing with. But I think remembering that a lot of the problems you can bag your way through while you're thinking is a helpful first bet.
I'll quickly look at the pupils, too. And again, this is just the first ten to 15 2nd overview. I'll open the eyes, look at the pupils.
If it's somebody bordering on somnolent or obtunded, I think a real nice trick as far as eliciting a response to stimuli, either simple nail bed pressure, sternal pressure, and then again, just jaw thrusting as probably the most noxious of stimuli. But you get a sense for how obtunded somebody is very quickly with just a, you know, doesn't even have to be aggressive, but just a gentle jaw thrust. And then other things. Uh, we call it the tox handshake. But, you know, take. Take your hand, maybe a gloved hand, and shove it in the armpit. Um, somebody, for example, with a big cocaine or methamphetamine, um, overdose, a big sympathomimetic will, you know, they'll be kind of sweaty.
[00:10:35] Speaker A: Oh, definitely.
[00:10:36] Speaker B: You think about diphenhydramine or benadryl, for example, um, Jimson weed, uh, devil's trumpet, some of these other anticholinergic plants. I've seen pre hospital atropine overdoses, too, actually, from EMS teams that have interesting taken people who are so bradycardic, giving them seven 8910 milligrams of atropine, and they end up dilated pupils. And, yeah, you'll feel nice, dry armpits. So, yeah, usually a good skin exam, skin pupils, respiratory effort, and then obviously, just, I think, derobing somebody and making sure they're not covered in any patches or are their clothes soaked with any chemical, for example, so quickly eliminating any external stuff. But that's probably the first, yeah, 45 to 60 seconds of a tox focused resuscitation in my mind.
[00:11:22] Speaker A: Yeah. And I think the really fascinating thing about what you just said is anyone from an EMT up through a paramedic could do all of those things on the scene, you know, like that. It's not like you're saying, well, I would draw this extremely complicated chemistry panel to determine the appropriate enzymes. Like, you're just talking about a good physical exam. And I think it's one of the interesting things.
[00:11:42] Speaker B: Well, it abbreviated.
[00:11:43] Speaker A: Right.
[00:11:44] Speaker B: But at the same time, it's like, this is 30 seconds of work. Exactly.
[00:11:48] Speaker A: Let's get some basic information. There's a really good chart I've used before with some toxicology lectures that has all the different types of, you know, overdoses. And it has, you know, a picture of a guy sweating and a picture of a guy that's dry, you know, big pupils, little pupils, fast heart rate, slow heart rate, respirations. Depressed, not depressed. And I think that's really helpful for providers to kind of have some level of understanding of what you might be saying. There's all these mnemonics, like, you know, the mat as a hatter, dry as a bone, blind as a bat. And one of the things I've noticed is that sometimes, you know, when I was working nine to one as a paramedic, we'd get called for intercepts for really sick patients. And it wasn't necessarily that that patient needed an immediate paramedic level intervention. It's that the advantage that paramedics have over some other providers is the schooling is a lot longer, and then you have the opportunity to do rotations with, like, doctors like yourself. Like, we're able to go into the hospital and participate with these physical exams.
[00:12:42] Speaker B: Spending the summer with us at UVM, which would be great.
[00:12:44] Speaker A: Yeah, exactly. So I think it's really fascinating that you said, you know, you know, some of those initial tests. I mean, this is stuff we can all do just as a quick check, which is really fascinating.
So you go through that, and let's say that you, you know, maybe you notice a few things. Maybe the respiratory rate is depressed, it's not responsive to naloxone. You're bagging them. They need additional respiratory support. You've done kind of that 32nd assessment. What would be like, the 201 level toxicology screening that you would start doing? Is this when you would start thinking about, like, labs or some other types of interventions to see what we can see here? Is it kind of going to depend on the patient's response to your.
[00:13:21] Speaker B: That's a great question. I think a lot of it's very context dependent.
[00:13:24] Speaker A: Right.
[00:13:25] Speaker B: So, um, you know, if you have some history that this patient, for example, is prescribed gabapentin, maybe orbaclofen, or some of these. These drugs that are likely to lead to eventually being obtunded, and if you're at the point where you're bagging them, then, yeah, just intubate them and move on. That's right. I mean, it isolates the trachea for sure.
It fixes most of those problems. And, you know, I mean, there are other sometimes direct reversal agents, I think, of, you know, naloxone is a good example of an anoleptic or, you know, an awakening agent, a reversal agent that has a lot of properties that are kind of outside of just opioids themselves. It actually, I mean, it can reverse CN's depression for many causes. Ibuprofen overdoses, interestingly, people don't think about, most people think of them as like, you know, big old nothing burgers. But if, like a toddler, for example, gets into a whole bottle of ibuprofen, a lot of it, for example, or a teenager overdoses on it, it can actually be a pretty potent CN's depressant. And so in large amounts. And there's some literature supporting that you can use naloxone to reverse that, even people with spontaneous intracranial hemorrhages, to a lesser extent alcohol ingestion. But naloxone will wake people up to varying extent. Flumezinil is another good example. We use that as a benzodiazepine overdose reversal agent, mostly in the hospital if people are too sedated.
But there's probably going to be a growing role for it with some of these other drugs in the market, too. We're seeing a lot of kind of novel benzodiazepines that are making their way into especially the kind of like 18 to 25 year old male range. We've, you know, had a number of cases come in, too. So, I mean, if you get context, if you get background about cases or information or you can scan someone's medalist, then you can start targeted stuff. But, yeah, yeah, otherwise I'm just going to intubate them.
[00:15:18] Speaker A: Yeah, there you go. Save that, Drake. Yeah, for sure.
[00:15:21] Speaker B: You know, downstream, the downstream toxicologist in me thinks about what do we do afterwards for kind of broadening and projecting and planning, like how long is this going to be a problem for? So some of these poisons, especially in large amounts, can be brain death mimics where people will be completely unresponsive oxidation for days at a time to the point where, yeah, I mean, baclofen, I think the probably most famous case was a patient who had overdosed on it, was on their way to the operating room for organ harvesting after being declared brain dead and then started to wake up on the OR table.
[00:15:59] Speaker A: Wow.
[00:16:00] Speaker B: So, yeah, there's a lot of good position statements on, you know, evaluating brain death in some of these overdoses, but they can be pretty potent, so. Yeah.
[00:16:08] Speaker A: Oh, man, that's nuts. Well, I'm going to see if I can challenge you here real quick, just for my own fascination.
I'm sure this is like your bread and butter, but I've always been so interested. I've had many an aspirin overdose in my life, in my nine on one career for people who are doing si. And one of the fascinating things that I remember about aspirin is at different points in its toxicology. Doesn't it have both a alkali, like, alkali state and an acidotic state that people can run through?
[00:16:38] Speaker B: Yeah, something like that. I mean, there. There is kind of a classic triple acid based disorder associated with it, but, you know, in reality, there's always so much overlap to these things.
[00:16:49] Speaker A: Right.
[00:16:49] Speaker B: The big problem, I mean, so salicylates, or salicylic acid, right. Is an acid in and of itself, but when it ends up entering tissues, it can be really problematic. And kind of as the ph drives lower, more of it gets dumped into tissues, too. And while it's doing that, it starts to stimulate the respiratory center. So people develop this, really not like a classic diabetic coosmal breathing, but you'll see this pattern of hyperpnea.
[00:17:18] Speaker A: Right.
[00:17:18] Speaker B: So big, deep breaths, pulling a lot of tidal volume.
[00:17:21] Speaker A: Definitely.
[00:17:22] Speaker B: And the kind of classic toxidrome for, like, a salicylate poison patient would be somebody who is confused.
I won't say altered, but usually it can vary between a mix of kind of mild agitation and delirium, all the way to eventually getting progressively more somnolent. But they'll be hyperpenic, that respiratory center stimulated. They're breathing off some of that carbon dioxide, too, to try and correct their ph. On their own. They'll be a little tachycardic, oftentimes because of some of the uncoupling that happens. They'll be a little diaphoretic, too, but they're really tough cases to manage, and people tend to underestimate how sick a salicylate poison patient can get and how much attention they really need. They need a lot of at least one to one nursing while they're really ill and a lot of attention to the labs and managing ph and all that. So I'm sorry you've had to deal with them. They're uniformly. They're a lot of fun to think through about their. Their nightmare cases, because so much can go wrong and often does.
[00:18:24] Speaker A: Oh, yeah. No. And I think the overdose cases were always fascinating to me when I was working nine one. Cause it was the only time I felt like a detective, you know? Like, especially if there was multiple medics on the crew, they'd be managing the patient. It's like, all right, we're gonna go on a hunt now. We're gonna go look at the trash, the bathroom trash, look at the cupboard.
[00:18:40] Speaker B: You know, and they're in that medicine cabinet. Boxes, you know? Well, the big thing, too. You see a seven day supply of pills, right? So a lot of, uh, you know, especially our very geriatric population here in Vermont.
[00:18:51] Speaker A: Yeah.
[00:18:52] Speaker B: They'll take their entire weekly pill planner, and, whoops. Sometimes open all seven days, like a. Like an advent calendar, just going fishing for that chocolate and.
[00:18:59] Speaker A: Yeah.
[00:19:00] Speaker B: And just. Just garbled down a whole week's worth of meds. And if you're old and sick enough, even. Even that amount can. Can be lethal.
[00:19:07] Speaker A: Yeah. I still remember my very first, uh, elderly opiate overdose. Threw me off. It took us, like, took me and my partner probably, like, 20 minutes to pick up on the fact that we were bagging and doing all the normal things and supplying supportive care, and, you know, we worked through the ABCs appropriately, so we. We were managing the patient, but I remember someone in the crew being like, do you want to try some naloxone? We have pinpoint pupils in respiratory depression, and we ended up waking the patient up and talking to them about it. And they take opiates for chronic pain, and they took too many opiates, and they didn't have anything to eat, and they just had this massive overdose. And I was like, at the time, the only opiate patients we were really seeing were a lot of illicit opiate use or opiate abuse at that time. This was ten years ago or so, and so just. It's funny how changing the environment you're in can almost, like. Like, throw you off a little bit. Like, I was. It wasn't like we were at the bus station or at, you know, a bathroom at a local fast food chain. We were just in some nice house.
[00:20:07] Speaker B: Yeah.
[00:20:07] Speaker A: And it was like, so not pigeonholing yourself into, you know, letting this.
[00:20:11] Speaker B: Well, it speaks to the problem of the opioid epidemic, too, and how it's, you know, essentially touched everyone's life in some way or another, either personally or professionally. Um, it's not the. Not the same landscape of, you know, kind of like. Like you said, young folks using heroin, like. Like it used to be in the eighties. Yeah, it's everywhere.
[00:20:30] Speaker A: Oh, yeah.
[00:20:31] Speaker B: Pill and snorting, injecting, you name it. So I think it also speaks to just how the landscapes change when you think about the use of pre hospital naloxone. Right. I mean, having some of these antidotes so widely available, publicly deployed, having police and other, even, like, lay responders trained in administering antidotes for poisons is kind of a novel thing in toxicology. I don't know if 2030 years ago, it seems so normal now. Right? I know, but back in the nineties, uh, I. It's just that's, that was not how the world was.
[00:21:05] Speaker A: I think we're a lot more medically inclined in general as a society. I mean, you have people doing bleeding control, stop the bleed. They're doing bystander CPR. They're doing, some are even doing ventilations with pocket mass at schools now. They're doing EpiPen administration. And these are not, you know, camp counselors or camp nurses. These are just normal, everyday teachers, you know? And so I think it's fascinating that we've kind of almost like this, you know, Red Cross or AHA style first aid programs are now kind of like the standard of societal care. I can't remember the last time I went to a cardiac arrest in a public setting that, where the person was not receiving some level of care, even if it was more care, you know, it was still, people knew what needed to happen, you know, and someone did something, and almost every code save I can think about had bystander CPR to the point where we just have to give them a shock or two, maybe give a little ventilations, maybe a little one dose epi, and, you know, it's, it's no problem. So it's really fascinating to see that. And then making sure that as a, as a nine to one provider, you really pump those people up, you know, like, hey, you know, oh, yeah, if they get the resuscitate, hey, you. You saved this person. Like, we didn't do anything. You did all the hard work, you.
[00:22:11] Speaker B: Know, and it reminds me, I think there's some, some study or, you know, literature out of the EM group down in Brigham and women's looking at the cardiac arrest survival rates at Gillette Stadium.
[00:22:23] Speaker A: Oh, yeah.
[00:22:23] Speaker B: Which are something like four or five times higher than the national average because you've got a bunch of, you know, generally, I'll say, you know, well educated, albeit Rowdy, Boston. That's right. Who are all Gillette, but all of them. Right. Same thing. It's that the one thing you see there, it's a sick population, 64,000 people, all cheering, eating fatty food and drinking beer. And so the incidence of cardiac arrest is decent at these football games, but everyone there know there's defibrillators everywhere. Yeah. You know, medics essentially on site and field docs, but everyone in the stands essentially knows CPR. And, you know, uniformly patients who end up with some sort of a VT Vf arrest or a shockable arrest in football stadiums, and just stadiums in general, do better.
[00:23:13] Speaker A: Yeah.
[00:23:13] Speaker B: And which it kind of, you know, it seemed counterintuitive to me at first, and then I'm like, oh, no, this is perfect. You've got 10 seconds at most of downtime before somebody's hands are on chest and starting, you know, hopefully high quality CPR, something.
[00:23:27] Speaker A: Yeah, some CPR.
[00:23:28] Speaker B: I know, with a. Well, just with the number of overdoses in the world, too, I think it's part. Part of the idea of just getting naloxone everywhere.
[00:23:34] Speaker A: Right.
[00:23:35] Speaker B: It's got to be something immediately available. And even if you overdo it and somebody ends up in withdrawal afterwards, um, we're even looking at options for treating withdrawal precipitated by naloxone, which is another fascinating pre hospital intervention fact that, you know, in Vermont, at least in some other parts of the country, were using buprenorphine in the pre hospital setting. It's just one of those things that's like, a decade ago seemed unfathomable.
[00:24:01] Speaker A: Yeah, it's so wild. I remember we got a. From the state department of Health when I was working in downtown Burlington. We got a big pallet filled with these, you know, opiate resuscitation rescue kits. And every, you know, some places got a couple boxes of it, and Burlington gets a huge pallet. So within, like, two months, the whole thing was gone. And the health department's like, you went through all that stuff, and we're like, yeah, people want this.
[00:24:24] Speaker B: When's the next palate?
[00:24:25] Speaker A: You know, and it's like. And the folks want this. You know, people who are using the drugs want it. Their family and friends want it, bystanders want it. People who work in downtown businesses want it because they're experiencing this. And like you said, it's. It's touching everybody, and people are running into this. So.
[00:24:39] Speaker B: Yeah.
[00:24:41] Speaker A: So just to kind of tie all these different threads together, um, do you want to share maybe, like, a case that came in that's relatively interesting and talk a little bit about, you know, how you approached assessment of it, how you made some decisions on treatment, and ultimately kind of what the disposition was.
[00:24:56] Speaker B: Yeah, actually, I could think of one from a while ago. I'll try to avoid any specifics, but it was a teenager who presented to a critical access hospital. Again, one of these, you know, I think these smaller hospitals, there's one I work at in New York that, you know, when I'm there, I'm the only doctor in the entire hospital.
[00:25:16] Speaker A: That's right.
[00:25:16] Speaker B: There's no other physician.
[00:25:17] Speaker A: Yeah.
[00:25:19] Speaker B: And I love it there. It's kind of like just practicing medicine. I think the, you know, the way it should be, and it forces you to get creative. But there are still a lot of these hospitals in America that are losing support from specialists, or they might be, you know, that had formerly had an obstetrics department, for example, that shut down. But a lot of rural hospitals are ending up in the scenario where there's really no one but maybe a single Er doc or a family document around in the day or at night. And so a patient presented to one of these hospitals, this teenager, saying she had eaten some mushrooms to get high is all that we had heard. And she came, and by the time I think EMS was called, she arrived tachycardic, confused, not really following commands, picking at things, spaced out, looking as it were. And the team had a lot of difficulty trying to essentially, you know, get the situation calm enough to where they could get iv access, try to get a urine sample for like, a urine drug screen, for example. She was just interfering with care is a good way to put about it, just generally swatting nurses away, you know, ripping telemetry leads off. And those ones are really tough to take care of. So when we think about mushrooms, there's many different types. For example, there's psilocybin containing psychedelic mushrooms.
You have gyrometra mushrooms, for example, which can lead to seizures.
Outside of the hallucinogenic ones, there are plenty of delicious ones, too. And so we could do a whole podcast on mushrooms alone, and some of them can make you behave with this kind of delirium where you're acting squarely. And so there was nothing really immediately life threatening.
Again, no problems with the abcs. And oftentimes, if it's just a presentation like this, just put the patient in a dark room, minimize stimuli, and let them sleep it off. So the problem came in the next morning.
It was a change of shift, and the girl had not really improved overnight. She was still, I think, when they checked her vitals again, still tachycardic. About 100, 3140 had had an episode of incontinence overnight, which, again, kind of unusual for a mushroom ingestion. Um, hadn't had anything to eat or drink and was still just, you know, very much confused. Getting a little more combative, actually. And so the decision was made then to transfer the patient to a higher level of care to pediatrics hospital, thinking, you know, she'd probably need some observation or admission, and ended up getting sent to our tertiary hospital, where she continued to deteriorate and then eventually had a seizure. And when she had a seizure, they were, the team was able to obtain iv access, and they put a Foley catheter in to after realizing that her bladder had about two liters of urine in it.
[00:28:09] Speaker A: Oh, wow.
[00:28:10] Speaker B: Yeah. So kind of unusual. Right. And after the seizure. So let's go through this case, right?
[00:28:15] Speaker A: Yeah.
[00:28:16] Speaker B: I gave you, let's say we only have 60 seconds, right. She's postictal but not interfering with anyone. If you have 60 seconds, what are the things that we want to look at on that kind of initial exam? Right. We talked about pupils.
[00:28:26] Speaker A: Pupils, yeah.
[00:28:27] Speaker B: So her pupils were about eight, nine millimeter saucers, really dilated, large tox handshake. Right. So those AR pits were just dry, dry, dry, dry, dry. Nothing at all.
Still tachycardic. Probably 100 3540 at that point.
So we start to kind of think like, oh, this is not a normal presentation, but there is a bit of a toxidrome here. Right, that kind of like as a hatter.
[00:28:52] Speaker A: Yeah.
[00:28:52] Speaker B: Dry as a beet.
[00:28:54] Speaker A: Yeah.
[00:28:54] Speaker B: So she had actually classic anticholinergic toxicity. And upon looking at the urine drug screen, there was a positive result for tricyclic antidepressants, which is one that isnt included on most of our modern urine drug screens, but there are some that still include it. And so that kind of led to our team having a bit of a hypothesis that, oh, what if this was a diphenhydramine ingestion? What if its not mushrooms at all? And this was just a teenager taking some benadryl, trying to get high, latest TikTok challenge or whatever. And ultimately that ended up being the case. So we gave benzodiazepines just to kind of correct the heart rate a bit. And once the post dictal state resolved, she was back and agitated. Unfortunately, our kind of favorite antidote for this physostigmine has been on national backorder for the last couple of years, and we just got it back on formulary, at least at UVM and some of our sister hospitals. Yeah. The treatment would be, essentially, you can immediately reverse Benadryl toxicity with physostigmine oh, wow. Yeah. Which is helpful. Yeah, I know. It's wonderful. It's one of those, like, just watching, like, the sun come through the clouds.
[00:30:05] Speaker A: Yeah.
[00:30:05] Speaker B: The heavens open up, like when you give this drug, and it works. It is. It's one of the most incredible things in the world, because it will take somebody from this really frustratingly delirious state back to essentially, you know, lucency. And so I've given it to patients before where they will, you know, they'll present exactly like this, and then within about a minute or two, they'll be able to have a conversation with you. And you can. You have this window where you can say, what did you take? You know, did you brew your tea with devil's trumpet?
[00:30:33] Speaker A: That's right. I know.
[00:30:34] Speaker B: Yeah, exactly. So it's one of those really satisfying things, but, yeah, it was a really interesting case, though, because everyone was kind of fixated on this, like, this false history, um, of. Of. I ate a mushroom, and it had nothing to do with that. It's just common things being common.
[00:30:48] Speaker A: Yeah.
[00:30:48] Speaker B: Right. I mean, Benadryl, I'm sure you've seen a couple of cases, too.
[00:30:52] Speaker A: Yeah, no, absolutely. I remember when I was working in downtown, we used to cover all the special events that would happen at the waterfront and different things like that. We'd have a contract to do medical standby, and it was almost like you could predict what types of toxidromes you were going to see based on who was playing. So, you know, we would have a. I remember when, you know, fish would come or, like, twiddle or something. We would see a lot of mushrooms, a lot of ass, like a lot of weed, that kind of thing. And then when, um, I forget who came down. Uh, there was a really heavy metal band that came down a couple years ago, and that was like, within ten minutes of the first set, there was, uh, seizure. We had seizures, fights like, aggression, delirium with agitation. Like, it's just entertaining how, like, this style of music can kind of lead towards the different types of overdoses that we see. Cause they have their own cultural uses.
[00:31:41] Speaker B: Of different things in Chicago. I mean, that's like a mass casualty event for the eds there. Oh, yeah, I remember as a fellow, it's. It's one of those things where I think, like, as the toxicology fellows, you're in a different scheduling pool than the rest of the faculty.
[00:31:53] Speaker A: Yeah.
[00:31:53] Speaker B: And everyone else knows to take that weekend off.
[00:31:56] Speaker A: That's right. I know.
[00:31:57] Speaker B: I found it was, like, mysteriously, it seemed like all of us were always working. All the toxicologists somehow ended up on that rainbow Saturday of lollapalooza. I know, and it's just a train wreck of, you know, all sorts of. Just, like you said, just, you know, psychedelics and math and ecstasy and. Oh, my gosh.
[00:32:14] Speaker A: Mix of all the above.
[00:32:15] Speaker B: Yeah, I know. Thinking about. He said a fish concert. I'm like, oh, man. Yeah, break out the acid.
[00:32:19] Speaker A: Oh, yeah. No, it's crazy. And most of them do pretty good. And the nice thing is, in those places, they're kind of as community based as they are. They all want the person to get help, so a lot of the times, they'll actually drag the person right out of the crowd to you so you don't have to fight through, you know, 100 5300, like, you know, head banging people, which is really helpful. But, yeah, it was a. It was good experience. You got to see a lot of different styles of people who are having a lot of different overdoses and kind of work through that process. And definitely Benzos were my friend for a lot of cases that I had, people who are just really amped up, really agitated, really having a hard time.
[00:32:55] Speaker B: You know, you just turn down the volume just a little bit. They're great. Little, like, volume switch.
[00:32:59] Speaker A: Yeah. I used to say, like, when? Because we would have some different options. We'd have ketamine for sedation. We'd have benzos for sedation. We've, you know, Haldol for sedation, a lot of different things that we could use based on what the patient was presenting as. And I used to describe it to new medics as, like, you know, ketamine is unplugging the unbalanced washer from the wall so you can reset. And Benzo's is just a wet blanket just to cool it down, just smother the fire a little bit, just get us back under control.
[00:33:26] Speaker B: Nice, easily titrateable. And, you know, it's for almost any. Any, you know, positive, amped up, you know, tachycardic, that type of a. That type of a toxicologic problem. They really just. I mean, they.
I say they solve the problem at the level of the brainstem and above, right. So all the peripheral stuff, all the problems you see with a lot of. A lot of different poisons, you can just kind of stop all the sympathetic outflow that happens from the brain, and that's what's really helpful. And a lot of the morbidity in these things, like cocaine, methamphetamine, it comes from seizures. Seizures, aspiration. And cardiovascular toxicity, and the way that you prevent a lot of that is just really judicious benzodiazepines. And sometimes it takes a lot. I mean, I've given upwards of 50 to 100 of midazolam milligrams, midazolam, lorazepam for methamphetamine cases. Unfortunately, we don't see as much of that here in the northeast as I did west. Yeah. But, yeah, I think somebody who's stuffing or packing a lot of cocaine or meth, then, I mean, there's no upper limit. You just do what you have to.
[00:34:32] Speaker A: I know, it's crazy. I remember one of my most interesting cases was with Sarah Schlein, actually, who I'm sure you know.
[00:34:37] Speaker B: Oh, yeah.
[00:34:38] Speaker A: I had a patient who had chest pain, and I gave them everything under the sun. Nitro, aspirin, you know, um, all kinds of meds, like high doses of all these things, and still had this crushing, uncontrollable chest pain, and it ended up being cocaine induced vasospasm. So she gave a little bit of benzos, and the pet pain went away, and I was like, I never would have thought magic to go down that route.
[00:34:59] Speaker B: Yeah, well, Joe, Sarah's so smart, so.
[00:35:01] Speaker A: Yeah. I appreciate you coming on the show today. Thanks for having me over, and I'm definitely getting you some of those tips that you gave us, so.
[00:35:07] Speaker B: My pleasure. Yeah. And reach out anytime if you need me. Or poison control, your favorite, 1802 22122.
[00:35:14] Speaker A: Got it.
[00:35:15] Speaker B: One of us is always there, ready to listen, learn, teach, whatever you want.
[00:35:18] Speaker A: Yeah, I definitely encourage anybody to call if you have questions, so. Thanks, Joe. Appreciate it.
[00:35:22] Speaker B: Thanks. Bye.
