Joey Wahler (Host): It addresses poisoning and other adverse effects from toxic substances. So we're discussing medical toxicology. Our guest is Dr. Nate Friedman. He's a Toxicologist and Emergency Medicine Physician with Eisenhower Medical Center. This is Living Well with Eisenhower Health. Thanks for joining us. I am Joey Wahler.

 Hi, Dr. Friedman. Welcome.

Nate Friedman, MD: Hi. It's great to be here.

Host: Great to have you with us. So first, for those uninitiated, what in a nutshell exactly is medical toxicology?

Nate Friedman, MD: Yeah, it's a great question and not very many people know about us. Medical toxicology most broadly is in the care of the poisoned patient. And so a lot of people will think about the obvious, which are things like overdoses, unintentional or intentional, snake bites, other terrestrial and aquatic envenomations, but also things like occupational exposures.

People who work around chemicals, who are breathing in or exposed to fumes, we take care of those as well.

Host: So it sounds like simply put you figure out what went wrong with somebody, having something go into their system that shouldn't have, and then how do you address it. Right?

Nate Friedman, MD: Exactly. And the other world that we sort of dabble in quite a bit is the world of drug - drug interactions, polypharmacy and adverse drug reactions that maybe are not too expected.

Host: So basically speaking, what education and training must someone like yourself go through to become a medical toxicologist?

Nate Friedman, MD: Medical toxicology is a subspecialty, which means that all of us, after completing medical school then go on to do a residency first. And the last time I checked, I think around 90% of medical toxicologists in the United States are emergency medicine physicians first. So after completing a three or four year residency in emergency medicine, they then go on to do what is the two year fellowship in medical toxicology.

So for me, I did a four year emergency medicine residency and then trained for an additional two in medical toxicology. But there are a few people who approach the career from internal medicine, pediatrics, and a couple of other primary specialties.

Host: Gotcha. And so once you knew you wanted to go into healthcare, I'm curious why medical toxicology, why the passion for that?

Nate Friedman, MD: Well in emergency medicine, that is where we tend to get exposed to some of the more acute poisonings and the acute overdoses, and those patients can be really, really sick. I've always loved taking care of the really sick, unstable patient and seeing if we can get them back on their feet and toxicology brings kind of an extra layer and an extra degree of difficulty.

You're not just stabilizing the patient, you're also playing a little bit of detective, and you're also sometimes using medications like antidotes that other people are not particularly familiar with or may have never heard of before. And I find that very intellectually challenging, and it's a very rewarding field to be in.

Host: It seems like something that would make for a great TV series.

Nate Friedman, MD: Yeah, it might, as a matter of fact, and I'm not saying Dr. House is the most medically accurate TV show out there, but they've done quite a few episodes where the underlying problem was a toxicology case.

Host: Interesting. So switching gears a little bit now, Eisenhower Health now offers medical toxicology bedside consultation services to the emergency department and hospitalized patients. So explain why that's so important.

Nate Friedman, MD: Yeah, absolutely. So right now, if you are at home, and God forbid your child gets into a chemical or a medicine that they're not supposed to have, or if that happens and someone comes to the hospital, either you or the doctor in the ER will probably call the Poison Center, and the Poison Center is a free phone resource.

They will help guide treatment for people at home and they'll help doctors guide treatment in the hospital, but they are over the phone and so their recommendations have to be extra super conservative because they're not there physically seeing the patient in the ER, in the hospital, and it's a great service.

The Poison Center is staffed with basically these professionals called specialists in poison information who are largely pharmacists. And having the ability to offer hands-on, eyes- on bedside care to patients in the hospital really asks a degree of care and attention that you simply can't get over the phone.

So a good example is if someone comes in after a poisoning, the poison center might want lots of tests, lots of follow up, and for that patient to stay in the hospital for a few days, again because they just can't see the person themselves and talk to them themselves. We can come to the bedside, whether that's in the ER or in the hospital itself, talk to the patient, talk to their family, call their pharmacies, figure out exactly what really happened, and then provide evidence-based best in class care that in a lot of cases, helps the patient get out of the hospital much more quickly.

Host: So it's hands-on. And typically speaking, if someone comes in and let's say they're in a condition where they're unable to tell you what they were exposed to, what's in their system, what's usually the first step in determining that?

Nate Friedman, MD: Sometimes after a poisoning it's hard to get information and so we get some of our information from the EMS providers that pick that patient up and bring them. We might get it from family, friends, roommates.

But also some poisonings, many poisonings will produce something that we call a toxidrome, and it's just a kind of cool way of saying syndrome where people exhibit similar findings on a physical exam regardless of who they are or what other medical problems they have. And I'll give you an example.

If somebody overdoses on Benadryl, for example, it's a common allergy medication that you've probably heard of. They look a certain way almost every time, and there's a spectrum, but coming to the bedside and just looking at them and doing a physical exam, it can get us about 90% of the way to the diagnosis without any other information, and that's really helpful and something that's very difficult to communicate to somebody like the Poison Center without some specialized training, and frankly, a lot of repetition in seeing these cases.

Host: Absolutely. So what would be some other examples here? When you talk about these services being offered 24/ 7 in-house, it allows your toxicology expertise to be applied to typically what types of emergency department conditions, what are the most common things these patients are checking in with?

Nate Friedman, MD: I would say the most common things that we will get consulted for are unknown overdoses or poisonings. Sometimes people will check in and they are confused or they are sleepy and nobody knows why. The testing that gets done in the emergency department doesn't reveal an obvious cause.

So frequently we will get consulted with the question of, could this be a poisoning that we don't know about because the patient can't tell us or won't tell us. So those sorts of detective mysteries are sometimes our wheelhouse. And then the other piece would be envenoanimations

Someone comes in with a snake bite, a bad spider bite, a scorpion sting. When I was in training, I trained in San Diego and so we'd see lots of aquatic envenomations like stingrays, and those are things that they would frequently call us for.

Host: And so if it's an undramatic animal bite, if you will. Like not a snake, but let's say some kind of an insect where someone may not have even been aware that they were bitten. They may be totally conscious and otherwise healthy, but experiencing some symptoms and just don't know what happened. Right?

Nate Friedman, MD: Yeah, exactly. And so, most bug bites and stings and those sorts of they're pretty benign, but usually when people come to the hospital, there's something going on where at least they think that it's not benign. If the emergency doctor or whoever sees them in the hospital thinks there might be an actual poisoning going on, they can call us to weigh in for help.

Host: Now most hospitals don't even have medical toxicologists on staff, so, give people an idea, if you would, how unique that is and how does it set Eisenhower Health apart from other hospitals in the area?

Nate Friedman, MD: It's very unique. Most of the time, the only places that you're going to find a medical toxicologist, who is doing consultations in the hospital are at large, academic university based medical centers. So for example, I trained at UCSD, UC San Diego. They have a toxicology program and it's mostly a problem of supply.

There's just not that many toxicologists. I think there's around 300 of us that are practicing in the entire United States. So it's a very small specialty. Having toxicologists out here in the Coachella Valley is quite unique for an area of this size, and it's worth mentioning that Eisenhower has three of us and we are the only medical toxicologists in the entire Coachella Valley. So we're serving the whole population.

Host: Wow. And only 300 in the whole country. That's pretty eye-opening, huh?

Nate Friedman, MD: It might be a little more than that. That's just the last time I checked. But it's such a demanding road to get here that the number of people we train per year is not very large.

Host: How about once assigned to a patient, how do you then follow them through treatment and recovery thereafter?

Nate Friedman, MD: So we will see them whenever we first get called, whether that's in the ER or on the inpatient side. So actually, right before we started this podcast, I got a phone call for a patient who's currently hospitalized that I'll go see later, and we'll keep following them every day that they're in the hospital.

If they need care after their hospital discharge, like many people do, we have a toxicology clinic where we will see people as outpatients. Yesterday I was in clinic. I saw two or three patients that had been hospitalized a week or two prior, just to make sure that they're on the up and up and recovering appropriately.

And so we can see people from hospital discharge in the clinic. We can also see referrals for people who think that there's a poisoning going on, but maybe don't need to go to the emergency department and get seen instantaneously, but do need some sort of ongoing care. And so we'll see that patient population in clinic as well.

Host: Gotcha. Couple of other things. What involvement would you say medical toxicologists like yourself have with the fentanyl crisis in the country?

Nate Friedman, MD: So a lot of us are involved in a bunch of different ways and I think it's important to note at the outset, that we've been dealing with this crisis for so many years now that most acute care providers, like emergency medicine physicians, they're pretty comfortable managing a quote unquote regular fentanyl overdose, if someone comes in after one. We're used to it, and so we actually, typically don't get called very often for those. But sometimes there's a concern that they actually took a different medication that was contaminated with fentanyl as opposed to using it on purpose, or that there's a concern that it's not actually fentanyl and it's contaminated with a novel drug.

So on the clinical side of things, we get involved in cases that are edge cases or where there's a concern that there's a new contaminant or a new fentanyl derivative that's making the rounds. And then on the research side, medical toxicologists are heavily involved in the field of what's called toxico surveillance, where people keep an eye on the drug supply by looking at public health labs, looking at law enforcement collections, and monitoring what's going on in the world of illicit drugs because it's not just fentanyl.

It's derivatives of fentanyl. There's a new class of drugs that are like fentanyl that behave slightly differently, but are also in the same kind of category. And so many of us are involved in research and monitoring so that we know what's coming down the pike as this drug crisis evolves.

Host: Very impressive indeed. And so in summary. What would you say is next for Eisenhower Health in terms of medical toxicology? What's coming along on the pipeline, so to speak?

Nate Friedman, MD: Yeah, so we're new. We're a new growing section at Eisenhower Health. I was the first one and I started, just under two years ago. So at this point, there's three of us. We're looking to add a fourth medical toxicologist at some point soon, and what that's going to do is it's going to give us the ability to expand our clinic offering to start making connections with the other area hospitals, because like I said, we're the only people in the valley and we're all at Eisenhower.

And so it would be great to be able to offer our services to patients that are a little bit more far flung in the Coachella Valley, besides just in Rancho Mirage and the surrounding area. I'd love to make some connections with the other area hospitals and we're working on making some inroads with some of the nearby VA and military partners because that's a whole different group of patients that are exposed to all sorts of stuff all the time.

Host: And Dr. Friedman, before we let you go, I'm also curious based on what you've told us, because there are so relatively few toxicologists and because it is such a demanding road to get where you are, if anyone listening might be interested in heading in that direction professionally, what do you have to be good at?

What do you have to have a good feel for? I would imagine science would be one thing. Yes?

Nate Friedman, MD: There's a joke in our world that we're some of the nerdiest doctors in the hospital. And I think in order to pursue a career in medical toxicology, the first thing you've gotta be is curious. And people that enjoy as they're doing their requirements for medical school, the people that really enjoy chemistry and pharmacology and like that world; those are people that often end up doing something like medical toxicology or going into an adjacent field. So those are the sort of base cases for toxicologists. But anyone who's curious, who likes mysteries and who likes spending a little bit too much time understanding the why of diseases, that's a good fit for us.

Host: Well, you mentioned chemistry there, and I couldn't even grasp the periodic table of the elements in junior high school. So I guess that counts me out, huh?

Nate Friedman, MD: It, it might, I mean, it's not too late, but it doesn't bode well for you. I'm sorry to say.

Host: I appreciate the candor. Well, folks, we trust you are now more familiar with medical toxicology, Dr. Nate Friedman, part of a rare breed, but obviously a crucial one in the medical field. Keep up all your great work and thanks so much again.

Nate Friedman, MD: Thanks for having me.

Host: And for more information, please do visit eisenhowerhealth.org. If you found this podcast helpful, please share it on your social media.

I am Joey Wahler. And thanks again for being part of Living Well with Eisenhower Health.