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To date, there appear to be no studies investigating the practice settings of all Medical Toxicology (MT) diplomates. The MT Assessment of Practice Performance Taskforce queried all MT diplomates about their current practice settings relative to the number of patients seen, the most common diagnoses, and the percent of time spent in their roles as medical toxicologists (MTs) and in their primary specialty. One hundred twenty-seven surveys were completed (44% response rate). Seventy-nine percent of respondents were affiliated with poison centers. Eighty-eight percent of participants were clinically active and reported seeing or consulting on behalf of at least ten patients over a 2-year period. Acetaminophen toxicity was the most common diagnosis encountered by respondents. Other common diagnoses included antidepressant toxicity, antipsychotic toxicity, mental status alteration, metal/environmental toxicity, envenomation, and pesticide toxicity. While respondents were likely to spend more time in direct patient care in their primary specialty, compared to consulting on behalf of patients, they were more likely to consult on behalf of patients in their role as MTs. Respondents spent more time in research, education, and population health in their role as an MT than in their primary specialty. Administrative activities were more commonly reported in association with the respondents' primary specialty than in their role as MTs. Most MTs encounter certain diagnoses with significant frequency and see a substantial number of patients within these categories. The majority spends more time on direct patient care in their primary specialty but is actively engaged in MT education, research, population health, and administration. A longitudinal assessment of MT practice patterns could inform MT curricular development and practice performance evaluation.

To date, there appear to be no studies that assess Medical Toxicologists’ (MTs) practice improvement (PI) activities in their Medical Toxicology practice settings. The MT Assessment of Practice Performance (APP) Taskforce queried all MT diplomates about (1) activities currently available in their practice settings that potentially would meet the requirements of APP, (2) potential APP activities that best fit with current MT practice, and (3) the relationship between MT practice patterns and APP requirements. One hundred twenty-seven surveys were completed. Participation in MT practice improvement activities is not universal, with approximately a third of the survey participants reporting that they are not involved in any practice improvement activity. Few respondents reported that they collected performance improvement-related data. Most who did so participated in CME, case, or chart reviews. Peer reviews, self-improvement plans based on chart reviews, and population research were considered the most valid measures of MT practice improvement. Communication skills were considered important topics for patient surveys. Suggested outcomes for peer assessment included accuracy of information provided, understanding medical staff concerns, timeliness of feedback, and helpfulness. Most respondents rated all of the APP options as being somewhat very intrusive. Access to those with sufficient knowledge of the diplomate’s practice improvement program to verify APP could pose a challenge to a successful completion of APP requirements. Optimal settings for the APP program administration are hospitals and poison centers. While barriers to MT APP activities exist, studying current MT diplomates’ opinions and practices could inform the future development and administration of such programs.

A case of combined, massive overdose of both atenolol and diltiazem in an adult male is reported. Cardiac arrest ensued which was responsive to cardiopulmonary resuscitation. Bradycardia, hypotension, and oliguria followed which were resistant to intravenous pacing and multiple pharmacologic interventions, including intravenous fluids, calcium, dopamine, dobutamine, epinephrine, prenalterol, and glucagon. Adequate mean arterial pressure and urine output were restored only after addition of phenylephrine to therapy with multiple agents and transvenous pacing. The patient survived until discharge after a hospital course complicated by nontransmural myocardial infarct on hospital day 4 and pneumonia. Laboratory testing subsequently revealed high serum levels of both atenolol and diltiazem. The atenolol level of 35 microg/mL in this patient is the highest reported associated with survival.This case illustrates severe cardiovascular toxicity after overdose of both atenolol and diltiazem. Oliguria, which has previously been reported in severe atenolol overdose, was successfully treated without hemodialysis by the addition of phenylephrine to aggressive therapy with pacing, inotropic, and pressor support.

In December 2011, the Medical Toxicology Subboard, composed of representatives from emergency medicine, pediatrics, and preventive medicine, approved a revised Core Content of Medical Toxicology. The Core Content encompasses the specialty of medical toxicology and outlines the areas of knowledge considered essential for the practice of medical toxicology. Functionally, the Core Content provides the organizational framework for the development of the medical toxicology certification and cognitive expertise examinations, and details the knowledge to be tested on those examinations, beginning with the 2014 examinations. In addition, the Core Content may serve as a template for the development of medical toxicology fellowship curricula. The previous version, initiated in 2000, approved in 2002, and published in 2004, will be retired and replaced by this new version. The first Medical Toxicology Core Content was developed to assist in the construction of the first examination in 1994. This document consisted of 22 major content areas and was organized, in part, by toxicant classification. Listed under most of these major content areas were exhaustive lists of drugs and toxicants of which a medical toxicologist was expected to have knowledge. In 2000, the Medical Toxicology Subboard embarked on a major revision of the original Core Content. This undertaking was initiated to update the 1994 Core Content, as well as to improve the framework that conceptualizes the expanding breadth of medical toxicology. In addition, the Subboard wanted to devise a conceptual document that would accommodate future discoveries and changes. A task force of Medical Toxicology Subboard members was convened to develop and draft the revised Core Content, and comments were solicited from stakeholders.