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Toxicology Rounds: The Most Pernicious Phrase in Toxicology

Gussow, Leon MD

doi: 10.1097/01.EEM.0000456986.51722.03
Toxicology Rounds

Dr. Gussowis a voluntary attending physician at the John H. Stroger Hospital of Cook County in Chicago, an assistant professor of emergency medicine at Rush Medical College, a consultant to the Illinois Poison Center, and a lecturer in emergency medicine at the University of Illinois Medical Center in Chicago. Read his blog atwww.thepoisonreview.com, follow him @poisonreview, and read his past columns athttp://bit.ly/GussowToxRounds.

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I was reading the chapter on calcium channel blocker overdose in Goldfrank's Toxicologic Emergencies when I came across a sentence that made me want to hurl the book through a window: “Orogastric lavage should be considered for all patients who present early (1 to 2 hours postingestion) after large ingestions and for patients who are critically ill.” (Emphasis added.)

Should be considered? What in the world could that possibly mean? Immediately after making this vague pronouncement, the author admits that the science supporting the recommendation is nonexistent: “Although the effects of orogastric lavage following overdose of a sustained-release [calcium channel blocker] have not been specifically studied and although most of these formulations tend to be large and poorly soluble because of their significant danger in overdose, orogastric lavage should still be strongly considered.”

I picture myself in the ED with a critically ill patient who ingested an overdose of a sustained-release calcium channel blocker. Her pulse is 38 beats per minute, and her blood pressure is 73/38 mm Hg. She does not look well, and I'm working on initiating interventions that have well-established benefits in these cases, such as high-dose insulin.

Suddenly I stop. “Doctor,” I say to myself, “the textbook says you should strongly consider gastric lavage. Let's take five, get some coffee, sit down, and think carefully about the pros and cons of pumping the stomach.”

Goldfrank's clearly stated that this question hasn't been studied. So what factors will enter into my careful consideration? Gastric lavage might be worth a shot if it were safe and free of complications and adverse effects, even though it has no proven benefit. I check the textbook again, and read: “When performing orogastric lavage in a [calcium channel blocker]-poisoned patient, it is important to remember that lavage may increase vagal tone and potentially exacerbate any bradydysrhythmias.”

Other downsides to gastric lavage, such as increased risk of aspiration, are well documented. This is getting complicated. No proven benefit, definite risks, but Goldfrank's still recommends considering lavage in these patients. Maybe I should check the literature referenced in the text, and come to my own conclusion. I'd better get another cup of coffee. And I should make a note to order the high-dose insulin and maybe a pressor at some point.

I think you see my point. Suggesting that an intervention “should be considered” when no rational criteria exist to guide such consideration is distracting at best and dangerous at worst. This useless advice is not limited to gastric lavage. Whole bowel irrigation, another unproven procedure associated with significant adverse effects, often gets the same treatment. Again from Goldfrank's: “Whole-bowel irrigation with polyethylene glycol should be considered in patients who have ingested sustained-release preparations [of b-adrenergic antagonists].”

I'm sure the authors of these chapters have the best intentions. They most likely note that lack of proven benefit does not mean proven lack of benefit, and think some patient somewhere might have an improved outcome if he receives lavage or whole bowel irrigation. What could be the harm in suggesting that these modalities be considered?

They obviously have never heard of W. E. Hick. Hick was a 20th-century British experimental psychologist. Hick's Law states that the time it takes to make a decision increases significantly as the number of possible choices goes up. A colloquial rephrasing of this law might be: “Keep it simple, stupid!” Adding nonessential considerations when treating critically ill patients is not a freebie, but comes at the expense of real costs in terms of time, cognitive energy, and missed opportunity.

This point was made very well in Lt. Col. Dave Grossman's book On Combat: “[H]aving to choose between options takes time, and the more options you have, the greater the reaction time. This is often referred to as ‘Hick's Law,’ but Sun Tzu said the same thing many years ago: ‘The more possibilities you present to the enemy, the more diffuse he is forced to become. The more diffuse he becomes, the more difficult it is for him to concentrate sufficiently to make a successful attack.’”

I suggest that the phrase “should be considered” be banned from textbook chapters, review articles, and case reports. Its use is a clear sign that the author is preaching from an idealized theoretical plane not attuned to the actual clinical practice of medical toxicology. (Hat tip to Scott Weingart, MD, and Cliff Reid, MD, for their brilliant discussion of On Combat on the EMCrit podcast: http://bit.ly/1oj96BW.)

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In Brief

Eight Percent of Children Account for 24 Percent of ED Visits

A retrospective study involving newborns to 18-year-olds found that eight percent of children account for nearly one-quarter of ED visits and 31 percent of costs, according to findings in Pediatrics. (http://bit.ly/1wIxHrV.)

Researchers compared the characteristics and ED health services of children based on the frequency of visits to the ED, and found that eight percent with four or more visits accounted for 24 percent of all visits and $1.4 billion of all costs. Increasing frequency was associated with an increase in the percentage of infants and a decrease in the percentage of children with chronic conditions.

The study concluded that frequent users, particularly infants without a chronic condition, not only disproportionately account for pediatric ED cost and utilization, but are the least likely to need medications, testing, and hospital admission.

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