Toxicology Pearls

The Poison Center, which is a public health institution, so it's housed here.

I'm Holly Wehmint, and this is Pediatrics Now, cases, updates, and discussions for the busy pediatric practitioner. Click on the link in this podcast for free credit that may include CME, MOC, or ethics credit, depending on our topic or podcast. Today, we're talking about toxicology pearls. Joining me here in the podcast studio is Robert Miller. Robert, you have a PharmD. So I'm a pharmacist by education. I've been in the toxicology world for the past eight years.

You work for the Long School of Medicine here at UT Health San Antonio. Of course, the larger name here is the University of Texas at San Antonio. You have an important message for clinicians. There's a phone number that's important to call if they have a patient who's in trouble, and there can be a lot of benefits to the doctor calling. So, yeah, I work for the South Texas Poison Center. The phone number is 1-800-222-1222.

That is the phone number for the, or really the Poison Center helpline, and this number is very useful to have. And in terms of for clinicians, there's a good reason to call where they can document this for a case and they can let their patient know, I just talked with the poison experts, or can you tell me more about that? We still get a substantial amount of phone calls from parents.

However, it's pretty close to 50-50 these days in terms of calls from parents, but then also calls from triage nurses, physicians in the emergency department who have a patient in front of them with a toxic congestion that they're looking for guidance on.

And we work at every other level too. Most of our calls will be the emergency department from the clinical perspective, but I also get calls all the time from school nurses, from pediatrician offices. Toxicology, we have a bit of a, when we're teaching and just from a didactic approach, sick or not sick. And that's kind of your first assessment. So if the patient is sick, we can walk you through what this is gonna look like.

Length of stay, and obviously the not just supportive care, but the specific types of supportive care. Antidotal therapy, when it's indicated, when it's not indicated. And I can give you, for patients who come in and they're just completely asymptomatic and you're trying to figure out, you know, how long do I need to watch this patient for? We can try and give you some pretty good ballpark disposition information. You can reassure parents and say, look, we talked to the poison control center.

Your child's going to be fine. Or I just got off the phone, poison control. This is the plan. Correct. Yeah. And from an emergency medicine perspective, this happens all the time. A lot of parents will just take their kids straight to the emergency room instead of calling us. And then so now it's the hospital staff that are calling us and we're giving guidance. And often, you know, because of EMTELA, I will never say, oh, they don't need to be in the ER. Just just kick them out.

That's not how it works. Obviously, if they're in the emergency room, they get to be seen by a provider and evaluated. So we will never say, oh, you can just turn them away. You don't need to see them. They're totally fine. They still get assessed. But we can walk you through the process of trying to get them a very rational kind of disposition. And once again, let's say that the child, maybe they don't need to be in the emergency department.

Maybe this is something that the phrase we often use is home observation is appropriate, but the parent is concerned and they need reassurance. You can provide them the case number that we gave you, and they are welcome to when they get back home, if they continue to have any questions or concerns, they can use that same case number. We'll be able to see the chart in the emergency room communication and can kind of provide that sort of continuity of care.

And so it's confidential, but not necessarily anonymous. Exactly. Yeah. Confidential, but not anonymous. This really is similar to any other medical charting software. We have the same precautions and the same training in how we're handling protected health information, and we do take it seriously. Robert, you work closely with our emergency clinicians, and I can only imagine what it's like when you're working a A 10-hour shift and you're getting call after call of people who are panicked,

probably. How do you do that? What is your strategy? I'm not rushing things along. There's no metrics. I am going to handle the call start to finish. I will say that I think we are very similar to pediatrics in that sense, and that a large part of our job is reassurance, and it is taking care of, you know, the child is our patient, but just as much to some degree, so is the parent. And we are once again trying to offer them up reassurance.

There's a lot of strategies and things I've learned over the years as to how I approach that. I think some things parents appreciate hearing is that this is, you know, to them, this is a very unique situation. Most parents will comment that they, you know, oh, this is my first time calling, or I've only had to call once before for my other kid. But for us, you know, we typically end a shift with anywhere between 30 and 40 calls. And so this is just business as usual.

So often I will try and reassure parents by explaining, oh, no, this happens all the time. You know, kid gets into a Zyrtec. Kids get into Zyrtec all the time. Kid got into melatonin. Well, ever since they made it a gummy, kids love to get into it. Oh, my kid got into my medicine cabinet and he ate the whole bottle of Tums. Well, no, that's not your fault ever since they made it into a smooth berry flavor instead of tasting like chalk.

Yeah, if kids get into one, they never get into one. They get into 30. And our listeners know very well, we're going through an epidemic right now of depression, anxiety, and adolescent self-harm. So.

Let's start off with that, with these toxicology pearls. What is your advice there when it comes to things that kids could easily find around the house, such as Tylenol, Advil? Exactly. So I think that really sets the stage for, we're kind of very unique in that regard. You know, most people will see, or excuse me, most physicians will get into a specialty and they will see just a very wide range of demographics. Obviously, in pediatricians, the demographic is the specialty.

And we're kind of like that, too. So there's kind of a there's an interesting sort of U-shaped curve where a very substantial amount of our call volume are what we call pediatric exploratory ingestion. So these are your children that are age zero through six that are crawling around, getting into stuff. And the median age is overwhelmingly two. The moment they start moving around, they are going to find things. And, you know, kids explore the world with their mouth.

So if they find something, they will get into it. So it might sound a little bit trite, but probably the number one advice for this age range is just basic practices of keeping stuff up high, keeping stuff locked up. Be cautious about storing chemicals and things of that nature under the cabinet. Be cognizant of the fact that when your relatives visit, they might bring pill minders. So even if you're very careful, you know, they may not be. Especially grandparents.

Grandparents in particular. And partly the issue is that for thinking about like a geriatric population, what medications are they on? They're frequently on anti-diabetic medications, blood pressure medicines, painkillers. And these are unfortunately a lot of the medications that do often send children to the emergency room. In contrast, if a child gets into a cholesterol drug, that usually we can keep something like that at home.

When I have three kids, when they were younger, we had this rule that I would stress with them. If they find something that looks like a candy, piece of candy on the floor to come show it to me or wherever they find it, the couch or whatever. And if it is a candy that they could eat, they could eat it. But if no matter what, if it's a medication, then I will give them a piece of candy.

And even just at a very young age, that did happen where there was a grandparent visiting and red pill had fallen out of the grandpa's pocket. And when one of the kids came up and showed it to me and I was so glad. So I don't know, does that sound like an OK strategy or? Well, you definitely hit on this is a fundamental just double edged sword with pediatrics. How do you convince kids to take medicine?

And, you know, we take steps both both at the personal level as parents, but also on sort of a commercial level, you know, kind of going back to what I previously mentioned, you know, we make these things taste good. We make them look like candy to sort of coax kids into being more amenable to taking them. But that comes with the consequence that at that age, they cannot tell the difference between candy and pills. And so that can sort of complicate the issue.

So what we typically recommend is, yeah, there's some specific context in which you have to use it. So it doesn't fit every single permutation of a toxic ingestion. But for most people with an acute acetaminophen ingestion within the past 24 hours that present to the emergency room, we can do a pretty good job of assessing if they need or do not need the antidote. So the antidote is in acetylcysteine. If the child is having anxiety, depression, there's a risk of self-harm.

Keep all medications locked up. Another thing that you encounter is something that happens because so many medications, as we know today, have so many different ingredients in them. Yeah, I will say that kind of gets to another core problem, kind of talking about acetaminophen in general. This is a very common situation I'll get. The parents bring their child into the emergency room and say, oh, they overdosed on ibuprofen.

So we might be having a conversation with the physician on, oh, here's what to expect with that. Generally, I don't want to say well-tolerated, but let's just say it takes a substantially greater amount of ibuprofen to cause true toxicity relative to acetaminophen. And so I'll walk them through the process of getting the labs and watching them for a couple hours. And then the labs come back and they have a positive Tylenol level.

And so, well, what's that happening? And then we go back and talk to the parent and we say, wait, so did they overdose on ibuprofen or did they overdose on Tylenol? And we'll get that, well, aren't they the same thing? And it's one of those things you kind of take for granted is when you're a healthcare worker, you recognize that aspirin and ibuprofen, naproxen and acetaminophen, these are all three distinct drugs. But for parents often it's just, well, that's the over-the-counter painkiller

we have at home. They're all the same. So that happens a lot. One thing I'll also mention is there's this phenomena called the acetaminophen occult ingestion. And here's how this generally plays out is where the child is trying to hurt themselves, so they overdose on the Tylenol at home. It doesn't do anything. So they conclude that, oh, it didn't work. So now they overdose on, let's say, their prescription medicine. So just to grab an example, let's say it's their eschatolopram, so Lexapro.

So the parents recognize that that's a problem. So they take them to the emergency room and, you know, we're working them up for the Lexapro overdose and we get that Tylenol level or we see their, or more realistically, if it's been greater than 24 hours, you might have a situation where the Tylenol level is undetectable. But now their liver enzymes are rising and we're trying to figure out what's going on. And then they finally disclose that they actually had overdosed on acetaminophen earlier.

So we actually have pretty good data on this about somewhere in the ballpark of 3% to 5% of patients who present to the emergency room with a chief complaint of a toxic ingestion that is not acetaminophen will ultimately end up having a positive acetaminophen level.

So if you're curious, this is why we are so adamant that if a psychiatric patient shows up to the emergency department with a toxic ingestion, we're going to recommend a Tylenol level just because it's easy to check and it can spare a ton of misery over the next 72 hours as opposed to if we miss it.

And there are a lot of marijuana products out there that look like candy and probably taste really good. Let's talk about THC. Let's talk about THC. So THC is a very interesting substance. Obviously, it's been around pretty much forever. But over the past 10 to 15 years, it really has just exploded in popularity. And a particular inflection point happened in 2018. This was when the federal farm bill passed.

So this is kind of a piece of omnibus legislation. It's just one of those things that every Congress has to pass to, you know, mostly what it's doing is keeping like farm subsidies going. However, in this particular 2018 version of the bill, it had an exception in which products that had less than 0.3% of THC and were hemp-derived were kind of legally allowed federally.

And so it's an interesting kind of gray zone where technically marijuana is still schedule one, but this particular product, let me rephrase that, these products that were derived from that hemp at that certain percentage were legally allowed. This was really the catalyst that caused this explosion of why there's a vape shop on every corner, basically. I'm sure anyone who's driving around Texas has observed this phenomena.

The problem is that these products, they're generally intended for what we would call like the experienced marijuana user. You know, these are people who know what dose gets them their desired effect. And most people would traditionally be smoking marijuana, which kind of is self-titrating, right? They smoke to a desired effect and then they stop smoking. However, for most users that do not want to smoke, they have turned to edibles.

And edibles present a pretty unique risk profile for children for multiple reasons. You know, one is kind of what we already talked about. These products are intended, and this is not an accident, like they look like candy. And more concerning is that they're explicitly marketed as candy in some context. They may obviously have warning signs and symbols all over them. What does that mean if you're a two-year-old, of course, right?

So parents may be able to read that and understand some precautions. But if kids find them and they look like candy, they will eat them. The main problem with edibles, of course, is that there's two issues. One is kind of a pharmacokinetic issue, right? Once again, you smoke, you get a desired effect, you stop. With edibles, you may not see the inebriation for two or three hours.

And so this applies to both adults that are trying it for the first time, but also for our kids that are just accidentally getting into it. They may eat one, they may eat two, they may eat ten. Thank you. And eventually, they're going to get that entire dose. It may be in a delayed fashion, but it may be a substantially greater dose than what they can tolerate. Obviously, in a two-year-old, any dose is going to be intolerable.

But even, quote-unquote, experienced users may be taken for a surprise. And so this is why you're seeing this kind of substantial explosion of this sort of alphabet soup of THC products. Most people are familiar with THC, but unless you work in toxicology and you see these ingestions or you're a user, then you may not recognize Delta-8, Delta-9, Delta-10, THCA, THCP, et cetera, et cetera.

And while there are some potency differences, and I don't want to say there's absolutely no qualitative difference between them, that that's not entirely correct, at the end of the day, from a pediatric perspective, all of them can be potentially inebriating for a child. And marijuana products, marijuana itself is much stronger today.

Yeah, that's correct. You know, generally the people who were making marijuana, but, you know, growing the plants, cultivating it, selling it, the stuff that would kind of come in from overseas, it was relatively weak in a modern sense. You know, your kind of person who's at Woodstock and smoking a blunt, that may have been like 5% THC back in the day. These days, this really is like an enthusiast industry. These people are obsessed with getting these concentrations as high as possible.

They're looking for a certain experience. And so these products, not only is this concerning for just the pediatric exposure, but I even run into this with adults too. A 50-year-old who has never tried marijuana before, or maybe they tried it as a teenager, might go to the gas station and see one of these products. Yeah. So they may find one of these products and try it for the first time.

And, you know, spoiler alert, a 30 milligram dose is not a really smart idea for someone who is completely naive to these products. So even adults can be really surprised at the magnitude of inebriation they can end up experiencing.

And it can't be good for the brain. Yeah, that's another concern, too, is there's obviously a very large debate about this, and I won't pretend that it is necessarily settled science, but epidemiologically, it's becoming pretty clear that these adolescents who, the earlier they start smoking, and obviously there's a cumulative dose effect, that it does seem to be linked to psychosis, psychosis, especially if there's any kind of either direct history or family history of

psychiatric illness, it does seem to just substantially increase their risk that as they move on to young adulthood and as an adult, there'll be higher risk for things like schizophrenia, anxiety, depression, etc. And so many medications and come in gummies, gummy form now. I remember even like prenatal vitamins in gummy form. Like if my toddler at the time got into that, that could be disastrous. But when it comes to a THC gummy, I just can't even imagine.

What do you do if a child ingests a gummy or gummies? Exactly. And this is what kind of gets to the heart of the matter. Someone might kind of naively, because in adults, it really isn't a big deal. most of the time. And I'm trying, I don't intend to be tried or anything like that. But as long as there's no fall risk or risk of secondary accident, most adults are not going to seize or have airway issues or a cardiac dysrhythmia.

It's just not going to happen at any reasonable dose in an adult as far as we can tell. But this kind of gets into a classic problem of just, you know, children are not small adults. Their CB1 receptors are fundamentally different and they do seem more sensitive to it. So, you know, don't get me wrong, your kid who gets into a single edible most likely will be okay with just clinical observation. They probably won't need substantial interventions or anything of that nature.

However, these kids who, you know, get the 400 milligram thing that looks like a nerd rope and down the whole thing, we actually do see children who have airway issues, dysrhythmias, seizures. So they are just categorically different. And once again, And because these are edible products, they can have substantially longer half-lives than the pyrolyzed marijuana products. And so these children may have a length of stay of sometimes as long as three days.

And then is there anything you want to say about the process of helping the child to survive? But we very rarely will go to stomach pumping just because by the time the child's presenting to the ER, most likely that that risk is passed.

And, you know, with a child who's coming in and already kind of attended and at risk for a seizure, we would be really concerned about being really aggressive with gastric lavage just because unless the airway is protected, you really are introducing an aspiration risk. So the care is symptomatic and supportive at the end of the day.

I will say from a disposition perspective, what we've kind of observed is generally, assuming the child is ambulatory to begin with, ambulatory status is kind of the first thing to go and the last thing to come back. So that can be kind of valuable to a clinician who's assessing, you know, is this child sick and when is this child ready to go home? Anything else, Robert, you want to say about THC and the products out there for the pediatrician or the parent?

So it was kind of interesting. There was a toxicology conference where we actually did have one of the, and I apologize, I don't remember his name, but one of the big wigs of kind of the, let's call it the Colorado cannabis industry came and kind of talked to us.

It was interesting to see because people were really just kind of grilling this guy with questions, but he made a comment that, look, you know, if you are using these products at home, you absolutely should have a lockbox, and they should be in that lockbox, no exceptions. And, you know, you can definitely kind of push back and say that, no, you know, you as an industry have some responsibility for this, and you really should be changing the packaging.

I think you kind of have to accept the reality that unless there's legislation forcing them to do this, they're probably not going to voluntarily do anything to kind of stop this situation. So while I kind of understand why people were very critical of him. Ultimately, he's not wrong. I actually do agree with that. If you are using these products, you absolutely need to have a lockbox.

Okay. And that's great advice. And then I know we're going to talk in a minute about Zen pouches, which I didn't even know what that was until over spring break when my son told me a relative we were with was taking them on the ski slopes. Zen pouches, so that's, it has a delayed response. Can you tell us about this? Yeah, so Zen pouches are becoming very popular, and they also have kind of introduced a unique concern for pediatrics.

So most of your typical nicotine products, well, one, you have to kind of differentiate, you know, is this a tobacco product or is this a straight nicotine product. And in both of these situations, traditionally, they've kind of been self-limiting. Like, it doesn't take that much nicotine for a child to develop nicotine toxicity. What are Zen pouches? Is it nicotine? So there's no tobacco in a Zen pouch. It's nicotine only? Yeah, exactly.

Correct, yeah. So your typical nicotine products are kind of divided into the kind of what we would call straight nicotine products. So these are things like a lot of smoking cessation aids, right? So you go and buy the nicotine gum, the nicotine lozenge, and then you have all your tobacco products, of course. Snuff, dip, cigarettes, of course. The other major nicotine player these days, of course, are the vaping products.

Both the kind of refillable ones with nicotine solution, but also what's kind of becoming the predominant one there are the disposable vapes you can buy at the gas stations and things of that nature. What makes Zinn unique is that this is a pouch that you kind of insert into your mouth and kind of just keep there either under the tongue or kind of bucally in general, and it will absorb the nicotine. And these are unique because this is not a tobacco product. This is straight nicotine.

And so this has kind of introduced a risk for children for a very specific reason, and that has to do with the kind of delayed absorption aspect of it. So kids frequently get into nicotine, and while it's very dangerous, you know, it only takes about 20 milligrams, and children really can have like full-blown nicotine toxicity, with fasciculations and airway problems because their accessory muscles are getting weak.

Yeah. So essentially what I'm concerned about is, you know, children having tremors. Nicotine is kind of what we would call biphasic in the sense that it starts kind of stimulatory, but then their muscles essentially just fire to a point where they get very rapidly fatigued after that sort of stimulant period. And that's when they start turning in. So what I would generally tell a parent is what I'm mostly concerned about sort of a floppy baby kind of situation, this hypotonia.

So how much, again, can you stress like in a Zen pouch if a child ingests can be dangerous? Yeah. So what makes Zen, yeah, basically any amount. And the reason for that is you might look at the Zen pouch and not think much of it because it's quote unquote only three to six milligrams of nicotine. Whereas in contrast, a cigarette can have quite a bit more than that. But you start getting into finer details of pharmacokinetics. So if a child ingests a cigarette, it's kind of gross.

But at the same time, like when you think about how much nicotine in that tobacco is bioavailable, kids ultimately only end up getting a couple of milligrams. And usually it'll be what we consider sort of self-limited. So the child will pretty much guarantee to get some an emetic effect from it. And they'll generally kind of puke it up before it's a problem.

So one of those exposures that in theory is very serious, but it's actually pretty infrequent that we have to send them into the emergency room. The Zen pouch becomes really problematic because it's sort of bypassing that issue, right? So because it's nicotine in this pouch and the child swallows it, what they've done is they've essentially swallowed an extended release nicotine product. So it's going to get past the stomach, it's going to go into their bowels, and there it's going to absorb.

So yes, it's quote-unquote only three to six milligrams, but the child is often getting the full burden of that nicotine dose, whereas more pragmatically in other contexts, they might have a much more limited exposure. And the emetic effect might not be as pronounced, so their ability to quote-unquote self-decontaminate is limited as well. And the parents may not even, what I've had very frequently happening is the kids like digging into the trash or finding these used Zen pouches, excuse me.

And what's concerning is you might think, well, they're used up, but you're not absorbing every bit of the nicotine. So even the used pouches still have some nicotine content. What's the appeal with the Zen pouches? I think, so I'm not personally a user, so I won't try and give like a subjective answer. Yes, I would have been very worried if you said you were Zen pouches. My understanding is just that, well, one, they're frequently flavored. So people tend to like that.

And I think also just like, once again, they are straight nicotine. So if you think of all the, a lot of the cancer risk and things like that stem primarily from the tobacco product. So let's say like if you're using snuff, you know, there is a risk of oral cancer that's pretty uncontroversial. Not to say that we don't have a ton of evidence that these Zen pouches are safe necessarily, but they're not tobacco. So a lot of your more traditional risk

factors in theory may be lower. So I think that's part of the popularity. I also think it's a little bit of like a Kardashian effect. like they're popular because they are popular. But nicotine can't be good for us, right? Yeah. I mean, often people will say, well, nicotine itself is harmless, but go ask any vascular surgeon and they will disagree with you.

That said, you know, it's kind of a risk like we talked a lot about marijuana and, you know, that obviously always triggers a very large debate of marijuana versus alcohol. And it's kind of like at the end of the day, yeah, some of this societal burden of these substances are pretty gargantuan. But when you get into the specifics of like which one is worse and which one is better, you know, it's all going to be very context dependent.

And again, it's something that's flavored, so it could be really attractive to a child who finds it. Exactly.

And dangerous. Kratom. Kratom. What is kratom and what's the concern there? So kratom is kind of an interesting substance. This is a plant that's had a very interesting history in the past 20 years. So this is a plant from Southeast Asia. And originally, so it's a very interesting pharmacologically, this is an atypical opioid, which you just don't run into that much. There's a few synthetic ones like tramadol, but as far as naturally occurring ones, there really aren't too many.

So this is kind of a unique drug in that context. And Kratom has had very much a transition period where originally Kratom was being used primarily by adults who were suffering from opioid addiction. And this was essentially their way of trying to do medication-assisted therapy or what we would call MOUD these days. You know, trying to stave off that Kratom withdrawal while they try and get off their fentanyl or their prescription opioids.

That has kind of transitioned into several interesting phenomena. One is that, yes, I don't want to say it's effective because we don't have any RCTs, obviously, randomized controlled trials. So no one is really doing any kind of evidence-based assessment of this as an opioid alternative. Mm-hmm. That being said, you know, just talking to patients and looking at kind of forums where people discuss using Kratom, it's very clear that Kratom itself has some addictive properties.

And so, you know, kind of the traditional accusation against MAT or medication-assisted therapy, excuse me, is, well, isn't the patient just replacing one addiction with the other? And that kind of happens with Kratom too. You know, this is not really physician-supervised in most contexts, and so that's kind of been a problem. But what's really happened is Kratom has kind of also emerged in this sort of gray, you know, legal but not legal kind of drug scene.

And so it's kind of transitioned to if you were an opioid user and you learned about Kratom, it was a very kind of under the table thing. You learned about it. You knew to ask for it. It was kind of a behind the counter thing. And that's really changed in the very recent history where now like everyone's familiar with this and it's kind of becoming more just like a general recreational drug and that's concerning for multiple reasons.

One is it is an opioid but it's an atypical opioid and as far as we can tell it's a bit controversial if this drug causes seizures or if it's kind of simply lowering the seizure threshold and so other risk factors are necessary for that to manifest. But regardless, you do have patients showing up to the emergency room with seizures.

Obviously, the reason I'm bringing this up is, you know, from a pediatric toxicology perspective, we now have the phenomenon of parents have this product in their home and their kids are getting into it because they can't tell the difference. Of course, once again, they typically don't look explicitly like candy, but they are in sort of an edible. They often don't look like pills either. So that can be a problem as far as pediatric exposure.

And when they come in, they actually, they can have seizures and we also, you know, it can also function like a more classic opioid in kind of children. And so we do see some respiratory depression as well. There's also been a very increasing incidence of adolescents that are using it. You know, this is sort of a, this is very popular right now on social media and Instagram. So, same basic principle. If you have a teenager, they may be very tempted to kind of start this stuff.

And once again, you know, there's really no doubt here that there are addictive qualities to it. And so, you know, if you have a child who's using it, it is something to seek medical advice about. And can you tell us about the harm it could be causing you? So as far as longitudinal risk, I think that is still to be determined at this time.

Acutely, it does go back to just that very basic pharmacology, just atypical opioid with a risk of seizures and with a risk of airway depression if they use too much of it.

Well, Robert, this is all so insightful. I really appreciate you being here in the podcast studio and talking about what you see on a day in, day out basis. Right now, the 1-800 number for the Poison Center, it might be moved to a three number like 911, but that hasn't happened yet. Exactly. So as of right now, the phone number is 1-800-222-1222. We would love to transition to a sort of three-digit number, so to speak, but there's some logistical issues, and you do have to have some

legislative involvement for that to happen. And so it's something we're working on. But unfortunately, I don't have a time frame at the moment. And Robert, I know you said that you're working on studying for your board exams. So there's not a lot of things you're doing outside of the world of medicine. But you have a favorite quote. So my favorite quote is by H.L. Mencken. And this is me paraphrasing it. Originally, it has a slightly different connotation.

But essentially, it's this idea that, you know, for every complex problem in the world, there's always a solution that's simple, elegant, and wrong. And I think that a lot about, that quote comes to mind a lot when we talk about medicine. Robert Miller with the Department of Emergency Medicine and the South Texas Poison Center in UT Health San Antonio. Thank you so much for being here today on Pediatrics Now. Been really insightful.

Yeah, thank you so much. Pediatrics Now is brought to you by the Department of Pediatrics at UT Health San Antonio and University Health's new Women's and Children's Hospital. Don't forget to click on the link in this podcast for free credit. I'm Holly Wayment. I'll see you next week. And so one thing I really want to stress is, you know, when you call a poison sinner, you talk to a human being. You know, there's no robots. There's no artificial intelligence.

There's no complicated phone tree standing between you and answer. You really just talk to another person.