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Interview with Dr. Lewis Goldfrank
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Interview with Dr. Lewis Goldfrank
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Language: EN.
Segment:0 .
Segment:1 The Evolution of Toxicologic Emergencies and Poison Control Centers.
I'm Lewis Goldfrank. I'm the professor of emergency medicine at New York University in Bellevue Hospital and the medical director of the New York City Poison Center. I've been at Bellevue for 40 years. Prior to that I worked in the South Bronx and in the North Bronx, that's where I learned my emergency medicine. And I learned that toxicology was consequential every single day that I worked.
And so that it's become a passion and a cause and a core value for preventing the next person from having the same type of poisoning or the same type of emergency event. So emergency medicine and medical toxicology are all about prevention, that every patient we see is a demonstration of failure in the public health system. Everything we put in our textbook, in our daily work is really to try to help people understand that so they can become activists to prevent things from happening and be public health advocates.
When I first started to work in the South Bronx, so that's-- I was a resident at Montefiore hospital. I saw patients dying of heroin overdoses. And I saw people getting hit by cars and falling out of windows, or having too much lead poisoning. It became obvious that there were things I hadn't really thought about in any textbooks I'd read in life. And heroin for example, was a terrible problem because we didn't have antidotes that were appropriate in those days.
We had something called nalorphine or levallorphan. Those were antidotes that really were mixed agonist antagonist. So that if you gave that to someone who had just taken a lot of a sedative hypnotic as opposed to an opioid, you might do more harm to them. And so that was, we were in the midst of a revolution that brought naloxone out of the laboratory and out of the pharmaceutical industry to the bedside.
And we became among the first to ever touch naloxone and used it. And that's sort of the end of the story, let's say, of our textbook today and the substantial evolution in its use. Not only is a lifesaving gesture after an overdose, but as a lifesaving gesture, as a preventive therapeutics for someone who has a high risk for an opioid overdose and naloxone was given to the family. Now it's given to the patient to take home.
It's given to the community, it's given to the fire and police, because we think that if you save someone's life today, maybe you have another chance to get that person to stop using opioids or to get onto a treatment therapy. So it's a big part of... It became very obvious to me. The first day I walked into the South Bronx and started to work. On the other hand, poisoning was very limited amount than what was taught in those days in medical school or in your clinical experience.
This was our first edition. This is the one wrote in the South Bronx and it was my job as a young faculty member in the South Bronx to teach every month and to find a topic to teach about. So I chose a toxin each month and I then met a guy named Peter Fritschoff who was the editor at that point of Hospital Physician. So he liked what we were talking about and he took one article a month.
And so ultimately, each of those teaching sessions, I tried to develop each month to do something for the residents and the training in the South Bronx with Montefiore and Morrisania, the public hospital. I created a document and for a while they were shared by Robert Kerstein who was there with me as the first-- Another one of the young attendings in the emergency department. And we created something, a topic, it would be a topic about heroin. It'd be a topic about a mixed overdose, it would be about lead poisoning, it could be about a host of things.
Whatever we saw we were going to write a chapter. And ultimately, initially it was just for these lectures then it was for publication. Then the guy who helped at Hospital Physician said, "Well, this should be published in a book." So this became the first book. These were the first 20 chapters, the first 20 talks that I gave about toxicology. And I carried that on for about a decade, writing one of those chapters or one of those speeches every month on a different toxin.
And ultimately, at that point we had enough core issues to see what a textbook would become. And it went from this version of a hundred some pages to a version that's 2000 pages. And it went from two people writing it to 200 people writing it. And then the task became using the best people handling a particular toxin in the world.
Someone who is excited about something-- strychnine who might see it more in China, or someone who really works on pesticides in Sri Lanka, putting together their information and us working together currently as a team of six leaders of the book. Six editors putting together in a meaningful fashion from the beginning to the end. And so that the values that we teach and the basic principles of the beginning of the book, the aspects of managing patients and then the chemical principles, all of the scientific principles, associated, all the special components of our body were carried throughout the entirety of the text.
So that everything we said in the chapter that talked about cardiovascular effects of a particular toxin would be found in the chapter on cocaine or the chapter on the beta-adrenergic antagonists or the calcium channel blockers or whatever you'd have. And we would say not only the pharmacology and the physiology was replicated and integrated, but also the treatments and the adverse effects in these things. And then over the years, one of the editors who joined to work with us right in the very beginning, my arrival here 40 years ago was a clinical pharmacist.
And this woman, Mary Ann Howland, took on the role of looking at every antidote that exists. And we linked the antidotes to the chapters and we linked the antidotes to particular toxins. We linked the understanding of the antidotes to the things we talked about in the basic pharmacology or looking at each of the organ systems and how it affected each organ system. So, this integration of the concepts, it's something that she's carried through for the entirety of her career on this devoted to clinical pharmacists through teachers at Saint John's and at the New York City Poison Center and at NYU and Bellevue hospital.
Many people have just stayed with the task, with great devotion for their careers, have made their careers in terms of really this understanding of what toxicology is. Because when we started, there really were no texts about toxicology. People didn't think that this was such an important topic. If you were to ask them, well, do we really have poisonings? People would say whether it was here or whether in Africa working or whether in China they would-- someone might say, "No, we don't have any poisonings." And then you'd walk around the emergency department and I would see them everywhere.
So we really knew that, poisonings is looked just like, you know, someone who has a toxin-- hepatotoxin, might look just like someone who was viral hepatitis. So people didn't really search for these things, didn't understand them well enough, there wasn't enough science behind it. So our job was to look at the big picture and the biggest picture in those days is based upon individual cases or when I came here and after the development of emergency medicine, we really worked through actually grants from the Nixon administration called 12-0-3 grants.
That really began the development of things like how does a poison center work? How does a trauma center work? How does a neonatal transfer system work? How do you handle burns? Things of this nature. So setting up systems. And so the system we had to set up was to set up a poison center. The poison center went from being a place what they called Sanitarians, receiving the calls, and Sanitarians were good for the clean water and the clean food, but they weren't necessarily good to talk about drugs.
And there wasn't really a system for them to have enough information and they weren't going to be the right people. So over time what happened is in poison services developed an understanding that you either needed nurses or pharmacists or maybe even doctors sometimes. And we often have doctors, let's say, who don't-- who come from another country don't have a license, who've worked in poison centers-- Basically it's nurses and pharmacists. And they became a well trained group that ultimately had to have achieve a level of excellence in understanding all the toxicologic information to be able to be on the phone and to work together.
And we created a system where you have the clinical pharmacists who are the information specialists. Then you have the residents or fellows in medical toxicology, and then you have the faculty and then you have the specialists in various areas who would help in handling these poison cases. And New York state has a law-- New York City has a law that says, "Every time a poisoning occurs, you see it in your emergency department or your hospital, you're supposed to report it to the New York City Poison Center." Now people aren't very faithful about that.
The reason that law was so important is that if you really had every single poisoning reported and you could then really document that what they said they were supposedly taking, they actually took and you could prove that really got into their body. That's the science of it. We really have a tremendous understanding of what really happens when people take products. We've never achieved that level of excellence because people don't report and we don't really know when a child is exposed.
It means that well, the container was there and it was open and it smells like something's there, but we don't know if it got into the mouth and it got absorbed and change the way the body functions. So, we lack a lot of that information. And so we don't do experiments on human beings because it would be unethical. So we don't have a lot of certitude in many areas, but we use the case examples to help us really understand the problem for people who clearly said they took something and they have all of this toxicity and we compare it to what we'd expect, and we begin to think that that represents a good part of what it is.
But we don't have big studies, but we do have a lot of personal experiences and a lot of information. That's what poison centers have really brought to the country. When I started in America, there were probably 600 plus poison centers. Today they're in the forties in number. There are high standards established by regulating groups of people who do toxicology.
And that really allows us to recognize what went wrong with each product that someone takes. Was it not packaged well enough, was it blister packaged, was it baby-proof controlled? Was it an open container of sulfuric acid? What was it? Was it lamp oil, whatever the process was, how did it get there? How did the child get in contact? Had we not done enough to protect people from it?
And so, the changes that went on over the years have really been the belief that I mentioned earlier that everything can be prevented, would be the philosophy. That's idealistic, but that's the way you operate, that everybody you see who has a poisoning is a failure in the public health system. The goal would really be to prevent that. These are the kinds of things that we teach extensively in our book. The whole discussion about the poison prevention, looking honestly at the data, looking at how prevention's developed, looking at the evolution of the process.
So really, it's what the Consumer Product Safety Commission and what's the Food and Drug Administration did, those are heroic bodies in America. The fact that they're being destroyed by a lot of political action is devastating for the things we do because it's just going to lead to more patients having more risks and products being available that shouldn't be available. We believe in the heroes of those organizations because they make our job easier.
We believe that you have to use technologic interventions to protect people, because we think education is great, but it probably doesn't save as many lives as we'd like. When we put those baby-- when people put those baby-proof capping on, or when people put blister packages, it made it tougher for a young child to get into it. It still may slow down someone who wants to overdose, but it's not going to have a big impact on someone who does it intentionally. Children do it unintentionally.
It may be that the parent did something that could have been prevented, but you really want to try to prevent the contact of someone's body from something out there that could be dangerous. And we've really worked hard on that and everybody's devoted to that process. That's the kind of work that really comes out of poison prevention and emergency medicine.
Segment:2 Current Treatment of Opioid Overdoses.
If you look at the textbook and say, "What do we do differently this time than in the past?" There'd be a couple of things.
Let's say people have said that there's limited time after the ingestion where you use activated charcoal. Activated charcoal was a great, preventive agent. Someone takes a bad toxin, you put activated charcoal, you can prevent absorption and you can prevent by absorption of the activate charcoal. And it may be good not only in the initial phase, but maybe in recirculation when the molecule, the toxin is metabolized and it comes back in the gut activated charcoal may block it.
So, over the years, there were a number of papers that suggested that if you got to the patient after an hour of ingestion, that it wasn't appropriate to give an antidote such as activated charcoal. We've always thought that was silly because the person who takes a massive amount of pills, doesn't have the same surface area to get all those pills in. If you put one acetaminophen tablet in, that's one thing.
But if you put a hundred in there, they're really not going to be finished. There's still gonna be lots of pills in the stomach at several hours. And if you take some of the newer matrix-based extended release products, they're going to be a big mass. Sometimes they're going to be adherent, sometimes the gel and the matrix bonds them together. Sometimes it's a mix overdose of a lot of pills. So we've always thought that there was lots in the-- still in the stomach, in the intestine that activated charcoal could help.
We've really enriched the discussion of this decontamination of the gastrointestinal tract. When we looked at the science associated with that, and so the authors of that chapter have worked extensively to demonstrate that it's certainly appropriate when you think someone has a consequential ingestion to use activated charcoal, and then may even be necessary in something like that, even hours after the initial ingestion.
And when you take someone who's got a very high concentration in the body already, you may transform what is a very consequential ingestion into a less consequential ingestion because you aren't going to absorb some of these things. And not let it get into the body, you're going to-- Sorry, when you will adsorb you'll block it, you'll pull-- the activated charcoal will bind to that molecule, you'll prevent absorption.
And what you really allow is the patient to have a nontoxic ingestion. And so we think that that kind of thought was a big deal. And we've really-- Because so many people, when you ask them, they'd say well, they're taught that in other books in toxicology or in general emergency medicine or someplace in pediatrics, that you don't have to do anything to a person after one hour. So we spent a great deal-- a number of pages really trying to clarify that because that's often a hallmark of great success in medical toxicology.
And so although it's simple, it's not a complex molecular issue, it's a simple preventive gesture while you still have a chance. And so I think we wanted to give people more optimism about that. We can never be sure, but we know it's a pretty safe approach to give someone a cup full of activated charcoal. And we know what we can do and we believe strongly in it and others who've said it's less consequential I think are misleading the public. And so we spend a lot of time explaining that concept.
Another concept that I think is different this time it's a big deal, is that, as I said, we went from in this first edition from naloxone being good for an opioid overdose. And if someone had an opioid, it's a pure opioid antagonist. So if the person didn't take an opioid and you gave naloxone, nothing would happen to the person. To the current stage we've added what we call special considerations. Also we have special considerations, we have sections called antidotes.
So, in the antidote chapter, we talk about three types of opioid antagonists besides naloxone. We talk about naltrexone, we talk about buprenorphine and we talk about methadone. Those we think are medication assisted therapies that become our responsibility as toxicologists and emergency physicians and probably the general public as well in terms of medical personnel that we've got.
Every time we have someone who's a risk for an overdose, because he or she has tried to abuse opioids or uses opioids indiscriminately, and that person's a very high risk of killing oneself either intentionally or unintentionally. One of the chapters is written by one of the experts of when people are patients who are released, or prisoners are released. If they'd been on opioids before they got into prison when they're released, they're going to go out and they're going to take some more opioid, they often going to die.
So really pushing this medication assisted therapy when people are released from prison, when people come to an emergency department and overdosed, we want to get people on a strategy if they have substantial dependence and substantial risk of killing themselves. We really have moved as part of everyone in the entire country and a good part of the world, moved rapidly to say we have to get people on therapy. We have to take advantage of the day they're in the emergency department to try to get them into something either shortly thereafter or immediately to get them onto therapy.
And that's what methadone offers us. That's what buprenorphine offers us. And naltrexone is a special case, but would do some of the same things. So thinking about how to use those three molecules, naltrexone is a longer acting product methadone is a longer acting Brockton, Buprenorphine is longer acting, let's say than the drugs that people use to-- That are dependent on that drug, like oxycodone or something else of that nature, the opioids that they might take heroin or fentanyl.
So we know we can prevent the next overdose if we work carefully with the patient to do that. So, the other thing that we discuss at length in the chapters is that, in the opioid chapter or the opioid antidote chapter or this harm reduction chapter, the special consideration, is that you can really think carefully about people that if-- in the old days we thought that two milligrams of naloxone was a good drug to start in the field. That was true because we didn't have any pre-hospital care at that point.
We didn't have any paramedics. They often came to the emergency department not having had any antidote. They didn't have good control of the breathing capacity, they didn't have any control over protecting people from a host of things we consider the standard of care for pre-hospital care today, in the past it was pretty low level. We hadn't trained people that hadn't been done in the 19-- in the early 1970s. So we gave them a lot of naloxone because we wanted to be sure they could breathe because we didn't think the airway could be protected by the people who were running the ambulance.
Today we'd say we have such great confidence in the people who take care of patients in the field that we'd like them to use far less naloxone, because we don't want the person to go into withdrawal. We'd like the person-- I don't have to have the person think yet if the patient's taken a bad overdose. I'd like the person-- if the person's breathing slowly, I'd like them to breathe a little more rapidly.
I don't have to have them come back to normal because I'd like them to still be calm enough that when they get to the emergency department, they can talk with us. I'd like them still to be calm enough in the field so they don't walk away and sign out against medical advice because they're suffering because they're in withdrawal. So when I get them to the hospital, I want to have the services in the hospital.
I want to have the paramedics in the field and the people in the hospital, whoever sees them, to be totally committed to getting these people on therapy, this medication assisted therapy, either buprenorphine, naltrexone or methadone. And so it's a change in philosophy that we're all tied into it across I think a great part of America to say we've got to give people an opportunity to stop what they're doing. We've changed our approach, which we discussed at length in this book.
Changed our approach from the idea that you and I could talk about your dependency on heroin or oxycodone and figure that you can go to a treatment program and you could stop using it without having any support, any medication assisted therapy. And we stopped believing that entirely. Most of the time I'm fearful that -- anybody who's sick enough to come in with an overdose and is using a risk drug is a high risk for death and that person's not going to be stopped just by a pleasant discussion or a tough talk discussion or someone to tell you heal yourself or things like that.
It's not going to work. I expect those people to get in more trouble and the family does as well. So we push people and we try to get people involved. We want to make sure that everyone who goes through an emergency department has someone to talk to and we talk about that as part of the strategy. The other strategy we have is that when we send this person home and there's family there or friends we either give them a naloxone kit. So that they have that to assist their family members because if there's one person there who's with the other person who knows about opioid use, probably the other person has been using as well, someone's going to abuse it; they know-- Everybody says, "I've seen-- witnessed one of my friends die" or "I witnessed one of my friends overdose and almost die." So everyone could help.
Someone would say, "Well, you know, these people are just doing this to themselves. By the time you've been on an opioid for a few weeks or months, you're locked in, your neurochemistry has been changed. Your desire to get that drug later is going to be there and it can be very substantial. So we don't expect to solve this easily. So, it's really a change in the pattern of how we respond to it.
And so we'd want to send people home with that naloxone. We want to give people all sorts of advice and we want to go through the kind of education that has to be accomplished to stop this lethal epidemic. And we talk at length in our chapter really about these drugs and about the way people become dependent and what dependency means and how people behave. And so that's a big change in what we've discussed. We didn't have discussions like that in the past.
So what we've done really is the education about opioids, for students, for nurses, for doctors is totally different than it was in the past. We had for example, very few particularly potent opioids to treat people with. In the old days, we had-- in the 70s, we probably had codeine in the hospitals. We may have had something called meperidine.
We didn't have many things you could use. We had a couple of the agonist antagonist something called Talwin or pentazocine. We didn't have many drugs. They weren't potent. They weren't long acting. They weren't designed to keep people with a steady state of oxycodone in their body, which lead to dramatic dependency. It was-- became in vogue to say, we're going to treat the pain number and we're going to push opioids substantially to relieve pain.
For things that were acute, it might be reasonable, but for things that were subacute or chronic and no one ever had the evidence that that was the case. And a place like this, there was very little utilization of opioids for that reason. But other people were pushing it and the pharmaceutical industry was pushing it and it really changed the pattern and the type of people who are using opioids.
It was for us great education because in many ways, I would say, in the past, all the studies we did would show this was an issue of-- maybe it was a greater concern in the inner city. It was all the people would say, "Well I hear the people who are black or brown have all this." So by-- the response was that, in being very careful and probably those of us in the inner city, were very careful about opioids for whomever we saw. But what it taught us in the unintended consequence of let's say racial prejudice was that people who were treating the people who lived in Vermont and New Hampshire and West Virginia and wherever southern Indiana, were individuals who were basically white.
And those people are the ones who became in these epidemics, dramatic changes. A place like Staten Island had very few heroin users in the past was rampant with oxycodone users. So that's where the pharmaceutical industry went. That's where people felt this might get by, so this is-- It teaches us that any human being given drugs that we are currently available can become tolerant, dependent, and develop substance abuse that leads to catastrophic complications.
So lots of these things we tried to discuss and we look at as big issues, and how we retaught all the things we've tried to talk about opioids. We've tried to emphasize again with clarity, the risks and benefits of the various drugs.
Segment:3 The “Bible” of Toxicology.
The advantage we have is we have six very active toxicologists as editors. So they're being exposed to everything that happens in the world. And so these all are registered on either on their computers or on their pads or whatever to put all the things that we see that we haven't discussed.
All the things that looked like deficits in what we had before, all the things we would like to try to teach differently. Ones that we think people have a hard time understanding like the example of activated charcoal, really emphasizing things that people were having trouble with, it's putting all the evidence back together. This is not a blog, this is not sort of a few people talking about stuff off the top of their heads. It's someone who's an expert writes a chapter and that chapter is sent to this office and then that chapter is sent to all the editors to review.
They all go over it with a fine tooth comb, they send it back to me. There are a hundred corrections on every chapter. Those chapters are then-- We try to integrate all of those things and we're going to send it back to the individual with all the corrections we think that-- all the things, all the queries we have, and then that person's going to revise it and send it back and it's going to go out to six editors again and we're going to do the same thing again.
The chapter is going to be read by a number of people in our poison center effort and they're going to suggest some errors that they find in what's going on, the things that are missing. We're going to add new references, we're going to add new ideas, we're going to try to correct things so that every chapter gets revised. We do it every four years and the process probably starts before the book is actually published and it ends just before the book is going to be published here.
You have to have a good contact at McGraw-Hill to make sure that we can make the essential changes even until the last moment. So the book is up to date and reliable. And so people don't say that it's neglected something that's of consequence. It's as current as a book can be. But the difference is that, you know, if you think about the competition between a digest book and a blog, and a textbook would be that, you know-- We just read this article today about hydrocarbons.
And so when you read it, someone worked for several years on putting that article together. And then, they sent it to a journal and theoretically the journal does a good job, it reviews that article and then sends the comments back to the author and they rewrite it a little bit and then send it off. And then we-- when it comes out in publication, we review the article and we find a hundred errors in it.
And that was a good article, it got published, but then it shows it was probably bad review by the editor at the journal and things like that. And so that's an article that someone doing a blog might read one article like that and two or three other articles like that. We'd say that, well, the idea of making that article was probably pretty good, but the presentation was poor. So anything you learned from it either wasn't statistically valid, wasn't toxicologically valid or just wasn't a population that's relevant to what you're doing.
So we'd say that that's-- if you're going to be able to handle anybody in the world on the telephone as a toxicologist, any part of the world someone's going to call you. Every one of these big poison centers has a number of toxicologists. They're going to count on you to know everything. So you're going to have a resource where you can get to it. Now sure when-- you can search and you can pull it all together. And we try to make sure that everything that's relevant, every paper that's relevant has been reviewed by the author of that particular chapter and that we've reviewed them and they've been re-read and they're commented on.
So you build together a document that people can say, they've tried as hard as possible to get all the facts together and they've looked at them objectively- That they have certain biases. We state our biases. If someone tells me that, this product never causes hypoglycemia, it's an oral hypoglycemic agent. One pill doesn't cause-- ever cause hypoglycemia in children.
And we'd say, "Well, we've seen that several times." No one's ever going to do a randomized controlled trial. But I'm going to say we've definitively seen that in children. We're going to say that it is unsafe to send the child home who comes in and said, "I took it." We're going to say we have to watch that child. We're going to have some knowledge that we can't prove from a statistical point of view. But we have the evidence of a couple of cases that had been studied very carefully to say that it does happen.
So it's combining people with lots of experience and respect for various complex methodologic approaches that happen in science or in a statistical analysis. But we also have anecdotes that we think are very consequential that add to the process. So it's a combination of that because, the things that were going to describe at length in this textbook-- Let's say in the plant chapter, we're going to talk about the fact that this is a dangerous time of the year, the spring.
People like some of our-- some of us in the room are probably going out to search for ramps, ramps are delicious this time of year. There's sort of, some people call them the wild leaks and things like that, but every year we're going to have someone who goes to seek out ramps, which is a variant of a-- like a wild leak or like a wild onion, it's a little different to the delicacy and the open air markets. You can get them for $10 for a dozen.
So people go searching all over the place. So in the United States when they go at this time of year, and they're not good enough to differentiate what the leaf of the lily of the valley looks like, how similar the lily of the valley looks to the ramp. They may get the lily of the valley, but when they take the lily of the valley, they're going to-- If they've taken a lot, they might very well die of something like digitalis poisoning because that's convallatoxin.
In Europe where the same thing occurs, Switzerland and Spain where in the spring those ramps look just like the autumn crocus. And the autumn crocus is going to contain colchicine and when they take that they're going to die. These are things that one gets case reports and these complications about-- you want to know what the herbalist is using. You want to know what the botanist or the forger is using.
We have to know various things and try to describe those things about which of these herbal preparations are dangerous? Which of these plants are dangerous? Which are they confounded with? What do people bring in from across the world? We can talk about in convulsant drugs you might think about if a young child comes into our emergency department and his family only speaks Chinese, he's just come from China. We might think that that person's taken a rodenticide that they have in China that we don't allow in the United States called Tetramine.
That is a very dangerous cage convulsant. So, that's experience. That's epidemiology. That's the way you have to think about problems as a toxicologist because the problems are often uncommon, often very complicated and they are life and death situation. So you need people with experience and we try to give people a lot of information. They can get it probably in lots of places. But what we do, we think we do it in depth.
We do it in an integrated fashion. If you're looking something up, we have a great index that we're working very hard on, for us it's the core to be able to find things. So you may have the term, you may learn about it in the basic principles about neurologic complications of toxins. Or you may read it in a chapter that's about rodenticides or about something that-- you're going to get it from different angles, but it's going to say the same thing.
It's going to be integrated so that it's not too repetitive, but it's got strong enough structure in each of the various chapters were it the antidotes, where we intervene from this perspective.
Segment:4 The Life of a Toxicologist.
Being an emergency physician or toxicologist you have a tough job. But I think as someone who practices with a vision towards a better world, you can feel very optimistic by being a toxicologist because you can figure out what's wrong with the patient through basic use of your skills in history and physical and looking for very special characteristics of each person.
In addition, what you can do once you've found that toxin and understand it is intervene and prevention. You can really work-- If someone comes in and has used a lot of coal to give accent to face or one's working with pottery and that person presents with some findings of lead poisoning, you're going to intervene and say that shouldn't be sold or that's a risk. How do we intervene and help people?
How do we work on the that lead glaze that's dangerous? So our job is to work with the public health system, the city health department, the state health department the federal government, and to work together to solve problems that are really a threat to humanity. And you can have a feeling that you're a public health servant and you're really devoting yourself to the public. Working in a place like the New York City Poisin Center or the poison centers that everybody else in this book works on across the world is that it's the one space in our society where it's free.
You can call, anybody can call 2-1-2 POISONS or the long number, right? I happened to choose 2-1-2 POISONS only because, we wanted that number very much. We thought about it for a long time and people said, well, first they don't use letters anymore on a telephone number. The other hand so over a period of time, many years ago, all of us called 2-1-2 POISONS until-- you know, I think probably 35 years ago, 30 years ago, one day I called and the person picked up and said, this is a nonworking number at the Celanese Corporation and so-- I explained to the person that I wanted to use that number for the New York City Poison Center.
So, and I told them actually, it's ironic, the Celanese Corporation is actually where my father worked. And so I'd said, "We want that number." So I sent it to the president, my father gave me the information and we got the number. We had to negotiate with the city of New York to be able to-- It was copper wiring in those days, it was a big deal. How do you get permission of the city of New York to accept $5,000 that it cost to change the wire so we can take the number, but we got the number, we still use the number.
There's a number that's a national number, but that number, by chance it was a way to advertise and we now-- we have 2-1-2 VENEMOS also so we can do it in Spanish. But it was little things that tried to help people have an easier access to the poison center and which made a difference in their lives. And you can feel every day that you're seeing something, either an injury from an ingestion, you might see a burn - hydrofluoric acid, or you might see the sulfuric acid.
And you think, "How was that material available?" What was actually going on that allowed that child or that adult to get into that? How do you accomplish that education? So you change the standards for the city, how can you dispose of hydrofluoric acid. How can you dispose of sulfuric acid? What do you do? The idea of what you do with all of these things. Let we talk about these things. We talk about each of these things.
We want someone to look at a poisoning and say, "I have to analyze all the failed steps in what went on to allow that to get into that child's mouth." We have to think through these processes in a very systematic fashion. That's really was this revolutionary paper by the National Academy of Sciences in the 1960s that worked on injury in America and how that led to really enhancement of poison centers, enhancement of, let's say, the control of the energy in a car, and thinking about how you protect people in the car seat belts, airbags.
How do you do these structural things and make this big difference and how do we do that for poisoning? So that became our task and many people are involved. We have people at the Poisin Center and one of the chapters about how to reach out to the community? How to be an activist in the community? How do you work on the prevention? We have a chapter on discussing the laws that have ensued to protect people from a drug that's not well developed or that a product that's not well prepared, so that-- People who are toxicologists some are at the CDC, some are teaching in intensive care units across the country.
Some are running educational programs in pharmacy. Some are in general internal medicine and emergency medicine, pediatrics. It's essential part of education for everybody in medicine and in public health and public policy, it's pervasive. It's the fact that just because you only had a few parts of some organic phosphorous compound in the apple you ate, or the fruits you ate, or the vegetables, it's there. And the question is should it be there? What do we tolerate?
What's our responsibility to make the environment safe for everyone in society?
Segment:5 The Reasons Why This is Such a Great Book.
We believe we have a great book. We've worked very hard on it. We have a team of people who spend the vast majority of certainly the last year before it's published and probably the year before that. So almost two years out of every four that they spend lots of their living moments with this book. Not many people are willing to invest that much energy on writing a book and to try to drive for the rigor.
We work with probably 200 other authors to make the book work. So you've got to have a lot of friends. You got to have a lot of people to cooperate with. You got to have people who trust in us, to take the criticism we offer and to say they will deal with it and they do believe in it. They share a lot of the same things I've discussed. They believe that participating is very useful for society. I mean it doesn't have to be in a solid version. I'm a solid version type.
It could be online. You offer it online. People can use it any way, but I think it's-- There aren't any big books like this left anymore. People who were doing maybe we'll do them again, but many people, as I said earlier, were led to believe that maybe books weren't the solution. You could do it just as well by an online chat such as this. I don't think this gets enough detail and it gets enough depth. I think that people learn when they really want to understand something, they have to go back and see what people 50 years ago thought about this when they have lots of these cases and the progress they made.
And we try to discuss the progress in all these. We try to discuss what's happened. We're try to get people the historical perspective. We try to give people the kind of depth that makes them want to be experts and makes them correct the errors we've made and change the world in their own fashion. And it gives people ideas. If you just take the top of the cream of the idea-- You know, it's not hard to get confused because you don't know how you got there.
I think the objective is to learn how to learn to think about things that others couldn't think about and to solve problems that others wouldn't have even looked at or addressed. I think you're trying to create-- To solve these problems you need some revolutionaries, people who believe that the world can be better and aren't going to take compromises. We try to take strong stands within the scientific boundaries that we think are fair, but we try to really take a firm stand about issues and I think we are confident that we can go beyond what others might say.
We do have a certain passion, but we think it's justified based upon the information we have.
Segment:0 .
Segment:1 The Evolution of Toxicologic Emergencies and Poison Control Centers.
I'm Lewis Goldfrank. I'm the professor of emergency medicine at New York University in Bellevue Hospital and the medical director of the New York City Poison Center. I've been at Bellevue for 40 years. Prior to that I worked in the South Bronx and in the North Bronx, that's where I learned my emergency medicine. And I learned that toxicology was consequential every single day that I worked.
And so that it's become a passion and a cause and a core value for preventing the next person from having the same type of poisoning or the same type of emergency event. So emergency medicine and medical toxicology are all about prevention, that every patient we see is a demonstration of failure in the public health system. Everything we put in our textbook, in our daily work is really to try to help people understand that so they can become activists to prevent things from happening and be public health advocates.
When I first started to work in the South Bronx, so that's-- I was a resident at Montefiore hospital. I saw patients dying of heroin overdoses. And I saw people getting hit by cars and falling out of windows, or having too much lead poisoning. It became obvious that there were things I hadn't really thought about in any textbooks I'd read in life. And heroin for example, was a terrible problem because we didn't have antidotes that were appropriate in those days.
We had something called nalorphine or levallorphan. Those were antidotes that really were mixed agonist antagonist. So that if you gave that to someone who had just taken a lot of a sedative hypnotic as opposed to an opioid, you might do more harm to them. And so that was, we were in the midst of a revolution that brought naloxone out of the laboratory and out of the pharmaceutical industry to the bedside.
And we became among the first to ever touch naloxone and used it. And that's sort of the end of the story, let's say, of our textbook today and the substantial evolution in its use. Not only is a lifesaving gesture after an overdose, but as a lifesaving gesture, as a preventive therapeutics for someone who has a high risk for an opioid overdose and naloxone was given to the family. Now it's given to the patient to take home.
It's given to the community, it's given to the fire and police, because we think that if you save someone's life today, maybe you have another chance to get that person to stop using opioids or to get onto a treatment therapy. So it's a big part of... It became very obvious to me. The first day I walked into the South Bronx and started to work. On the other hand, poisoning was very limited amount than what was taught in those days in medical school or in your clinical experience.
This was our first edition. This is the one wrote in the South Bronx and it was my job as a young faculty member in the South Bronx to teach every month and to find a topic to teach about. So I chose a toxin each month and I then met a guy named Peter Fritschoff who was the editor at that point of Hospital Physician. So he liked what we were talking about and he took one article a month.
And so ultimately, each of those teaching sessions, I tried to develop each month to do something for the residents and the training in the South Bronx with Montefiore and Morrisania, the public hospital. I created a document and for a while they were shared by Robert Kerstein who was there with me as the first-- Another one of the young attendings in the emergency department. And we created something, a topic, it would be a topic about heroin. It'd be a topic about a mixed overdose, it would be about lead poisoning, it could be about a host of things.
Whatever we saw we were going to write a chapter. And ultimately, initially it was just for these lectures then it was for publication. Then the guy who helped at Hospital Physician said, "Well, this should be published in a book." So this became the first book. These were the first 20 chapters, the first 20 talks that I gave about toxicology. And I carried that on for about a decade, writing one of those chapters or one of those speeches every month on a different toxin.
And ultimately, at that point we had enough core issues to see what a textbook would become. And it went from this version of a hundred some pages to a version that's 2000 pages. And it went from two people writing it to 200 people writing it. And then the task became using the best people handling a particular toxin in the world.
Someone who is excited about something-- strychnine who might see it more in China, or someone who really works on pesticides in Sri Lanka, putting together their information and us working together currently as a team of six leaders of the book. Six editors putting together in a meaningful fashion from the beginning to the end. And so that the values that we teach and the basic principles of the beginning of the book, the aspects of managing patients and then the chemical principles, all of the scientific principles, associated, all the special components of our body were carried throughout the entirety of the text.
So that everything we said in the chapter that talked about cardiovascular effects of a particular toxin would be found in the chapter on cocaine or the chapter on the beta-adrenergic antagonists or the calcium channel blockers or whatever you'd have. And we would say not only the pharmacology and the physiology was replicated and integrated, but also the treatments and the adverse effects in these things. And then over the years, one of the editors who joined to work with us right in the very beginning, my arrival here 40 years ago was a clinical pharmacist.
And this woman, Mary Ann Howland, took on the role of looking at every antidote that exists. And we linked the antidotes to the chapters and we linked the antidotes to particular toxins. We linked the understanding of the antidotes to the things we talked about in the basic pharmacology or looking at each of the organ systems and how it affected each organ system. So, this integration of the concepts, it's something that she's carried through for the entirety of her career on this devoted to clinical pharmacists through teachers at Saint John's and at the New York City Poison Center and at NYU and Bellevue hospital.
Many people have just stayed with the task, with great devotion for their careers, have made their careers in terms of really this understanding of what toxicology is. Because when we started, there really were no texts about toxicology. People didn't think that this was such an important topic. If you were to ask them, well, do we really have poisonings? People would say whether it was here or whether in Africa working or whether in China they would-- someone might say, "No, we don't have any poisonings." And then you'd walk around the emergency department and I would see them everywhere.
So we really knew that, poisonings is looked just like, you know, someone who has a toxin-- hepatotoxin, might look just like someone who was viral hepatitis. So people didn't really search for these things, didn't understand them well enough, there wasn't enough science behind it. So our job was to look at the big picture and the biggest picture in those days is based upon individual cases or when I came here and after the development of emergency medicine, we really worked through actually grants from the Nixon administration called 12-0-3 grants.
That really began the development of things like how does a poison center work? How does a trauma center work? How does a neonatal transfer system work? How do you handle burns? Things of this nature. So setting up systems. And so the system we had to set up was to set up a poison center. The poison center went from being a place what they called Sanitarians, receiving the calls, and Sanitarians were good for the clean water and the clean food, but they weren't necessarily good to talk about drugs.
And there wasn't really a system for them to have enough information and they weren't going to be the right people. So over time what happened is in poison services developed an understanding that you either needed nurses or pharmacists or maybe even doctors sometimes. And we often have doctors, let's say, who don't-- who come from another country don't have a license, who've worked in poison centers-- Basically it's nurses and pharmacists. And they became a well trained group that ultimately had to have achieve a level of excellence in understanding all the toxicologic information to be able to be on the phone and to work together.
And we created a system where you have the clinical pharmacists who are the information specialists. Then you have the residents or fellows in medical toxicology, and then you have the faculty and then you have the specialists in various areas who would help in handling these poison cases. And New York state has a law-- New York City has a law that says, "Every time a poisoning occurs, you see it in your emergency department or your hospital, you're supposed to report it to the New York City Poison Center." Now people aren't very faithful about that.
The reason that law was so important is that if you really had every single poisoning reported and you could then really document that what they said they were supposedly taking, they actually took and you could prove that really got into their body. That's the science of it. We really have a tremendous understanding of what really happens when people take products. We've never achieved that level of excellence because people don't report and we don't really know when a child is exposed.
It means that well, the container was there and it was open and it smells like something's there, but we don't know if it got into the mouth and it got absorbed and change the way the body functions. So, we lack a lot of that information. And so we don't do experiments on human beings because it would be unethical. So we don't have a lot of certitude in many areas, but we use the case examples to help us really understand the problem for people who clearly said they took something and they have all of this toxicity and we compare it to what we'd expect, and we begin to think that that represents a good part of what it is.
But we don't have big studies, but we do have a lot of personal experiences and a lot of information. That's what poison centers have really brought to the country. When I started in America, there were probably 600 plus poison centers. Today they're in the forties in number. There are high standards established by regulating groups of people who do toxicology.
And that really allows us to recognize what went wrong with each product that someone takes. Was it not packaged well enough, was it blister packaged, was it baby-proof controlled? Was it an open container of sulfuric acid? What was it? Was it lamp oil, whatever the process was, how did it get there? How did the child get in contact? Had we not done enough to protect people from it?
And so, the changes that went on over the years have really been the belief that I mentioned earlier that everything can be prevented, would be the philosophy. That's idealistic, but that's the way you operate, that everybody you see who has a poisoning is a failure in the public health system. The goal would really be to prevent that. These are the kinds of things that we teach extensively in our book. The whole discussion about the poison prevention, looking honestly at the data, looking at how prevention's developed, looking at the evolution of the process.
So really, it's what the Consumer Product Safety Commission and what's the Food and Drug Administration did, those are heroic bodies in America. The fact that they're being destroyed by a lot of political action is devastating for the things we do because it's just going to lead to more patients having more risks and products being available that shouldn't be available. We believe in the heroes of those organizations because they make our job easier.
We believe that you have to use technologic interventions to protect people, because we think education is great, but it probably doesn't save as many lives as we'd like. When we put those baby-- when people put those baby-proof capping on, or when people put blister packages, it made it tougher for a young child to get into it. It still may slow down someone who wants to overdose, but it's not going to have a big impact on someone who does it intentionally. Children do it unintentionally.
It may be that the parent did something that could have been prevented, but you really want to try to prevent the contact of someone's body from something out there that could be dangerous. And we've really worked hard on that and everybody's devoted to that process. That's the kind of work that really comes out of poison prevention and emergency medicine.
Segment:2 Current Treatment of Opioid Overdoses.
If you look at the textbook and say, "What do we do differently this time than in the past?" There'd be a couple of things.
Let's say people have said that there's limited time after the ingestion where you use activated charcoal. Activated charcoal was a great, preventive agent. Someone takes a bad toxin, you put activated charcoal, you can prevent absorption and you can prevent by absorption of the activate charcoal. And it may be good not only in the initial phase, but maybe in recirculation when the molecule, the toxin is metabolized and it comes back in the gut activated charcoal may block it.
So, over the years, there were a number of papers that suggested that if you got to the patient after an hour of ingestion, that it wasn't appropriate to give an antidote such as activated charcoal. We've always thought that was silly because the person who takes a massive amount of pills, doesn't have the same surface area to get all those pills in. If you put one acetaminophen tablet in, that's one thing.
But if you put a hundred in there, they're really not going to be finished. There's still gonna be lots of pills in the stomach at several hours. And if you take some of the newer matrix-based extended release products, they're going to be a big mass. Sometimes they're going to be adherent, sometimes the gel and the matrix bonds them together. Sometimes it's a mix overdose of a lot of pills. So we've always thought that there was lots in the-- still in the stomach, in the intestine that activated charcoal could help.
We've really enriched the discussion of this decontamination of the gastrointestinal tract. When we looked at the science associated with that, and so the authors of that chapter have worked extensively to demonstrate that it's certainly appropriate when you think someone has a consequential ingestion to use activated charcoal, and then may even be necessary in something like that, even hours after the initial ingestion.
And when you take someone who's got a very high concentration in the body already, you may transform what is a very consequential ingestion into a less consequential ingestion because you aren't going to absorb some of these things. And not let it get into the body, you're going to-- Sorry, when you will adsorb you'll block it, you'll pull-- the activated charcoal will bind to that molecule, you'll prevent absorption.
And what you really allow is the patient to have a nontoxic ingestion. And so we think that that kind of thought was a big deal. And we've really-- Because so many people, when you ask them, they'd say well, they're taught that in other books in toxicology or in general emergency medicine or someplace in pediatrics, that you don't have to do anything to a person after one hour. So we spent a great deal-- a number of pages really trying to clarify that because that's often a hallmark of great success in medical toxicology.
And so although it's simple, it's not a complex molecular issue, it's a simple preventive gesture while you still have a chance. And so I think we wanted to give people more optimism about that. We can never be sure, but we know it's a pretty safe approach to give someone a cup full of activated charcoal. And we know what we can do and we believe strongly in it and others who've said it's less consequential I think are misleading the public. And so we spend a lot of time explaining that concept.
Another concept that I think is different this time it's a big deal, is that, as I said, we went from in this first edition from naloxone being good for an opioid overdose. And if someone had an opioid, it's a pure opioid antagonist. So if the person didn't take an opioid and you gave naloxone, nothing would happen to the person. To the current stage we've added what we call special considerations. Also we have special considerations, we have sections called antidotes.
So, in the antidote chapter, we talk about three types of opioid antagonists besides naloxone. We talk about naltrexone, we talk about buprenorphine and we talk about methadone. Those we think are medication assisted therapies that become our responsibility as toxicologists and emergency physicians and probably the general public as well in terms of medical personnel that we've got.
Every time we have someone who's a risk for an overdose, because he or she has tried to abuse opioids or uses opioids indiscriminately, and that person's a very high risk of killing oneself either intentionally or unintentionally. One of the chapters is written by one of the experts of when people are patients who are released, or prisoners are released. If they'd been on opioids before they got into prison when they're released, they're going to go out and they're going to take some more opioid, they often going to die.
So really pushing this medication assisted therapy when people are released from prison, when people come to an emergency department and overdosed, we want to get people on a strategy if they have substantial dependence and substantial risk of killing themselves. We really have moved as part of everyone in the entire country and a good part of the world, moved rapidly to say we have to get people on therapy. We have to take advantage of the day they're in the emergency department to try to get them into something either shortly thereafter or immediately to get them onto therapy.
And that's what methadone offers us. That's what buprenorphine offers us. And naltrexone is a special case, but would do some of the same things. So thinking about how to use those three molecules, naltrexone is a longer acting product methadone is a longer acting Brockton, Buprenorphine is longer acting, let's say than the drugs that people use to-- That are dependent on that drug, like oxycodone or something else of that nature, the opioids that they might take heroin or fentanyl.
So we know we can prevent the next overdose if we work carefully with the patient to do that. So, the other thing that we discuss at length in the chapters is that, in the opioid chapter or the opioid antidote chapter or this harm reduction chapter, the special consideration, is that you can really think carefully about people that if-- in the old days we thought that two milligrams of naloxone was a good drug to start in the field. That was true because we didn't have any pre-hospital care at that point.
We didn't have any paramedics. They often came to the emergency department not having had any antidote. They didn't have good control of the breathing capacity, they didn't have any control over protecting people from a host of things we consider the standard of care for pre-hospital care today, in the past it was pretty low level. We hadn't trained people that hadn't been done in the 19-- in the early 1970s. So we gave them a lot of naloxone because we wanted to be sure they could breathe because we didn't think the airway could be protected by the people who were running the ambulance.
Today we'd say we have such great confidence in the people who take care of patients in the field that we'd like them to use far less naloxone, because we don't want the person to go into withdrawal. We'd like the person-- I don't have to have the person think yet if the patient's taken a bad overdose. I'd like the person-- if the person's breathing slowly, I'd like them to breathe a little more rapidly.
I don't have to have them come back to normal because I'd like them to still be calm enough that when they get to the emergency department, they can talk with us. I'd like them still to be calm enough in the field so they don't walk away and sign out against medical advice because they're suffering because they're in withdrawal. So when I get them to the hospital, I want to have the services in the hospital.
I want to have the paramedics in the field and the people in the hospital, whoever sees them, to be totally committed to getting these people on therapy, this medication assisted therapy, either buprenorphine, naltrexone or methadone. And so it's a change in philosophy that we're all tied into it across I think a great part of America to say we've got to give people an opportunity to stop what they're doing. We've changed our approach, which we discussed at length in this book.
Changed our approach from the idea that you and I could talk about your dependency on heroin or oxycodone and figure that you can go to a treatment program and you could stop using it without having any support, any medication assisted therapy. And we stopped believing that entirely. Most of the time I'm fearful that -- anybody who's sick enough to come in with an overdose and is using a risk drug is a high risk for death and that person's not going to be stopped just by a pleasant discussion or a tough talk discussion or someone to tell you heal yourself or things like that.
It's not going to work. I expect those people to get in more trouble and the family does as well. So we push people and we try to get people involved. We want to make sure that everyone who goes through an emergency department has someone to talk to and we talk about that as part of the strategy. The other strategy we have is that when we send this person home and there's family there or friends we either give them a naloxone kit. So that they have that to assist their family members because if there's one person there who's with the other person who knows about opioid use, probably the other person has been using as well, someone's going to abuse it; they know-- Everybody says, "I've seen-- witnessed one of my friends die" or "I witnessed one of my friends overdose and almost die." So everyone could help.
Someone would say, "Well, you know, these people are just doing this to themselves. By the time you've been on an opioid for a few weeks or months, you're locked in, your neurochemistry has been changed. Your desire to get that drug later is going to be there and it can be very substantial. So we don't expect to solve this easily. So, it's really a change in the pattern of how we respond to it.
And so we'd want to send people home with that naloxone. We want to give people all sorts of advice and we want to go through the kind of education that has to be accomplished to stop this lethal epidemic. And we talk at length in our chapter really about these drugs and about the way people become dependent and what dependency means and how people behave. And so that's a big change in what we've discussed. We didn't have discussions like that in the past.
So what we've done really is the education about opioids, for students, for nurses, for doctors is totally different than it was in the past. We had for example, very few particularly potent opioids to treat people with. In the old days, we had-- in the 70s, we probably had codeine in the hospitals. We may have had something called meperidine.
We didn't have many things you could use. We had a couple of the agonist antagonist something called Talwin or pentazocine. We didn't have many drugs. They weren't potent. They weren't long acting. They weren't designed to keep people with a steady state of oxycodone in their body, which lead to dramatic dependency. It was-- became in vogue to say, we're going to treat the pain number and we're going to push opioids substantially to relieve pain.
For things that were acute, it might be reasonable, but for things that were subacute or chronic and no one ever had the evidence that that was the case. And a place like this, there was very little utilization of opioids for that reason. But other people were pushing it and the pharmaceutical industry was pushing it and it really changed the pattern and the type of people who are using opioids.
It was for us great education because in many ways, I would say, in the past, all the studies we did would show this was an issue of-- maybe it was a greater concern in the inner city. It was all the people would say, "Well I hear the people who are black or brown have all this." So by-- the response was that, in being very careful and probably those of us in the inner city, were very careful about opioids for whomever we saw. But what it taught us in the unintended consequence of let's say racial prejudice was that people who were treating the people who lived in Vermont and New Hampshire and West Virginia and wherever southern Indiana, were individuals who were basically white.
And those people are the ones who became in these epidemics, dramatic changes. A place like Staten Island had very few heroin users in the past was rampant with oxycodone users. So that's where the pharmaceutical industry went. That's where people felt this might get by, so this is-- It teaches us that any human being given drugs that we are currently available can become tolerant, dependent, and develop substance abuse that leads to catastrophic complications.
So lots of these things we tried to discuss and we look at as big issues, and how we retaught all the things we've tried to talk about opioids. We've tried to emphasize again with clarity, the risks and benefits of the various drugs.
Segment:3 The “Bible” of Toxicology.
The advantage we have is we have six very active toxicologists as editors. So they're being exposed to everything that happens in the world. And so these all are registered on either on their computers or on their pads or whatever to put all the things that we see that we haven't discussed.
All the things that looked like deficits in what we had before, all the things we would like to try to teach differently. Ones that we think people have a hard time understanding like the example of activated charcoal, really emphasizing things that people were having trouble with, it's putting all the evidence back together. This is not a blog, this is not sort of a few people talking about stuff off the top of their heads. It's someone who's an expert writes a chapter and that chapter is sent to this office and then that chapter is sent to all the editors to review.
They all go over it with a fine tooth comb, they send it back to me. There are a hundred corrections on every chapter. Those chapters are then-- We try to integrate all of those things and we're going to send it back to the individual with all the corrections we think that-- all the things, all the queries we have, and then that person's going to revise it and send it back and it's going to go out to six editors again and we're going to do the same thing again.
The chapter is going to be read by a number of people in our poison center effort and they're going to suggest some errors that they find in what's going on, the things that are missing. We're going to add new references, we're going to add new ideas, we're going to try to correct things so that every chapter gets revised. We do it every four years and the process probably starts before the book is actually published and it ends just before the book is going to be published here.
You have to have a good contact at McGraw-Hill to make sure that we can make the essential changes even until the last moment. So the book is up to date and reliable. And so people don't say that it's neglected something that's of consequence. It's as current as a book can be. But the difference is that, you know, if you think about the competition between a digest book and a blog, and a textbook would be that, you know-- We just read this article today about hydrocarbons.
And so when you read it, someone worked for several years on putting that article together. And then, they sent it to a journal and theoretically the journal does a good job, it reviews that article and then sends the comments back to the author and they rewrite it a little bit and then send it off. And then we-- when it comes out in publication, we review the article and we find a hundred errors in it.
And that was a good article, it got published, but then it shows it was probably bad review by the editor at the journal and things like that. And so that's an article that someone doing a blog might read one article like that and two or three other articles like that. We'd say that, well, the idea of making that article was probably pretty good, but the presentation was poor. So anything you learned from it either wasn't statistically valid, wasn't toxicologically valid or just wasn't a population that's relevant to what you're doing.
So we'd say that that's-- if you're going to be able to handle anybody in the world on the telephone as a toxicologist, any part of the world someone's going to call you. Every one of these big poison centers has a number of toxicologists. They're going to count on you to know everything. So you're going to have a resource where you can get to it. Now sure when-- you can search and you can pull it all together. And we try to make sure that everything that's relevant, every paper that's relevant has been reviewed by the author of that particular chapter and that we've reviewed them and they've been re-read and they're commented on.
So you build together a document that people can say, they've tried as hard as possible to get all the facts together and they've looked at them objectively- That they have certain biases. We state our biases. If someone tells me that, this product never causes hypoglycemia, it's an oral hypoglycemic agent. One pill doesn't cause-- ever cause hypoglycemia in children.
And we'd say, "Well, we've seen that several times." No one's ever going to do a randomized controlled trial. But I'm going to say we've definitively seen that in children. We're going to say that it is unsafe to send the child home who comes in and said, "I took it." We're going to say we have to watch that child. We're going to have some knowledge that we can't prove from a statistical point of view. But we have the evidence of a couple of cases that had been studied very carefully to say that it does happen.
So it's combining people with lots of experience and respect for various complex methodologic approaches that happen in science or in a statistical analysis. But we also have anecdotes that we think are very consequential that add to the process. So it's a combination of that because, the things that were going to describe at length in this textbook-- Let's say in the plant chapter, we're going to talk about the fact that this is a dangerous time of the year, the spring.
People like some of our-- some of us in the room are probably going out to search for ramps, ramps are delicious this time of year. There's sort of, some people call them the wild leaks and things like that, but every year we're going to have someone who goes to seek out ramps, which is a variant of a-- like a wild leak or like a wild onion, it's a little different to the delicacy and the open air markets. You can get them for $10 for a dozen.
So people go searching all over the place. So in the United States when they go at this time of year, and they're not good enough to differentiate what the leaf of the lily of the valley looks like, how similar the lily of the valley looks to the ramp. They may get the lily of the valley, but when they take the lily of the valley, they're going to-- If they've taken a lot, they might very well die of something like digitalis poisoning because that's convallatoxin.
In Europe where the same thing occurs, Switzerland and Spain where in the spring those ramps look just like the autumn crocus. And the autumn crocus is going to contain colchicine and when they take that they're going to die. These are things that one gets case reports and these complications about-- you want to know what the herbalist is using. You want to know what the botanist or the forger is using.
We have to know various things and try to describe those things about which of these herbal preparations are dangerous? Which of these plants are dangerous? Which are they confounded with? What do people bring in from across the world? We can talk about in convulsant drugs you might think about if a young child comes into our emergency department and his family only speaks Chinese, he's just come from China. We might think that that person's taken a rodenticide that they have in China that we don't allow in the United States called Tetramine.
That is a very dangerous cage convulsant. So, that's experience. That's epidemiology. That's the way you have to think about problems as a toxicologist because the problems are often uncommon, often very complicated and they are life and death situation. So you need people with experience and we try to give people a lot of information. They can get it probably in lots of places. But what we do, we think we do it in depth.
We do it in an integrated fashion. If you're looking something up, we have a great index that we're working very hard on, for us it's the core to be able to find things. So you may have the term, you may learn about it in the basic principles about neurologic complications of toxins. Or you may read it in a chapter that's about rodenticides or about something that-- you're going to get it from different angles, but it's going to say the same thing.
It's going to be integrated so that it's not too repetitive, but it's got strong enough structure in each of the various chapters were it the antidotes, where we intervene from this perspective.
Segment:4 The Life of a Toxicologist.
Being an emergency physician or toxicologist you have a tough job. But I think as someone who practices with a vision towards a better world, you can feel very optimistic by being a toxicologist because you can figure out what's wrong with the patient through basic use of your skills in history and physical and looking for very special characteristics of each person.
In addition, what you can do once you've found that toxin and understand it is intervene and prevention. You can really work-- If someone comes in and has used a lot of coal to give accent to face or one's working with pottery and that person presents with some findings of lead poisoning, you're going to intervene and say that shouldn't be sold or that's a risk. How do we intervene and help people?
How do we work on the that lead glaze that's dangerous? So our job is to work with the public health system, the city health department, the state health department the federal government, and to work together to solve problems that are really a threat to humanity. And you can have a feeling that you're a public health servant and you're really devoting yourself to the public. Working in a place like the New York City Poisin Center or the poison centers that everybody else in this book works on across the world is that it's the one space in our society where it's free.
You can call, anybody can call 2-1-2 POISONS or the long number, right? I happened to choose 2-1-2 POISONS only because, we wanted that number very much. We thought about it for a long time and people said, well, first they don't use letters anymore on a telephone number. The other hand so over a period of time, many years ago, all of us called 2-1-2 POISONS until-- you know, I think probably 35 years ago, 30 years ago, one day I called and the person picked up and said, this is a nonworking number at the Celanese Corporation and so-- I explained to the person that I wanted to use that number for the New York City Poison Center.
So, and I told them actually, it's ironic, the Celanese Corporation is actually where my father worked. And so I'd said, "We want that number." So I sent it to the president, my father gave me the information and we got the number. We had to negotiate with the city of New York to be able to-- It was copper wiring in those days, it was a big deal. How do you get permission of the city of New York to accept $5,000 that it cost to change the wire so we can take the number, but we got the number, we still use the number.
There's a number that's a national number, but that number, by chance it was a way to advertise and we now-- we have 2-1-2 VENEMOS also so we can do it in Spanish. But it was little things that tried to help people have an easier access to the poison center and which made a difference in their lives. And you can feel every day that you're seeing something, either an injury from an ingestion, you might see a burn - hydrofluoric acid, or you might see the sulfuric acid.
And you think, "How was that material available?" What was actually going on that allowed that child or that adult to get into that? How do you accomplish that education? So you change the standards for the city, how can you dispose of hydrofluoric acid. How can you dispose of sulfuric acid? What do you do? The idea of what you do with all of these things. Let we talk about these things. We talk about each of these things.
We want someone to look at a poisoning and say, "I have to analyze all the failed steps in what went on to allow that to get into that child's mouth." We have to think through these processes in a very systematic fashion. That's really was this revolutionary paper by the National Academy of Sciences in the 1960s that worked on injury in America and how that led to really enhancement of poison centers, enhancement of, let's say, the control of the energy in a car, and thinking about how you protect people in the car seat belts, airbags.
How do you do these structural things and make this big difference and how do we do that for poisoning? So that became our task and many people are involved. We have people at the Poisin Center and one of the chapters about how to reach out to the community? How to be an activist in the community? How do you work on the prevention? We have a chapter on discussing the laws that have ensued to protect people from a drug that's not well developed or that a product that's not well prepared, so that-- People who are toxicologists some are at the CDC, some are teaching in intensive care units across the country.
Some are running educational programs in pharmacy. Some are in general internal medicine and emergency medicine, pediatrics. It's essential part of education for everybody in medicine and in public health and public policy, it's pervasive. It's the fact that just because you only had a few parts of some organic phosphorous compound in the apple you ate, or the fruits you ate, or the vegetables, it's there. And the question is should it be there? What do we tolerate?
What's our responsibility to make the environment safe for everyone in society?
Segment:5 The Reasons Why This is Such a Great Book.
We believe we have a great book. We've worked very hard on it. We have a team of people who spend the vast majority of certainly the last year before it's published and probably the year before that. So almost two years out of every four that they spend lots of their living moments with this book. Not many people are willing to invest that much energy on writing a book and to try to drive for the rigor.
We work with probably 200 other authors to make the book work. So you've got to have a lot of friends. You got to have a lot of people to cooperate with. You got to have people who trust in us, to take the criticism we offer and to say they will deal with it and they do believe in it. They share a lot of the same things I've discussed. They believe that participating is very useful for society. I mean it doesn't have to be in a solid version. I'm a solid version type.
It could be online. You offer it online. People can use it any way, but I think it's-- There aren't any big books like this left anymore. People who were doing maybe we'll do them again, but many people, as I said earlier, were led to believe that maybe books weren't the solution. You could do it just as well by an online chat such as this. I don't think this gets enough detail and it gets enough depth. I think that people learn when they really want to understand something, they have to go back and see what people 50 years ago thought about this when they have lots of these cases and the progress they made.
And we try to discuss the progress in all these. We try to discuss what's happened. We're try to get people the historical perspective. We try to give people the kind of depth that makes them want to be experts and makes them correct the errors we've made and change the world in their own fashion. And it gives people ideas. If you just take the top of the cream of the idea-- You know, it's not hard to get confused because you don't know how you got there.
I think the objective is to learn how to learn to think about things that others couldn't think about and to solve problems that others wouldn't have even looked at or addressed. I think you're trying to create-- To solve these problems you need some revolutionaries, people who believe that the world can be better and aren't going to take compromises. We try to take strong stands within the scientific boundaries that we think are fair, but we try to really take a firm stand about issues and I think we are confident that we can go beyond what others might say.
We do have a certain passion, but we think it's justified based upon the information we have.
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