The Poison Lab

As reports of severe illness and death come in, the Bozeman outbreak moves from medical mystery to full public health investigation. Local and state investigators race to identify the source, shut down the risk, interview patients, collect food samples, and figure out whether anyone else could still be in danger.The early signal points toward one unlikely ingredient: morel mushrooms. But for toxicologists, that raises more questions than answers. Morels are supposed to be edible. Rapid vomiting and diarrhea usually suggest foodborne illness, not a deadly mushroom poisoning. So investigators have to ask the question that will drive the rest of the series: is the morel really the culprit, or is something else hiding in the meal?In Episode 2 of A Morel Dilemma, we meet the public health team on the front lines, hear how the outbreak was contained, and begin testing the first theories behind what made diners so sick.

In this episode of The Poison Lab, host Ryan Feldman is joined by Dr. Amy Zosel, a medical toxicologist, emergency physician, and educator. Together, they use real poisoning cases to practice identifying toxins and flexing their toxic differential The conversation dives into intriguing and challenging toxicology cases, with a focus on educating listeners about real-world poisoning scenarios, myth-busting internet misinformation, and providing practical clinical insights. Mini episode with Dr. Robert Bassett on Remembering Poisonous Mushrooms Dr. Zosel and Ryan discuss:14:15 Case 1 33:04 Case 2News story37:00 Case 3 New story48:00 Case 4 News storyUS outbreak "Robocough"Study about Naloxone in Clonidine overdose++Spoiler++: Below this will be key takeaways regarding managing the poisonings discussed, it may ruin your experience if you are guessing the poisons Key Takeaways:Amatoxin Mushroom Poisoning: The classic delayed onset of severe GI symptoms, followed by a latent phase, can mask progressive liver damage. Early recognition and treatment with hydration, silibinin, and possible liver transplant are critical.Tetramine Toxicity: Known for causing refractory seizures, tetramine is a rare but serious poisoning often requiring aggressive supportive care and anticonvulsants.A Lethal mushroom hiding in edible mushrooms Mushroom foraging dangerResources Mentioned:National Poison Control Hotline: 1-800-222-1222National Suicide Prevention Lifeline: 1-800-273-8255SAMHSA Free Helpline: 1-800-662-HELP (4357)Follow The Poison Lab:Twitter: @LabPoisonInstagram: @tox_talkWebsite: www.ThePoisonLab.comSubscribe and Review:Love what you're hearing? Help us reach more toxicology enthusiasts by leaving a review on Apple Podcasts, Spotify, or wherever you listen. Don’t forget to share this episode with your colleagues and friends!A Morel DilemmaSupport the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: Toxtalk1@gmail.comMore Show ResourcesRyan's Medical Games and ResourcesShow Website

In this special collaboration with NephMadness, we're diving into the world of nephrotoxins with an expert panel from Virginia Commonwealth University. NephMadness is an educational competition modeled after March Madness, and this year, one of the featured regions focuses on plant-based nephrotoxins. Together, with our expert panel we break down the competing nephrotoxin teams: Tubular Toxins vs. Oxalate Offenders. Joining us are Dr. Anna Vinnokova (Nephrologist), Dr. Rachel Khan PharmD (Neph pharmacist), Dr. Ethan Downes (Nephrology fellow), and the legendary nephrotoxicologist, Dr. Josh King (Board certified Nephrologist and Toxicologist). We ALMOST named this episode "Getting Downe with the Mad Neph King and the Bean Queens"... but we didn't, your welcome. After the show, go to the blog and vote for your favorite!Expect irreverent musings, deep dives into toxic plant exposures, and a mystery case reveal that will leave you questioning your diet.Topics and Timeline of Episode:IntroListener Guesses With Josh and Ryan– 8:30Listener Winner – 25:42NephMadness and Guest Introductions – 28:07Toxin Reveal – 33:41NEJM Case reportTubular Toxins – 35:46Aristolochic Acid & the Belgian Weight-Loss Clinic Outbreak – 40:30Black Licorice & Its Surprising Toxic Effects – 47:16The Oxalate Offenders Team: How Dietary Oxalates Harm the Kidneys – 52:00Historical Context: First recognized through sheep die-offs when herds grazed on Halogeton glomeratus, a high-oxalate plant, leading to fatal poisoning.Oxalate in Plants: Functions to bind excess calcium in the soil.Impact on the Body: Plants high in oxalate but low in calcium can contribute to oxalate accumulation, this leads to binding calcium in the blood, creating calcium oxalate crystals and acute renal calculi. Chronic inflammation from excess oxalate deposition leads to CKD progression.High-Oxalate Foods: Spinach, Swiss chard, rhubarb, cashews. Everything in moderation!Practical Advice for Clinicians & Patients on Herbal Medicine Use – 1:00:00Resources for identifying nephrotoxic herbal productsTalk to your patients non judgmentally, open conversations, discuss efficacy (or lack there of, see resources below) and safetyHerbal medicines are not FDA approved and may not contain what they claim toHerbals may not all be safe: Josh King Discovering Contaminants– 1:01:11Wrap up– 1:08Key Takeaways:Aristolochic acid is a direct nephrotoxin, associated with progressive kidney damage and urothelial cancers.Black licorice toxicity results from 11β-hydroxysteroid dehydrogenase inhibition, leading to excess cortisol activity, hypertension, potassium wasting, and rhabdomyolysis.Regulatory gaps in herbal supplements can lead to unexpected toxicities, making consumer awareness essential.High dietary oxalate intake increases the risk of kidney stone formation and chronic kidney disease.NephMadness is open to everyone—vote for your favorite nephrotoxin team and join the conversation!Resources Mentioned:NephMadness: Follow along and fill out your bracket!AJKD BlogNational Kidney Foundation Herbal Medicine GuideNational Center for Complementary and Integrative Health (NCCIH)Poison Control Center (Available 24/7 for toxicology questions): 1-800-222-1222Follow The Poison Lab:Twitter: @LabPoisonInstagram: @tox_talkWebsite: www.ThePoisonLab.comDon’t forget to rate and review the podcast on Apple Podcasts, Spotify, or your preferred platform. Share this episode with your fellow nephrology and toxicology enthusiasts!Thanks for tuning in, and remember: If it sounds too good to be true, it might just be nephrotoxic. Stay safe and stay curious!

Finally, the journal club to rule ALL journal clubs. In this episode of The Poison Lab, we tackle one of the biggest topics in emergency medicine and toxicology: Should naloxone be given during opioid-associated cardiac arrest? With three fantastic studies published in 2024, we’re diving into the data and hearing directly from the authors themselves.Join host Ryan Feldman as he interviews Dr. Eric Quinn, Dr. Joshua Lupton, and Dr. David Dillon, some of the minds behind the latest research exploring the role of naloxone in out-of-hospital cardiac arrest (OHCA). With perspectives ranging from clinical outcomes to practical implementation, this episode offers a deep dive into what these studies tell us—and what remains unanswered.But that’s not all! Featuring special guests Spencer Oliver and Chris Pfingston from EMS 2020, this roundtable discussion incorporates the real-world insights of prehospital EMS professionals who face these decisions every day. Together, the panel unpacks:Conflicting evidence on naloxone’s impact on ROSC and survival.The challenges of interpreting retrospective studies in a high-stakes setting.Ethical dilemmas surrounding randomized trials for naloxone.Practical considerations for paramedics and emergency physicians in the field.Whether you’re a toxicologist, EMS professional, or just curious about the intersection of drugs, overdose, and resuscitation, this episode is packed with actionable insights, expert opinions, and engaging discussions.Tune in now to explore the science, controversy, and future directions for naloxone in cardiac arrest care!Studies discussed in the showOutcomes of Out-of-Hospital Cardiac Arrest Patients Who Receive Naloxone in an EMS System with a High Prevalence of Opioid Overdose – Dr. Eric Quinn.Association of Early Naloxone Use with Outcomes in Nonshockable Out-of-Hospital Cardiac Arrest – Dr. Joshua Lupton.Naloxone and Patient Outcomes in Out-of-Hospital Cardiac Arrest in Northern California – Dr. David Dillon.Studies and guidelines mentioned Editorial by Dr. Lavonas on Dr. Lupton's study AHA 2023 Guidelines for poisoning cardiac arrestAHA 2021 Position statement on opioid overdose out of hospital cardiac arrest Study of opioid overdose death after bystander naloxone training mentioned by ToxoShows mentionedChris and Spencer's excellent EMS showRyan's Interview on Poisoning Cardiac Arrest Guidelines with Dr. Eric LavonasJournal club with Ryan and Dr. Dillon Timestamps and chaptersIntroduction (0:00–12:25)Podcast IntroductionOverview of The Poison Lab and this episode’s focus.Introduction of the TopicExploring naloxone use during out-of-hospital cardiac arrest (OHCA).Introduction of GuestsDrs. Eric Quinn, Joshua Lupton, and David Dillon: authors of 2024 studies on naloxone in OHCA.Spencer Oliver and Chris Phingston: paramedics and co-hosts of EMS 2020.Background (12:26–26:08)Rationale for Studying Naloxone in OHCAAddressing the lack of evidence for naloxone use.High prevalence of opioid overdoses in study regions.EMS provider questions about naloxone’s role in suspected opioid-associated OHCA.Overview of Existing Guidelines and Research2021 AHA guidelines and scientific statement on opioid-associated OHCA.Challenges in Determining Opioid Overdose as the Cause of OHCADifficulties with pulse checks and drug testing limitations.Summary of the Three 2024 StudiesDr. Quinn’s study: No significant benefit of naloxone.Dr. Lupton’s study: Benefit in early naloxone use for non-shockable rhythms vs no or late naloxone.Dr. Dillon’s study: Benefits of Naloxone in OOHCA, even in presumed non-drug-related OHCA cases.Discussion (26:09–48:31)Identifying Potential Opioid OverdoseImportance of scene cues and patient history.Study Methodologies and Confounding FactorsAge as a significant confounder.Techniques used to control confounding (logistic regression, propensity score matching).Potential Benefits and Harms of Naloxone in OHCARisks of administering naloxone unnecessarily.Ethical concerns about withholding naloxone in trials.Broader physiological effects of naloxone.Challenges with current CPR ventilation techniques and naloxone’s potential role in improving respiratory drive.Review of Current GuidelinesAHA: Consider naloxone for high-risk cases.ILCOR: Does not recommend naloxone due to insufficient evidence.Future Directions and Conclusion (48:32–55:00)Need for a Randomized Controlled Trial (RCT)Importance of defining naloxone’s role in OHCA.Challenges in RCT design, including ethical concerns and patient selection.Final TakeawaysCautious optimism, but more research needed.Emphasis on standard ACLS protocols while awaiting further evidence.A Morel DilemmaSupport the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: Toxtalk1@gmail.comMore Show ResourcesRyan's Medical Games and ResourcesShow Website

Join host Ryan Feldman in an insightful episode of "The Poison Lab" as he sits down with Dr. John Downs, Director of the Virginia Poison Center, and one of the leading experts on per- and polyfluoroalkyl substances (PFAS), commonly known as "forever chemicals." Known for their persistence in the environment and human body, PFAS have raised significant public health concerns over the past few decades. Dr. Downs shares his journey through occupational medicine, toxicology, and public health, which uniquely positioned him to provide expertise on PFAS exposure, health risks, and ongoing regulatory efforts. Together, they delve into the origins, uses, and potential health effects of these ubiquitous compounds, while examining government policies, environmental impact, and strategies to reduce exposure. A must-listen for anyone interested in the intersection of environmental health and toxicology! Episode Breakdown:2:42 – What Are Forever Chemicals?8:01 – History of PFAS and Associated Health Concerns15:41 – Government Regulation of PFAS20:42 – Shortcomings in PFAS Regulation25:20 – How Individuals Can Mitigate Risk31:15 – Testing for PFAS Levels and Exploring Treatment Options41:14 – Future Directions and Research Needs for PFAS45:29 – Conclusion and OutroKey Topics Discussed2:42 – What Are Forever Chemicals?PFAS are a large group of man-made chemicals that are persistent in the environment and human body.The podcast focuses primarily on PFOA (perfluorooctanoic acid) and PFOS (perfluorooctanoic sulfonic acid), as these were the first compounds identified as having very long elimination half-lives, measured in years, and not undergoing significant human metabolismThe podcast mentions that there are potentially thousands of different PFAS compounds and that more research is needed to determine if they all induce the same health effects as PFOA and PFOSCommonly used for their water- and oil-resistant properties in nonstick cookware, fast food wrappers, firefighting foams, and more.8:01 – History of PFAS and Associated Health ConcernsFirst created by Dupont chemical, used widely in 1940's in TeflonLarge contamination of water by PFAS identified in West Virginia townLed to landmark study in West Virginia (the C8 study) on epidemiological data of PFAS-related health risks.Effects noted: High cholesterol, thyroid dysfunction, ulcerative colitis, hypertension in pregnancy, decreased immune response to vaccine, and certain cancers (testicular and kidney cancer).PFAS in the EnvironmentPFAS are not easily degraded, leading to bioaccumulation in humans and animals.Non-stick cookware: Teflon, the trade name for non-stick cookware, was one of the earliest applications of PFAS, utilizing PFOA.Firefighting foam: PFAS was used in firefighting foams, particularly for aviation fuel fires. This has led to contamination of groundwater around military installations and airports.Fast food wrappers and other consumer products: PFAS are used to make products water and oil resistant, including fast food wrappers, clothing, upholstery, and popcorn bags.Biosolids: The nitrogenous waste produced after wastewater treatment, have been found to contain concentrated PFAS. These biosolids are sometimes sold to farms as fertilizer, potentially contaminating water and crops.Ski wax: Ski waxers have been found to have a high degree of PFAS exposure10.Major sources contaminated drinking water, military bases, and consumer product (Teflon, waterproof jackets, popcorn bags etc...)15:41 – Government Regulation of PFASEPA Health Advisory Limits (2009): These were the first non-enforceable limits set for PFOA and PFOS in drinking water. These limits were revised several times over the next 15 years, becoming progressively lower.EPA Enforceable Limits (2024): The EPA published its final rule for enforceable limits, known as maximum contaminant levels (MCLs), in April 2024.The goal is for PFOA and PFOS to be completely non-detectable in drinking waterRecognizing that non-detect is difficult to achieve, the EPA set an MCL of 4 parts per trillion for both PFOA and PFOS.A combined limit of 10 parts per trillion was set for four other unspecified PFAS compounds.Practical Steps for IndividualsTips for reducing personal PFAS exposure, such as using alternative cookware, avoiding certain fast-food packaging, and considering home water filtration.The Future of PFAS ManagementOngoing need for more research to fully understand PFAS health impacts and develop effective mitigation strategies.He discusses potential alternatives to PFAS and the importance of balancing industrial needs with public health concerns.Additional ResourcesBooks: Exposure by Rob Bilott (inspiration for the film Dark Waters)CDC and EPA websites for information on PFAS and water quality testingDr. Downs guidance from the American College of Medical Toxicology

In this exciting live episode from the 2024 North American Congress of Clinical Toxicology (NACCT) in Denver, Ryan dives into 12 of the most impactful research abstracts presented at the conference directly with the authors themselves. Covering a wide range of toxicology topics—from the NACSTOP2 trial on acetaminophen overdose, ECG intervals, cannabis toxicity in young children, and more—each guest breaks down their study’s findings and clinical relevance. If you missed the conference or want a deeper understanding of the year's most important toxicology research, this episode is for you. Check the show notes for links to the published abstracts, the full list of studies discussed, and time stamps for where you can find those studies.