Love Hurts Episode 1
Interested in aphrodisiacs? Want to know what EKGs have to do with mustaches, and what toads have to do with van Gogh? Listen to find out.
This is the Pick Your Poison podcast. I’m your host Dr. JP and I’m here to share my passion for poisons in this interactive show. Will our patients survive this podcast? It’s up to you and the choices you make.
Today’s episode is called Love Hurts. If you’re interested in aphrodisiacs, if you want to know what EKGs have to do with mustaches, and what toads have to do with van Gogh then stay tuned!
Our patient today is a twenty-five-year-old man who comes to the emergency department complaining of vomiting and diarrhea. The nurse pulls you into the room saying, “Come quick!” This patient doesn’t look good, he needs your help. He’s sitting on the stretcher, his skin is pale and sweaty. His heart rate is 40 bpm and his blood pressure is 90/60. His breathing and oxygenation are normal.
He denies any history of medical problems and says he doesn’t take any medicines. He denies any attempt at committing suicide. The nurse starts an IV and gives him some IV fluids.
Question #1 on today’s interactive podcast.
Which of the following tests is the quickest for giving a clue about what is poisoning our patient?
A. an EKG
B. lab testing
Suddenly the cardiac monitor beeps. Our patient collapses back into the bed and passes out. What the hell just happened to our supposedly normal healthy patient? If you chose option A. an EKG, you have a valuable clue about what happened to the patient. Choice B will give you the correct answer and it will give you a more definitive answer than the EKG. But it’ll take at least an hour to get the results back, time we don’t have to wait.
To figure out what’s going on with the patient let’s review what we know. He’s complaining of vomiting and diarrhea. These are incredibly common complaints in the emergency department. Sometimes they are associated with life-threatening conditions, but in young healthy people often indicate something as basic as a stomach virus. There is a red flag in this case and that’s the patient’s low heart rate. People with vomiting and diarrhea can become dehydrated, lowering the blood pressure. But in a young healthy patient, the body will attempt to compensate for the low blood pressure with a fast heart rate.
Therefore, we should be very concerned about the low blood pressure and low heart rate, suspicious they’re caused by something extraneous, i.e. a poison. This is a poison podcast so let’s not waste time and get right to the toxicological causes of slow heart rate, bradycardia in medical terms and low blood pressure, hypotension.
There are 4 big categories. The first three are caused by drugs specifically calcium channel blockers, beta-blockers and alpha blockers. These are medicines like clonidine, Norvasc, atenolol, and metoprolol. All of these drugs are used to treat high blood pressure. The patient doesn’t have high blood pressure and he’s just told us that he did not try to commit suicide, so the odds he took someone else’s medication are pretty low.
Before we get to the fourth category let’s take a detour for some fascinating facts. Remember the scene from the movie the Wedding Crashes where they put eye drops in someone’s drink to cause diarrhea?
Fact or fiction - eyedrops cause diarrhea?
Fiction. One of the ingredients in Visine is tetrahydrozoline, it’s a very similar drug to clonidine. So if you put Visine in somebody’s drink, what you get is a low heart rate, low blood pressure, and a depressed mental status. In fact, they might become unconscious. We know these facts thanks to school cafeteria pranks and malicious spouses.
Back to our patient could this be tetrahydrozoline? Did somebody put Visine in his drink? It might’ve been on my list except for the lethal arrhythmia now racing across the heart monitor. ventricular tachycardia. Basically, the two biggest chambers in your heart, the ventricles, are twitching, rather than pumping in an organized fashion. This means blood and oxygen are not circulating. Which means your heart, lungs and brain won’t be functioning in the next few seconds or minutes.
You put your fingers on the patient’s neck to check for pulse. No pulse. The nurse starts CPR. What’s the first thing you do in a code? Something I learned in medical school. Check your own pulse. In other words, calm yourself down so you can run the code. Your panic attack isn’t going to help the patient.
As you take a deep breath and slow your own heart down, another nurse puts defibrillator pads on his chest and asks if you want to shock him. If you chose option A. the EKG you’d be considering an antidote rather than just standard CPR and advanced life-support measures.
So what did it show? The EKG shows a classic swooping line in the shape of Salvador Dali’s mustache. If you want to see what this looks like check out the video podcast on YouTube or go to the website at pickpoison.com where I’ve posted a picture. This classic sign on the EKG means the patient has been exposed to digoxin or a digoxin like substance.
What is digoxin? It’s a drug used to treat atrial fibrillation and congestive heart failure. It’s an old medicine. Its first official publication was in 1785 by English physician named William Weathering for the treatment of dropsy. Dropsy is the old-fashioned word for edema, the swelling that accompanies congestive heart failure. Heart failure is when the heart isn’t pumping strongly enough, so fluid backs up in the body, first in the legs then as it becomes more severe, the lungs. But digoxin’s effectiveness was noted by medical practitioners for medical use even earlier and it has a long history of use as an herbal remedy. The reason for this? It’s a naturally occurring compound found in the beautiful foxglove plant.
Why would our young, healthy patient take digoxin? Great question but given that he’s pulseless with a lethal arrhythmia we should treat first and ask questions later.
The good news is an antidote exists for digoxin toxicity. The brand name is Digibind the medicine works how it sounds. It’s an antibody to the digoxin molecule which binds to the drug and inactivates it.
Which brings us to Question #3 give the digoxin antibody?
Choice A. yes give it immediately
Choice B. Hold on, just wait and don’t give it. We don’t know if he actually took digoxin.
If you administered the antidote digoxin antibody, good choice patient is still alive. If you decided to wait, CPR and advanced life support failed and you have to pronounce a 25-year-old man dead.
Often times in toxicology and quite frankly even emergency medicine we do not know what is the cause of the patient’s illness because we haven’t had time for testing or test results to come back. So both ER doctors and toxicologists have to weigh the risks and benefits of treatment options without knowing for certain if the treatments are the right ones.
In this case if we weigh the risks and benefits of the digoxin antibody the scales are tipped in favor of administering it. And the reason for this is because there’s basically no harm in giving Digibind if the patient hasn’t taken any digoxin. In this healthy patient the medicine will circulate around will be eliminated by the kidneys and that’s that. On the other hand, if you give it and if you’re right as we suspect the patient has been exposed, however it happened, we can potentially stop this life-threatening arrhythmia, get rid of the lethal quantities of digoxin and save the patient.
We tell the nurse to give 10 vials of digoxin antibody while we continued CPR and our usual advanced life support medicines. And in a few minutes the arrhythmia stops in the patient has a pulse and even wakes up. Furthermore, his heart rate is now in the 70s and his blood pressure is almost back to normal.
So what happened to this patient? Now that he’s awake we can as more questions. He continues to deny ingestion of any drugs, he had no intention of hurting himself. So we asked important questions in toxicology. We ask about over-the-counter medicines and supplements. Patients often aren’t very forthcoming with these medicines a because very commonly they feel that these substances can’t be toxic or they fear judgment by medical practitioners.
All natural doesn’t mean nontoxic. Take cocaine and opium for example, both all natural. Supplements can contain compounds of any sort. The FDA, as you know, regulates drugs for quality control and there are strict rules about prescribing etc. The supplement industry however is not regulated. This means things can be found in supplements that aren’t supposed to be there.
After some gentle encouragement, patient finally admits that he did take a supplement that he bought at a bodega in his neighborhood. He says he took an aphrodisiac called Rock Hard. It was a large square pill which he had trouble swallowing.
At this point the astute toxicologist knows what’s going on. Digoxin -like substances have been found in aphrodisiacs variously called Jamaican Love stone, rock hard, black stone and Chan Su.
Question #4 Other than digoxin pills and foxglove plants, where can digoxin like substances be found?
A. other plants
B. toads
C. humans
D. Fireflies
The correct answer is all of the above. Cardenolides are digoxin-like substances plant sources. Foxglove, oleander, lilies-of-the-valley, Siberian ginseng are some other sources. Bufanolides are derived from animal sources like Bufo toads and interestingly fireflies. Humans have naturally occurring endogenous dig-like substances in low quantities.
Rock Hard and similar aphrodisiacs contain poison excreted by Bufo toads. Also known as Cane toads are an invasive species in Australia and other parts of the world where they do not have natural predators. There are many reports of dogs dying after eating the toads.
Someone, somewhere, decided the toad venom would work is an aphrodisiac.
According to the Internet, one of the toxicologist’s most reliable resources, these square shaped pills are meant to be rubbed on the male external genitalia. That’s right rubbed on, not ingested. Apparently rubbing just the right amount leads to tingling and prolonged performance. Too much leads to burning and complaints from female partners about intra-vaginal burning.
Oftentimes the pills are sold in bodegas or gas stations without instructions. Or the instructions are written in a language that is different from patients, Chinese for example. This leads to confusion, ingestion, and unfortunately death.
Digoxin is a fascinating topic and a great example of the classic toxicology aphorism. Paraphrasing Paracelsus, one of the fathers of modern toxicology, the dose determines the poison. Digoxin in therapeutic doses can treat heart failure and atrial fibrillation. But in overdose can be lethal.
So how does digoxin work? It increases calcium inside the heart cells. Increased calcium makes muscle contractions stronger. The heart is basically just a big muscle. This is why it helps patients with congestive heart failure whose hearts aren’t squeezing enough thanks to damaged muscle. But increase the calcium too much and muscles start contracting chaotically i.e. fibrillating. The heart has to relax, fill with blood, then squeeze to pump blood and oxygen to the body. If the heart is fibrillating, there’s no time for relaxation, which means no blood is circulating which means not enough oxygen being carried to the body and the brain and the heart itself.
Back to our case, the patient has several recurrent episodes of ventricular tachycardia. Each time you give additional doses of Digibind. After forty-eight hours his symptoms finally stopped and he is discharged from hospital life.
This is a fictional case, as are all our cases, to protect the innocent. But it is based on real poisonings that have occurred periodically. One of the first published reports came from New York City poison center in the 1990s. Ingestion of an aphrodisiac with toad venom resulted in the death of four otherwise healthy twenty and thirty-year-old men. One who was given Digibind after recognition of his symptoms survived.
This illustrates how the route of exposure influences poisoning. Had the patient rubbed it on his groin rather than ingesting, at worst he’d have experienced local irritation, not life-threatening systemic toxicity. And it raises the always fascinating topic of aphrodisiacs and how far patients are willing to go for bigger and better sex.
The word aphrodisiac is derived from Aphrodite the Greek goddess of love. They have a very long history extending, I’m sure to the dawn of humankind, but at the very least to the beginning of recorded history. Somethings like chocolate and oysters we’ve all heard of, but other more adventurous things have been tried over the course of human history. Things like bird’s nest soup, cobras’ blood, baboon urine, ambergris which is sperm whale vomit, caterpillar fungus, gladiator’s sweat and the penis and testicles of just about every animal including bulls and tigers.
I don’t know about you but that list is way more likely to put me in the wrong mood than the right one.
Our patient was one of the lucky few who’ve survived ingestion of poisonous toad secretions. One lesson here is to be skeptical about products touting health benefits in such nonmedical settings as a bodega or a gas station.
I hope you made the right choices today and kept our patient alive. We’ve arrived our last question in today’s interactive podcast.
We discussed with digoxin has to do with Salvador Dali’s mustache. But what does it have to do with another artist Vincent van Gogh? Specifically, what’s the potential relationship between digoxin and his famous painting starting night?
Post your answers on our Twitter feed @pickpoison1. I’ll post the answer in the next 24 hours.
Finally, thanks for your attention. I hope you enjoyed listening as much as I enjoyed making the podcast. It helps the podcast if you subscribe, leave review and/or tell your friends. Please leave your comments I love to hear from listeners.
All the episodes are available on our website pickpoison.com, apple, spotify or any other location where podcasts are available. Our Facebook page and Instagram pages are both @pickpoison1. Additional sources like references, photos, and EKGs are available on the website along with a transcript.
Remember while I’m a real doctor this podcast is fictional and meant for entertainment and educational purposes not medical advice. If you have a medical problem, please see your primary care provider. Thank you. Until next time, take care and stay safe.
This is the first historical episode, looking back at riveting, and often harrowing, stories of poisoning from the past.
Today we’ll discuss the Moscow Theater Crisis and what happened when Chechen rebels held Russian theatergoers hostage. Did the Russians government’s unusual response to the crisis help or hurt the hostages? We will also touch on what these events from twenty years ago have to do with today’s very current drug epidemic. Want to know what links these two seemingly disparate things? Stay tuned to find out.