Poisoning Outbreak: Aconite Poisoning at Markham, Ontario Restaurant

 A Markham restaurant remains closed after a number of patrons became seriously ill Sunday night. A toxic plant is believed to be what caused a dozen people to become sick after eating at a Markham restaurant. It's been traced to two specific Mr. Wright brand. Spice products suspected of being poisoned.

As public health officials try to understand what we're working, uh, assumption right now is a particular spice that was used. That's something that should be nowhere near a kitchen. The lethal dose in humans can be as little as two milligrams. A tablespoon of this stuff would be enough to kill several dozen people.

It's rather rapid onset within minutes, stomach upset, followed by numbness of the face, but they don't tend to die of that. They tend to die of the cardiac complications, arrhythmias of the heart that are very, very difficult to treat. Hey, everybody, you are listening to the Poison Lamp, a show about poisoning for people who manage poisoning.

I'm your host, Ryan Feldman, clinical Toxicologist and Emergency Medicine Pharmacist. Today's episode is something brand new and something I've been really excited to share with you. I've been working on it for over a year. It marks the start of a special series that we're calling. Outbreak these episodes explore real world poisoning outbreaks, hearing directly from the people that were there, sometimes featuring patients that were involved, and always hearing the perspective of the healthcare and public health workers who respond during these.

ncy departments like Ali from: 2018

Or how about when people were showing up to ERs, bleeding from every orifice after smoking, rat poisoned, contaminated, synthetic marijuana. Trust me when I say that these are very intense experiences for the healthcare workers trying to manage them. You're trying to solve a medical mystery in real time, and people are crashing in front of you.

The stakes really don't get much higher. And while there are plenty of poisoning outbreaks in our history, they're not exactly an everyday occurrence. So healthcare providers don't get a chance to practice responding to them, which is why it's so important. We learn as much as we can from every single one, and that's what this series will do.

Talking to the people who are there on the front lines of poisoning outbreaks, tracking cases, tracing back the poison to its source, and learning how to treat these people with mystery symptoms. And we're gonna kick this series off with my absolute favorite toxin Aconite. A deadly plant alkaloid, known as the Queen of Poisons.

If you've listened before, you might remember one of our earlier episodes called Open and Shut. Where I talked about aconite and how it's been used in some interesting murders with two colleagues of mine who had co-published a review paper with me on aconite. Between the three of us, across three different health systems and multiple poison centers, we had collectively taken care of one case of aconite in all of our combined careers.

It's a famous poison, but it's not around very often now, yet. On a single night in Markham, Ontario, 12 people were poisoned after eating a take out chicken dish. I mean, put yourself in their shoes. You're eating dinner with a friend. You notice a bitter taste, numbness on the tongue, and suddenly your friend collapses.

Others in the restaurant start to experience similar symptoms. I can only imagine being one of the impacted patients, let alone the people who need to respond to this. And in this episode, we'll talk to those experts who managed to keep everyone safe during this outbreak, you'll hear from Dr. Jessica Kent.

An emergency physician and the current toxicology fellow who helped the toxicology team during this outbreak, you'll hear from Dr. Abha Sia, an intensivist who managed some of the most critically ill patients with limited resources as multiple people presented to his hospital. We'll hear from Dr.

Margaret Thompson the on-call toxicologist for the Ontario Poison Center. Who is fielding calls, not only from hospitals trying to treat patients, but from patients who are worried that they were gonna become sick from eating at the restaurant. And finally, we'll hear from the lab team who played a critical role in confirming that this poisoning was from Aconitine that toxin found in the aconite plant.

Dr. Randy Purvis, an analytical chemist, Bryn Schirmer. Walk us through what they had to go through scrambling to confirm that this was aconite, as well as their experience in a number of other poisoning outbreaks, and how you can find a poison when you're not actually sure what you're looking for. I cannot wait to share this episode about what it was like to be on the front lines of an extremely lethal mass poisoning and how they navigated the unknown and what we can learn from them to be ready for the next one.

A note to the listeners, this show is made by medical professionals and many medical professionals are listeners. We occasionally run into some medical jargon, but this content is really for everyone and I do my best to make sure everyone can follow along, and I'm really excited to let you know that the next installment of this series, which is a five part mini series, is specifically designed.

To ensure that anyone who's interested in learning about these poisoning outbreaks can understand it all. Now, before we dive in, just a quick shout out to our supporting members. Thank you so much. Your support keeps this project alive. Members get early access to episodes, ad free listening, bonus content, and access to expanded versions of episodes.

The supporting membership has had access to this episode for months, and I'm hopeful to bring a more in-depth discussion to them as well. If you want to help us grow and share these stories to help care for the next poison patient, you can help support our operating costs for as little as $1 a month at www@thepoisonlab.com slash support.

But you actually don't need to pay anything to support the show. I'm just happy you're here and if you find this valuable rating and reviewing it. Wherever you're listening will help us share our message. Finally, one last disclaimer. The Poison Lab is for educational purposes only. It is not medical advice.

If you think someone's been poisoned or you find yourself in the position needing to care for 12 people poisoned by plants, call your local Poison center in the us. That number is 1 802 2 2 12 22. Or contact your doctor. Poison Centers will provide you with free confidential medical advice 24 7 that you don't have to get from a podcast.

Alright, let's get into it. Cannot wait to bring you this first episode of the Outbreak series Inside the aconite poisoning of Markham, Ontario. Six deaths have now been linked to the capsules leased with cyanide. Parishioners at church became sick after drinking coffee, tainted with arsenic. An outbreak of lead poisoning tied to pouches of cinnamon apple sauce.

Hundred thousand reward to anyone with information on who may poison.

Hey everybody, you are listening to the Poison Lab, a show about poisoning from people who treat poison. And today we have a really rarefied group of guests. You heard in the intro what we're talking about today, a mass outbreak of poisoning. And I have three guests on with me today. I'd like to have them introduce themselves to you, to, you can hear exactly who they are and what their work involves and how they were involved in this outbreak, which they're gonna walk us through.

And I'd like to start off with the person who I was able to cajole into agreeing to this in the first place. And that would be Dr. Jessica Kent. Would you mind introducing yourself to the listeners? My name's Jess. I am a second year fellow at the University of Toronto's clinical pharmacology and toxicology program.

I'm also an emergency physician at St. Michael's Hospital. And starting off with me, I had the least most limited role in me in the management of these cases as the fellow actually wasn't on call that night, but was on the next day. And I ta was tasked with getting the story together from our end, ICU and the public health end.

But I did very little of the management myself. But you were the connector of the pieces, which is And the connector. Yeah. Which is very important. And most importantly, you had an email address for me to reach out to, which was super helpful. Next, I'd like to introduce Dr. Abhasa. Yeah, my name's Abai. I'm an intensivist at Markham STO Hospital as well as, uh, St.

Joseph's Hospital in, uh, Toronto. Uh, and I was involved that night taking care of some of the patients, uh, in the ICU. Thank you Dr. Satya. And finally, a perspective I think will be incredibly important for many of the listeners, Dr. Margaret Thompson. Hi everybody, I'm Margaret. I am an emergency physician at St.

Michael's Hospital with Jessica as well. I am the, uh, toxicologist who was on call, uh, for the Ontario Poison Center on the night of the incident and corresponded with Dr. Abney about the care of these patients. Thank you so much, everyone for joining us. So we have a poison center perspective. We have a frontline clinician perspective.

We have the fellow on cleanup duty the next day perspective, which is I've seen that happen as well. Sometimes something happens and the next day everyone has to deal with it as well. So these are all great perspectives to have here. So I guess I'd like to start off just with a little clip. So I'm gonna read you something from the Markham, Reddit.

I know, and this was from the night of, and it says, this is just a heads up to anyone working today about a serious presentation occurring overnight in Markham. Just in case anyone sees this in the emergency department, all patients ate a chicken dish at an Asian restaurant located in Markham. The patients complained of bitter taste of the food followed by numbness, tingling of the face, body, extreme nausea and vomiting, then cardiac arrhythmias and hypotension.

Six, presenting to MSS H four in ventricular tachycardia, three coding five in the IC U2 intubated, and four more patients redirected to other hospitals. Patients presented with sodium channel like toxicity and responded to bicarbon boluses than infusions. Police and public health are involved, but this restaurant was serving food up until last night.

This. Fits the effects of a plant called Wolf's Spain, but we're only speculating to the actual cause right now. So that was an internet user on a message board on the night of the Markham outbreak. And it sounds like there was a lot of patients presented to multiple areas at once, but I'd love to hear a little bit of a timeline from those who were there.

So would you mind briefly describing the outbreak? When did you notice there was potentially more than one patient? Was this something that multiple hospitals contacted a poison center for and that gave us a signal? Or did multiple patients show up to one hospital? Can I hear a little bit about the beginning?

I might take a little bit of that on this. I think the information that was posted on Reddit was wrong. Based on, wait, wait, the internet was wrong. Uh, this is new. You know, having, you know, reviewed the case series a number of times. We know that there was, you know, nobody in cardiac arrest, et cetera, et cetera.

I think we should leave that to Abney 'cause he was on the floor in the emergency department in the ICU at the affected hospital. Yeah, fair enough. So I think it was quite obvious upfront that there was some type of exposure or a toxin. And I remember getting called, saying that there were two patients, uh, in the emergency department with refractory ventricular tachycardia.

And the emerge doctors had asked me to come see the patient, come help with them, and they had the story upfront that it was immediately after eating this chicken dish from this restaurant. So I, I think. Pretty early on, we identified that it was some type of exposure, toxic, toxicology related presentation.

And at that point, when I got to the emerge, it was very clear that there were another two patients, I think in the emerge with the same symptoms. And they were giving me information that there were seven other patients who had similar symptoms that would be on their way to our hospital. And realizing that this is like a disaster for us because we're not a, like, we're a, we're a community hospital and I don't have like residents or fellows or anything like that.

It's just me. And so I think it was relatively early on that we knew that this would be something that may, um, exceed our capacity to manage all of these patients. So that's kind of when we identified that A, that there was some type of poisoning and B, that there were gonna be a lot of patients potentially coming in.

So it sounds like perhaps. An attribute of this specific poison, which is that it does tend to be rapid acting, may have provided a benefit in identifying the source here, which was the patients themselves noted the temporal relationship between ingesting the food and developing symptoms. There. Some, somebody said, I ate something and I'm feeling bad.

Nobody had to go in and say, give me the last 10 meals you ate, or What have you been doing differently? And even more specifically, they, they noted that it tasted really strange as they were eating it, which is within the first few bites. And so I think it, the link to the food was very clear and obvious.

Yeah, the bitter taste of many toxic alkaloids is a well-developed evolutionary intuition, bitterness in, in past foods. If you don't recognize that sometimes it leads to you not being able to pass that bitterness trade on. And it's, I can only imagine suddenly realizing. Okay. We have multiple people presenting from one restaurant or from at least corroborating.

They each ate the same thing. That immediately is gonna bring up some alarm bells. You're at a resource limited site. Can you talk a little bit about who did you call for help in this essentially poisoning mass casualty scenario? Dr. Satya had called the Code Orange in his facility and had been able to divert patients to another facility.

Can I clarify code orange? Oh, sorry. The code orange for us is like the external disaster code so that it's, this isn't quite a disaster in the traditional sense of the word, but essentially call people in and you know. Put the hospital and the system on Alert Tech, mobilize some resources. Luckily we have a great team at the hospital.

I think there were, you know, there were two Emerge docs on who were extremely helpful helping manage all the patients. There's an overnight internist who, you know, could offload some of the other patients who needed to be taken care of. And I, I called my director of the ICU and both and help manage, like, flow issues because I just wanted to be able to focus on patient care.

Uh, but also she was helpful in, in managing some of the really sick patients as well. So I, I was able to mobilize a lot of resources and help for us. Did everyone go to the ICU? No. So not everybody went. I, I mean, we took the sickest, I think three, four patient, four patients, maybe up to the ICU to manage.

A couple of them were less sick and we just watched it emerge with similar treatments. And so in relation to the actual outbreak itself. So you got multiple things going on here, number one. You have incredibly sick patients that are experiencing life-threatening toxicity. Number two, you don't know how many are out there or were exposed.

So from a now maybe, you know, public health standpoint, when do we start to involve any other organizations or what were next steps from that? When ANet called me as the toxicologist on call at the poison center, it was more to discuss a differential, but I did, you know, mention we need to talk to public health.

But I believe that somebody in the emergency community there had already done that. They had been able to identify the Asian restaurant from which the, all of the patrons had developed symptoms and public health went in to shut them down. And it may be that they, the restaurant was already closed, it was after hours.

I can't remember that detail of it. But you know, immediately we had all said, you know, call public health. We have to stop further people from becoming exposed. Great to hear Dr. Satia, you contacted the Poison Center to discuss the differentials of what could be coming through. As someone who I take calls for the Poison center, I, you know, you know, there's a fair amount of, Hey, you know, my child ate toothpaste.

Hey, they got into Tylenol. There's only so many times you get, I have multiple patients in refractory ventricular tachycardia right now. So I would love to hear a little bit about the conversation between you two, Dr. Thompson and Dr. Satya regarding the initial differential and initial management strategies as this was evolving with limited information.

You know, I, as I was on call, the first, um, conversation that I had with anybody at. Markum was with Dr. Satya who had reached out and I believe a number of these patients had been in the emergency department and maybe there were seven by then. And it was two to three hours after the initial presentation before I got involved and was able to talk about a differential.

But I got information about, you know, tingling around the lips, significant nausea and vomiting and dysrhythmias. And I had managed in the past a case series and another epidemic of SI gutter poisoning where the patients had also had that sort of symptomatology. The dysrhythmias were different. They had all had third degree heart block and complete heart block.

When I got called about that group. It didn't quite fit. They had eaten at an Asian restaurant. We weren't sure what the, all of the ingredients were. There were many spices that were described by some of the patients. We weren't sure if there was vegetables, could there have been some organophosphate contamination of the products because they had the nausea, vomiting, tearing, you know, a lot of symptoms that were cholinergic.

And so we discussed that was, you know, as a possibility. And then we had been aware of a outbreak of poisoning from aconite contamination of ginger in British Columbia, which I think there were three patients involved where a spice had been contaminated with aconite and maybe six months before this outbreak had occurred.

And so I believe I had said, you know, and there's weird and wonderful toxins as well, the possibilities. This, you know, could also be aconite, but. I'm not sure I would put that in the top of my differential, but had considered it. Truthfully, kinine is one of those substances that, you know, you might talk about once a year.

You might think about it twice a year. Certainly not something that would come top of mind. You know, truthfully, I would be thinking immediately of probably puffer fish of some kind or maybe nefarious poisoning. Very serendipitous that there was a recent exposure in British Columbia. I came across that as I was researching this, and in fact, you know, they were not as unstable as suggested by the time I got called.

So I didn't really contribute much to the acute care these patients. It was, you know, aggressive, supportive care. It was Dr. Ney who was able to, you know, resuscitate and stabilize these patients, and I'll let him go into some of the details of that. In terms of patient management. Yeah, so I mean, as I said, when I got called, it was.

That these patients have refractory ventricular tachycardia and they had, the Emerge doc had shocked them a couple times and it wasn't working. And I think at that point, hearing the story and I was worried about maybe some type of sodium blocker toxicity. And so that's my upfront strategy until I kind of arrived, whether it was toxic or metabolic, like thought it was clear at that point.

It's, you know, don't do the same thing over and over again and you know, just let's try to manage supportively. So as I was making my way over, I just said, you know, start amiodarone, start sodium bicarb. Right? Common things being common. A wide complex QRS and toxicology is sodium channel blocker until proven otherwise.

It's, and honestly, really the rest of that was really just about triaging which patients were sickest. So I could see them first and manage them, moving them up to the ICU where there's, you know, I have additional nurses who can support me. Then going through my ma, my supportive management of these patients.

It was a lot for the IC nurses to manage. It was a lot of nausea, vomiting, hemodynamic instability, persistent PVCs, ventricular runs of ventricular tachycardia. And at that point I really just went down my management of refractory VTU, which, and then going through my ma my supportive management of these patients, you mean 99.9% of toxicology supportive care?

Yeah, exactly. Yes. Yeah. I mean, we have infinite poisons, 50 antidotes, and the rest is supportive care And benzodiazepines sounds kind like that was the progression, which is so useful to know, really. I'm so curious about, uh, any nuances related to management. But I wanted to first just stay on the topic of identifying the outbreak.

I, I wanna know from a, so I work part of my job as in the emergency department. I happen to be one person who. Gets to look at every patient as one of the pharmacists. And I can see like, oh, that's weird. Why do I have six people here with, you know, VTAC? But each individual emergency doctor is dealing with their own patients and they might not be talking to each other.

I know it's not uncommon when you have a very sick case for someone to maybe cruise by or get a curbside consult from each other, but how would the emergency doctors aware that they had similar patients showing up? Were patients sharing information amongst themselves or was it the emergency department who was like, Hey, we have a weird trend here.

I think Abnet, you said that there's only two emerge docs. So they would've been talking to each other with two sick patients like that and others with the nausea, vomiting, kind of combination of symptomatology. Yeah, it, it's not like a massive emerge either. So the, the tumor shocks, were they beside each other?

Managing patients together when it came? So, very interesting to hear. Probably a benefit that it was a smaller emergency department with two docs working. 'cause it's easy to share information that way. Where I work, we have, you know, six teams and some of 'em are, you know, 40 feet away from each other. So they have no idea what's going on in the other person's bay.

So it's in another world if this was a different hospital, it might have not have been so rapidly and easily identified. So I think that's actually really interesting. Within the Emerge department it was easy. I think the more interesting question is about the dissemination of information between institutions and, and whatnot.

Especially as we were di starting to divert patients away. And that was quite informal, to be honest. Like calls to the emerge department at the other hospital to just kind of say, this is what we think. It's, and you know, this is what seems to be working. Really interesting piece of information dissemination in this case was the informal channels with which the information went out.

Hey everyone. It's Toxo. Please don't be alarmed. My voice processor is in the shop, so Ryan is letting me borrow this new module. If this is your first time listening to this show, I help Ryan with useful context or additional insights that the listeners might like. After the recording is done, Dr. Kent is about to reference someone named Dave.

She's referring to Dr. David Jink, who helped disseminate information on the night of the outbreak about what the toxin could be using his Twitter account. Back to the show, Dave had a very nice, widely retweeted. Is it still calling? Do you still retweet? It's now called X React. I will Die on the hill that it is Twitter.

He had a really great tweet about the outbreak, and I think that's where a large amount of people got their primary info about this. Dr. Erling is a, um, toxicologist associated with the Ontario Poison Center, as well as, you know, has this huge presence on Twitter or now known as ex, but he didn't have any restriction as to what information he could send out on official channels.

He's got such a large following and he's so trustworthy in terms of the information that he sends. That became a huge source for the medical providers in the city who, you know, would, you know, worry that they might too, get a patient with that particular symptomatology. How useful. Another one of our colleagues, I think, woke up one of the other medical toxicologists at the Poison center and a merged doc at St.

Mike's woke up to like a hundred emails in the morning with queries about stuff. Like there were lots and lots of like. Back door communications here. Very little coming form, very little formal information, I would say. So there was a lot of that. What's interesting, you asked about the people and, and did they know and was there conversations among them?

And there was the, it's a very small c like a very small community. When I spoke with public health about this, the, the people who became unwell, many of them were related or close friends. Ah. And they also knew the restaurant order very well. And the chef. Yeah. So not only were they kind of talking amongst the family, friends.

Group chat, I imagine on the patient level of communication. Uh, but they were also feeding things back to the restaurant, which is very interesting. Yeah, that is a really interesting, you know, we're social primates, we like to share and talk and information has value. So nomad, if there's no official information, there will be other routes in one way or another.

So I remember that tweet from Dr. Dink. I saw this evolving and I was like, oh boy. And uh, you know, of course there's issues with sharing information too early. I'm sure that, you know, you can lead cause unnecessary panic and things like that. But also people need to be aware of things. So it's a really interesting equipoise that you have to balance there.

And I know a lot of people found that information sharing valuable. And Dr. Thompson, I'm wondering, was there from a, now you were on call that night, was the Poison center able to be utilized as. A resource to help connect multiple hospitals with information on potentially treating whatever this exposure was.

Well, from the point of view of, you know, I think there was a couple of different specialists, we don't have that many who work on any particular shift. And so I believe that there was calls in, you know, to multiple specialists from different people saying, you know, we've got a patient with this and this, and they talked to each other basically before they got in touch with me saying, you know, I think there's something going on out there.

This patients at two different hospitals with this complex of symptoms. Dr. Uh, Safia wants to speak to you, but there was some certainly collaboration with that in our specialists about, you know, having multiple patients at a couple of different hospitals. And, but it was more like, if more patients come, what should we suggest?

And so, you know, what information would we give them with heads up basically as to how to take care of. Those patients. What had Dr. Satya tried? What had worked? There were some worried, well, because of the internet, there were people who called in to say that, you know, I have eaten at that restaurant. Am I gonna get sick too?

Some, and I guess because things spread so quickly on the internet. The Reddit thread. The Reddit thread, yeah. But that's exactly what the poison center is there for. That's wonderful that, you know, it was able to be used as a resource to help curb some of the worried Well in the, and that's always gonna happen in any outbreak.

So what a useful, truly a resource to have available to people in times like that. That being said, I, I also think that like with all the informal communication there, there was, I mean that Reddit post a good amount of misinformation, but I also, even through the informal medical community posts, that word public facing, I remember the next morning after I had managed some of these patients.

My recent group of co-fellows, we have a WhatsApp group, and somebody sent out like a long kind of message saying like, oh, like we hear about these poisoning. This is what's working. Similar things like, you know, two patients had coded, which I guess is a relatively imprecise word, but I, and I think there was like a lot of other misinformation and I was confused because I had, you know, I was just taking care of all these patients and so I thought it was just interesting how even through the medical community and not necessarily public facing, there was that information or that that misinformation in the broken telephone that kind of propagated threat.

Right. It's not uncommon for people to talk about a case they've heard about. Right. And as it continues to propagate through more and more distance, users of telephone, as you'd say, it can warp and change and it's hard to verify, but it's still, yeah, it still gets out there and back channel communication obviously is very common.

You know, it's not like we only talk to each other via. Uh, you know, administrative emails. There's a lot of WhatsApp groups. We all have those too. You know, sometimes I get a text saying, Hey, this patient got cannulated for ecmo. They're coming to your hospital. I'm like, what? And it's like, okay. Yeah. So these things do happen and that, I bet you they're actually by and large, more useful than many of the other communication channels.

But that's pr perhaps another topic in terms of information sharing. Obviously this evolves over the course of days with the overall management, but in this initial period, you know, were any of you in contact with public health at a regular basis or getting updates on confirming on them, confirming.

What this was, or how many more patients might be coming. What was the organizational involvement with other groups as could be expected when, you know a bunch of sick patients are coming in, experiencing something that's quite rare. It was a bit chaotic. Public health has their very own, you know, channels and protocols in ways with which they do things.

So, you know, they kind of went down their roots and certainly we heard from them when they announced that they'd confirmed that the toxin was indeed aconite. But in preparing for my presentation, I went and met with public health now, you know, two years later to get their full, like the full story of what they actually did.

Right? Because it was a bit it from our perspective, and correct me if I'm, it just seemed like public health is gonna do their thing. Oh, it's aconite. That's kind of what we thought it was. But then I actually wanted to know what they did and I can talk about it either now or coming up to what they actually did to identify the aconite.

But while we're on the identification piece, a really cool thing here that we haven't talked about. It was actually one of the ICU nurses who really kind of directed us down AKA night. Interesting. Which is really cool. So maybe you wanna talk about that before I go down my piece on public health. I would love to hear more.

Yeah, for sure. I mean, like, to be honest, you know, this was kind of later at night, right? So I think as you know, Dr. Thompson had mentioned the restaurant was already closed, but it was later at night. So this was kind of overnight work and my main focus was just supportive management on these patients and getting up and triaging them.

So I wasn't really thinking as much about, you know, what this could be. I didn't have time to look thing at that. But, uh, one of our nurses, Eric, who works in our ICU, it was doubled on a couple, like less sick patients, had some time while he was managing those patients to just really Google their symptom and he just Googled it.

And I remember like a couple hours into, uh, my management, I had like, well, a few minutes to breathe and he came up to me and he just showed me this and he was like. Do you think this could be it? And I read more about it. I was like, this is exactly how they described all of their symptoms. Wow. And I think that's when I called Dr.

Thompson and asked, look, like we looked this up, like is this a possibility? And I think that was kind of why we, it all kind of started making a bit more sense to us. Started to click. The Internet's not always right, but it knows a lot. It's got a lot of information in there. I was really hoping you say one of the nurses was like a huge Agatha Christie fan and new used in some books.

No, but that is fantastic. I mean truly, you know, what else do we do in our minds? We have our clinical database of substances capable of causing certain symptoms. We synthesize the symptoms we're seeing in our patients and we kind of scrub it through our own internal database. And that's what other things like Google or AI do as well.

I mean, they're very effective tools. So it, it's great that it was able to help lean in and, and actually lead to some early identification. And I'll put out a point here for some listeners. In a scenario like this, it's very normal to have really maybe a class of 30 things that it could be, but it's hard to really narrow in on things without history and con confirmatory testing.

Many medicines can and block sodium channels and many foodborne toxins can cause non-specific gastrointestinal illness. The tingling around the mouth and it sounds like the paresthesias cardiac arrhythmia, that is relatively indicative of something that is interfering with our excitable cells. And our excitable cells all have sodium channels on them, so that helps us cue in on sodium channels, but there's many different sodium channel toxins out there.

I'd love now to talk a little bit about anything you discovered Dr. Kent, about how they actually were able to trace back this substance to being. What kind of investigation happened with public health? They found out what this was, so I'm sure they're working very hard. I would love to hear a little bit about what happened.

Yeah, so it was really, it was very cool. They, so the restaurant was already closed by the time that we were taking care of these patients. They had a public health officer come to the emergency department and do their public health investigation, but then an officer went to the restaurant the next day to speak with the owner, the chefs.

And as I was saying earlier, the patients, they were of the same community where it had already been fed back to this restaurant. It sounds like that this was the dish, that this was the common dish that people had eaten and it was this hand sheared chicken dish. And interestingly enough, that dish contains a unique ingredient that's not used in any other dish, which.

Incidentally had just been purchased that day, that being the Gga powder or San Ginger. Wow. So that's how they kind of narrowed it down to what possibly was causing the toxicity. And then they sent off that San Ginger powder for testing. This went through the Canadian Food Inspection Agency. They sent the bags off to the, the lab in Saskatchewan, I believe.

Yeah. What they found in that bag was that it wasn't a spice that was contaminated with aconite. It was just aconite. It was a bag of aconite error. It was pure kinine. Wow. Yeah. And they con confirm, they did confirmatory testing on several of the patients who had come to hospital. They, uh, saved some blood samples, which were sent off to the local forensics lab, and they were able to confirm the presence of aconite metabolites via GCMS testing.

I believe what they did. Wow. That's fantastic. You know, actually, if you read some of the literature. Related to ide, there are outbreaks in almost all of the literature, the majority of patient cases originate from Asia related to traditional Asian medicines of names of which I will butcher. But Cha Wu and Zi are some of the names.

I pre apologize. I'm, I'm not a great linguist. But th those actually use aconite in various forms. And in that literature they actually have, many of these hospitals were like checking levels on patients and they've even correlated specific levels with toxicity. I could never get an aconite concentration in a million years.

So it's fascinating to hear that, you know, sometimes people are checking for these things and I hope if there's a case series published that we get to hear a little bit about the concentrations that are there. It might be interesting. And from the lab medicine side, so an another, I, I do some work in the forensics here.

So after the fact, I was at the forensics unit and hearing about. You know, their perspective on how they had to go down and hunt the methods that they would use to test the aconite. Like, and you just, you're, you just, at least I as like a clinician, I'm like, oh yeah, you just send it to the lab. They test it and then you get an answer.

And then that's clearly, that is so far from what actually happens. And I already misspoke. It wasn't GCMS, they, it was LCMS with QOF, or I'm gonna butcher what they did because I'm not a lab person. But it was very complicated and it was a whole big process on their end as well. That is incredible. So you're talking about anytime I read a paper about maybe like, you know, postmortem drug concentrations, there's an entire three paragraphs about how they did the, the actual analysis and I just skip it.

So you're telling me that is actually useful to these people who are doing public health work? That is good news. Hey, it's Ryan, and this is me interrupting the show eight months after it was recorded because so far we've heard about this outbreak from the voices of the frontline clinicians. But there are many people involved in an outbreak like this, like the chemists who are scrambling to try and detect what poison it is so we can actually direct treatment.

And eight months later I got a hold of the chemist who did that in this outbreak. We sat down for a great discussion covering things like how the lab got involved, what it was like on their end, and more interesting topics like. How you could test for poisons when you're not even sure what you're looking for.

Not every poisoning has symptoms so clear that your ICU nurses can google them and give you a clue of what to test for. Shout out to Eric. What if you just have people with mystery symptoms and you're not sure what the cause is? These two guests, Dr. Randy Purvis and Brynn Schirmer are analytical chemists with experience in detecting poisons responsible for multiple outbreaks.

They have such a great perspective. It's not overly technical. Don't worry. And they shed a lot of light on the problems that arise when trying to identify poisons. When you're not even sure what it is, if it's really not your cup of tea, skip ahead. Exactly. 10 minutes from this mark and it'll all be over.

Okay. Let's dive in. Would you both mind briefly introducing yourself and explaining your role and the type of work that your laboratory does? Bryn Scharmer, I'm the section head for the lab here, the Center for Veterinary Drug Residues. It's located in Saskatoon, Saskatchewan, in Canada. Hi, I'm Randy Purvis.

I'm the research scientist here. Our name says The main reason for what we're doing, which is testing a veterinary drug residues in foods of animal origin. Uh, but we are first and foremost, uh, analytical chemists. Uh, so we often get asked to do other types of analyses. In this case, we were asked to look at the conine samples that were involved in that food poisoning incident.

And do you remember the first call you got about that, or is this day one? Was this? Day five. It was through our national headquarters. I don't know how far that would've been. It was a matter of days though. It was pretty rapid. In your national headquarters, that would be like your Canadian CDC, more like the USDA, actually because of the food angle.

By the time you were contacted, were they suspecting Aconitine? They asked us to look for Aconitine, yeah. I think it's maybe just the presentation of the symptoms that are observed in the er. The one in Markham was a big restaurant case. There had been an earlier conine poisoning incident in British Columbia earlier in the year, and that's where we were initially asked to get involved.

So we already had a method that had been up and running, but by a stroke of almost luck, there was a prior. Poisoning from Aite, which is truly a very rare poisoning. It doesn't happen very often. Yeah, and you already had methods in place for that? Yes. The one in Markham, we did receive the samples. We don't normally test for it.

There was a bit of front end work to get the reference material in house and work it up on our instruments, put it through a method that we've used for probing unknown matrices that we have in a simple method. The colloquial term is a dilute and shoot method where you don't do a lot of extensive cleanup to the extract.

You just extract the sample and then inject it. That helps you look for many different things. Is that correct? Yeah. The more selective you make the extraction, the more likely you're gonna leave something else behind. If you don't know what's there, it's better to start with a, a more broad based extraction.

Have you had experience where you didn't know what the toxin was and you guys had to help identify what could be on there? We have. We actually have another. Sample sample that came to us through other means to see if it was a conine and it wasn't. But we were able to actually suggest another toxin through the non-targeted workflow that we have.

And that's where So Randy's expertise comes into it? Yeah. So in the setting where you're looking for a poison or a substance and we don't even know what the substance is, we just think it's there, it seems like you can't do a targeted test 'cause you don't know what to target. So this is non-targeted analysis.

And Randy could, would you potentially just be able to explain sort of the broad differences between a targeted and a non-targeted analysis? Now, I'll give it a try. So in your biological samples, there are literally thousands and thousands of compounds in there. So when you're doing targeted, we know what we're looking for.

So we can. Make our methods so that we can specifically find these things in there. Um, so for thousands and thousands of compounds in there, if you're only looking at five, it's much easier to make a method for that. Then somebody comes up to you as with the sample and says, what's in here? And that moves into what the untargeted is.

That gets kind of frightening. 'cause now you gotta start going through literally thousands of compounds. There are libraries that help you identify the compounds, but these libraries are only starting to grow. And one of the problems is that right now this is all fairly new. So generally over half the compounds in there haven't yet been identified.

When people will say to you what's in there, it's kind of a loaded question. So it sounds like untargeted analysis is just. Writing down a list of almost every single thing that you were able to extract from the sample. But it doesn't tell us anything about whether the thing you extracted was toxic or relevant in any way.

Right, exactly. With the untargeted, it becomes a little easier if you actually are able to compare two samples. So if you have what you know, let's say the spice they were using before and then they have the new spice, what you can do is actually use the untargeted to look for differences between those two.

So then if you start having new uh, peaks show up, you can specifically interrogate or look at what the identities of those peaks are. Hey, it's Ryan interrupting. One more time to make sure everyone's up to speed. Dr. Purvis is referring to peaks on a mass spectrometer, which is complicated, but it's a visual representation of.

The presence and relative abundance of specific ions or fragments of a molecule within the sample being analyzed. So if you have a really large peak, it means there is a large amount of whatever that substance is that's about as well as I understand it. So if you can grasp half of that, I think we're good to go.

n that from a previous job in: 2007

And then we worked our way back to see if that was in the food and it was, wow. What was in it? It was melamine, melamine. Melamine and cy uric acid. So that, that was an interesting one because melamine is not known to be toxic. I thought there was a case where they were adding melamine to food. Yeah. The protein was correlated to the amount of nitrogen, so they found a non-toxic molecule that was nitrogen rich and put it in the food to make it look like there was a higher quality protein than was actually there.

What happened in that case was the melamine that they had used to contaminate the food was itself contaminated with sinic acid and the two compounds together just clog up the kidneys. That was a huge case. It was the largest consumer recall ever at the time, but to me, from an analytical chemistry perspective, it was really fascinating because there wasn't tens of thousands of signals in those samples.

There was two. It was a giant peak of melamine and a giant peak of cynic acid. Wow. What a great example of how. Evaluating from those who actually became sick might give us more clues. So you could take an untargeted analysis of blood from a healthy person and an untargeted analysis of blood from a person who became ill, and look for the differences there because we know what's supposed to be in blood.

Blood. So we kind of have that library, and that would be another way. But when you don't have a comparative sample, then it becomes very difficult. Sometimes things can get buried, and by buried, I mean if the thing is in there in a very high concentration, the peaks will come out very high in the spectrum.

So if you're seeing really high peaks, those may, and you haven't seen that before, those may come out right away and you, you go, oh wow, this is something that's in there, and a huge concentration. But if it's something that's poisoning you and it takes a very little amount. Then all of a sudden it might be buried in the baseline of all the other peaks that are in there, and it may not be easy to find.

So if it's a really potent thing that's in a low concentration, yeah, it could get buried. Fascinating. Well, this has been so illuminating. I really, really appreciate hearing both your perspective, not just on the methodologies and how we can find some of these unknown or known toxins in poisoning outbreaks, but also the gaps that we have and why, despite the sophisticated methods, there's still some blind spots.

Thank you so much, both of you for joining I that's really, really wonderful. Thank you. Thanks. Okay. Back to the show. I guess just from a timeline standpoint, I'm curious at what point did um, you all as clinicians involved in the outbreak get to learn about the fact that it was. Three days for them to get their confirmatory testing.

I know anything about the course of aconite, it's turbulent but short. So I'm curious, was that able to be used in time to impact any care or it was more or less just, Hey, we did it right. It's all supportive care anyway. Right. So Right, right. It's not like we missed an antidote. That is true. Like alvan. I I think pretty much everyone was discharged by that point.

Exactly. Yeah. It was, it was a very quick recovery, consistent with most of toxicology, which is you make your absolute best guess in, in 99% of cases you, you know, a lot of cases you never actually know unless they told you, but, well, with that. I would love to now talk a little bit about, you know, the truly rarefied experience you had in managing multiple patients with a sodium channel opener.

And I've certainly read plenty about it, but this is something many of us don't get to see. So the first things that pop in my head when I think of aconite are tingling and arrhythmia, but there's obviously many other organ systems and nerves and heart. Dr. Kent, Dr. Thompson, you may have read a fair amount about aconite In the, before this occurred, did it seem to match up with what you thought it would be?

And Dr. Satya, if you could talk about just the range of symptoms and did you notice anything unexpected or unusual? I guess we, yes, had read a lot about it in the past. We had actually had one previous patient with kinai poisoning who went on to die. That patient did present with, um, bidirectional ventricular tachy tachycardia, and was treated as if it was a D poison patient.

He had presented so unstable that he had not had, you know, able to complain about the tingling around his lips or, um, anything like, like that. So did you have bidirectional ventricular tachycardia with your patients or was it just standard VTA? No. So it was like a wide range of everything, to be honest.

It, I, and so to be clear, I had never looked into or heard of aconite before, so I had no expectation of what the, I didn't wanna imply that maybe, but, well, usually it's only toxicologists who wrote about this at some point. Yeah, exactly. I thought, thought what was strange was that the dysrhythmias were extremely wide ranging.

So, you know, one patient even had some, you know, first to intermittent second degree art block. Some of them, like in hindsight, were more bidirectional vt, but it wasn't, obviously, it more looks like just like a wide complex tachycardia, but not always super fast. And then even in between, after they were on Amiodarone and the bicarb, they were still having intermittent, like frequent PVCs, PHC, like a lot of just ECT in general.

So it wasn't like a clear cut, just one dysrhythmia. It was, it really ran the gamut, at least to me. And uh, you mentioned there was nausea and there a fair amount of vomiting. What was the most challenging part to treat other than I suppose the cardiac arrhythmias that of course I think we would run into issues with.

Yeah, I, I think the sickest patients, like the couple sickest patients were, were having quite a bit of persistent vomiting as well as just agitation, confusion, and I think general more to the degree of how sick they were, like more like a delirium based thing as opposed to necessarily central neurologic toxicity.

But those were the things that were hard to manage and, and part of the reason why I ended up having to intubate. Certain patients because, so, so it wasn't necessarily an airway compromise scenario, it was almost a neurologic indication for intubation, which is of course, just as you know, indicated. I'm curious if there was any, I mean, did any other patterns emerge?

A few of the very sick patients were like acidotic. I mean, but you know, people who, anybody who's sick will be a bit acidotic with like lactic acidosis or whatnot. I, I do wonder sometimes if that's why the bicarb was effective despite it not being an anecdotal therapy is 'cause part of the management of, you know, refractory intra tachycardias to manage electrolytes and manage acidosis because all those negatively impact the patient, but also increase the chance of current arrhythmias.

So I, I mean, I need to touch on that for a second. So yeah, acidemia can lead to increased ECT and correcting that is certainly helpful. There is a theory. That, and I've asked multiple people this, Steve Curry, who's a toxicologist in Arizona, has a blog about plant-based sodium channel openers. If you scroll all the way down to the bottom, you could see a comment from me asking him a question about whether sodium bicarbonate would have a role because, and I apologize to any non-medical listeners, you could put your ear muffs on right now.

I wanna talk a little bit about mechanism, but hey, it's Ryan and I am interrupting us here because this part of the show. I had to cut out a little bit. Look, I get really excited about this stuff and the mechanisms and how these things cause toxicity, and there's a lot of debate as to whether sodium bicarbonate, which is a drug we use for sodium channel blockers, would also work for sodium channel openers like aconite.

It's an interesting argument because sodium channel blockers are actually treatments for sodium channel openers. So how could I use one other drug sodium bicarbonate to treat both a blocker and an opener? You could see how this doesn't make a ton of sense, but there actually are some rational lines of thought for how sodium bicarb could work.

For both of these. It has to do with sodium channel openers, eventually causing similar effects as sodium channel blockers, and a lot of debate over what the actual mechanism of sodium bicarbonate is, whether it's an increased sodium current. Or if it's raising the pH and making the body more alkaline, which influences how the drug binds with the receptor, nobody really knows, which is why I was absolutely fascinated to find out whether or not sodium bicarbonate helped the patients in this outbreak because it could provide some proof of concept to a pathophysiologic mechanism.

But I'm not going to subject you to the five minute ramble that I went on in the show. If you really, really want more information, I'm probably going to release a bonus episode of Toxo explaining all of this mechanism. So check the show notes and if you find the link, it means I went through with it and you are welcome to nerd out with me.

But for now, just know that this is kind of a debated therapy and it's really interesting to hear about whether or not it worked. Okay, back to the show. I know this is anecdote. There's no comparator. What impact did you feel you saw with sodium bicarb? Did you ever see QRS narrowing? Did you ever see, you know, termination of a rhythm?

I, again, I'm just like prefacing this by it. It was, it was all highly anecdotal. Yes, AK all talks evidence, highly anecdotal. But anyway, it felt a lot like that sodium bicarbonate health and, uh, for, you know, whether that's the managing the bi, the acidosis or you know, just even providing volume because we're writing isotonic bicarb at like one DMLS per hour.

But then, like I, I remember for 100 patients, they, they stopped it for a little bit 'cause, you know, patient was doing okay and they seemed shortly after to go back into, you know, having more activity and non-sustained bt and then we started it and kind of got to look up better. But again, like, I think it, you know, it was such a small case theory.

Like IWI wouldn't hang my hat on that as a specific anecdotal therapy, but it felt like it helped, which I know it's not very good medicine. Yes, a massive dose of disclaimer, this is pure anecdote, but at some point, I mean it's your quote unquote small case series is probably one of the largest case series that exists.

So it's at least useful to hear about. I mean, nobody seemed to get worse that, right. Well, and that's the thing, I think a lot of the, like, especially sodium bicarbonate tends to have relatively few downsides and a pretty good safety profile. We use it a ton in the ICU for many different things and I get like the worst case scenario is usually just the volume overload associated with having to run isotonic bicarbon for a long period of time.

Yeah, absolutely. And of course you're probably doing multiple interventions at once, so very difficult to tease out what the specific effect was in terms of anti-arrhythmic management. Lots of debate over, you know, some people actually could find some information about flecainide, which is a sodium channel blocker that really sticks on the sodium channel for a long time.

Compared to some others like lidocaine. So some have recommended that it sounds like, you know, 99% of the people when they see Y complex tachycardia, a lot of people go for amio and that's very reasonable. And it sounds like that was the majority of the antiarrhythmics used was amiodarone in this case.

Not for a good reason other than like a very common antiarrhythmic we use that we're very comfortable with both the dosing and, and using it. And so not that they're necessarily, the other ones are worse, but I just, I don't use lechinite as often. I don't even IV lidocaine, I tend not to use that often and you know, to run infusions of those medications or repeated doses, you know, the ICU nurses aren't as comfortable or used to doing it.

So I think that was part of a bit of a consideration. In general, you know, everything we do is a benefit versus risk assessment and when the benefit is at best debatable in terms of what is best, the only thing you can actually control is risk, which is gonna have to be directly. Correlated with your comfort level and using the medication appropriately.

So I think that's a good caveat. Do what you know you could safely do. Well, I appreciate hearing that perspective, and, and, and I wanna say, first off, as a team, it's incredible, but it's really a feat of coordination and clinical skill that this turned out the way it did. Really just think you should all get significant recognition for that.

But looking in the future from where you all stand, do you think that boys and centers and emergency departments, is there any way that we could better prepare for something like this, a mass outbreak? One thing I felt that I learned from this case, I mean, I learned many things from this case series, but one was that this is probably going to happen again.

The way that, the way with which the public health investigation went, their conclusion for how this aite ended up in this door. The, the bag was labeled Sam Ginger. How did the Aite get in the bag? And through Public Health's investigation, they linked it back to China and in Guang China Guang province, I guess this aconite had been misnumbered and thus improperly labeled.

And it was a company that shipped both aconite for medicinal purposes as well as thin ginger for food. And there's really nothing we can do about that to prevent that from happening again, like here in, in Ontario. So I think just hammering home the relationship between poison center, frontline care providers as well as the public health is important because this is going to happen again.

And it may not just be Stan Ginger and Kinine. Yeah, exactly. Other, you know, toxins that can get, you know, can contaminate our food. I, I need to comment on that for a moment. So I appreciate you bringing that up, Dr. Kent. We, yeah, we never really figured out how. This actually got in there, which you just shared with us.

It was a mislabeling from a food and medicine supply co, you know, or medicinal compound supply company. I'm not sure if that's great to like have, I make both edible products and poisonous products and sometimes I mix them up. I'm trying to get, think of a good allegory. It's like the arsenic and cookie company.

I mislabeled my cookies and now they're arsenic. But you know, I'm actually gonna be talking with a few other groups and there are other cases right here in America that were related to imported products from China and China. I'm actually from at least one other one that I'm gonna be talking with. I'm actually surpri, not surprised, but I'm hopeful to hear that the public health department was able to actually get a root cause from the manufacturer that shipped it here and understand how the mixup happened.

That's actually really great. To show that there is level of cooperation, because sometimes once you leave, you know, your own country's borders. There's, it's hard to get information out of other places. And it sounds like, yeah, it was a mix up. It, it absolutely could happen again. So, so we do need to prepare by having these conversations and, you know, doing these podcasts.

Right. I might mention that since this episode has occurred, we've had a much closer relationship with the public health in the community. So, you know, there were many different public health units involved. Actually, you know, the way that it's set up in Canada or in Ontario is there's an, you know, Ontario body and then there's a, you know, every community has their own public health physicians and officers and such, and we've had a lot of discourse and such with people to decide who is gonna be responsible in the future.

For what part of the investigation and what part of the communications that should go out and such. Still in the works, we're still having these meetings, but we hope that the Poison center will be better connected in the future. I think the Poison Center has such a, a valuable role that could play in a lot of these just from information dissemination, collecting patients understanding who else might be exposed, that's not presented to an emergency department, so I could see so much utility for the poison center involvement.

I think when we reviewed our code orange policy, it, it feels like it's not the traditional use of a code orange, but feels like most of the code oranges are built with a trauma focus or an external traumatic disaster as opposed to a mass poisoning. Yeah. Even the language around it, when we reviewed our code orange policy is more specific to that.

Yeah. But it's not just traumas. What you might think is not a traditional code orange. I would say it's about as code of orange as it can get. Having multiple patients present with very potentially severe toxicity, whether it develops or not. Well, that was really useful. I would like to, I guess, just give an opportunity if you wanted to discuss what were important factors in managing this successfully.

I think that's up to you. Ebony, you were at the bed. You were at the bed though. Oh, okay. Fair enough. Yeah, fair enough. Uh, honestly, I think the biggest factor was my team. Like I had a lot of help. I think this was three or four months into like after I'd finished fellowship and just started Wow. Under practice and intensive events.

So I had a lot of help both from the emergency physicians who started the cases and, you know, were able to help me manage the cases as I was triaging the most sick patients up. I had a lot of help, you know, from emerge nurses from the internist on who was taking offloading a lot of additional work in the emergency department.

My director of the ICU came in overnight to help me, even though she wasn't on call because I was the only person who would wake up at that time. And all the staff, all the workers who helped with flow code orange activation, it was a, like a massive team effort. And without that, like the ICU nurses, all my ICU team, so the nurses and the rts and, and the on-call pharmacist to help us with med, everybody else who helped, and of course the ICU nurse who identified the poisoning team.

Very, very helpful to have a highly functioning team. And well, I really appreciate all of you sharing your perspective on how you work together to not only identify and notify appropriate public health. Manage, having multiple patients present with very potentially severe toxicity, whether it develops or not, is certainly something that takes a high level of skill and clinical ability to manage.

So I really appreciate hearing your perspective. I think I certainly gained some valuable insight and I hope other listeners who might find themselves in a position where you're helping manage an outbreak of who knows what, gathered some insights on how to identify, communicate, and treat a mass poisoning.

So thanks for having us and thanks for having us. Yeah, this was really great. Thank you. Just, wow, that was such an incredible discussion. A huge thank you to Dr. Jessica Kent, Dr. Abha Satia, Dr. Margaret Thompson, Dr. Randy Purvis and Bryn Schermer for sharing their expertise on managing this mass poisoning outbreak.

The insights they had. And recognizing, treating and coordinating care during these rare but extremely high stakes events are invaluable. Not just for toxicologists, but for anyone in medicine, and honestly, anyone who's ever eaten an unlabeled powder because apparently they can be poisonous. And of course, a big thank you to you, our listeners, whether you're in healthcare, toxicology, or just fascinated by these complex cases.

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