Speaker 1: Hi, I'm Aaron Welsh and I'm Aaron Olman up dank
Speaker 1: and this is this podcast will kill.
Speaker 2: You And we're obviously doing things weird because why are
Speaker 2: you hearing from us? Straight away?
Speaker 1: That really felt weird. I was like, there's no first
Speaker 1: hand to count, so I just how do we begin.
Speaker 2: Ease into this?
Speaker 3: No?
Speaker 2: We eased in last week?
Speaker 1: Yeah, yeah, last week.
Speaker 2: Did you listen? If you haven't heard last week's episode,
Speaker 2: I'm not saying like you must pause this and go
Speaker 2: check it out, but like you probably should because we
Speaker 2: had so much fun talking and learning about what is
Speaker 2: poison control and how did poison centers come to be?
Speaker 2: Like where did they arise from? And how did we
Speaker 2: even figure out that that needed to happen. It's a
Speaker 2: great episode. Definitely check it out. And so today we're
Speaker 2: picking up essentially where that left off.
Speaker 1: Right, So we learned all about how they came to be,
Speaker 1: but we didn't learn what they do, how they work,
Speaker 1: who works there, all of these questions that are really
Speaker 1: kind of integral to the existence of poison control centers today.
Speaker 1: And so that is what we're getting into this week.
Speaker 1: And we are getting into that with the help of
Speaker 1: an actual, super duper expert doctor Suzanne Dourion, who is
Speaker 1: the medical director of the Connecticut Poison Control Center and
Speaker 1: is an associate professor at the University of Connecticut School
Speaker 1: of Medicine, and she's a toxicologist. I mean, like, honestly,
Speaker 1: it's this conversation was so much fun. She knows everything
Speaker 1: about all the stories she has.
Speaker 2: This is why we don't need another first hand account
Speaker 2: because she's got so many stories for us. It's phenomenal.
Speaker 2: She sat down with us to answer all of our
Speaker 2: burning questions about what it is like on the other
Speaker 2: end of that phone line when we call in to
Speaker 2: Poison Control, what it took to become a medical director
Speaker 2: of a poison center, what it takes to be a
Speaker 2: poison specialist, by the way, best job title I've ever
Speaker 2: heard of, And there's so much more in this interview.
Speaker 2: We are thrilled to be able to have had this
Speaker 2: conversation and to share it with all of you. It's
Speaker 2: it's going to be a really great episode. We're stoked,
Speaker 2: it really is.
Speaker 1: Before we get into all of that, it is quarantiney time.
Speaker 2: It still is. It still is the same drink as
Speaker 2: last week.
Speaker 1: It's just that good.
Speaker 2: Name your Poison?
Speaker 1: Yeah, I mean, and if you want to stick with
Speaker 1: last week's like recipe, it is whiskey again of whatever kind,
Speaker 1: probably not a pede scotch blah blah blah whatever. Do
Speaker 1: a whiskey and then peaches, lemon juice, simple syrup. It's delicious.
Speaker 1: But hey, it's called name your poison. If you're like,
Speaker 1: you know what, I'm going to do a variation on this,
Speaker 1: I'm going to do something else. I'm going to do
Speaker 1: nectarine instead of peaches. Wow, go wild, wild, go absolutely wild.
Speaker 2: All that to say, the recipe is on our website,
Speaker 2: it's on our social media. Do you follow us on
Speaker 2: social media? We're on TikTok, We're on Instagram, we're on Twitter.
Speaker 3: Rex.
Speaker 2: Is that what they're calling it these days.
Speaker 1: I'm not sure.
Speaker 2: I think it's it's like Prince the artist formally known
Speaker 2: as so it's like X formally.
Speaker 1: Website formally on Twitter.
Speaker 2: Yeah, yeah, okay, anyways, we're there, Aaron, Yeah, do peach
Speaker 2: pits contain cyanide?
Speaker 3: Great?
Speaker 1: Just have that realization accroutely question.
Speaker 2: I don't know.
Speaker 1: Okay, we just confirmed via the search engine that we
Speaker 1: all use that. Yes, indeed, peaches contain peach pits contain
Speaker 1: well a compound that gets turned into cyanide when digested.
Speaker 1: And we didn't realize this. I mean, we should probably
Speaker 1: have just like delete all this in editing and then
Speaker 1: claim that we knew it from the beginning, but.
Speaker 2: We record our other intro. Yeah it's too late now.
Speaker 1: Yeah anyway, Yeah, we totally this did this intentionally. Oh,
Speaker 1: to enjoy your drink. Back to the other stuff website.
Speaker 1: This podcast will kill you dot com check it. We
Speaker 1: got great stuff.
Speaker 3: You know.
Speaker 1: It's got transcripts, it has got links to merch links
Speaker 1: to music by Bloodmobile, links to our bookshop, dot org
Speaker 1: affiliate account, our Goodreads list. It's got to submit your
Speaker 1: first hand account form. If you all have a Poison
Speaker 1: Control Center story, send us it. We would love We
Speaker 1: would love to hear those stories. Use the first hand
Speaker 1: account form or email us whatever.
Speaker 4: We have a.
Speaker 1: Contact us form on our website. Things can we get
Speaker 1: into the episode.
Speaker 2: Let's take a quick break and then we'll get to
Speaker 2: hear from doctor Susanoyan herself.
Speaker 1: Let's do it.
Speaker 2: We are thrilled to have you here, Doctor Doyon, thank
Speaker 2: you so much for joining us. If we could start
Speaker 2: off with you introducing yourself a little bit and telling
Speaker 2: us how you became interested in the field of toxicology
Speaker 2: and how you ended up as the medical director of
Speaker 2: a poison control center.
Speaker 3: Thank you, thank you for having me.
Speaker 4: This is just for me, a wonderful opportunity to share
Speaker 4: a little bit about the world of poison centers. So
Speaker 4: my name is Suzanne Doyon or Duyon, and I'm a physician.
Speaker 4: I went through medical school, but after finishing medical school,
Speaker 4: emergency medicine was where I was headed. And so I
Speaker 4: did a residency in emergency medicine. And during those four
Speaker 4: years as an emergency physician, you rotate to a number
Speaker 4: of different places. You do a little bit pediatric work,
Speaker 4: you do this at the other one of the rotations
Speaker 4: was a whole month at the New York City Poison Center,
Speaker 4: and I just, you know, really really enjoyed that work.
Speaker 4: So upon finishing my four years, I chose to do
Speaker 4: what they call the fellowship. So that was my entire training.
Speaker 4: Four years of medical school, four years of emergency medicine,
Speaker 4: and two years of medical toxicology. What was it about
Speaker 4: the specialty that attracted you?
Speaker 3: Right? And so, of course poisonings are very, very interesting.
Speaker 4: But really it's the opportunity to really dig deep into
Speaker 4: a subject matter, to have an expertise, and to honestly
Speaker 4: bring that expertise to the bedside, to physicians with a
Speaker 4: little bit less expertise and guide them, you know, through
Speaker 4: through the process. Because I always found emergency medicine to
Speaker 4: be in more of a horizontal specialty, you know, a
Speaker 4: little bit a lot of different topics. This was an
Speaker 4: opportunity to know a lot about one small topic and
Speaker 4: that really attracted me. Now following that, you asked me,
Speaker 4: how do I become a medical director of a poison center?
Speaker 4: So once you do all this training, you have a
Speaker 4: couple of avenues you can go in the industry.
Speaker 3: You can do a number of things.
Speaker 4: But the two big avenues are are you going to
Speaker 4: be in a hospital where you consult at the bedside
Speaker 4: and see poison patients at the bedside and you're responsible
Speaker 4: for that one patient in front of you and make
Speaker 4: decisions accordingly. The other avenue, which is the avenue I chose,
Speaker 4: is to go more into a bit of more of
Speaker 4: a public health around, so to speak. You become medical
Speaker 4: director of a poison center, and then yes, you are
Speaker 4: to some degree involved with the management or the care
Speaker 4: of a patient at a bedside because you will be
Speaker 4: on call for the poison center. But also as a
Speaker 4: medical director, you will make more population based decisions. You
Speaker 4: will build kind of decision trees. You will have to
Speaker 4: make big decisions on you know, this antidote for my patient,
Speaker 4: my entire state patient population versus this antidote. How are
Speaker 4: we going to kind of deal with this. I found
Speaker 4: that to be very, very impactful because again, the decisions
Speaker 4: you may impact the population of your state. So that's
Speaker 4: millions of people usually. And then, as I said, we're
Speaker 4: on call, what does that mean. So when a poisoning
Speaker 4: is that that's severe, we have physicians on call twenty
Speaker 4: four to seven, three sixty five. So occasionally that's me,
Speaker 4: but I parachute in and talk to the physician at
Speaker 4: the bedside. So the physician at bedside sees whatever it
Speaker 4: is that they see, whatever poisoning that they're seeing, they
Speaker 4: give me the details. We go back and forth with
Speaker 4: questions to try to kind of get the stories. Rate
Speaker 4: I help with the diagnostic testing and any therapy that
Speaker 4: is administered at the bedside. So just to give you
Speaker 4: an idea. You know, cyanide poisonings don't occur very often.
Speaker 4: A given poison center of my size, Connecticut is about
Speaker 4: three point five million people will get about one sinid
Speaker 4: overdose per year. So there's no single physician in a
Speaker 4: hospital out there that has a lot of experience with
Speaker 4: sinnid overdose. It just doesn't exist. But I get to
Speaker 4: see about one a year. It's not a whole heck
Speaker 4: of a lot, but I get to see one a year.
Speaker 4: So after ten years, I've seen about ten ors roughly.
Speaker 3: And so there are.
Speaker 4: Antidotes for sinite poisoning, but often the physicians I'm speaking
Speaker 4: to have never given the antidote before. They're just like,
Speaker 4: I'm a little bit uncomfortable here. I've never given this before.
Speaker 4: And I'm like, that's okay. I'll stay on the phone
Speaker 4: with you. Just stick me on hold. I will not
Speaker 4: disappear from the phone, administer it. If you run into
Speaker 4: any problems, I'm right there and we can kind of
Speaker 4: navigate whatever difficulties you're having.
Speaker 3: Now.
Speaker 4: In reality, the sin aine antidote is pretty easy to administer,
Speaker 4: it's pretty safe, but still it's addressing that comfort or
Speaker 4: that lack of comfort. So sometimes we stay on the phone.
Speaker 4: We really do stay on the phone with the physician
Speaker 4: in a critically ill patient to really help them at
Speaker 4: the bedside. So I find that very rewarding as well.
Speaker 4: It's not population based medicine, it's a case by case medicine,
Speaker 4: but it's very, very rewarding.
Speaker 1: Of course, you get an incredibly diverse array of phone
Speaker 1: calls at a poison control center every single day, and
Speaker 1: I was hoping you could take us through sort of
Speaker 1: this decision tree for what happens when you get a
Speaker 1: phone call? What are the first steps, what are the
Speaker 1: questions asked? What sort of paths can you follow down afterwards?
Speaker 4: So first of all, let's talk about the phone and
Speaker 4: the phone system. We are not like nine to one one.
Speaker 4: Our phone number is a one eight hundred number. It's quaint,
Speaker 4: we're working. We would love legislation to have a three
Speaker 4: digit number, but getting Congress to dergree is a little
Speaker 4: bit difficult at times hundred number. No matter where dialed
Speaker 4: from a landline, cell phone, doesn't matter, will be answered
Speaker 4: twenty four seven three sixty five. And I want to
Speaker 4: specify here, not by AI, not by artificial intelligent A
Speaker 4: person will answer it on occasion, there's weight times, but
Speaker 4: we really strive to keep our weight times extremely short.
Speaker 4: So one eight hundred number available twenty four hours a day.
Speaker 4: We never, ever, ever not answer the phone. But what's
Speaker 4: going to happen? So you're going to get a person
Speaker 4: who's gonna first ask sort of what's the emergency? Is
Speaker 4: this really really something extra emergent or is this something
Speaker 4: I can take my time and get the patient's name
Speaker 4: and so on and so forth.
Speaker 3: But they will ask you your name or the name
Speaker 3: of the child.
Speaker 4: You know, if it's a parent calling, they will ask
Speaker 4: the age of the person. They will often ask, you know,
Speaker 4: a gender as well, And then what happened? What's the scenario?
Speaker 4: Was it ingested? Is this more of a dermal exposure
Speaker 4: that we're worried about. Is it an ocular exposure that
Speaker 4: we're worried about. Is it an injection exposure that we're
Speaker 4: worried about. Is this an acute exposure It just just
Speaker 4: happened one time right now, just happened or is this
Speaker 4: something that was every day for the last month or
Speaker 4: so or something like that. Is this an accidental exposure
Speaker 4: or is this something intentional? And ultimately, what is this substance.
Speaker 4: Is it a drug, Is it a chemical that we
Speaker 4: find in the household. Is it a snake bite, is
Speaker 4: it a spider bite? Is it something that was breathed in?
Speaker 4: Is it some kind of smell or some kind of
Speaker 4: smoke or some kind of gas in your neighborhood. So
Speaker 4: then once all this information is collected, often the poison
Speaker 4: they're called poison specialists. The poison specialists right off the
Speaker 4: top of their head, knows what the ingredients are, knows
Speaker 4: what are the potential pitfalls, and we'll make recommendations. So
Speaker 4: the recommendations will vary from stay at home and we
Speaker 4: don't need to worry about it too too much to
Speaker 4: you need emergent immediate medical help. How they make these
Speaker 4: decisions is based on their intrinsic sort of internalized knowledge
Speaker 4: of things. And then I create for them one hundred
Speaker 4: to two hundred different complicated algorithms that they can follow
Speaker 4: as well. The algorithms are available for them twenty four
Speaker 4: to seven.
Speaker 3: It's on a computer platform.
Speaker 4: And over time though they internalize again a lot of
Speaker 4: these algorithms. You use the same algorithm every day for
Speaker 4: you know, a weeqbe internalized. It usually so that's that's
Speaker 4: what happens when they call it poison center.
Speaker 2: I love it, having called the poison center several times.
Speaker 2: It's just it's always a phenomenal experience. If that, If
Speaker 2: that is a thing that you can say about an
Speaker 2: emergency situation.
Speaker 3: I'm happy to hear this.
Speaker 4: We strive to be nice, polite on the phone, but
Speaker 4: we almost we mostly strive to be helpful. Collectively, in
Speaker 4: the United States, every poison center feels the same way.
Speaker 4: If we're not helpful, we just get then we have
Speaker 4: failed terribly at our jobs.
Speaker 1: Let's take a quick break.
Speaker 2: So speaking of that, of your staff and everyone that
Speaker 2: you have at your poison center, who are the people
Speaker 2: the poison specialists who work at the poison center. What
Speaker 2: kind of training does someone need to have to be
Speaker 2: able to be a poison center phone operator?
Speaker 4: So who are the people answering the phones. They are
Speaker 4: not operators, they're not volunteers. They're paid. They are usually
Speaker 4: of two trainings. They are pharmacists or nurses. If they're pharmacists,
Speaker 4: usually they're licensed in the state in that state, and
Speaker 4: nurses are licensed as well. If they're nurses, they're usually
Speaker 4: they usually have one or two years of critical care
Speaker 4: experience or something like that, and that's to qualify for
Speaker 4: the job. Now, once they qualify for the job, there's
Speaker 4: usually about one year of solid training that goes on
Speaker 4: where they are supervised in real time. We listen to
Speaker 4: their calls to supervise and make sure that they do
Speaker 4: the job correctly. And as they get better and better
Speaker 4: at their jobs, of course, then we don't listen to.
Speaker 3: Every single call.
Speaker 4: A lot a lot of one on one teaching hours
Speaker 4: and hours hours of didactic training, all this culminating into
Speaker 4: a certification exam. Once they become certified, they can really
Speaker 4: fly solo on the phones. If the case is very,
Speaker 4: very serious, they will then immediately call the physician on call.
Speaker 4: The physician on call is someone like me, someone with
Speaker 4: medical toxic callology training. We can sometimes just speak to
Speaker 4: the poison specialists to give them some guidance, but sometimes
Speaker 4: this is just.
Speaker 3: Plain so serious.
Speaker 4: We must speak to the ED physician, to the intensive
Speaker 4: care physician whoever is at the bedside of the patient
Speaker 4: to help with what's going on. So yesterday I was
Speaker 4: on call. Sometimes the patient had been in the ED,
Speaker 4: the patient was stable, completely stable, but they had done
Speaker 4: all the labs, and the labs had been reported back
Speaker 4: to the poison specialist, and it is at that point
Speaker 4: that the poison specialists call me to review the labs
Speaker 4: to see if based on the labs, it was safe
Speaker 4: to send the patient home from the ED and not
Speaker 4: admit to patient. So sometimes the questions are those, you know,
Speaker 4: how can we safely take care of this patient and
Speaker 4: so on and so forth, And think about that that saves
Speaker 4: an admission, Yes, it's saves healthcare resources. But think about
Speaker 4: the patient. The patient is not facing an emission. The
Speaker 4: patient's family doesn't have to drive back and forth to
Speaker 4: the hospital to visit the patient, if the patient doesn't
Speaker 4: get pricked for blood work, and so on and so forth,
Speaker 4: the patient gets to sleep at home. All these things
Speaker 4: are good, good things for the patient, for the system
Speaker 4: in general. So we try as much as possible to
Speaker 4: keep the patients away from the hospital if we can.
Speaker 4: So this was a good use of poison centers in
Speaker 4: terms of health saving healthcare resources and doing right by
Speaker 4: the patient.
Speaker 1: The poison decks. What can you tell us about the
Speaker 1: poison decks?
Speaker 4: So poison index is how some people call it. Other
Speaker 4: people call it micromedics. We use the terms interchangeably.
Speaker 3: But what is this? What is this mammoth that it is?
Speaker 4: So I will tell you the poison specialists are probably
Speaker 4: in micromedics every minute of every shift.
Speaker 3: But what is it. It's an online database.
Speaker 4: There's an Internet and there's an intranet version there, but
Speaker 4: it's a huge, huge, huge database. You know, you just put,
Speaker 4: for example, mister clean whatever, some kind of cleaner you
Speaker 4: use in the household, but you put the brand name
Speaker 4: and it will start outlining the ingredients for you. But
Speaker 4: you say, you can get that from the label. So
Speaker 4: why do we have microetics Because then micromedics classifies the
Speaker 4: different individual ingredients into kind of categories or buckets, so
Speaker 4: to speak, and that helps us kind of understand the
Speaker 4: product much much, much much better.
Speaker 3: So they let me give you an example.
Speaker 4: Let's say this cleaning agent used in the household has
Speaker 4: benzol ammonium chloride.
Speaker 3: We and poison centers all know what that is, but
Speaker 3: you don't. Let's say you're a new poison specialist. You
Speaker 3: don't know what that is.
Speaker 4: Micromedics or Poison Index is going to classify bisol ammonium
Speaker 4: chloride into cat ionic detergents. Now the poison specialists should
Speaker 4: know catonic detergents. Of all the detergents out there, those
Speaker 4: are the ones I need to worry about. So there
Speaker 4: starts the process. And in caonic detergents, it's only concentrations
Speaker 4: of the desergents above seven point five percent or so
Speaker 4: that we worry about. So the next step once the
Speaker 4: poison specialists recognizes ca ionic detergent is go back what
Speaker 4: percentage this is this? Two, three percent, five percent, seventeen percent,
Speaker 4: what is this? And then take it from there. So
Speaker 4: it's a combination of knowing how to use the database.
Speaker 4: But that's what micrometics does. You need to be able
Speaker 4: to read labels as well. There's a so if we're
Speaker 4: very fortunate in the United States that we have very
Speaker 4: strong labeling laws. They date back to the nineteen sixties,
Speaker 4: and so they will list the active ingredients and they
Speaker 4: will list the inactive ingredients. And then when you see
Speaker 4: that list of active or inactive ingredients, this it doesn't matter.
Speaker 4: The most concentrated one will appear first, not the most
Speaker 4: toxic one. The most concentrated one will appear first, and
Speaker 4: then the least concentrated ones will appear least and usually
Speaker 4: if the concentration is less than one percent, mandated to
Speaker 4: put it on the label at all. Those are the
Speaker 4: basic basic rules, so that again, if you know these rules,
Speaker 4: you could start decoding a little bit these labels that
Speaker 4: we have on all.
Speaker 3: The products out there.
Speaker 4: But that's what we do with micromedics, that's what we
Speaker 4: do with labels using brand names. It helps us kind
Speaker 4: of drove down to what the ingredients are and what
Speaker 4: the toxicities are.
Speaker 2: So how do you analyze the risks of ingestion or
Speaker 2: exposure when there are multiple substances either the example that
Speaker 2: you gave of, like a cleaning product that has this
Speaker 2: long list of ingredients, or someone who either intentionally or
Speaker 2: accidentally took a mixture of different medications. Like, how do
Speaker 2: you I assume, with the assistance of micromedics, prioritize these
Speaker 2: ingredients and what other data do you need to be
Speaker 2: able to work through that problem?
Speaker 4: So I think we probably encounter that, honestly a little
Speaker 4: bit more when people ingest different medications, and these are
Speaker 4: called dr drug interactions, and they're getting a lot more
Speaker 4: common than they used to be. There are not that
Speaker 4: many honestly computer programs that help you with it. So
Speaker 4: what it is is, honestly just having a basic knowledge
Speaker 4: of what gets metabolized, what way, and what medications can
Speaker 4: interfere with that metabolism, So that's a pharmacokinetic or you know,
Speaker 4: just knowing intrinsically that, for example, a medication gets primarily
Speaker 4: eliminated by the kidneys, and then just hearing that either
Speaker 4: another medication is added, or just hearing that the patient's
Speaker 4: kidney function, the patient's renal function is a.
Speaker 3: Little bit off.
Speaker 4: So having a little bit of knowledge of these kinetics
Speaker 4: is important. So we have to teach the poison specialists.
Speaker 4: We really kind of just have to teach and teach
Speaker 4: and teach them. Then we have the other drug drug
Speaker 4: interactions that we call pharmacodynamics. So a drug binds to
Speaker 4: a and another drug is added that binds to the
Speaker 4: exact same receptor. That's basically bottom line, knowing how every
Speaker 4: drug out there works, and we carry that knowledge. We
Speaker 4: just have that knowledge, we teach it and so we
Speaker 4: can often just right off the top of our head
Speaker 4: say that mix of that drug with that drugs is
Speaker 4: not going to be a good mix, because they tackle
Speaker 4: the effect they target the same receptor, and that's going
Speaker 4: to be a bit of a problem.
Speaker 3: We're going to have too.
Speaker 4: Much of an effect or not enough an effect, depending
Speaker 4: on whether they're agonists and antagonists and so on and
Speaker 4: so forth. When we're talking about all the different chemicals
Speaker 4: in household cleaners, for example, the cleaners are all there
Speaker 4: to kind of clean, so they all have they're all
Speaker 4: there to aim for one given thing, and the active
Speaker 4: ingredient is the active ingredient for the purpose of that product. So,
Speaker 4: for example, and insecticide, you look at the active ingredient,
Speaker 4: the active ingredient is the ingredient to kill insects. So
Speaker 4: is that going to be an active ingredient in the
Speaker 4: human Maybe? Maybe not right, So, a lot of insecticides
Speaker 4: these days contain what we call pyrethrins.
Speaker 3: Pyrethrins kill insects, but they're not particularly problematic in humans.
Speaker 4: So we're not going to worry too much with the insecticides,
Speaker 4: or at least the active ingredients. Then we're going to
Speaker 4: start looking at all the other things they added there.
Speaker 4: Things to make it more liquid, things to make it smell,
Speaker 4: god knows what smell. They're searching for, things to make
Speaker 4: it maybe a bit oily, so when you spray it
Speaker 4: on your plants, because it's oily, it stays on the leaves.
Speaker 4: All these things we're going to look at and see
Speaker 4: if it's particularly problematic for humans. And then so if
Speaker 4: they patient ingested the insecticide but also then ingested turpentine,
Speaker 4: so then does the turpentine interact with the insecticides. So
Speaker 4: that's just a lot of thinking, a lot of thinking,
Speaker 4: but again we navigate that.
Speaker 3: And again try to figure out how to best help
Speaker 3: the patient at that point in time.
Speaker 1: Let's take another quick break. You mentioned how some of
Speaker 1: the calls that you're getting more of these days involve
Speaker 1: interactions between different medications. As people are going on more medications,
Speaker 1: have you noticed any other trends in what calls you're
Speaker 1: getting more or what types of calls you're getting more
Speaker 1: today compared to calls in the past, or even just
Speaker 1: like in the overall number of calls that you're getting.
Speaker 4: Absolutely, so we keep abreast of these trends, and so
Speaker 4: you're going to hear a whole host of things as
Speaker 4: just a population shifts in what it is that they purchase,
Speaker 4: what it is that they have in the home, what
Speaker 4: children have access to. So you're going to hear a
Speaker 4: lot of noise right now about melatonin, for example. So
Speaker 4: the melatonin products have been largely manufactured into gummies.
Speaker 3: They look like little candies. Some of them are actually
Speaker 3: shaped like little teddy bears, but they certainly have very
Speaker 3: beautiful colors. They look like candy.
Speaker 4: So not surprisingly, even though they are provided in big
Speaker 4: jars with child resistant caps, children are just either breaking
Speaker 4: through the child resistant cap or some way shape or
Speaker 4: form getting into the gummies. And so there's a lot
Speaker 4: of you know, melotone gummies. So on the issue of gummies,
Speaker 4: marijuana gummies, lots of those around. So the states that
Speaker 4: have legalized marijuana adult use marijuana will have usually a
Speaker 4: component of the marijuana products that are what we call
Speaker 4: the edibles. And the edibles can be all kinds of
Speaker 4: different confections, and so some states have been very strict
Speaker 4: on this. Connecticut that has been very strict on this
Speaker 4: are edibles must have uninteresting square shapes, they can't have
Speaker 4: any interesting colors, they're kind of bland.
Speaker 3: Really. They must be in child resistant containers.
Speaker 4: A given edible cannot contain more than five milligrams per edible.
Speaker 4: Five miligrams of THHC the five DELTAHC, the active ingredient
Speaker 4: in marijuana, and you cannot have more than one hundred
Speaker 4: milligrams in a bottle, so that if the child gets
Speaker 4: into the entire bottle, it's still a large amount of
Speaker 4: five PhD for the child. But we're not talking thousands
Speaker 4: of milgrams. We're talking one hundred milligrams. And so gummies,
Speaker 4: you're going to hear a lot about gummies as being
Speaker 4: a problem. The changes in abortion laws are recent, so
Speaker 4: we haven't quite quite studied yet or produced the data yet,
Speaker 4: but we expect an increase in use of herbals dietary
Speaker 4: supplements to terminate a pregnancy in women who have very
Speaker 4: few other options that I can't say that we've seen,
Speaker 4: but we're watching this. We're watching this right now, we're
Speaker 4: surveilling this. We've definitely seen an uptake in the GLP
Speaker 4: one receptor agonis, the ozempic go Z. There a couple
Speaker 4: of others out there, injectables that are used for the
Speaker 4: management of diabetes, but more recently for weight reduction, and
Speaker 4: we see all kinds of behavior with that from wellness
Speaker 4: spas that are dispensing ozempic. We've also had people who
Speaker 4: if one dose of ozempic is good to lose weight,
Speaker 4: then doubling the dose is probably better.
Speaker 3: You have to be very calpful with these products. The
Speaker 3: escalation of the dose is very very slow, So if
Speaker 3: you escalate the dose too quickly, you run into adverse
Speaker 3: effects and they get a lot of nausea and vomiting
Speaker 3: and lasts for days and days and days. It's a
Speaker 3: gesstro paresis type of nausea vomiting, so problematic.
Speaker 4: Back to the the ozembic dispensed from non retail pharmacies,
Speaker 4: one such product was analyzed. It contained insulin. It did
Speaker 4: not contain any sema glue type, which is the ingredient
Speaker 4: in ozembic. It contained insulin. So the Wellness Spa sent
Speaker 4: non diabetic patients who were looking to lose weight. They
Speaker 4: sent them home with syringes of insulin. Of course, the
Speaker 4: opioid epidemic, we're seeing a lot a lot of that.
Speaker 4: The opiod epidemic right now is really a fentinyl epidemic.
Speaker 4: That is our major major issue in the United States
Speaker 4: is the fentanyl. It's potency. Everybody is kind of hot
Speaker 4: under the collar about xylazine. But it's really the fentanyl
Speaker 4: that is the problem, and we're not out of it.
Speaker 4: Most of us don't predict we're going to be out
Speaker 4: of it for a good ten years. It's going to
Speaker 4: take time to change the tide on that big, big epidemic.
Speaker 4: So I would say those are the big, big trends
Speaker 4: we're seeing right now, but of course that will change
Speaker 4: in six months.
Speaker 1: What do you find to be the most rewarding aspect
Speaker 1: of this work that you do.
Speaker 4: I think the times I go yeah, right, usually the
Speaker 4: appropriate use of an antidote. Appropriate meaning we thought the
Speaker 4: problem was right, We aim to solve the problem with
Speaker 4: an antidote, and then the patient did well. A cyanide
Speaker 4: overdose that gets the appropriate antidote, turns the corner and survives.
Speaker 4: Because sind is quite toxic, is just a cause for celebration.
Speaker 4: But they come in all shapes and forms. I remember this.
Speaker 4: It was very way back, but funny story. The child
Speaker 4: was bidden by copperhead, had a pretty significant wound to
Speaker 4: the hand and was seen in the hospital that could
Speaker 4: not they could not emit pediatric. So this child went
Speaker 4: from this pripher hospital by helicopter to a what we
Speaker 4: call tru shree kre Pediatric Center and got the antidote.
Speaker 4: In the meantime, did very very well, did recovered. I
Speaker 4: think he was seven or eight and kind of left
Speaker 4: the hospital and so think about this. He was out there,
Speaker 4: got bidden by snake, got an antidote, helicopter, ride to
Speaker 4: the city, all this stuff. He goes, I've got a
Speaker 4: story for show and tell. I've just got the best story.
Speaker 5: That was just like, yeah, you probably do. And that
Speaker 5: was just it still brings a smile to my face.
Speaker 5: Just really really funny. Those are yay moments for us
Speaker 5: in poison center circles, but it's usually saving a life,
Speaker 5: getting the antidote right, getting it in quickly, and the
Speaker 5: patient turns the corner, and any physician will tell you
Speaker 5: that that's just you feel like a thousand bucks, our
Speaker 5: million bucks. You really really feel like you're superstar at
Speaker 5: that point in time, and it's so great to turn
Speaker 5: and turn to the family say yeah, he's going to
Speaker 5: do okay. So those are there, our great saves and
Speaker 5: our great great moments. They're few and far between, but
Speaker 5: they're great.
Speaker 1: That was such an amazing conversation, Aaron. We could have
Speaker 1: talked all day.
Speaker 2: I was just gonna say, I could have sat there
Speaker 2: for so many more hours, just like picking her brain
Speaker 2: and asking for stories, and no, I know, I would
Speaker 2: love to sit for a day in a poison center
Speaker 2: as well, just to like hear it and experience it.
Speaker 1: I yeah, well, and it's also I think what's really
Speaker 1: amazing to me is that, like, this is a hugely
Speaker 1: impactful area of public health that I didn't really ever
Speaker 1: think that much about, or know that much about, or
Speaker 1: know what's an option. And I just think it's really
Speaker 1: amazing to know that. Okay, let's say that you go
Speaker 1: into the field of medicine and you're like, I want
Speaker 1: something that has one foot in public health and one
Speaker 1: foot in medicine. This is a great opportunity for that.
Speaker 1: And if you're or if you're just like, hey, you
Speaker 1: know what I want to keep in my brain an
Speaker 1: absolute database of compounds and what organ metabolizes them and
Speaker 1: what receptor they use and blah blah blah, like it's
Speaker 1: so cool. Yeah.
Speaker 2: Also, Aaron, I will I agree one hundred percent that
Speaker 2: this is like, especially coming from the field of public health,
Speaker 2: not realizing how amazing and impactful poison control is. That's
Speaker 2: what we're about to get into is like, ye, what
Speaker 2: poison control can do for you, what it's already doing
Speaker 2: that you didn't even know about. I will say that
Speaker 2: we're going to focus on the US, and this has
Speaker 2: been a very US centric episode, but we're also going
Speaker 2: to get into just how much the US doesn't focus
Speaker 2: enough on poison control hint, hint, funding wise, and I
Speaker 2: will get a little bit into the global status of
Speaker 2: poison control centers worldwide. Spoiler there's never enough of them,
Speaker 2: but they do exist. Nope, and yeah, because there is
Speaker 2: just there's so much there, Aaron, I can't wait to
Speaker 2: get into it. So currently, as of twenty twenty four,
Speaker 2: there are fifty five poison control centers which have recently
Speaker 2: rebranded into poison Help Center. I think is that they're
Speaker 2: calling themselves. So not every state has their own poison
Speaker 2: control center, but every state in the US is served
Speaker 2: by at least one poison control as are all US territories.
Speaker 2: But here is a thing that I again thinking back to,
Speaker 2: like how this started, I just love this about the
Speaker 2: poison control centers in the US is that all fifty
Speaker 2: five five of these use a centralized reporting system which
Speaker 2: is called the National Poison Data System and we heard
Speaker 2: a little bit about this and the information system that
Speaker 2: they used in our interview. But this reporting system is
Speaker 2: the National Poison Data System or the NPDS. This uploads
Speaker 2: real time data of every single call that is made
Speaker 2: to all of these poison control centers. This generates so
Speaker 2: much data that we can use to understand the impact
Speaker 2: of poison control centers and be able to actively in
Speaker 2: like real time see trends like we talked about in
Speaker 2: our interview on like what are people calling poison control
Speaker 2: center about? Surprise, surprise, it's ozepic these days, right, Yeah.
Speaker 2: And so from this we also get these incredible annual reports.
Speaker 2: The most recent annual report that came out was from
Speaker 2: twenty twenty two that was released in January of this year,
Speaker 2: and it happened to be the fortieth NPDS report, so
Speaker 2: happy anniversary. And so this gives us some pretty solid
Speaker 2: statistics on how many people are calling and for what reasons.
Speaker 2: So in twenty twenty two in the US, there were
Speaker 2: over two point four million encounters logged. Of these, over
Speaker 2: two million of them two million, sixty four thousand, eight
Speaker 2: hundred and seventy five were human exposures. Fifty thousand of
Speaker 2: them were animal exposures and three hundred and sixty thousand
Speaker 2: of them were information requests, which means people contacted poison
Speaker 2: control even though there wasn't an actual exposure. Okay, And
Speaker 2: we can see what the top substances were that people
Speaker 2: called about or that people were exposed to. And these, interestingly,
Speaker 2: like the top four main categories, haven't changed a ton
Speaker 2: over the years. And what's interesting is that in this report,
Speaker 2: because it was the fortieth, they had a data table
Speaker 2: that was like, compared to nineteen eighty three when this
Speaker 2: started and twenty twenty two, what are the differences, And
Speaker 2: there are definitely some. But top of the list for
Speaker 2: exposures is analgy six and that is things like estatamenifin
Speaker 2: or titlanol and ibiprofen, which account for eleven percent of
Speaker 2: all calls. Ok Next on the list is household cleaning substances,
Speaker 2: followed by antidepressants and then cosmetics or personal care products,
Speaker 2: which is also interesting, now who is calling in we
Speaker 2: get that information as well. Unsurprisingly, unfortunately, kids under five
Speaker 2: account for the majority of exposures, like kind of overall,
Speaker 2: so kids under age three accounted for twenty eight percent
Speaker 2: of all exposure calls, and kids under five accounted for
Speaker 2: forty percent of all human exposures.
Speaker 1: Okay, and they are.
Speaker 2: Actually more likely to be exposed to cleaning over analgesics,
Speaker 2: which is like we talked about, because they're easily accessible
Speaker 2: and a lot of times we might not think about
Speaker 2: them having as kid proof of access like a lot
Speaker 2: of our medications do these days. All told, all of
Speaker 2: these over two million exposures resulted in three thousand, two
Speaker 2: hundred and fifty five cases of death, two thousand, six
Speaker 2: hundred and twenty two of which were judged as directly
Speaker 2: related to the exposure. And what I found really interesting
Speaker 2: is that out of all of these poison control calls,
Speaker 2: whenever there is a death that's reported, there's a really
Speaker 2: complex review process where they go back to that data
Speaker 2: to try and determine how likely it is that the
Speaker 2: exposure was related to the death. If that makes sense.
Speaker 1: Okay, interesting. Yeah, So that.
Speaker 2: Was like a lot of data thrown at us. And
Speaker 2: there was a really interesting radio Lab episode that I
Speaker 2: listened to. You listen to it?
Speaker 3: I did too.
Speaker 1: Yeah, it was so good.
Speaker 2: It's really great. Their production value can't be matched but
Speaker 2: one of the things that they mentioned in that episode
Speaker 2: is that calls have been on the decline to poison
Speaker 2: control centers, and it's in this report as well too.
Speaker 2: Calls have been on the decline. There have been a
Speaker 2: fairly continuous decline in total calls to poison control centers
Speaker 2: since about two thousand and eight, which is when it peaked.
Speaker 2: When it peaked, there were just over four point three
Speaker 2: million calls to poison control centers in two thousand and eight,
Speaker 2: which included two point four million exposure calls, human exposure calls,
Speaker 2: and one point seven million information calls. There was some
Speaker 2: spikes during the pandemic, especially related to disinfectant use and
Speaker 2: then COVID vaccines and things like that, which is probably
Speaker 2: interesting in its own right, very interesting, huh, But I'm
Speaker 2: not going to get into the detail. But what I
Speaker 2: think is so interesting about these trends specifically, are a
Speaker 2: few important detail that are even bigger picture than just
Speaker 2: a declining calls. What this declining call seems to reflect
Speaker 2: is a number of different things. The report from twenty
Speaker 2: twenty two sites that there has been overall declining birth rates,
Speaker 2: which is important because exposure rates are so much higher
Speaker 2: in children under age five interesting and an increasing reliance
Speaker 2: on the Internet because a huge part of what I
Speaker 2: just said, one point seven million calls were information only
Speaker 2: calls compared to three hundred and sixty thousand information calls
Speaker 2: in twenty twenty two. So when someone is looking for
Speaker 2: just information about a substance without a direct exposure, they're
Speaker 2: going to go to the internet first. And that makes
Speaker 2: a lot of sense. Now, as of twenty fifteen, poisonhelp
Speaker 2: dot org can actually get you really similar information to
Speaker 2: what you're going to get from a poison control call
Speaker 2: because you can get in touch with poison Control via
Speaker 2: their website poisonhelp dot org as of twenty fifteen, So
Speaker 2: some of these cases might still make it into the
Speaker 2: poison control database if they're coming from that website, if
Speaker 2: that makes sense.
Speaker 1: Uh huh.
Speaker 2: But what we can't necessarily interpret from this reduction in
Speaker 2: calls is that exposures are decreasing, because what this data
Speaker 2: from twenty twenty two shows is that exposures with more
Speaker 2: serious outcomes, including hospital facility calls and calls that result
Speaker 2: in major harm or death, have actually been on a
Speaker 2: slight increase across the same time period.
Speaker 1: Okay, what are the characteristics of these calls, Like, are
Speaker 1: there patterns in this?
Speaker 2: Not necessarily patterns aside from just that they're more serious
Speaker 2: calls that have a more serious outcome, whereas information only
Speaker 2: calls and calls about less serious exposures tend to be
Speaker 2: have been on the decline around the same period, and
Speaker 2: it's not a huge increase. I think it was like
Speaker 2: zero point one point seven percent from last year, for example,
Speaker 2: and that's about on average. I think it's like one
Speaker 2: percent ish over the years. But it is really important
Speaker 2: right that people are still having dangerous exposures and still
Speaker 2: relying on poison control to call, either from their home
Speaker 2: or health care facilities are relying on calling poison control
Speaker 2: for information, and so this is a really important thing
Speaker 2: that poison control centers are kind of grappling with, is
Speaker 2: like how to bring themselves into the twenty first century,
Speaker 2: which is really important because we can look at lots
Speaker 2: of data and see how important poison controls are in
Speaker 2: terms of lives saved and in terms of healthcare dollars saved.
Speaker 1: Aaron, uh huh, which.
Speaker 2: I love to talk about. We don't like to think
Speaker 2: about healthcare dollars, but we talk about them on this
Speaker 2: podcast a lot, because, especially in the world of public health,
Speaker 2: you have to unfortunately justify your existence using dollar signs,
Speaker 2: and it happens that in the case of poison control,
Speaker 2: we can absolutely do that. There was a ton of
Speaker 2: different studies that I saw, but I'm actually going to
Speaker 2: cite a few that were really old just because they
Speaker 2: highlighted this point so well. There was a paper from
Speaker 2: nineteen ninety one when the state of Louisiana closed their
Speaker 2: poison Control center, and then they were able to compare
Speaker 2: after this closure in Louisiana, information between Louisiana and Alabama,
Speaker 2: which is right next door, has very similar demographics and
Speaker 2: prior to the closure of the Louisiana Poison Control Center
Speaker 2: had very similar, almost identical triage patterns for exposures of
Speaker 2: their poison control center. So when they looked at the data,
Speaker 2: it was like really really similar calls that were coming in, Okay,
Speaker 2: And what they found is that the rates of people
Speaker 2: who had to end up going to the emergency room
Speaker 2: or urgent care or the doctor's office in Louisiana after
Speaker 2: the close sure of this poison control center, four times
Speaker 2: as many people sought care for poison exposures in Louisiana
Speaker 2: compared to Alabama during that time, and the estimated cost
Speaker 2: of this hospital and outpatient utilization for things that these
Speaker 2: are low level exposures that did not need to be
Speaker 2: managed by health care facilities at all, was one point
Speaker 2: four million dollars.
Speaker 1: Oh my gosh.
Speaker 2: And you might say, well, that's not that much money
Speaker 2: when you look at like huge health care spending overall,
Speaker 2: but it was also three times as much as the
Speaker 2: poison Control Center cost to run in its entirety.
Speaker 1: Oh my gosh. Okay, So I have a question though,
Speaker 1: just like logistically, when you call poison control, it's eight
Speaker 1: hundred two two two one two two two. That's the number.
Speaker 1: So when Louisiana shut down, it's poison control. What did
Speaker 1: that mean if you were in the state of Louisiana
Speaker 1: and you call that number. That is such a good question.
Speaker 2: I don't know what happened in nineteen ninety one.
Speaker 1: Okay, nineteen one, so things might have been organization.
Speaker 2: So I don't know if like they just lost access entirely.
Speaker 2: I know that they had enough data to be able
Speaker 2: to say there's no access here. Let the parent see
Speaker 2: what happens. Yeah, because right now, when a poison control
Speaker 2: center shuts down and we'll get there, then calls are
Speaker 2: going to be rerouted, and but it could end up
Speaker 2: then overwhelming another poison control center if you don't have
Speaker 2: enough people to kind of run it, and that sort
Speaker 2: of a thing.
Speaker 1: Okay, but yeah, that another question following get it to me.
Speaker 1: After this report came out, did Louisiana immediately go oh wow, whoops.
Speaker 2: I don't know the timeframe, but there is one now okay.
Speaker 1: Hopefully it was nineteen ninety two or like whenever.
Speaker 2: It was three.
Speaker 4: I don't know.
Speaker 2: But there are a lot of other things that go
Speaker 2: into how much poison control centers can help. Right There
Speaker 2: are a lot of other examples like this. There's also
Speaker 2: some really good ones. There's a paper that details how
Speaker 2: in El Paso, when they coordinated really well with a
Speaker 2: poison control center, they have documented that they were able
Speaker 2: to avert like seventeen hundred ambulance calls in a really
Speaker 2: short time period. There's a review paper from two thousand
Speaker 2: and nine, and a lot of these papers were really
Speaker 2: quite old, but it had a lot more numbers, and
Speaker 2: that combined with a report that I will say was
Speaker 2: commissioned by the American Association of Poison Control Centers, so
Speaker 2: there was some bias for that because it was a
Speaker 2: consulting firm commission by poison Control But looking at all
Speaker 2: of this data, the overall cost savings estimate of poison
Speaker 2: control centers is between seven and fifteen dollars per dollar spent,
Speaker 2: which accounts for close to a billion dollars in healthcare
Speaker 2: savings annually. And that's not even counting how many lives
Speaker 2: are saved, because there are a lot like there is
Speaker 2: a lot of data that shows that you can reduce
Speaker 2: hospital length of stay and you can improve health outcomes
Speaker 2: by having access to poison control center. Despite this, budgets
Speaker 2: are constantly at risk for poison control centers in the US.
Speaker 1: It's the same story for public health in general. And
Speaker 1: it is infuriating.
Speaker 2: It is the most infuriating and just the tail as
Speaker 2: old as time. Honestly, most of the funding for poison
Speaker 2: control centers is a mish mash cobbled together budget, right.
Speaker 2: Some of the funding comes from state budgets, some comes
Speaker 2: from federal budgets. There's like over twenty nine different agencies
Speaker 2: which contribute to various poison control centers and I said
Speaker 2: that there are fifty five poison control centers in the US.
Speaker 2: If you read some of these papers, they'll tell you
Speaker 2: that there are sixty one, because there used to be,
Speaker 2: but in the last few years several of them have
Speaker 2: closed due to budget cuts. Poison control centers in the
Speaker 2: US are so vulnerable it is bananas when you look
Speaker 2: at the data of how much they contribute, how many
Speaker 2: dollars they save, how much data we are able to
Speaker 2: generate from this real time reporting system, like the value
Speaker 2: that they bring is incredible. So that's our rant. I
Speaker 2: don't know how to fix that, but it's a thing.
Speaker 1: I mean invest in public health, yep, yep.
Speaker 2: Now, globally, speaking of investing in public health, as of
Speaker 2: January twenty twenty three, only forty seven percent of World
Speaker 2: Health Organization member states have poison control centers, so it's
Speaker 2: a pretty low number. Most of the countries in Europe, Australia,
Speaker 2: the UK, they all have poison control centers, but especially
Speaker 2: in low and middle income countries. There's a lot of
Speaker 2: parts of the world where people just don't have access
Speaker 2: to this information, which is a huge issue.
Speaker 1: Right well, and I think it just sort of shows
Speaker 1: in general that pattern where it's expensive to invest initially
Speaker 1: in poison control centers, but over the long run it
Speaker 1: saves money exactly. But if you don't have that initial
Speaker 1: investment and it's more like okay, well just triaging right
Speaker 1: the healthcare situation, then preventative stuff is like down the line, right, Yeah.
Speaker 2: If you're so deep in survival mode you can't think,
Speaker 2: yeah that ony steps ahead. Yeah it's tough, but they're
Speaker 2: incredibly valuable. I also so that everyone can say they
Speaker 2: know exactly how to contact if you are exposed to
Speaker 2: a potential poison, or you're worried you are exposed to
Speaker 2: something has it is, you too can have the joy
Speaker 2: of calling your friendly neighborhood poison control center. The phone
Speaker 2: number is one eight hundred two to two one two
Speaker 2: two two, or you can go to poisonhelp dot org.
Speaker 2: And another plug for the incrediblepoisonhelp dot org webs site
Speaker 2: is that in twenty twenty two they updated this website.
Speaker 2: So in addition to you, if you don't want to
Speaker 2: talk on the phone, you are not into talking on
Speaker 2: the phone, A lot of people aren't into talking on
Speaker 2: the phone, you don't necessarily have to. You can through
Speaker 2: their website fill out this information. They ask you very
Speaker 2: specific questions and you essentially go through the same exact
Speaker 2: steps as you would talking to someone on the phone,
Speaker 2: which is great. But as of twenty twenty two, they
Speaker 2: also have an option where you can say that this
Speaker 2: is a test or an information call rather than an
Speaker 2: actual exposure, which I think is just really really helpful.
Speaker 2: If you're like kind of worried about something but you
Speaker 2: don't know if anyone is exposed, but you're just worried
Speaker 2: about bringing something into your house or whatever it is,
Speaker 2: you can go there and get some information. It's phenomenal.
Speaker 1: M That's all I got.
Speaker 2: Erin poison controls.
Speaker 1: Wow, love them, love them. Are there poison control t
Speaker 1: shirts that we can.
Speaker 2: You know what we should find out?
Speaker 1: We should find it, get some but until then, until
Speaker 1: we can get our hands on a T shirt or
Speaker 1: make a T shirt or shirt, until then you can
Speaker 1: read more all about it. Specifically. Let me tell you
Speaker 1: where I got my information today. Saren already told you
Speaker 1: last week.
Speaker 2: Unsurprisingly, almost entirely, my information was from the twenty twenty
Speaker 2: two Annual Report of the National Poison Data Systems or NPDS,
Speaker 2: from America's poison centers it was their fortieth annual report.
Speaker 2: It was really phenomenal. There is literally so much detail
Speaker 2: in this report, it's like it just keeps going on
Speaker 2: and on and on. But I also had a number
Speaker 2: of really interesting papers about the impact of poison centers,
Speaker 2: both historically and today. And then a list from the
Speaker 2: World Health Organization of a directory of poison centers which
Speaker 2: isn't entirely up to date but is really interesting. You
Speaker 2: can find the list of these sources from this episode
Speaker 2: and every single one of our episodes on our website
Speaker 2: This podcast will Kill You dot Com under the episodes tab.
Speaker 1: Thank you again, so so much, doctor Doyon for taking
Speaker 1: the time to chat with us and sharing those amazing stories.
Speaker 1: We had the best time, we really really did.
Speaker 2: And also thank you for being so enthusiastic and like
Speaker 2: sending more ideas and things that we have so many
Speaker 2: more things to cover. I am thrilled about it, yes, totally.
Speaker 2: Thank you also to Bloodmobile for providing the music for
Speaker 2: this episode and every one of our episodes.
Speaker 1: Thank you to Tom Bryfocal and Leana Scuialacci for the
Speaker 1: amazing audio mixing.
Speaker 2: We love it. Thank you to everyone at Exactly Right Network.
Speaker 1: Thank you to you listeners for listening. I we really
Speaker 1: hope that you enjoyed these last two episodes and learned
Speaker 1: more and maybe if again. If you have a poison
Speaker 1: control story that you want to share, please send it
Speaker 1: our way.
Speaker 2: Yeah, love to hear it. Thank you especially to our patrons,
Speaker 2: Thank you so much for supporting us on Patreon on
Speaker 2: We really appreciate it. It means the world to us.
Speaker 2: It really does.
Speaker 1: Well. Until next time, wash your hands
Speaker 2: You filthy animals.