"Everything in the world is made of this," explains Robert Hoffman, MD, director of NYC's Poison Control Center. "How you put these elements together determines whether a substance is toxic or not." (Photo by Bud Glick)

Life on the Line

Whatever Poison You Pick, It’s Up to the Experts at NYC’s Poison Control Center to Make Sure It Doesn’t Kill You

New York City’s Poison Control Center, established in 1955, is one of the oldest programs of its kind in the country. It’s a unique partnership between the city’s Department of Health and Mental Hygiene, Bellevue Hospital Center, and NYU Langone Medical Center. Fielding some 70,000 calls annually, the center provides assistance and advice 24/7 to anyone who dials 212-POISONS. The center’s director since 1994 is Robert Hoffman, MD (’84), associate professor of emergency medicine and medicine. He was encouraged to become a toxicologist by his mentor, Lewis Goldfrank, MD, chairman of the Department of Emergency Medicine and director of emergency medicine at Bellevue and NYU Langone, who also serves as the center’s medical director. Dr. Hoffman is an editor of and contributor to Goldfrank’s Toxicologic Emergencies, the definitive textbook in the field. Drs. Hoffman and Goldfrank met with news&views recently to discuss the center’s vital role in public health.

When the phone rings, what happens?

On a typical day we get about 200 calls—our service is free and confidential. The phones are answered by poison information specialists who are pharmacists, nurses, or physician assistants. We train them to take emergency calls, and after about one year, they can become certified by the American Association of Poison Control Centers. Once we find out from the caller what happened, we use computer programs to look up a poison’s effects to determine the best course of action, which may range from going to the hospital to simply waiting it out. In addition to advising on treatment, our role is to understand the epidemiology of poisoning and help prepare for disasters. Our data is merged with data from our counterparts nationwide. If scattered cases of cyanide poisoning start turning up, for example, the terrorism alarms would go off.

Are most callers in crisis?

About 45,000 calls per year involve human exposures. We deal with parents who are frantic about things their children may have swallowed, doctors who need help managing critically ill patients in the hospital, and people who have questions about their medications. The rest are requests for information about events that haven’t yet occurred, such as people concerned about interactions between their medications or between their medications and foods—these are ideal opportunities to prevent poisoning. If we know you’re going to be sick, we can help you get an ambulance and make sure that appropriate first aid is provided before it arrives. More than half the calls concern children, but most don’t need to go to the hospital. Last year, we successfully managed almost 20,000 childhood cases at home. Since each visit to the pediatric emergency department costs about $500, that’s a savings to the public of $10 million, which is far greater than the center’s budget.

What makes a substance a poison?

At a high enough dose, virtually everything is toxic, even water and oxygen. What keeps our job exciting is that every time something new comes to the market—a pharmaceutical, an illegal drug, a chemical product—we have to learn about it. We’re often challenged with unknown exposures or things that have never been described before. We’re medical detectives.

How do antidotes work?

Antidotes either remove the toxin or counteract its effects in the body. In the majority of cases, general management of poisoning coupled with sound medical judgment is more important than finding the right antidote. We treat the patient, not the poison, and we do that like any emergency: beginning with the ABCs (airway, breathing, circulation), monitoring vital signs, and providing supportive care. It’s rewarding to use antidotes, but some can be more dangerous than the poison.

Do the experts ever get stumped?

We see many of the same things over and over again, so we generally know what’s out there. But if it’s new to New York—like a traveler who comes here sick from a medicine or a venomous bite he got in another country—it’s our job to figure it out. We have robust medical resources, probably more than any other poison center, including backup from physicians at NYU Langone and Bellevue. There are always two toxicologists on call, and we can draw upon experts in hyperbaric medicine, plants and mushrooms, spiders and snakes, and other specialties who volunteer their support. Plus, we have colleagues around the world. Toxicology is a small discipline, so we’re all on a first-name basis.

Does your public service go beyond poison control?

The Poison Control Center is public health in action. When the Department of Health and Mental Hygiene is closed, we’re its eyes and the ears. We play a major role in terrorism preparedness and disaster medicine. Whether it’s a meningitis outbreak or an anthrax attack, we’re involved.

What role do you play in educating and training toxicologists worldwide?

We have the world’s largest training program in medical toxicology. We established one of the first fellowships in toxicology in the U.S. We’ve probably trained close to half the toxicologists in America. Every emergency medicine physician in New York City trains with us for a month. People come here from across the globe, and we’ve helped create poison centers in Hong Kong and Denmark. Currently, we’re working through NYU Langone to support one in Ghana.

Any challenging cases come to mind?

Two people showed up at a hospital complaining of stomach problems, followed by foot pain so bad that they couldn’t walk. The hospital called us after their exams and lab tests were all normal. When we examined them ourselves, we found that one was losing her hair. Two of their friends had similar, milder symptoms but were not in the hospital. After some questioning, we found that they had all shared a box of homemade candies a few days earlier. We had the remaining candies analyzed, which confirmed our suspicion of thallium poisoning. With treatment, all four recovered. The police finally determined that the candy was poisoned by an ex-boyfriend. It was an unusual case, and we were glad to be called in to help solve it and ensure the right treatment.