 This is State Tech Hawaii. The immunity matters here. Good morning. This is Craig Thomas, your host on Much More Medicine, assisted, as always, by engineers Eric and Rich. And with me today is my friend, Dr. Diana Felton. She is an emergency doctor, but also our state toxicologist. So I'm delighted you're here. Welcome. Thanks, Craig. I'm happy to be here. Excellent. And you know, I don't know a lot about toxicology. I know even less, I'm just admitting it, I call the poison center when I want advice. Good. And we're going to talk to you about toxicology. But you know, I'm really interested in your job, how it fits into things, how it's structured with the state, and also a little overview on what it's like to be a toxicologist. Sure. Hawaii has an interesting setup within our Department of Health. So unlike most states, our Department of Health and our state EPA are all one agency under the Department of Health. That is interesting. It is. And because of that, it allows for a position like mine, which is technically in the environmental side of the Department of Health. But it's really a crossover position. So my position as the state toxicologist in the Hazard Evaluation and Emergency Response Office is to take any sort of hazards, particularly hazard substances or other hazards that come up in the state and really consult on and apply the medical and human health effects aspect of them. You know, I bet that's really interesting. And I know you cover a broad variety of things. Hawaii's got some interesting, nearly unique exposures, I think, relative to the mainland. Absolutely. And of most interest of that and most unique really in the world in some ways is our volcano. Let's talk about that. I can understand swimming in lava is a bad idea. And incidentally, I was working in Hilo years ago when somebody went wading in lava. It's a bad idea, I'll tell you. But I also know that there are some other issues we should talk about. There are. And from a toxicology perspective, the biggest issues from the volcano, particularly an active volcano, but other times as well, are the emissions and the air quality. And in particular, an erupting active volcano is going to emit mostly particulate matter, ash, and sulfur dioxide. What's interesting and what I've learned recently from our geologists is that as the volcano calms down and cools, and the surface cools, you end up with a sort of wetter but cooler environment near the surface of the earth. And that allows the sulfur to come out, instead of sulfur dioxide, as hydrogen sulfide. And that's really noticeable because the hydrogen sulfide is very smelly. It has a really noxious odor, smells like rotten eggs. And the smell threshold for it is very low, meaning that you only need a tiny amount of hydrogen sulfide in the air to really smell it. No, hydrogen sulfide is notable because it's a very, it can be a very dangerous gas. It's considered a knockdown agent. It's something that can knock people out, make them unconscious, or even kill them very quickly. That's at much, much higher levels than we are seeing emitted from the volcano and much, much higher than you would smell it. Got it. So noxious, certainly can't sneak up on somebody with it, and it's not the major gaseous health risk from the volcano. Exactly. And right now, people are smelling it at times in some of the areas around in the Lower East Rift Zone, of course, up at the sulfur vents up near the summit. People smell it. But it tends to be, at least so far, in what we know from Kilauea and the history that we know of less of a problem than the sulfur dioxide that we experienced during the big eruptive events like this last summer. Let's talk about sulfur dioxide. Well, I'm interested in how about sulfur dioxide. I'm interested in your thoughts of something else because these gases are both clear. They're invisible, at least initially. I think that sulfur dioxide may interact with ozone or something. Is it a factor in smog? I guess my point is the fog we see has also been studied, and it's irritating, but my sense has minimal health risks. Is that a fair summation that's been looked at for a long time? Yeah, it depends is really the answer. I like that answer. The sulfur dioxide is often a big component of fog as is particulate matter and some of the other things that come out of the volcano. And fog and depending on the amount of sulfur dioxide in particulate matter can have varying effects for people. The biggest concern is that when the levels of sulfur dioxide get high enough, they really can aggravate respiratory problems. So what I'm hearing you say that I think sort of consistent what I've seen over the years, the obviously they're associated the particulate matter and the sulfur dioxide, but sulfur dioxide is likely the real issue. Exactly. And on the screen, you can see right now is our, this is our Department of Health guidance on short-term advisory levels for sulfur dioxide. So we have this color coded system and some of the key points I think on it are, on the left is the concentrations that we monitor with a number of air monitoring devices on the Big Island. There were more active during that eruption, but still plenty, but each color goes along with some recommendations. And this is how we try to communicate with the public when the levels change and who might be at risk. So in particular, it says sensitive groups on the list and sensitive groups tend to be people with respiratory problems like asthma, COPD, emphysema, sometimes the very old and the very young. And those groups are likely to be more sensitive to the respiratory effects from sulfur dioxide than the average person. And so one way I've always thought about sensitive groups is if you give enough of a noxious agent to anybody, we'll all cough and wheeze. But there's a whole subset of people who start before anybody else has any effect at all. That's exactly correct. The other thing I've got your chart is, PPM stands for parts per million. So you're talking fairly small amounts, it looks like. Most of the time. Well, exactly. I just thought I'd get the units out there. So what did we learn if anything went over the last eruption? And do you by any chance have a ballpark figure? And this may be an unfair question. How much was being emitted on a sort of average daily basis during the height of the eruption? Sure, we're still really analyzing the data from the during the eruption at different times. There were up to 17 air monitors in the general area. And many of them were recording data points every second or every five seconds. So there's millions and millions of data points. So with the help of some collaborators in the Department of Health, the United States Geologic Survey and a gentleman by the name of Dan Spiker who works at Oregon Health Sciences University, we've been slowly starting to analyze and collect the data in meaningful ways. What we found is the really high exceedances of those advisory levels where we really would start to worry about people tended to be very brief. There were very few that lasted even as long as an hour. So it really calls into questions about how do you advise people to evacuate or not if these periods where the levels of sulfur dioxide are going up are very brief. And that's really the challenge what we're trying to sort out from the data to be able to make plans for the next time something like this happens, how we can make sure to keep people safe, provide good recommendations without inconveniencing people unnecessarily. You have a sense for how far from the active eruptions you ever spike into those levels? That's a good question. So certainly with the data that we have, the highest levels were right in lower Lailania states. And in fact, the monitor that recorded the highest levels burned down a few days into the eruptives. So you're thinking it was close to the lava. Yeah, so that was right there. Farther away in some of the other neighborhoods, there were definitely periods of time that exceeded some of the national, well certainly the national air quality standards, which are a little hard to apply in this environment. But we did do some comparisons with workplace standards. Now it's not a perfect comparison because workplace standards are people eight hours a day, five days a week, don't account for sensitive populations, et cetera. But we did find some of the time, some of the averages exceeded some of those workplace standards in some of the neighborhoods, other neighborhoods in the Pona area. You know, you're touching on why, and you know this better than me, maybe you can help our listeners understand why toxicology is so tricky. Because humans are lousy research subjects. You know, we don't comply with the rules, whatever the rules are for a study. You can't really experiment on people directly. We live a long time, so change matters over 30 or 40 years sometimes. And my sense is most of toxicology is observational and case reports and things like that. Is that fair? That is very fair. And we do our best to combine all the information we can gather. And a lot of those studies are, as you say, observational, their epidemiology studies on humans, oftentimes occupational exposures, case reports, and then animal studies, which are difficult to correlate directly with what would happen in a human. And oftentimes putting together all that information, you still don't end up with a good model for exactly what's occurring to an individual being exposed to a chemical. And so it's really a struggle to try and understand how some of these hazardous chemical exposures may be actually affecting either an individual or the population. And sometimes answers only become obvious years down the road. You know, I think toxicology is particularly difficult but the, well, I'll see what you think of this. For me, and I don't know how many patients I've seen in a virtual environment over my career, but it's gotta be more than 70,000 and it might be 100,000. Unmemory, never that good, how good and good as it used to be. So it's quite possible, I'm forgetting the previous case that was exactly like what I'm seeing on a particular shift. But in any event, my sense is that essentially every shift, and I don't know, you see what 20 or 25 patients on a shift typically, essentially every day a patient presents with a somewhat different constellation of history and symptoms and exposures and physical exam or laboratory findings than I've ever seen before. And so that means every day you gotta like, wonder what the knowledge we have supports doing here. Is that? Yeah, that's exactly the same. No two individual cases are gonna be exactly the same. There's so many variables with each scenario. Then you compound that with the difficulty of studying these problems. As you mentioned, we can't go around giving, taking a group of people, giving half of them a poison and half of them not and then seeing what the differences are. I have a list, I'll give you the, no, don't. So doing traditional double blinded randomized studies like we like to do in medicine is just really not an option in toxicology. So we really have to look historically, we have to use pharmacology, toxicology and biochemistry to try to anticipate what some of the problems are. And then we look retroactively at people that have been exposed and what happens, but often times the models just don't quite match what's happening and Kilauea and what's happening at the volcano is a classic example. There's really not been other eruptions in our history that were like this one, either at Kilauea or in other parts of the world. There's a lot of information in the medical literature about experiences on other volcanoes, Mount Etna, the volcano in Iceland that erupted a bunch of years ago, but those were different geologic conditions, different kinds of volcanic emissions and the information those researchers gained from those experiences is helpful, but doesn't directly necessarily apply to our experience. We're all part of the great experiment. We're gonna take a break and after the break we're gonna talk about some other, maybe not Hawaii specific, but Hawaii common issues. So I'll look forward to that conversation. This is Think Tech Hawaii, raising public awareness. Choose to treat it with the help of a physical therapist. Physical therapists treat pain through movement and exercise. No warning labels required and you get to actively participate in your care. Choose to improve your health without the risks of opioids. Choose physical therapy. Aloha, I'm Marcia Joyner, inviting you to come visit with us on cannabis chronicles, a 10,000 year odyssey, where we explore and examine the plant that the news has given us and stay with us as we explore all of the facets of this planet on Wednesdays at noon. Please join us, alo. Welcome back, this is Craig Thomas, your host on Much More on Medicine and with me is Dr. Diana Felton, our state toxicologist and emergency physician, because of course that's a true calling. So before the break we were talking about, honestly you're a fascinating job of trying to sort out what toxins in the environment are doing, what are an issue, what aren't, and how difficult that is. In Hawaii, both by location, cultural practice, we have some exposures that aren't so common in most of the rest of the country, especially if you were indexed the rest of the country as say, Kansas, not a lot of fish in Kansas. So let's talk about that. What does our seafood diet, when none of this conversation is designed to discourage people from eating seafood, which is clearly associated with some significant health benefits, both for adults, pregnant women and kids. But there are some things we should know about and discuss. Absolutely, and I just wanna reiterate that, that eating fish is good for you and should be done on a regular basis, but there are particular choices to be made depending on your particular risk that can make it a healthier pastime. So in particular we tend to focus on mercury as a contaminant of fish. Mercury has been contaminating fish for a long time. It's bio-accumulative, which means that it builds up in especially the bigger fish who have eaten the smaller fish, who have eaten the smaller fish. So the bigger fish tend to have higher levels of mercury and in particular when mercury is really a problem is in the pregnant women. Mercury is toxic to the developing brain. So for pregnant women to minimize their mercury consumption is really a good idea. In addition, mercury takes a long time, almost a year to eliminate from your body. So if you're pregnant or thinking about becoming pregnant or you're nursing, it's really a good idea to try to minimize the amount of mercury that you ingest. At the same time, you wanna keep eating fish and seafood because of the health benefits, both to yourself and to the developing fetus. So it's really about choosing the right fish to eat and doing so in healthy ways. And the fish we think about with the most concern are the really big fish. So things like swordfish, things like a cheeky shark, those tend to have the highest mercury levels and are really not recommended for any of these populations to eat at all. And in fact, I would probably recommend that most people don't ingest these because of the high levels of mercury. As far as fish that it's okay to eat, but you should probably think about having maybe twice a month be things like ahi, opa, oh no, some of the bigger pelagic fish are really gonna have some of the higher levels of mercury. And then there's a lot of fish that you can eat pretty much whenever you want. And those tend to be the smaller fish. One easy way to remember is if a fish fits whole in your frying pan, it's probably safe from a mercury standpoint just because it's gonna be small enough that it won't have bio accumulated as much mercury. Thanks, and my understanding, and correct me if I'm misrepresenting anything here, is this is becoming an increasing problem because we're putting a lot more mercury into the atmosphere which ultimately ends up in the ocean like most things do. That's correct. Sadly, that's part of our experiment. Okay, let's talk about, well, you know what? Something else we're putting in the environment? There's plastic. And the associated things like the PFAS stuff. Incidentally, I don't know if you saw this, there was a scheme involving a large floating boom to try to sweep plastic out of the ocean. Only mention it because it was launched with great fanfare, didn't work. Oh well, maybe we should not put plastic in the ocean. It's a thought. Anyway, let's talk about that. Sure, there's a new emerging group of chemicals that are referred to as contaminants of emerging concern. And they're called PFAS, P-F-A-S. It stands for Perfloral Alkal Substances. And what they are is basically long carbon chain molecules with a lot of fluoride ions attached. And they're used particularly in waterproofing, so waterproof clothing, stain resistant things. They're in some personal care products. They're in a lot of to-go food containers to keep things, you know, oil and grease from leaking through. And then they're in a lot of firefighting foam. And the main problem environmentally that we're seeing with these chemicals is that they're very biologically persistent. They don't break down in the environment, and so they stick around. And they end up in the surface water, in the groundwater, in our nearshore waters. And they're in some of the studies done by the CDC. They found them in the presence of them and pretty much everyone they studied throughout the United States. So these are chemicals that are very prevalent. We don't yet know exactly what their human health effects are. We certainly don't know how much you need to be exposed to before you start having human health effects from. But they are a topic of major concern and a lot of sort of new research to try and understand how much is out there, how much are we consuming and what is the dangers of them. So they have been found in fish and a number of states have done studies on some of their locally caught fish in lakes near factories that produce these chemicals, found pretty high amounts of in the fish. We have not studied this yet in our ocean fish in Hawaii, but Department of Health, we do have some plans going forward. They're in the very early stages, but we're attempting to do some studies to see along with current levels of mercury and some other contaminants, what is happening with our fish that people in Hawaii are eating. And hopefully with that information, we'll be able to get a sense of what is a safe amount to eat. In a similar way that we've been able to make some recommendations about mercury, we hope to be able to make it about the PFAS chemicals as well. Maybe the even better recommendation would be stop putting mercury and plastics into the environment. That is a good recommendation. I did a couple of lakes in Hokulea. We found plastic wherever we went. There was a recent round the world sailboat race where they sampled water all over the place. And even at Point Nemo, which is way down in the Southern Ocean. It's called Point Nemo because it's supposedly the furthest place from land. There was plastic in the water. So undoubtedly PFAS is also. Let's talk about, so these are new relatively and emerging problems. Well, mercury's clearly a problem. PFAS probably is a problem. I understand several of them have been banned because they're highly likely to cause human health effects. Let's talk about some traditional fish-related problems. And I had in mind both scombrite and ciguatera, both of which happened here. So let's start with scombrite. Scombrite's kind of can be quite spectacular. I'll give you, my first exposure to scombrite was spectacular. I was working in the emergency department. I got a call from a now retired, so I won't use his name, but the ophthalmologist who called me up and said, hey, I had the ahi plate from some restaurant we'd all recognize. And now my eyes are glowing red. Now ophthalmologists tend to like all specialists to focus on their organ of specialization. So I said, name unknown, step back from the mirror a little ways and see if the rest of you is glowing red. And of course it was. And he had scombrite fish poising, so did his receptionist. And we treated him and he did well. But let's talk about scombrite. I think scombrite's fascinating because it truly is a toxin. It's just a toxin that's created in natural fish and causes such a strong histamine reaction that I think our incidence is probably very under reported because it looks so much like an allergic reaction. It looks exactly like an allergic reaction. And exactly, so unless the history of the appropriate kind of fish is put together with an ideally a sample is later tested by your department, you'll never know. And so I'm sure you're right. There are all sorts of people who get itchy and hives and stuff and never put it together with that piece of ahi from the night before that didn't get appropriately refrigerated. Correct. So yeah, it's my sense is it's like eating an allergic reaction. And well, why don't you tell us how this happened? But so my understanding of how it happens is that as if the fish is not properly refrigerated from sort of point of catch all the way through to the cooking, then or not cooking, if you're eating it raw, the cooking or not doesn't seem to affect whether you get scrombrite or not. And a toxin is produced in the fish tissue. You go to eat it and it causes a histamine react really similar to an allergic reaction. You end up with flushing, sometimes difficulty breathing, hives, rash, itchy. GI symptoms too. Yeah, nausea and vomiting, some diarrhea. Really a pretty fairly profound reaction for a lot of people. And short-lived, luckily, usually only six to eight hours I think of symptoms and tends to get a little better with our treatment in the emergency room, but not as dramatic as an allergic reaction would get better with the same treatment. That's true and I suspect it's dose related, namely there's a lot of histamine out there. And yes, at least the theories of how this happened are exactly what you said. Somebody catches a fish, they don't ice it, or sometime later, maybe when it's in the fish market or waiting to be cut up into stakes in somebody's backyard. The bacteria from the surface of the fish get into the muscle. The muscle, of course, is what we eat and break down the tissue a little bit and produce histamine and histamine is the messenger of allergy. And histamine like compounds and there you go. And allegedly, and I've never had a person tell me this, it's supposed to make the fish taste kind of peppery, I don't know. One of the key things is if you've never, fish allergies in general are rare. So if you have an apparent allergic reaction after eating a piece of fish, stop everybody else from eating it and get it tested. And if it's severe, come see us and we'll treat you. But Department of Health, I know test these and it looks for histamine and related compounds. And the other thing is, if it's a restaurant, and we've done this from the ER, it's not the restaurant's fault, they got the fish, might even be frozen when they got it. They can't tell. We give them a call and I'm like, you know what, I would pull that ahi out of the menu tonight and then they get all that tested. Anything else we should say about scumbrite? No, I think that covers it. Okay, we're gonna, you know what, we're gonna have to have you back because we're gonna have to wrap up. We have lots of things to talk about. Siglotero would be the next and there are other fascinating environmental things that, so we'll have you back. One point about the fish poisonings that we discussed, doesn't matter whether you cook them, doesn't matter whether you froze them, anything at all. Listen, I'm serious. We've just scratched the surface. We should have you back. We'll solicit topics that people would like you to address and we'll figure out a time in the future. Sounds great. I really appreciate you coming. Thank you for having me. Excellent, so again, this is much more on medicine and our guest today is state toxicologist, Diana Feld. Thanks.