UVA Today

/ Greater Good /

Chris Holstege’s Poisonous Career Choices

In the fall of 2004, University of Virginia medical toxicologist Chris Holstege found himself in the thick of an international political mystery.

Viktor Yushchenko, a pro-Western candidate for the presidency of Ukraine, had grown seriously ill, suffering from excruciating back pain, violent nausea and other worrisome symptoms.

Any number of relatively routine things could have caused some of those conditions, but they were soon joined by other unusual issues. More than one team of doctors struggled with a diagnosis.

Yushchenko had a pretty good idea what was happening to him. He suspected poison, and his face would eventually tell the full story.

In the following weeks, the handsome and tanned Yushchenko’s wrinkle-free complexion would turn mottled and disfigured, like a marshmallow held over a flame.

When I saw him, I shook his hand and I said, ‘Sir, you have the face of dioxin.’”

In-Demand Expertise

For Holstege, the dioxin poisoning case was one in a line of incidents drawing on his experience as a medical toxicologist. He’s a poison expert. And as specialists go, there aren’t many like him. There are only five at the UVA Health System, and they are responsible for handling poison-related patients, calls and consultations in a 49-hospital network across central and western Virginia.

Besides his work as chief of the Division of Medical Toxicology, he is a professor of emergency medicine, medical director of the Blue Ridge Poison Center and executive director of the UVA Student Health Department.

The relative scarcity of medical toxicologists means deeply experienced experts like Holstege might play key roles in investigations, criminal trials and even international events.

Chris has an international reputation in toxicology and demonstrates an uncanny ability to think out of the box.”

Holstege also was part of a team of experts assigned by a federal judge in 2009 to explore the mental health issues of Bruce Ivins, a microbiologist authorities determined was responsible for mailing letters contaminated with anthrax to members of Congress and the media in 2001.

Chris has an international reputation in toxicology and demonstrates an uncanny ability to think out of the box, said Dr. Gregory Saathoff, a professor in the Department of Public Health Sciences and Department of Emergency Medicine in the UVA School of Medicine. That shows through in his writing, teaching and clinical care. Just as important, he is well-regarded as a leader in the field, who has an expansive network of relationships that reflects not only his mastery of content and research, but also the respect of his colleagues.

2009

Pirates take control of the USS Maersk Alabama container ship on the Indian Ocean off of Somalia. Armed with assault rifles and other weapons, they present a complex challenge for negotiators trying to defuse the situation.

The pirates are running out of khat — a leafy plant chewed as a stimulant. Negotiators lack expertise on how the drug, or lack of it, will influence the mood or behavior of desperate men already in a volatile setting. Months before the hijacking, Holstege spent time in the Middle East and was well acquainted with khat. Negotiators quickly requested his reports.

Holstege’s research in hand, negotiators have important information to help guide their interaction with the pirates and help to guide next steps. Running out of time — based on a variety of factors — leaders decide the interaction is too volatile and the pirates are killed in order to save the hostage.

How Holstege ended up in Vienna — and at Viktor Yushchenko’s hospital bedside when doctors there announced the dioxin poisoning to the world — has all sorts of UVA touch points. Because the poisoning occurred in the middle of another country’s election controversy, the U.S. government wasn’t about to get officially involved.

Friends of Yushchenko’s family sought help from an organization called the Critical Incident Analysis Group, a UVA-based organization that brings together professionals with international expertise to review how critical incidents — terror acts, for example — affect society and what can be learned from them.

Saathoff, who serves as the group’s executive director, assembled a team of experts, including Holstege and several others whose identities have not been made public, to review the Yushchenko case. The UVA team members maintained full confidentiality until Yushchenko’s family requested that they speak to a Washington Post reporter about their involvement for an article published in 2005.

The group eventually had copies of Yushchenko’s medical reports in hand. But those from Austria were written in German — sparking another UVA collaboration, as a professor of German lended his help.

Solving the Puzzle

With the translated medical records in hand, Holstege got to work. It was Oct. 30, 2004. His six children were all in bed for the night, and his wife was out of town on a trip to visit family. Holstege spread the records across his kitchen table.

Like reading a mystery novel, he couldn’t put the documents down and worked through the night, creating grids that included lists of pertinent positives and pertinent negatives, cross-referencing toxins and symptoms. Clinicians who had earlier reviewed his case considered a number of potential medical causes for Yushchenko’s ailments. Poisons, such as heavy metals, were considered as a possible cause. As I reviewed the data, I said, ‘No, it’s not heavy metals,’ Holstege recalled. Absolutely not.

Then I went through everything I could think of — all known toxins.

He can move with lightning speed that speaks well of his emergency medicine background. He has an ingrained competitive spirit but is also one of the most effective medical collaborators I have known.”

By morning, he had it narrowed to a class of toxins called polyhalogenated aromatic hydrocarbons of which the most notorious is tetrachlorodibenzo-p-dioxin (TCDD), or simply known as dioxin, a diagnosis he then shared with Saathoff who forwarded the working diagnosis to the family. Subsequent testing confirmed Holstege was correct. A class of chemical compounds commonly associated with Agent Orange from the Vietnam War era or industrial processes, TCDD is a widespread environmental toxin, but one rarely associated with criminal poisonings.

It involved putting the whole pattern together, he said of the work. His pattern fit dioxin beautifully and the confirmation tests showed that.

Saathoff said he was surprised at the time by how quickly Holstege reached his conclusion, though he has since come to know and appreciate his colleague’s combination of expertise and efficiency.

He can move with lightning speed that speaks well of his emergency medicine background, Saathoff said. He has an ingrained competitive spirit but is also one of the most effective medical collaborators I have known.

Weeks later, Holstege, Saathoff and UVA neurologist Dr. Lawrence Phillips flew to Austria to meet with Yushchenko and his wife, and help develop treatment plans. Though only three from UVA traveled, Saathoff said the University’s dermatology and radiology departments were key contributors in the process leading up to the trip as well.

Yushchenko would ultimately win the Ukraine presidency in a second election held after officials invalidated the results of the first. The poisoning remains an open criminal case.

2010

An Ohio doctor stands trial for the suspected murder of his 38-year-old wife. Prosecutors must build a case proving that the doctor, Yazeed Essa, laced a calcium supplement gelatin capsule with cyanide and gave it to his wife.

The prosecution must demonstrate that gelatin capsules can be laced with cyanide, remain chemically stable, and then release their contents after being ingested when reacting with the acids in the stomach.

Based on research previously conducted at UVA for the FBI, Holstege testifies that such a scenario could be done easily by Essa with previous historical examples given to the Jury. Essa’s wife, in effect, has a time bomb in her system, which ultimately killed her.

A jury convicts Essa of aggravated murder. He is sentenced to life in prison.

Pandora’s Box

Back on Grounds, Holstege is in the fifth year of an appointment as the Executive Director of Student Health. With more than 20,000 students on Grounds, the center handles a volume of inquiries and visits that rivals a bustling small-city hospital.

Across the country, at institutions of higher education and beyond, health experts like Holstege know they must stay up to date and be prepared to provide increasingly sophisticated levels of education in their communities about dangerous substances that are more readily available than ever.

The Internet has opened Pandora’s box, he said, adding that an increasing number of emerging substances are falsely rumored as safe.

In truth, health professionals often know little about new synthetic drugs or variants of known substances, Holstege said.

Holstege has assisted in the prosecution of distributors, and his work includes learning how emerging substances affect people and sharing that information with colleagues and students.

The challenges are national in scope, and extend beyond substance abuse to include performance-enhancing drugs, threats to students traveling overseas, the chronic role of drugs and alcohol on the body and the role of surreptitiously administered drugs in sexual assault cases. Answering the challenge requires a combination of education, outreach and an ability to respond quickly to a changing landscape.

I personally think we can lead the country in the care of our students, he said.

A Commitment to Service

Soft-spoken, but direct, Holstege would rather pore over medical records or detectives’ notes in some unsolved case than watch TV or most other pursuits.

He is an independent thinker who demonstrates the courage of his convictions, Saathoff said. Although he is professional in his work, he doesn’t ever sacrifice his opinion and values for the sake of diplomacy and social grace.

Chemistry, his original interest that sparked a career in toxicology, still speaks to Holstege throughout his work. He laughs at his wife’s familiar joke that his work also serves as his hobby, and it doesn’t exactly translate into small talk at parties.

It’s a good line. The kind that probably breaks the ice nicely at an actual party, but sounds more like humility than reality.

The good part of it is you’re helping. There’s a lot of good in the world, and there’s more good than bad.”

Managing the toxicology division, directing the Student Health Department, overseeing the regional Blue Ridge Poison Center, teaching aspiring physicians, working in the emergency room — they’re all service-centered pursuits. And Holstege is quick to point out that none of the successes are possible without UVA colleagues with similar passion and dedication.

For him, the work remains deeply fulfilling. And motivating. To a degree, he hopes, it also serves some preventive purpose.

Educating people about the dangers of toxins may help prevent the kind of deep anguish and guilt that he’s seen in the parent of a child who has died after ingesting something like a household cleaner that wasn’t stored carefully.

Nailing down cyanide as the killer of an innocent spouse, or confirming on the witness stand that a drug placed in a drink facilitated a rape, can help bring justice to bear. And it sends a signal.

There are people out there on the other side. Bad people, he said. We want to put them on notice. We have a pretty good network of smart people who can figure this out and put a spotlight on you. You’re not going to get away with this.

Having spent years dealing with the aftermath of what happens when bad people use toxins for destructive purposes, Holstege pauses. There’s no denying or avoiding that element. But it’s not really the point, not the thing that inspires him.

The good part of it is you’re helping, he said. There’s a lot of good in the world, and there’s more good than bad.

Dr. Christopher P. Holstege is a Professor in the Departments of Emergency Medicine and Pediatrics at the UVA School of Medicine, as well as Chief of the Division of Medical Toxicology and Executive Director of the Student Health Department. He also serves as the medical director of the Blue Ridge Poison Center, is a consultant to the Critical Incident Response Group of the Federal Bureau of Investigation, and contributes to the work of the UVA-based Critical Incident Analysis Group.