Follow me on twitter: @DougBorys.  Same off-the-wall tox tidbits with less key strokes.  Good for me and good for you. 

Starbucks Poisoner

This morning I checked with fascination for an update on the "Starbucks Poisoner".  ABC News had this report.   Two interesting tidbits from this report.  The alleged poisoner was described as a chemist.  She worked at a Johnson and Johnson subsidiary developing drug delivery systems.  You would think an expert on drug delivery could figure out a better way to deliver a poison.  Dart gun maybe?  an umbrella?  Clearly no creativity.  The news report called her a chemist rather than a pharmacist.  I will be be sure to remind our students that they two can become "chemists".  Hopefully their moral compass will be pointing a little straighter. 

The other interesting tidbit is that the poison, rubbing alcohol, was in lethal amounts.  Two bottles, mixed with juice is not likely a lethal dose.  Rubbing alcohol is most frequently isopropyl alcohol.  It is more intoxicating than ethanol.  It is also a frequent substitution for ethanol with some needy people run out.  More intoxicating means a couple of shots of isopropyl will get you drunker than a couple shots of booze.  So in theory it is more lethal than ethanol.  People do drink themselves to death, both acutely and chronically.  A novice drinker can put themselves into a coma with 9 - 12 ounces of ethanol.  More is needed to be make you forget to breath and be lethal.  Isopropyl would take a little less.  But a bottle (12 oz) of juice that was pure isopropyl would be only a start.  In addition, isopropyl is very hard on your stomach.  Most novice drinkers would vomit it back up before it is absorbed. 

So is isopropyl alcohol a poison? Yes.  Can you drink enough to induce death? Yes.  Did these two bottles spiked with isopropyl alcohol have to cause death?  Very unlikely in an adult.    

Nonetheless, I am sticking with Fiddleheads and Alterra for my coffee.

Interesting news day... 

First there is the story on Plan B One Step being offered over the counter to kids over the age of 15.  (I was corrected over breakfast that those are young women.)  Clearly a story of cultural, religious and political impact.  It also will have an impact on pharmacists in their day to day practice. 

Next there was the story of congress demanding US intervention in Syria over the alleged use of sarin gas.  You can understand the hesitancy of the President after the fall out over the Iraq war and WMD intelligence.  But nerve gas is a horrible weapon that does not discriminate who it injures.  Clearly a story of important worldwide political impact.  But nerve gas will also effect pharmacists as we prepare to serve poisoned patients.  And, or course, this is a fascinating tox story.

By now we all know the Elvis impersonator has been exonerated and a different guy was charged with mailing ricin to our President.  Any story that involves any connection to Elvis is fantastic.  Any story that involves Elvis also involves toxicology.   That goes withour saying.  But including a WMD like ricin, that's just gravy.   
  
Then there is Michael Jackson's wrongful death trial.  Drugs, overdose and toxicology.  Can anyone believe the doctor's story that Michael Jackson injected himself?  Propofol is an extraordinary sedative.  Stay tuned for for more fun tox news out of Hollywood. 

The best story of all was buried deep in today's Milwaukee Journal Sentinel under national news.  Something about a poisoning at Starbucks.  An e-mail from a colleague with this link was waiting for me this morning.  PHARMACIST ARRESTED FOR LEAVING POISONED ORANGE JUICE AT STARBUCKS.  A pharmacist.  Really!?  According to the story two bottle of orange juice laced with isopropyl alcohol were placed in the refrigerator.  Thankfully no one drank them.  That has to be the top news story of the day.  Toxicology, poisoning and pharmacists, amazing.

Interesting news day...

  

Ricin, Elvis and Las Vegas

On Wednesday an Elvis impersonator was arrested for mailing an envelope with ricin to President Obama.  Thankfully the envelope was intercepted before it ever got to its intended victim.  Read a nice summary here.   Of course there is more to the story.  According to the New York Times the suspect had uncovered a plot to sell body parts on the black market.    

Ricin, body parts and an Elvis impersonator.        

Ricin is not an easy poison to get.  It sounds simple.  Grow a castor bean plant (Ricinus communis), harvest the beans, get to ricin out, sing "Jail House Rock" and put the ricin in some letters.  Fortunately it is not that easy.  But "Suspicious Minds" have tried.  In February 2008 a man in Las Vegas was admitted to the hospital with respiratory difficulty and eventually lapsed into a coma.  It was discovered that he was attempting to process ricin. 

Ricin is leftover in the "mash" that results from the production of castor oil from castor beans.  It is nearly impossible to get poisoned by eating castor beans.  The beans pass whole thought your body and the ricin is not absorbed very well.   But once it is absorbed into the body it leads to alterations in protein synthesis.  The result is nausea, vomiting, diarrhea, dehydration, and then cardiac and hepatic injury.  Thankfully toxicity is treatable. 

Its Friday, the end of a difficult week.  We have had deaths in Boston, explosions in Texas and winter that will not leave.  We can be grateful for a sense of humor and Elvis.   Enjoy!     

West, Texas

One of my favorite small towns in central Texas is West.  It was a perfect distance to drive a girls basketball team for a tournament.  It was midway for those trips to Dallas when an emergency ice cream stop needed a Dairy Queen.  Or the cherry limeade at the Sonic called your name.  There is the kolache bakery where mouth watering delicacies awaited.  Every Labor Day weekend was Czech Fest.  A celebration of everything great about being Czech and about West. 

Yesterday there was a massive explosion and fire at a fertilizer plan in West.  Many buildings were leveled.  The number of dead or injured will not be known for some time.  A horrible situation for a cute little town.  Read about the explosion here.    

Fires in chemical plants are full of danger.  The first concern is the risk of ignition.  As in this fire the chemicals used to make fertilizer are highly combustible.  It appears the fire was under control when it reignited and exploded.  All fires produce carbon monoxide, a gas that prevents your hemoglobin from carrying oxygen.  House fires, and chemical fires, also produce cyanide.  Cyanide stops your cells from utilizing oxygen and creating energy.  In addition nitrogen and sulfur oxides are produced.  Those chemicals are irritant gases that burn your eyes and your lungs.  Some of those gases can scar your lungs leading to long term damage.  Some gases are also heavier than air.  They will pool in low lying areas putting additional people at risk. 

As you can imagine the situation is West is fraught with danger for everyone.  Maybe it is time for all of us that are going about our days hundreds of miles away to say a prayer for everyone that lives in my favorite Texas small town.

Apricots

Life in toxicology can be equally fascinating and disturbing.  Take the patient that I consulted on recently. 

This elderly women was diagnosed that morning with cancer.  No doubt a rough way to start your day.  The horror experienced by the family had to have been considerable.  One family member decides to act.  She read that  apricots kill cancer cells.  So she ground up a bunch of apricot seeds and gave them to her mother.  Later that evening I get involved when the mother is being treated in a hospital emergency department for headache, confusion and agitation.  The patient while fascinating from a tox aspect, is also fascinating from a moral view.  What if the daughter decided it was best to give her mother the apricots to ease her pain and end her life.  It is also well know that apricot seeds are poison.   

Under normal circumstances there is no risk of cyanide poisoning from accidentally eating an apricot pit.  The small amount of cyanide is bound within a hard shell.  Normally the seed or pit passes through you intact.  But what happens when it is ground up in a blender?  The safety capsule God put around the poison is now gone.  The cyanide, through still in small quantities, becomes available.  So how about if you you grind up a bunch of pits in a blender?  The potential to become ill becomes much higher. 

The initial signs of cyanide toxicity are confusion, agitation, headache, nausea and vomiting.  Cyanide prevents your cells from utilizing oxygen and producing energy.  The tissues that need oxygen to work, your brain and heart, eventually stop.  Thankfully there is a treatment.  Sometimes when there is a small exposure to cyanide just giving fluids and oxygen does the trick.  For the majority of patients a more invasive antidote is given.  The antidote, hydroxocobalamine, binds the cyanide you have in your body then you can get rid of it. 

Apricots as a cancer treatment.  Is it the cure we have all been waiting for?  Unfortunately the data tells us no.  Can it cause bad adverse effects, even death?  Unfortunately, yes.  Thankfully, our patient had a good outcome.
 

Carbon monoxide is everywhere...

Over the last two Weeks I have been a little short on tox blog posts.  But this week one news item jolted me back.  "MTV star dies of carbon monoxide poisoning".  The death was carried by multiple news outlets including this piece on the Today show.  It seems that "Buckwild" star Shain Gandee, his uncle and a friend decided to do a little mudding.  As one who lived in rural central Texas; that sounds like a normal Saturday to me.   Unfortunately they got stuck in mud that covered a part of the truck.  Like all of us I suspect they ran the car in order to stay warm until someone showed up to pull them out.  But the mud covered and plugged the tail pipe. 

Carbon monoxide is a result of incomplete combustion of any fuel with carbon in it, including gasoline.  Carbon monoxide is a insidious killer.  It starves your vital organs of oxygen by altering the hemoglobin in your blood.  First you get get a little giddy and sleepy, then slowly go downhill until your heart stops.  With the tailpipe clogged there was no place for the exhaust to go.  So the carbon monoxide filled the truck. 

So carbon monoxide is everywhere.  Even in Ford Bronchos in the hills West Virginia.  Carbon monoxide knows no favorites.  Even reality TV stars.   

Poisons in your home

Thank you AAPCC http://aapcc.wordpress.com/2013/03/21/poisons-in-your-home/ 

Methanol in Libya

An interesting note just came across my desk.  It is fascinating that the world is so big yet so small.  Today in Libya there is a massive outbreak of methanol poisoning secondary to drinking bad homemade ethanol.  As of Sunday the death toll was staggering.   

Methanol is an alcohol that is sometimes added to ethanol. to give it a kick.   Sometimes the result of bad distilling and production.  During the time of prohibition methanol poisoning jumped due to poorly made illegal ethanol.  I guess today is no different.  Methanol has many actions on the body.  The end for many is severe acidosis and death.  For some they will survive, but be blind.  Thankfully there is a treatment.  The treatment, fomepizole, is very effective.  That brings me to the note below.  This request came from a physician and toxicologist who is the head of the Norwegian Center for NBC Medicine.   

Dear all members of AACT;

I just wanted to inform you all that there is an ongoing methanol outbreak in Libya; various reports exists, but as for yesterday, up to 79 fatalities and > 700 patients were reported (depending on the source sited). Medecins Sans Frontieres (MSF) is mobilizing large scale, and we are leaving today (Dr Morten Rostrup, MD, PhD ­ Dept of Acute Medicine, Oslo University Hospital, Oslo & former international president of MSF), and on Sunday (Raido Paasma, Estonia and myself) to support them.

We have been able to get hold of quite a bit of fomepizole from our own stock in Norway, the distributor in Scandinavia (SOBI), and we will likely also have donations from the producer in Europe, EusaPharma. We are also bringing along some equipment and enzymes to establish the formate analysis in Libya. If there are any of the AACT members who have stores of fomepizole they want to donate, also which is soon to expire (recently expired fomepizole would also do); Please contact me ASAP on the below address: If it could be in Oslo by Saturday evening or Sunday morning, I will be able to carry it along with my luggage, hence no formal papers for import to Libya is needed.

Thank you all in advance for helping our Libyan friends

US Poison Centers

From the American Association of Poison Control Centers.


Poison Centers: Protecting Health While Saving Americans Time and Money
American Association of Poison Control Centers Observes Annual National Poison Prevention Week

ALEXANDRIA, VA. – America’s 57 local poison centers save lives 24 hours a day, seven days a week by providing free, confidential medical advice to people in poison emergencies, according to Marsha Ford, MD, FACMT, FACEP, president of the American Association of Poison Control Centers.

Since 1962, the third week in March has been designated National Poison Prevention Week and has focused national attention on the dangers of poisonings and how to prevent them. America’s 57 poison centers are committed to safeguarding the health and well-being of every American through poison prevention and free, confidential, expert medical services.

“National Poison Prevention Week is a great time to acknowledge the important, life-saving work done every day by the experts at America’s poison centers,” Ford said. “People who call their local poison center can be assured that the health care professionals who answer their calls have received the highest training possible. Despite the critical services provided, however, poison centers are in jeopardy after suffering federal funding cuts of 36 percent in 2011 and additional cuts at the state and local levels.”

In 2011, U.S. poison centers fielded more than 3.6 million calls, including about 2.3 million cases of human exposures to poisons. Poison centers save lives by providing free and confidential health-care services 24 hours a day, seven days a week, 365 days a year in more than 150 languages. Highly trained, expert health-care professionals at poison centers across the country provide immediate advice to people who call with poisoning emergencies. Poison centers also save money. About 90 percent of the people who call with poison emergencies are treated at home following the advice of poison center experts – saving an estimated $1.19 billion in health-care costs each year.

“America’s system of poison centers is one of the most successful and cost-effective public health programs in the nation,” said AAPCC Executive Director Debbie Carr, MEd. “As our representatives in Washington, D.C., and in state legislatures across the country make decisions about funding for poison centers, it’s important they carefully consider the impact of those decisions on the health and finances of the American people. The millions of Americans who rely on poison centers each year illustrate the importance of the poison center system that safeguards the health of our friends, neighbors and family members.”

For more information, contact Loreeta Canton, director of public relations and member services for the American Association of Poison Control Centers, at 703.894.1858 or canton@aapcc.org or visit www.aapcc.org.

About the American Association of Poison Control Centers:
The AAPCC supports the nation’s 57 poison centers in their efforts to treat and prevent drug, consumer product, animal, environmental and food poisoning. Members staff the Poison Help hotline at 1-800-222-1222 that provides free, confidential, expert medical advice 24 hours a day, seven days a week, 365 days a year from toxicology specialists, including nurses, pharmacists, physicians and poison information providers. In addition, the AAPCC maintains the only poison information and surveillance database in the United States, providing real-time monitoring of unusual poisoning patterns, chemical exposures and other emerging public health hazards. The AAPCC partners with federal agencies such as EPA, HRSA and the CDC, as well as private industry.

To learn more, visit www.aapcc.org, like us on Facebook, follow us on Twitter, or read our blog at aapcc.wordpress.com. To join your voice with other poison center supporters, register for the AAPCC advocacy network at www.capwiz.com/aapcc – click on “Action E-List.”

Poison Prevention Week

Happy Poison Prevention Week!  As pharmacists and health care providers we all share the responsibility of keeping our patients safe.  But safety goes beyond that to their families.  We need to teach patients the risk of medications to them and their children.  At the very least we can tell them about the phone number to the local poison center, 1-800-222-1222.  While thinking about medication and poison safety have you thought about your children?  Your extended family?  Brothers and sisters?  Nieces and nephews?  Keep that poison center phone number handy!   


AAPCC and America’s Poison Centers Observe National Poison Prevention Week

ALEXANDRIA, VA. – The American Association of Poison Control Centers (AAPCC) is cautioning parents, grandparents and caregivers that children act fast, and so do poisons, according to Salvador Baeza, PharmD, DABAT, director of the West Texas Regional Poison Center.

“About half of all poison exposures reported to poison centers involve children younger than 6, most often occurring when parents are busy preparing meals, caring for other children, or completing everyday household chores. Poisonings also occur when the normal routine changes – during holidays or while moving, visiting or traveling,” Baeza said. “National Poison Prevention Week is the perfect time to poison-proof your home to keep your children and grandchildren safe.”

Since 1962, the third week in March has been designated National Poison Prevention Week and has focused national attention on the dangers of poisonings and how to prevent them. America’s 57 poison centers are committed to safeguarding the health and well-being of every American through poison prevention and free, confidential, expert medical services. Poison centers respond to calls 24 hours a day, seven days a week in order to help those who have been exposed to toxic substances.

In 2011, U.S. poison centers answered more than 3.6 million calls, including about 2.3 million calls about human exposures to poisons. Children younger than 6 accounted for about half of the calls placed to poison centers about poison exposures. The top five substances involved in poison exposures for children younger than 6 were cosmetics/personal care products; painkillers; household cleaning substances; foreign bodies/toys/miscellaneous; and topical preparations.

The experts at America’s 57 poison centers urge parents, grandparents and caregivers to take the following steps to keep children safe from poisonings:

• Inspect your home and garage to make sure medicines, cleaning products, pesticides and fertilizers are stored up high, away and out of sight of children.
• Tell children what medicine is and why you must be the one to give it to them. Never call medicine “candy” to get them to take it.
• Don’t leave medicines or vitamins on counters, window sills, bedside tables or the refrigerator top.
• Take your medicine where children can’t see you; they may try to imitate you.
• Teach children to always ask an adult before eating, drinking or touching anything.
• Keep cleaning products and household chemicals in their original containers with their original labels intact.
• Keep batteries out of a child’s reach. Call your local poison center right away if a child swallows a battery.
• Keep magnetic toys and other magnetic items away from small children. Call your local poison center right away if you think a child has swallowed a magnet.
• Know the name of all household plants in your home; remove any poisonous plants from your house and yard.
• Remember that child-resistant is not child-proof. Layer the protection: re-seal and lock up, out of sight and reach.

Epinephrine

Today, in 2001, Kristen Gilbert was found guilty of murder by poison.  Kristen was a nurse taking care of patients at the VA hospital in Northampton Massachusetts.  She injected her patients with high doses of epinephrine.

Epinephrine is a drug familiar to everyone.  It is a naturally endogenous neurotransmitter that your body produces everyday.  It is an  alpha 1, beta 1 and beta 2 agonist.  In normal levels it stimulates your heart, lungs and blood vessels.  For someone in the midst of heart attack, or an asthma attack, that's good.  We want to stimulate our heart to work better and beat faster and our blood pressure to go up.  During an asthma attack we want our lungs to open up.  But what happens when you give too much?   The heart is driven so fast it can not efficiently pump blood.  The normal electrical transmission of the heart is disturbed and arrhythmias result.  Or the heart stops much like a heart attack.   

Kristen Gilbert had a high rate of heart attacks on her watch.  At first everyone marveled at how compassionate and competent she was in the midst of a crisis.  But then other  nurses became suspicious.  Some think Kristen poisoned her patients to show off.  After all, not all of them died.  Others thought she did it because her boyfriend was part of the emergency response team.  What better way to foster a relationship. 

Kristen Gilbert was convicted of four counts of murder and two of attempted murder on this day in 2001.

Bark Scorpion, Ouch!

Like every good Wisconsinite I am reading every word I can find about the Brewers in spring training.  With Ryan Braun continue to shine?  Can Carlos Gomez have a full, productive year in center field?  Can John Axford lead a revamped bullpen?  But what grabbed the headline late last week?  Doug Melvin stung by a scorpion! 

There are many species of scorpions in the US.  In Texas we frequently encountered Centruoides vittatus or the stripped scorpion.  The typical response to a scorpion sting was, "man up".  You put an ice pack on it and went about your day.  The pain at the site of the sting was said to be excruciating.  But rarely were there any further problem.  So man up and bite a bullet! 

That is not the description given by Doug Melvin.   In this article  he described numbness that gradually moved up his arm into his shoulder.  That on top of the excruciating pain.  After a visit to the local hospital ED he did fine.  The scorpion that stung Doug Melvin is the Centruoides exilcauda, the bark scorpion.  That scorpion is well know for it's neurotoxin venom.  It is far and away the most poisonous of the scorpions in the US.  Pain and numbness are normal effects.  The venom poisons sodium channels in your nerves.  Functioning sodium channels are required for nerve conduction, the ability to activate muscles and to feel pain.  Scorpion venom opens those channels resulting in excessive stimulation.  In this case pain and numbness.  That nerve stimulation and the resulting effects on muscles can be life threatening in small children. 

So Doug Melvin, thank you for teaching us all about scorpions in Arizona.  Now about the Brewers starting pitching...

I'm Going Home

Woodstock Music festival - 1968.  Much has been written about the music, the people and the drugs.  The story behind the festival is a must read.  The movie is a must watch for anyone with an interest in the history of music in the United States. 

The drugs ranged from beer and booze to LSD and quaaludes.  Marijuana was said to be widely available.  Yet few were hurt and less were arrested.  Is there a lesson there for all of us? 

For me the highlight of the music (no I was not there!) was Alvin Lee and Ten Years After.  Their rendition of "I'm Going Home" became an instant classic played by every garage and cover bad in the 70's.  Alvin Lee died yesterday of complication following routine surgery.  Enjoy the music.

The death of Cruz

So a dog got poisoned, or at least the owner thinks so.  Whats the big deal?  That was an everyday occurrence in Texas.  When you are trying to kill feral hogs or coyotes sometimes bad things happen.  This dog poisoning was covered by the New York Times.  This dog was a prized pure-bred Samoyed that competed at the Westminster Kennel Club Dog Show last month. 

Typical dog story.  An evening meal of steak and then spending the night at a midtown hotel.  The morning an uneventful show.  But just a few days later falling extremely ill vomiting blood.  Rush to veterinary hospital where the dog expired.  The vet thought it looked like rat poison.    

Rat and mouse poison commonly contain anticoagulants.  Substances that are intended to change the way your body clots resulting in the animal bleeding to death.  Early rodenticides contained warfarin.  The same warfarin that is a common drug to prevent clot formation in people.  Warfarin inhibits vitamin K clotting factors (II, VII, IX, X) plus anticoagulant proteins C and S.  Specifically the C1 subunit of vitamin K epoxide reductase.  In people use of warfarin comes with very close monitoring of clotting times.  In addition, patients have to be very careful with their diets and physical activities.  Fall and bump your head while on warfarin; the result can be catastrophic.  Second generation rodenticides contain a super-warfarin.  A substance that is extra potent and lasts for a long time in the body.  It also takes some time to act.  Its cumulative effect is devastating.  An effect rodenticide. 

When a dog eats the rodenticide a similar course takes place.  Nothing happens at first as the body burns up its stores of the clotting factors.  But slowly, over a few days, the animal bleeds internally.  Breathing becomes difficult and movement painful.  All due to blood being where it shouldn't be.  Eventually, without treatment, the animal dies.      

Was this an accidental poisoning or murder?  The owners think the later while to vet believes the former.  Was it a competitor?  Was it an animal rights group?  Was it just a dog eating the rat poison in the subway?  We will never know.