Merry Christmas!

Tis the Season to be Poisoned

 ‘Twas the morning post-party, when all through the house,
No adult was stirring, not even your spouse.
The children, you thought, were asleep in their beds.
But, what you didn’t know, they had other ideas in their heads.

Your house was awash in post-party trash,
And the kids thought this was a gold mine—better than cash.
There were ashtrays with butts and glasses with drink,
And a visitor’s purse lay there by the sink.

The kids were delighted and felt ever so free,
And then their bright eyes—locked onto the tree!
There was tinsel, and lights that bubbled so merry,
And a strange plant with fruits, called “Jerusalem Cherry”.
Food was left out on the table all night,
And if they could have seen the bacteria—what a horrible sight!
And there by the fireplace was a box shaped just right,
That contained some powder to make fire colors bright.
A small toy broke open, and there at their feet,
Was a round tiny battery that looked good to eat.

As you see your home, where you thought poisons naught,
On this holiday season, was NOT as safe as you thought!
As you rose from your sleep and rubbed your eyes free,
You looked for the kids, and a disaster you see!

You sprang to the phone, not a moment to spare,
And talked to the folks you knew would be there.
Your poison center sure helped you get through the mix,
And you thought—“How’d we ever get into this fix?”
For you see holidays can present problems so rare,
That before they can happen, you must be sure to prepare.

It takes just a moment to think what might be,
And clean up your trash, so your home’s poison free.
And so, my dear friends, keep the holidays bright,
Put all away, and sleep peaceful tonight.
Have a holiday bright, that is full of good cheer,
And from the staff of the poison center—“Have a Safe Year!”

Written by John H. Trestrail III, R.Ph, ABAT
Clinical and Forensic Toxicologist

Thank you to the the American Association of Poison Control Centers blog.   

Poinsettia

Yesterday we had a winter storm here in Wisconsin.  What says Christmas more than a fresh layer of snow?  Filled with the spirit I stopped on my drive home to purchase a poinsettia.  The beautiful Christmas plant now sits in a place of honor near our other decorations.  Fresh snow and a poinsettia, how festive!

The Poinsettia has a great history in the poison world.  Lore will tell us that the poinsettia is an extremely dangerous plant.  Eating just a single bud will lead to a child's death.  That fear comes from a story that originated in Hawaii.  Back in 1920 a small child supposedly ate a poinsettia plant.  Later, that child died.  But the story, like any urban myth, has grown and morphed over the years.  There has never been any verification that it ever happened.  None-the-less, is a poinsettia poisonous?  A colleague did a study looking at the ingestion of poinsettias as reported to a Poison Center.  Here is the link to the paper in the American Journal of Emergency Medicine.    There were over 22,000 exposures of which not a single patient died.  In fact, over 92 % had no problems related to the plant.  Pretty compelling work.  Poinsettias may cause some stomach upset, nausea or vomiting, if you make a salad of it.  A child tasting the plant will likely never have a problem.  Nor will your dog or cat.   But like anything else; it is always important to practice prevention and avoid any accidental ingestion. 

Today pick up a poinsettia and enjoy its beauty.  Merry Christmas!

It's poison! I tell you, it's poison!

It's a Wonderful Life is a great Christmas movie.  Released in 1947 it was nominated for multiple Academy Awards.  It is must see entertainment for this time of the year. 

Of course this is my favorite scene...

GOWER
What kind of tricks are you playing, anyway? Why didn’t you deliver them right away? Don’t you know that boy’s very sick?

GEORGE (in tears)
You’re hurting my sore ear.

INT. FRONT ROOM DRUGSTORE – DAY

CLOSE SHOT

Mary is still seated at the soda fountain. Each time she hears George being slapped, she winces.

INT. BACK ROOM DRUGSTORE – DAY

CLOSE SHOT – GEORGE AND GOWER

GOWER
You lazy loafer!

GEORGE (sobbing)
Mr. Gower, you don’t know what you’re doing. You put something
wrong in those capsules. I know you’re unhappy. You got that
telegram, and you’re upset. You put something bad in those capsules. It
wasn’t your fault, Mr. Gower . . .

George pulls the little box out of his pocket. Gower savagely
rips it away from him, breathing heavily, staring at the boy
venomously.

GEORGE
Just look and see what you did. Look at the bottle you took the
powder from. It’s poison! I tell you, it’s poison! I know you
feel bad . . . and .. .

George falters off, cupping his aching ear with a hand. Gower looks at the large brown bottle which has not been replaced on the shelf. He tears open the package, shakes the powder out of one of the capsules, cautiously tastes it, then abruptly throws the whole mess to the table and turns to look at George again. The boy is whimpering, hurt, frightened. Gower steps toward him.

GEORGE 
Don’t hurt my sore ear again.

But this time Gower sweeps the boy to him in a hug and, sobbing
hoarsely, crushes the boy in his embrace. George is crying too.

GOWER
No . . . No . . . No. . .

GEORGE
Don’t hurt my ear again!

GOWER (sobbing)
Oh, George, George . . .

GEORGE
Mr. Gower, I won’t ever tell anyone. I know what you’re feeling.
I won’t ever tell a soul. Hope to die, I won’t.

GOWER
Oh, George.

That scenes holds the two most important ingredients for greatness:  a pharmacist and poison.  Certainly, like me, you are thinking; I wonder what the poison was?  Thinking time frame and patient the list is endless.  The time is mid to late 30's. The drug is a powder.  The medication is intended for a child.  Plus it sounds like an emergency.  Was the child feverish, stomach problems, in pain, difficulty waking him up?  What could the poison be?

Mt first though was that the boy ate a barbiturate or an opiate and was sleepy.  Treatment at the time was something to get him up, nicotine, strychnine or cocaine.  All have odd tastes.  Maybe the boy broke his leg and was getting tincture of opium or laudanum.  Opium is very bitter tasting.  It could be that the child was intended to get a liquid and Mr. Gower made capsules.  The easiest answer if that he put too much aspirin in a capsule to treat a fever.  Instead of a child's low dose he made an adult dose. My guess, after much speculation - belladonna.  It would be in a bottle likely marked poison.  It would be used for stomach ailments, even colic in babies.  In a large dose it would be harmful.  Plus it tastes extremely bitter.    

Thankfully George Bailey saved the baby and Mr. Gower the pharmacist. 

Merry Christmas and remember....  "every time a bell rings an angel gets his wings."

Mustard Gas?

Once a week I get the honor of reviewing reports from US poison centers that contain items of public health interest.  Included in that list are any weapons of mass destruction.  Without that layer of review those calls would go directly to the CDC and Homeland Security.  This is a 24 hour a day service, as are poison centers, with a two hour response time as a goal. 

Last evening I reviewed a call to a poison center.  An adult male in Florida with dyspnea who was exposed to mustard gas.  Yikes!  Mustard gas was used in WWI as a chemical warfare agent.  It was known to cause skin and eye blistering on contact.  Plus difficulty breathing on inhalation of high concentrations.  Nasty stuff.  It was used against the Kurds by Iraq.  It was also found in Iraq during the second gulf war.  

So how did a homeowner in Florida get exposed to mustard gas?  It turns out he purchased an insecticide at Home Depot.  When he used it he developed difficulty breathing.  He called Home Depot to find out what was in the product.  The ever bright clerk at Home Deport, clearly feeling some holiday mischief, told him that the product contained mustard gas. Nice.  It turns out the product was likely a pyrethroid insecticide. 

In the end the patient was fine.  I wonder if the Home Depot guy knows how close he came to having someone from the CDC or FBI knocking on his door.

Holiday Hazard

The holiday season is here.  Time for fun and relaxation.  For those of you who are planning to have some serious fun, this toxicology question popped into my in box. 

Which drug is most implicated in deaths that occur in hot tubs or saunas?

The primary drug that contributes to deaths in hot tubs or saunas is ethanol with cocaine and cocaine-ethanol in combination as the second most common drug related contributors to these deaths. (Press E. The health hazards of saunas and spas and how to minimize them.  1991 Am J Pub Health 81:1034-1037)

Thank you AACT Question of the Day!

Murder by Poison

Murder by poison.  The reasons for murder - love, money and power - have been around for all of time.  But the chemicals used by poisoners change.  Socrates died from hemlock.  The Borgia's used arsenic.  Nazi Germany used cyanide.  Over the last decade there is a new poison of choice, ethylene glycol.

Ethylene glycol is in car antifreeze.  It is the chemical that keeps our radiators from overheating in the summer and turning into ice blocks in the winter.  To make it easily visible it is colored bright pink or fluorescent green.  It is great for our cars.  Unfortunately ethylene glycol is a hazard to our environment, pets and us.  Accidental ingestion of antifreeze by small children can be devastating.  The ingestion of antifreeze spills by animals leads to countless deaths every year.  But it is murder by ethylene glycol that is troubling. 

Last week I heard of an elderly gentleman being slowly poisoned with ethylene glycol by a relative. A horrible way to grab the poor man's inheritance.  But it has happened before.  Here is news story of a man that killed his wife for her life insurance.  Here in Wisconsin  Mark Jensen  was convicted of murdering his wife so that he could continue an affair with another women. 

What is common in all three of these cases, and many more, is that death by ethylene glycol is easily discovered.  All it takes is a level of suspicion.  Then men go to prison for the rest of their lives.  In addition ethylene glycol poisoning is easily treated.  Two good reasons why murder by ethylene glycol should never happen. 

Murder by poison.  What will be the substance of choice be for the next decade? 

          

E-cigarettes

News flash... Cigarette smoking is bad for you!  Maybe not such a news flash.  Smoking has been linked to a variety of diseases and forms of cancer.  Smoking is the direct cause, or is a significant factor, in 80 % of patients with lung cancer.  It is the cause of emphysema.  Even the tobacco companies admit that smoking may not be in the best interest of your health.

 

Nicotine is a component of tobacco smoke.  It is the chemical that induces everything from pleasure to addiction.  Smoking cessation products primarily center around nicotine.  Give a product to replace nicotine, gum or a patch, and then slowly decrease the dose.  The patient's need for nicotine lowers and they soon will be smoke free.  But the recidivism rate for nicotine addiction remains extremely high.  It is had to quit.  Wouldn't it be great if we had a product that made smoking safer and at the same time helped people kick their addiction?  Now there is, the e-cigarette. 

 

E-cigarettes are small electronic devices that look like cigarettes.  They are held like cigarettes and must be puffed and inhaled like a cigarette.  They deliver a metered dose of nicotine without all of the other contaminants.  The dose can be decreased to assist is smoking cessation.  For those that can't seem to quit, or do not want to quit, c-cigarettes provide alternative to standard tobacco products.  E-cigarettes do have side effects.  According to the Medical Letter the most common adverse effects seen after using e-cigarettes are:  dry mouth, sore throat and a non-productive cough.  Of course the jury is still out on the long term safety of these new products. 

 

E-cigarettes are they a hero or a villain?  Time will tell.

Chlorine Gas

Last week the CDC published a paper on a chlorine gas release.  It was published  in Morbidity and Mortality Weekly Report (MMWR)  and outlined a tragic accident.  An employee at a poultry processing plant poured sodium hypochlorite into a drum that contained a small amount of an acidic solution.  A chemical reaction ensued resulting in the creation of a green-yellow cloud of chlorine gas.  The cloud was first felt in the small room where the drum was stored but eventually leaked into the plant.  195 employees sought medical help, 152 were hospitalized (five to intensive care) and three developed a permanent form of asthma called, "reactive airways dysfunction syndrome".  Even sadder than the harsh health consequences is that this entire episode could have been avoided.  The employee knew not to mix the two chemicals.  The drum was labeled with a warning not to mix the chemicals.  But the drum was in the wrong place and the employee could not read the English warning label. 

The report does not address the concentrations of the two solutions.  They are only described as sodium hypochlorite and an acidic solution.  I suspect the concentrations were significant, but each of us has those chemicals in our home.  We all have a bottle of bleach (sodium hypochlorite).  We have a bathroom/toilet/kitchen/tile cleaner (acidic) also.   How often do you read the labels?  Did you know mixing them can cause a chemical reaction?  Everyday people mix the two, produce chlorine gas and have an exposure. Those with a asthma are at very high risk for a severe and even life threatening reaction. 

This case is an extreme example of what can happen in your home.  Hazards than can accidentally land you, your family or your friends in the hospital simply by mixing them.  Remember, keep all products in the original containers and then read, and head, labels.              

Lead in our dinner

Each year a wonderful family near and dear to my heart celebrates Thanksgiving with extended family by hosting a feast of venison, duck and pheasant.  All of which were "acquired" by the host.  The big celebration includes family members of all ages.  Small children abound.  The last thing anyone thinks about is the risk to the children of lead poisoning from the shot in the birds.  Clearly not an issue; when the birds were cleaned all the lead shot was removed. 

According to a study published in 2010 there remains some risk to the children.   (Here is a link to the study.)   In that study a number of game birds were first x-rayed to determine the number of lead shot they contained.  The birds were then dressed and cooked and the shot removed.   The meat of the birds was retested for lead concentration.  To the surprise of many the meat in some birds contained very high levels of lead.  That was despite there being no visible pellets, nor anything on x-ray.  The theory is that there are micro-lead pieces left behind along the path of the pellets. 

Lead poisoning from this source is of little or no risk to adults.  But is it a risk to small children?  Maybe, but probably not.  One time lead exposures are rarely a problem.  But for those children already at risk (living in an old house with lead paint, living near an industrial area where lead is used, etc.) this adds just one more insult. 

What advice to give this wonderful family?  Eat away and save some leftovers for me!   

Martha Marek

Today is the anniversary of the execution of Martha Marek.  Martha lived a fascinating life in Vienna.  Most people kill for love or money.  In Martha's case she had trouble finding an income source to match her desired lifestyle.  It seems the income source she did choose, insurance claims, lead her down an unpleasant path.  So Martha killed for money.  Those that fell victim to Martha included her husband, daughter, an aunt and two boarders.  Her downfall was getting caught defrauding an insurance company over some paintings she claimed were stolen.  Her notoriety grabbed the attention of the police who decided to exhume the bodies of the deceased.  All were found to have high levels of thallium in their bodies.

 

Martha Marek was executed by guillotine on December 6, 1938.    

Chemical Weapons and Syria

This morning I heard a news report that Syria has chemical weapons and may use them them to quell its civil war.  The news spread reports of fear and outrage across the globe.

The specific chemical is sarin, or GB.  Sarin was originally developed in Germany in 1938 as a pesticide.  Its utility as a chemical weapon rapidly became apparent.  But it was never used in WWII.  Sarin was used by the Aum Shinrikyo cult in 1995 as part of a massive subway attack in Tokyo.  Eleven people died and an estimated 5,500 were injured.  In the late 80's Iraq used sarin gas in an attack on Kurdish rebels.  In those attacks the death toll has been set at 5,000 with another 65,000 injuries.  Many people today still suffer the effects of the two attacks continents apart. 

Sarin is an organophosphate nerve agent.  An exposure to sarin causes a buildup of the neurotransmitter acetylcholine in the body.  Exposure quickly causes blurred vision, sweating, vomiting and tremors.  In time nausea and vomiting worsens, diarrhea starts and fluids build in the lungs leading to respiratory arrest.  Sarin is a liquid that rapidly gets absorbed through the skin.  Thankfully it quickly evaporates so the threat to life is short.  There is an antidote.  But how do you stockpile enough to treat 65,000 victims?  More than the antidote; how can you possibly treat that many people in one small area?

The idea of using a chemical weapon like sarin is horrifying.  Even Adolph Hitler, the man who ordered the genocide of millions, thought chemical warfare was out of bounds.  We can hope and pray that the conflict is Syria ends soon, before the unimaginable happens.

Pesticides and disasters

This last couple of weeks I have been thinking about pesticides, cyanide, toxic gases and other poisons.  Most of what is taught is abstract and fact filled.  We know how cyanide and organophosphate pesticides work.  We also know how to treat patients that get exposed.  Many times that treatment is lifesaving.  But sometimes the exposure is so great, the scope so immense that all we can do is turn away in horror and pray for victims.

In 1969 Union Carbide built a chemical plant in Bhopal, India to make the pesticide carbaryl (a carbamate insecticide).  The process used in Bhopal utilized methyl isocyanate as an intermediate.  Phosgene, an extremely toxic gas, was also used as an intermediate.  Right from the start safety was a concern at the plant.  Warnings were issued by multiple groups over a number of years over differing parts of the manufacturing process.  There were multiple small leaks, some resulting in death. 

Then on the 2nd and 3rd of December, 1984 the unthinkable happened.   Water entered a tank that was over filled with methyl isocyanate.  A runaway reaction ensued.  The exothermic reaction increased the temperature within the holding tank resulting in the automatic opening of a release valve.  A toxic gas cloud resulted.  The cloud was blown over the city of Bhopal.  The principle component of the cloud was methyl isocyanate.  In addition the cloud may have contained hydrogen cyanide, phosgene, carbon dioxide and other gases.  The gas was heavier than air staying close to the ground. 

It has been estimated that over 500,000 people were exposed to the toxic cloud.  Many animals died, even the leaves on the trees yellowed and feel off.  The immediate death toll was 2.259 people.  But total estimates range upward to 20,000 deaths and over 500,000 injuries.  The long term effects on health are still being felt today.  The total scope of this man-made disaster may not be known for decades. 

Today, on the anniversary of this horrific event, think about cost of pesticides we demand.  In Bhopal India that cost is not measured in bushels of produce or dollars per acre.  It is measures in the deaths of loved ones and the lingering health effects in others.

Dog bites snake

For the dog lovers in the world here  is a cute video about a women who was rescued by her Yorkie.  It seems the dog's owner was in her backyard when she was bitten on the heel by a snake.  When the little Yorkie sensed the danger it leaped to the owner's defense.  Multiple bites later, bites to both the dog and snake, the owner was safe and the snake was dead.  Unfortunately the little dog was ill. 

 

Snake bites to the face in dogs are not unusual.  The risk is the tremendous amount of swelling that can develop.  Swelling that may eventually close off the dog's airway.  Dogs can be readily treated with steroids or is severe cases, antivenin.  Outcomes, as in this case, are nearly always positive. 

 

One thing to remember.  When bitten by a snake it is NOT important to bring the snake to the ED.  Just tell the nurse you were bitten by a snake.  The ED staff will take care of the rest.  It is in attempting to corral or kill the snake that others get bitten.  Sometimes it is even a cute little Yorkie. 

 

 

       

Cyanide

Cyanide was originally discovery in the 18th century.  In the 20th century it became a means to commit suicide, murder and mass execution.  Cyanide is also a substance used in variety industries ranging from mining to electroplating and is a byproduct in oil refineries.  Exposures, both chronic and acute, do happen.  Thankfully there are antidotes available to treat cyanide poisoning.

Treatment initially starts with oxygen.  Refinery workers with low level cyanide exposure have done well with only oxygen as treatment.  The key is low level exposure.  Patient that are more symptomatic require more aggressive care.  For decades we have successfully used the Lily cyanide antidote kit as our source of life saving drugs.  Unfortunately the antidote kit, which consists of amyl nitrite, sodium nitrite and sodium thiosulfate, is no longer being manufactured.  Amyl nitrite can be purchased in bulk from a variety of distributors.  Sodium nitrite and sodium thiosulfate is available as an FDA approved combination product, Nithiodote, by Hope Pharmaceuticals.  There is a different antidote, hydroxocobalamine (Cyanokit) that is also available.  It is easier to use, works quickly and has a good adverse effect profile.  It can also be used in patients suffering from smoke inhalation.  Hydroxocobalamine has a long history of successful use in Europe.  Its downfall - cost.  Many hospitals simple do not carry it.

As health care providers and pharmacists it is incumbent on us to insure that we have the right tools to treat patients is the best way possible.  As the old kits expire hopefully hospitals will appropriately start stocking hydroxocobalamine. 

Yasser Arafat

Yasser Arafat is a fascinating historical figure.  Initially he gained fame as a military leader focused on denying statehood for Israel while championing statehood for Palestine.  Eventually he rose to become Chairman of the Palestine Liberation Organization.  In 1994 he received the Nobel Prise for the Middle East peace negotiations in Oslo.  Mention Yasser Arafat and many see a great man and hero fighting for Palestine.  Mention his name to others and he is vilified as a terrorist responsible for hundreds and thousands of deaths.     

Yasser Arafat died in 2004 from what was declared a massive brain hemorrhage. Almost immediately there were rumors surrounding his death.  Some claimed he died of AIDS or cancer.  Others claimed he was poisoned.  Over the last few years the debate has grown.  The focus has been on the theory that he was poisoned by Israel using everything from polonium to thallium.   Early this morning his body was exhumed and samples taken.   Here is an article from the BBC about the exhumation that gives some background.   

Time will give us a few more answers.  But the results of this process will likely only open more wounds and create more unanswered questions.  For toxicologists Yasser Arafat will remain a fascinating figure as we attempt to tie his clinical picture to what is discovered by these tests and then compare the data against more accusations.  To get your toxicologic juices flowing; does the clinical picture of polonium poisoning match his death?

Happy Poison Free Thanksgiving!

The Holiday Season is here.  Thanksgiving is tomorrow with its abundance of food, family and football.   For many this is a season of true joy as we celebrate together with friends and family. 

Today and tomorrow as you focus on preparing and consuming your feast there are a few pointers to keep in mind.  Remember to keep hands, utensils and countertops clean.  No spreading bacteria from one food or person to another. The American Association of Poison Centers blog has a nice poster  that should remind you of some important pointers on cooking your turkey.  The CDC Food Safety Program also has an excellent website that will answer many food preparation questions.  The last great resource for you is the Butterball Turkey Hotline.  Nutritionists and home economists are available for you to talk.  Turkey smells funny, give them a call.  Cat ate part of the turkey, give them a call.  Call 1-800-288-8372 (1-800-BUTTERBALL) for fast expert help.  And at all times, for any issue, remember the number to your local poison center:  1-800-222-1222.

Stay safe and enjoy a wonderful poison-free Thanksgiving!    

      

Holiday Guests

The Holidays are here.  Starting this afternoon traffic will pick-up, airports will start to clog and homes will get that last cleaning.  Part of getting ready for the holidays is to make sure your home is ready for all your holiday guests.  Food is properly prepared for the variety of dietary needs you will encounter.  The beer frig and liquor cabinet and adequately stocked.  And the house is safe for everyone. 

But no matter how well we poison proof our homes some guests bring their own poisons.  Cyanide as stuffing seasoning?  Strychnine for the soup?  or is it arsenic for the candied yams.  No, none of those.  It is big brother or crazy uncle that chews and spits into his diet coke can.  So far this year the Illinois Poison Center has reported 24 exposures to chewing tobacco spit.  The Missouri center another 32.  The adults all know that is his spit can.  But to a curious two year old it looks like diet coke.   Nicotine that is contained in tobacco gets concentrated in what gets spit into the can.  Nicotine frequently causes nausea and vomiting.  More serious effects like an increase in heart rate, drowsiness and seizures have all happened to unsuspecting children

This holiday season keep your medications and cleaning products put away, your carbon monoxide detector working, cooking utensils clean and keep an eye out for a wayward spittoon.

Help needed!

Winter is coming.  With the first blast of cold furnaces kick in and heating bills go up.  With furnaces turning on the number of people poisoned by carbon monoxide jumps dramatically.  Today the Milwaukee Journal-Sentinel posted an alert warning us about risks of carbon monoxide poisoning.  So get your furnace checked, get a detector and be smart. 

Sadly, accidents and carbon monoxide poisoning still happen.  What could be sadder than a home full of small children and puppies being evacuated into the cold due to carbon monoxide?  It is WHEN MY FAVORITE BREWER HAS TO EVACUATE DUE TO CARBON MONOXIDE.  The Journal-Sentinel was again all over the story.    Thankfully it appears that no one was injured due to the high levels of CO.  Randy Sprecher, if you need a clinical toxicologist to help you determine if your beer is still good I would be happy to help.  If you need an additional 55 or so young college aged aspiring pharmacists/toxicologists to assist, I know where they are too!    

Please help yourself and your family by purchasing a carbon monoxide detector.  It may save a life, and it could be yours. 

Please help my favorite brewery by toasting with a Sprecher Oktoberfest tonight.  I know I will.

Angel of Death

Richard Angelo graduate with honors from nursing school.  He was a volunteer fireman and an eagle scout.  Richard had a reputation for heroism arriving when patients were arresting and reviving them.  Unfortunately for his patients he desire to be a hero went a little far.  

 

Richard was hired to work the graveyard shift at Good Samaritan Hospital in Long Island.  For some odd reason there was a large number of codes during the graveyard shift when Richard was there.  As one patient was slowly deteriorating he pressed his call button.  An alert nurse responded and recognised something was amiss.  A urine sample was obtained and it contained panucuronium and succinylcholine, but neither was prescribed.  The patient survived and described a large bearded nurse with glasses who was in his room.  The police took over from there and found bottle of Pavulon and Anectine in nurse Angelo's home. 

 

Pancuronium and succinylcholine are neuromuscular blocking agents commonly used in surgery and for emergency intubations.  They both prevent muscle contraction by effecting conduction at the neuromuscular junction.  Your muscles can not work (no waving for help, no breathing, nothing), yet you are wide awake. 

 

On this day in 1987 Richard Angelo, nicknamed the "Angel of Death", was arrested for murder.  It is estimated that in the seven months he worked at the hospital nurse Angelo poisoned 35 patients, or which 10 died.   

McAfee murder

Dear Fellow Toxicology Enthusiasts,

A story broke yesterday about a murder Sunday night in Belize allegedly perpetrated by the McAfee Antivirus mogul, John McAfee. As the story goes, a builder colleague, Gregory Faull, filed a formal complaint with police against Mr. McAfee for his “roguish behavior” and erratic use of firearms. He has, over the past several months, been posting in drug forums about his pursuit to obtain a certain purified substance that authorities suspect they will find in his system when he is caught.

Name that drug!

For those who want to cheat: http://gizmodo.com/5959812/john-mcafee-wanted-for-murder

 

Kidneys and acetaminophen

Acetaminophen poisoning.  The epidemic of liver injury seen in hospitals today is thought to be due to high use of acetaminophen by all of us.  Changes in liver function has been documented following just a therapeutic dose in some people.  Liver transplants and death have also been widely reported following both acute and chronic ingestion of acetaminophen.   

But that is not the whole story.  There is a group of patients that also suffer kidney damage secondary to acetaminophen poison.  It is known that the kidney contains some of the same enzymes that in the liver change a small portion of acetaminophen into a toxic metabolite.  And when following a large acute overdose renal toxicity is something that needs to be monitored.  But how frequent is renal toxicity noted in patients with acetaminophen poisoning?  In a study published last year (Nephro Dialysis Transplantation 2011; 26(11):3501-08) only 21 % of patients that were inpatients in an intensive care unit with liver toxicity due to acetaminophen did NOT develop renal toxicity.  The over whelming majority had some level of kidney impairment.  Most of those patients did recover kidney function.  But a small percentage of patients develop chronic kidney failure. 

Being aware of acetaminophen induced hepatic damage is very important for all of us.  But don't forget the kidney, it is another organ that we should worry about.

Quinoa?

Yesterday I was asked an interesting question.  Can I eat the quinoa I prepared before the power went out nine days ago?  Two thoughts came to mind.  First, What is quinoa?  and second, food poisoning.  After a little research (ask and you shall be told) I now know what quinoa is.  Food poisoning is something that we should all be familiar with.  Food poisoning covers a variety of illnesses.  There is the standard bacterial food poisoning caused by E. coli or salmonella.  We have all gotten sick with diarrhea, vomiting and cramps because of something we ate.  Then there are parasites secondary to eating bad or poorly prepared food.  Yuck.  Food allergies are also a problem.  Everyone with a peanut allergy knows that peanuts are the number one cause of death due to food related anaphylaxis. 

So food poisoning is nothing to be ignored.  Rather we should all be taking precautions to avoid it.  Yet every year many, many people suffer from food poisoning.  Many due to their own decisions.  This is the time of the year when food poisoning ramps up.  We have treats left over from Halloween to consume.  Soon we will have thanksgiving leftovers.  Then day old trays from Christmas parties.  There are many websites to help you with your food related questions.  But this one is the best.   Use it frequently this holiday season, I know I will. 

Nine day old quinoa prepared with fresh fruit and a little milk that has been sitting at room temp.  According to Food Safety.gov, throw it away.  The question for you to answer; Is the risk of getting sick worth the deliciousness of the food?       

Drugs and pregnancy

Today I saw an interesting question...  How many women use illicit drugs in pregnancy? 

We all know that different drugs cause different birth defects.  Prescription, over-the-counter and illicit drugs can all cause birth defects.  Some effects are truly horrific, like those due to thalidomide, and avoidable.  Others far more subtle.  In a perfect world no pregnant women would ever take a drug, legal or illegal.  But this is not a perfect world.  We still get headaches and we still get colds.  Chronic diseases do not go away when you become pregnant, nor do addictions.  So we keep taking drugs. 

So how many women take illicit drugs when pregnant? 4.7 %  Interestingly, more than 6 % of pregnant women reported the use of multiple drugs.  Drugs that include tobacco, alcohol, prescription and illicit.  The 4.7 % admit using at least one illicit drug sometime during pregnancy. 

Thank AACT question of the day.

Formication

Words.  Every discipline has its own words.  There are strange words in chemistry and equally strange words in poetry.  But medicine and toxicology may top them all. 

Today's word is "formication".  I know what you are thinking. "I saw one of those growing in a cave!"  Close, but incorrect.  Formication is an odd delusion that is associated with methamphetamine abuse.  The abuser thinks that their skin is being infested and bitten by bugs.  What do you do when bugs on your skin?  You pick them off.  So formication is the act of picking your skin when nothing is there.  As a result your skin doesn't look to good. 

Its true, sometime a picture is better than words. 

   

Happy Halloween!

Today is the day we celebrate witches and warlocks, toxic brews and zombies that come to life.  I like to think of witches and warlocks not as evil creatures but simply back yard chemists and drug users.  Much like the guy with a meth lab today.  The "flying" that has made witches famous.  Likely due to use of hallucinogens.  There are many people who think they can fly after taking drugs.  Why not witches?  The green color they are associated with?  The hallucinogens came from plants, green plants.  So they are green from grinding up jimson weed and flying around secondary to delirium.  But the broomsticks?  The broomsticks may have simply been a method of drug delivery.  It could have been an easy method getting drug to your skin.  Or the world's must uncomfortable suppository.  Either way, the broomstick could have been a way to take a drug.  But zombies, there is no explaining that, right?.  Maybe there is...  Haitian voodoo practitioners know how to extract the neuro toxin from puffer fish, tetrodotoxin.  The toxin causes paralysis of the face and extremities, speech impairment and slowed respirations.  Let's see... barely breathing, can't move your arms and face, can't talk. Sounds dead to me.  Now bury the victim.  Let the toxin wear off, dig him up and dead comes back to life.  Zombies!   

Today is also the day we celebrate costume parties, dressing up and trick-or-treating.  Take a minute to read these simple safety tips offered by the American Association of Poison Centers.     Most importantly be smart and be safe.  And don't let any voodoo doctors mix your drink!

 

 

 

 

 

 

Poison from the sky

October 30 is a great day.  Not only is it the day before Halloween, it is also the anniversary of the day of the first report published on the hooded pitohui.  (Science 258:799-801, 1992)  Hooded what?  The hooded pitohui is the only known venomous bird.  How awesome is that! 

The venom of the pitohui is similar to the poison found in dart frogs.  The venom is a neuro toxin that impacts sodium channels.  Its effects range from numb lips to being unable to breath and death. 

We all know that we never look up at birds flying overhead with our mouths open.  Now you have a new problem to think about.  Venom! 

Prison, Pruno and Poison

Prisoners have long been creative in their ability to access ethanol. Ten years ago hand sanitizer was the readily available source of ethanol. A few prisoners drank the sanitizer straight from the bottle with side effects from the glycerin. Others strained the sanitizer through socks and salt resulting in pure ethanol. Genius!

Now I read about "pruno" being the drug of choice in prisons. Is this brilliant biochemistry or just another way to harm yourself?

“Pruno, or prison wine, is an alcoholic liquid variously made from apples, oranges, fruit cocktail, ketchup, sugar, and possibly other ingredients, including crumbled bread. Bread supposedly provides the yeast for the pruno to ferment. Pruno originated in (and remains largely confined to) prisons and jails, where it can be produced cheaply, easily, and discreetly. The concoction can be made using only a plastic bag, hot running water, and a towel or sock to conceal the pulp during fermentation. The end result has been colorfully described as a "vomit-flavored wine-cooler", although flavor is often not the primary objective. Depending on the time spent fermenting, the sugar content, and the quality of the ingredients and preparation, pruno's alcohol content by volume can range from as low as 2% (equivalent to a very weak beer) to as high as 14% (equivalent to a strong wine).” http://en.wikipedia.org/wiki/Pruno Accessed 10/29/2012

I am sure many people have had positive effects from pruno over the centuries. A report published in MMWR (MMWR October 5,2012. Botulism from drinking prison made illicit alcohol. 61(39):782-784) illuminated an interesting side effect. At the Utah State Maximum Security Prison eight inmates were diagnosed and treated for foodborne botulism after consuming pruno.  All patients received antitoxin and three required mechanical ventilation.  None of the prisoners died.  Foodborne botulism comes from a toxin produced by the anaerobic bacteria, clostridium botulinum.   In this instance the bacteria came from a potato. 

So next time you are looking to brew your own.   Try to avoid any ethanol brewed in a garbage bag.

Garlic

Halloween is less than a week away.  Hopefully you have a cupboard full of garlic to ward off vampires. 

But what does it mean when you smell garlic?  Garlic odor is a sign of heavy metal poisoning, specifically arsenic and selenium.  So this Halloween think of the that nice neighbor that smells of garlic.  Are they hoarding garlic to keep the vampires away?  Of are they secretly poisoning the neighborhood with arsenic and selenium? 

In many parts of the country Sunday will the day for trick-or-treating.  Take the time to appreciate the joy and happiness that will be coming to your door.

Rock and Roll!

Today marks the anniversary of the first time the Rolling Stones appeared on the Ed Sullivan Show.  The October 25, 1964 show marked the entrance of the Stones as icons in rock and roll history. 

The Rolling Stones have long been linked to drug use.  Guitarist Keith Richards has written about his extensive abuse of a variety of substances.  Brian Jones, the original leader and guitarist of the band, was have heavy drug user before his death in 1969.   Check out Brian Jones on the harmonica during their Ed Sullivan set.   

And yet the band plays on...
 
The Rolling Stones live at Zilker Park, Austin Texas, 2006. Enjoy!

Energy Drinks

Energy drinks are an interesting part of our culture.  We use them in the morning to get started.  We use them in the afternoon to keep going.  We use them to get through long work shifts.  Then at the end of the day we mix them with vodka.  The use of energy drinks in various forms has been around for centuries.  Early Europeans drank coffee imported from Arabia and Turkey and tea that was imported from China.  Native laborers in the mountains of Columbia chewed coca leaves for energy.  During the civil war the North blockaded the South preventing the import of caffeine.  It is easy to see that energy drinks, be it my morning cup of coffee, or the afternoon Diet Coke enjoyed by many, are part of our culture. 

As with any drug there is always a downside.  In 2010 US poison centers assisted in the management of over 500 patients that were exposed to an energy drink.  Of those five had a life threatening event.  Fortunately, none died.  Today it was reported that the FDA had received reports of five deaths secondary to consuming energy drinks.   Here is a link to the New York Times article.   Caffeine has a well known list of side effects.  A little to much caffeine and we can all get jittery and have an upset stomach.  Not to mention the feeling that your heart is racing.  But what if you take a giant dose, or have a preexisting heart condition.  In those situations the outcome is not good. 

A drug being part of our culture is not a bad thing.  Most of the time it is a really good thing.  But it is important to remember that all drugs, including caffeine and energy drinks, have side effects.  Plus some people should never take some drugs.  As our Friends at Erowid.com tell us, "Know your body - know your mind - know your substance - know your source."              

 

Politics and Poisoning, US style...

Today is the last Presidential debate for 2012.  We are sure to witness attacks by each candidate and elaborate stories thrown out in an ingenious defense.  The only poison we will witness will be in the form of venomous words.    But the use of poisonings to influence politics has been going on for centuries.  From Alexander the Great to Caesar Augustus and Napoleon Bonaparte, poisoning for power has long been practiced.  Viktor Yushchenko told us the poisoning to change elections still exists in this, the 21^st century.  But certainly poisoning for political gain would never happen in this country.   

The Dalles, Oregon is a quaint community of nearly 13,000 that lies on the banks of the Columbia River.  It is the county seat of Wasco County in northern Oregon.  Back in 1981 the local Big Muddy Ranch was sold and within three years became a thriving religious community.  The ranch was incorporated as a city, Rajneeshees.   At its peak the city had a population of 7,000 followers of Bhagwan Shree Rajneesh.  It did not take long for the new city to be embroiled in a string of disputes with the nearest city, Antelope Oregon, and the county.    

In 1984 the followers of Rajneesh ran for election in two of the open seats on the Wasco county circuit court.  Fearing that they did not have enough votes to win Rajneesh followers decided to influence the electorate in an unusual way.  Today we see attack ads that may sometimes contain a small kernel of truth.  But that is child’s play.  Rather the followers of Rajneesh made the concerted effort to limit the number of voters by poisoning many local salad bars with salmonella. 

First two Wasco county commissioners were deliberately poisoned and became ill, one was hospitalized.  Next salmonella was spread on the doorknobs and urinal handles in the courthouse.  But again, not enough people became ill.  The community then spread salmonella on ten different salad bars through the city.  According to a paper published in JAMA in 1997 that details the public health investigation, 751 people became ill.  The poisoning occurred in two waves and lasted from September 9 to October 10.  After ruling out all of the normal modes of disease transmission it was confirmed that the mass poisoning was caused by a single strain of salmonella typhimurium.   The bacterium was found in stool samples of the ill, on the food from the restaurants and in the laboratory of the commune.  Common symptoms of the victims included fever, chills, abdominal pain, nausea, vomiting and diarrhea.  The victims ranged in age from a newborn to an 87 year-old.   ( Török TJ, Tauxe RV, Wise RP, et. al.  A Large Community Outbreak of Salmonellosis Caused by Intentional Contamination of Restaurant Salad Bars.  JAMA. 1997;278(5):389-95) 

So what happened to the election?  When rumors spread throughout Wasco County that the commune was behind the poisonings, voters showed up in big numbers.  The Rajneeshees eventually withdrew their candidates from the ballot.  The terrorist plot was foiled.    

Poisoning and politics.  Will we be reading next month of an election influenced by the verbal poison of the candidates and the venom of special interest groups?  Hopefully we will not be reading about a power grab made with the assistance of one of life’s oldest political friends.   And yes, it can even happen in your backyard.

Clean Water

Today marks the 40th anniversary of the Clean Water Act. Worldwide the lack of clean water is a tragedy that leads to the death of millions every year.  Be it swimming, fishing, boating or just brushing your teeth, we can all be grateful for a law that was passed by a wise US Congress a generation ago.  Here is a brief summary of the Clean Water Act.