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.