Is It Poisonous?
24 Hours a Day, 365 Days a Year,
Washington Poison Center Has the AnswerWilliam O. Robertson
Case #I: Three preschoolers, aged 4 to 5 years, boasted to their parents about having eaten "lots" of rhododendron blossoms. Their mother called the Washington Poison Center for advice. Based on experimental animal data and experiential human data, we were able to reassure her that rhododendron blossoms are remarkably "nontoxic" and even nausea or vomiting were unlikely. Follow-up calls confirmed that we were correct. Case #2: A 64-year-old man was admitted to the hospital shortly after midnight because of confusion, aggressive behavior, and several episodes of emesis over the prior four hours. His physician suspected either a stroke or a subarachnoid hemorrhage. A CAT scan was normal but other test results showed mixed respiratory alkalosis and metabolic acidosis with a serum bicarbonate of less than 12, which prompted a call to the Poison Center. The physician-toxicologist listed the common causes for these findings - methanol and ethylene glycol - but suggested giving specific attention to salicylate level, which proved to be 110 mg%. The patient recovered after treatment, and subsequent investigation confirmed a suicide attempt the prior afternoon.
Case #3: Fire aide units were called to a Tacoma geriatric nursing home after a bottle of cleansing solution had spilled in the kitchen and its "vapors" had spread throughout the patients' rooms. The units called the Poison Center. We were rapidly able to identify the product as primarily a dilute hypochlorite solution. Its vapors had a characteristic odor, but none of the patients had pulmonary symptoms and we advised that none required transport to the hospital.
These examples typify the range of problems posed to the statewide Washington Poison Center, which receives more than 135,000 telephone inquiries each year. Some 40 years ago, hospitals in Seattle and Spokane activated rudimentary poison control centers to address the problems of toddlers eating house-hold products and over-the-counter medicines. The first center in Seattle, established in 1956 in the University of Washington's Department of Preventive Medicine (forerunner to the School of Public Health) answered about 300 calls in its first year. However, the round-the-clock need for information prompted the center's move to Children's Orthopedic Hospital (now Children's Hospital and Regional Medical Center) in 1957.
Cardex to Computer
In the early years at Children's Hospital, largely untrained clerical staff in the Admitting Office answered phone calls and consulted a 5x8-inch card file containing ingredient and toxicity information on approximately 1,000 items. This index was supplied by the National Clearinghouse of Poison Control Centers, which was established in 1954, less than two years following the creation of the nation's first center in Illinois. Within several years the Children's Hospital center moved to the Emergency Department, where it was staffed by nurses, and then in the mid-1970s to the Pharmacy During the seventies, the number of "centers" across the state burgeoned to 14, all located in hospitals.The microfiche technology of the early seventies allowed expansion of the information database to more than 40,000 items. With the advent of computers and CD-ROM technology, the database grew exponentially; today, remarkably detailed, organized information on more than one million items is available in less than I I seconds! So, too, our responding staff is now almost exclusively trained graduate pharmacists and nurses backed around the clock by board-certified "physician-toxicologists." They are employed specifically to answer telephone inquiries.
Recognizing the pleas and plans of medical and hospital leaders, the Washington State Legislature began to fund the poison center program in 1980 but limited support to four politically designated units, so mergers soon followed. Washington was the first state to provide public support and tie it to the volume of phone calls received. The state continues this support, while private sources are being sought to augment its public and professional education program. Today, Washington is still far ahead of other states in providing this service.
With the help of the State Department of Health, the four centers in Seattle, Spokane, Tacoma, and Yakima were combined in 1993 into a statewide center located in an office building in north Seattle. Comparable consolidation is occurring elsewhere and the number of "regional centers" nationwide will eventually total between four and 40 depending on practicalities and technologic progress.
Day-to-Day Operations
Forty years ago, we anticipated that health professionals would make all inquiry calls to the centers. Remarkably quickly, the focus shifted to the public. Over the years, however, more and more health professionals and then institutions began to call. Today their complex questions account for more than 10% of calls and consume much of our staff time. Questions concerning children accounted for more than 95% of early calls; today it is less than 60%. Calls concerning adult problems of drug interactions, medication "mixups" (drug errors), suicide attempts, drug abuse, occupational exposures, and environmental contaminations require some 80% of our effort.For each incoming call a staff member completes a standardized record. All records are tallied for each local center and annually totaled for the entire country by the American Association of Poison Control Centers. The AAPCC's retrospective database of more than 20 million clinical exposures and outcomes is available to guide treatment options, Poison centers in Washington State were among the first to realize that "publication bias" had vastly overrated the possible toxicity of rhododendrons, mistletoe, foxglove, and other plants (unless brewed and consumed as tea). For example, among the more than 100,000 annual calls nationwide about plant ingestions, only one or two fatalities occur, primarily in adults. Consequently, poison centers are far more confident in reassuring callers that a child who eats a leaf or a berry is rarely at risk and can be safely observed at home.
Similarly, Washington centers were among the first to note that toddlers who consumed too many children's chewable vitamins with iron never seemed to get ill. Based on more than 100,000 nationwide cases, we can now report that not a single toddler has developed significant symptoms and thus we recommend against "heroic" treatment measures, including racing to the nearest hospital and risking traffic fatalities. Similarly, more than 65,000 clinical cases show that children have a remote risk of poisoning from ingesting the rat poison Warfarin. Observation at home for bruising or bleeding appears to suffice, and thus avoids emergency department visits and repeated prothrombin time determinations.
Successes and Challenges
Poison centers have evaluated and promoted many effective preventive measures. Child-resistant containers achieved some 60% of the reduction in mortality from poisoning among children 5 years of age or less. Safety caps, product labeling, drug imprint systems, "Mr. YUK" awareness campaigns, more alert parents, attentive health care providers, cooperative manufacturers, government regulations, and other initiatives helped reduce the number of deaths from 460 in 1962 to fewer than 50 by 1994. Successful local programs continue to stress public awareness and education on poison prevention. Spokane's annual, schoolwide "Mr. YUK" Poison Prevention Poster Contest" draws more than 5,000 entries and the winners are displayed on city billboards during Poison Prevention Week.Still, all is not well. Extrapolations from nine years of New York State data show that drug errors in hospitals - decimal place errors, similar sounding and looking names, and ever-present human errors - kill 100 to 150 children each year. Our Washington center is leading a statewide effort to urge all prescribers to add a "notation of purpose" (e.g., "for cough" or "for diarrhea") on all prescriptions so that both the pharmacist who fills it, or the patient who takes it, perhaps as only one of five to 15 different daily drugs, will be less likely to make a mistake, We have already succeeded in convincing Washington State, and recently the federal Food and Drug Administration to mandate the use of imprint codes on all solid medication forms so as to better label the individual dosage units and further minimize error.
When the program began some 40 years ago, 1.2 million chemical entities were listed by the American Chemical Society; today that number exceeds 13 million. Our initial focus was on acute exposures; now we - along with others - have begun to try to get a better idea of the real or imagined chronic effects of natural as well as synthetic chemicals. I'm convinced that scientific data from our nation's poison center network can help us determine which medicines, pesticides, pollutants, or other chemicals are really cause for concern and how best to manage them.
Recommended Reading
Litovitz TL, Smilkstein M, Felberg L, et al: 1995 Annual Report of the AAPCC Toxic Exposure Surveillance Systern. Am J Emerg Med 1997; 15:447-500.
Lovejoy F, Robertson WO, Woolf A: Poison center, poison prevention, and the pediatrician. Pediatrics 1994; 94:220-224.
Robertson WO: When fear collides with scientific probability, guess what wins? Poison Network 1995; 15:1-2.
Author
William O. Robertson, M.D., is medical director of the Washington Poison Center and professor of pediatrics at the University of Washington School of Medicine.
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Created: 5/6/98 Updated: 7/15/99
