Doctors warned to stay alert for threats from toxic agents

Washington -- Carl Flynn, MD, a family physician in Caribou, Maine, a small city of 6,000 tucked into the nation's far northeast corner, never expected an act of terrorism to strike close to home. But it did.

In what could be the largest arsenic poisoning case ever in the United States, one person died and 15 others were hospitalized last April when the coffee at a church social in nearby New Sweden was spiked with this deadly substance.

It is believed that the poisonings were carried out by a respected member of the congregation, but the suspect killed himself shortly after the incident. The case remains open.

Dr. Flynn and other local physicians were ultimately able to handle the emergency with help from the state toxicologist, who was preparing a supply of antidote in kits for shipment to all state hospitals as part of a bioterrorism readiness effort. Instead, the toxicologist pulled out the arsenic antidote and sent it directly to Dr. Flynn.

But getting to this step -- pinpointing the appropriate treatment -- was puzzling. Dr. Flynn remembers sitting with two other physicians, heads bent over textbooks as they wondered, "What are we going to put these people on?" As it turned out, there is little information on what happens when people drink a large amount of arsenic all at once. The textbooks weren't helpful and are now being rewritten using the Maine patients as case studies.

The most important lesson learned from this incident is that physicians must keep their guard up, said Dr. Flynn. "Physicians need a high index of clinical suspicion that there could be something going on."

Arsenic is only one of many possible chemical weapons that could be used by a terrorist, whether homegrown and self-educated or foreign-born and al Qaeda-trained.

The possibility of accidental exposure to toxic agents should also be kept in mind.

There is a vast array of chemicals close at hand almost anywhere in the country, and many already have a history of nefarious uses, according to the American College of Medical Toxicology. It has developed a course called "Chemical Agents of Opportunity for Terrorism: The Medical and Psychological Consequences."

As the terrorism alert warnings change from yellow to orange and back again, physicians would be wise to maintain their vigilance.

In the world after Sept. 11, 2001, "terrorists can make the unlikely' happen," said Paul Wax, MD, the course director and a medical toxicologist at Banner Samaritan Medical Center in Phoenix.

Dr. Wax and colleagues presented an abbreviated class version to congressional staffers and others on Jan. 14 on Capitol Hill.

The first step toward a safe community is understanding which toxic agents are already in the neighborhood, said Curtis P. Snook, MD, an associate professor of emergency medicine at the University of Cincinnati School of Medicine.

About 850,000 U.S. businesses use, produce or store toxic industrial chemicals, said Dr. Wax. Among the chemicals on this long list of lethal substances are ammonia, chlorine, formaldehyde, phosgene, sulfur dioxide and carbon monoxide.

Toxic substances can be found at farm and garden supply stores, photo labs, college labs and toxic waste dumps as well as the many industrial facilities in the nation.

The Environmental Protection Agency has reported that 123 chemical plants across the country have enough toxic chemicals to kill or injure 1 million people, according to course material.

Dangerous agents can also be ordered over the Internet. Last year a high-school student poisoned a rival for a classmate's affections using potassium cyanide purchased from a Web site, said Dr. Wax.

Building expertise

If there is a release of toxic chemicals, physicians should be prepared to handle panicky patients' many phone calls. They should also be sure that all experts in handling an emergency know each other, said Dr. Snook.

Simply recognizing poison as the cause of a patient's ills can be difficult. Dr. Flynn attributes the quick identification of the Maine arsenic poisonings partly to luck and partly to the fact that so many people were made ill -- all of whom ingested the coffee and said it tasted "weird." If there had only been one or two poisonings, identification would have taken much longer, he said.

Poisons also aren't always immediately lethal. Karen Wetterhahn, PhD, a professor of chemistry at Dartmouth College in Hanover, N.H., died nearly a year after being accidentally exposed to a highly toxic mercury compound in 1996.

But physicians aren't on their own when it comes to identifying and treating patients with unknown ailments. Contact state poison control centers for help, Dr. Flynn recommended. He found Maine's poison control center in Portland to be a great resource.

Federal assistance is also available. A team of two Centers for Disease Control and Prevention toxicologists and an epidemiologist visited Caribou after matters settled down.

These experts had continually monitored the situation during its height and were prepared to step in should their help have been needed. It wasn't.

The revelation that the CDC has an infrastructure in place to detect and monitor chemical exposures throughout the country and is ready to serve as a backup to overwhelmed physicians is reassuring, said Dr. Flynn, who is still amazed that the deadly event occurred in his area. "It's such a friendly community."