Cold Fire

What toxin can spontaneously combust in the emergency department? What poison is so potent that the patients' vomit and stools are a danger to staff members? Why are there no bones at the famous battle of Waterloo where ten thousand men died in one day? 

Transcript

This is the Pick Your Poison Podcast. I’m Dr JP. ER doctor. Toxicologist, and unapologetic lover of all things poison. What toxin can spontaneously combust in the emergency department? What poison is so potent that the patients' vomit and stools are a danger to staff members? Why are there no bones at the famous battle of Waterloo where ten thousand men died in one day?

Stay right here to find out.

This is an interactive story. 

Survival isn't guaranteed. 

What happens next depends on you. Will our patient live or die? 

It's up to you and the choices you make. 

So gown, up, and let's go. 

Today’s episode starts in the emergency department.

The All Star intern approaches, “Can I run a case by you?” she says “It’s something I’ve never seen before.”

“Sure,” you say. “What’s going on?”

She hesitates. “I’m not sure how to describe it. Let me present the case—and then I think you need to see it.”

“You can't describe it.”

She shakes her head. “It’s… weird. Really weird.”

“Can you put "weird" in medical terms?”

“Ummm, no Just come to the room with me after.”

This is a little unusual. “Go ahead,” you say.

The patient is a 53-year-old woman with the chief complaint of nausea, vomiting, Diarrhea and abdominal pain.”

You blink. It sounds disappointingly routine. You’re expecting something like a foreign body stuck somewhere it shouldn't be, a bizarre trauma, maybe. 

She continues, “The patient’s abdominal pain started a few hours prior to arrival. She's had multiple episodes of vomiting though no blood in the vomit or in her stools. No fever, No urinary complaints. 

Her vital signs are as follows: afebrile temperature of 98.6 F or 37 C. Heart rate is 110 beats per minute. blood pressure 120/80, respiratory rate 18 with an oxygen saturation of 100% on room air. 

Her exam is notable for some mild abdominal tenderness but otherwise unremarkable. The intern’s already ordered lab work which was normal, a urine specimen which shows no sign of infection, as well as a CAT scan which was also negative and treated her with IV fluids, pain medicine, and nausea medicine. Despite this, the patient hasn't improved, which we'd expect with if she had something basic like gastroenteritis, i.e. a stomach virus.

Okay she says, "barely having taken a breath during the presentation." Come with me please.” 

Question number one: What are you expecting to find?

A. psychiatric presentation issue

B. Parasites

C. An unusual physical exam finding.

You brace yourself to see something the patient thinks is a parasite. Think this is fiction? It's not. I can't tell you how many times patients have brought their stool in plastic baggies or shopping bags to show me something they insist is a parasite. It's never once been an actual parasite.

Immediately on entering the room you are struck with a strong wave of garlic odor, presumably the patient ate something very garlicky prior to arrival. There's also a strong odor of stool, i.e. poop. The Intern points to the bedside commode the nurse put in so the patient wouldn't have to walk down the hall every time to use the bathroom. 

You raise an eyebrow. The Interns pulled you in here to show you the contents of the patient's commode?

Look at it she says. It's smoking.

Uh-oh.

She’s right. If you're a toxicology fellow, I bet you got this one already. The patient has smoking stools. There's a pile of stool in the commode with smoke rising up from it.

While you look in surprise and pull out your phone to take a video, the intern asks some more questions. The patient denies taking any medicine, including. over-the-counter medicines, and supplements. She doesn't smoke. She's an occasional drinker and denies illicit drug use.

The triage nurse puts her head in and says to the patient, "Your husband's here. Should I let him back?"

The patient says no, “I don't want him here.”

You look away from the smoking stool in surprise. It's up to the patients if they want to allow family members at the bedside, most want their families back as soon as possible. There are definitely exceptions, like cases of domestic violence, Psychiatric Complaints, or women of childbearing age with pregnancies and patients with potential STIs. Understandable why patients may not want family members back in these situations. But for abdominal pain and diarrhea it's a little unusual. That said it's up to the patient.

The tech hands you an EKG to read from triage. You've groan silently it has ST elevation, meaning a heart attack. You're concerned about this patient, but the cardiac cath lab has to be activated immediately so you in the internal have no choice but to move to the critical patient first. 

In the middle of the STEMI the triage nurse says your patient's husband is pounding on the doors, insisting on coming back. Security has had to restrain him. He's yelling he has important information and needs to speak to the doctor.

Put him into the family consultation room, you say, and I'll talk to him in a few minutes. Every emergency department has a space where family members can sit when they aren't allowed back. Mostly for families of critical patients, say with trauma or in cardiac arrest, to wait while we try to stabilize them.  

At this moment it's a distraction to say the least. Your plan was to let him wait there until the intern had time to talk to him but security is saying he's now threatening staff. You decide to quickly handle it yourself. The patient's refused to let him back, meaning we can't discuss her health with him.

The husband it's pacing around the small family room. Thank you doctor for talking to me. He says immediately. He tells you he arrived home today earlier than planned from a work trip. He was surprised his wife wasn't home, but assumed she had gone out. 

That is until he found the suicide note on the bedside table.

You're certainly glad you came out to talk to him now. It would have been much easier if he'd simply told the triage nurse what the information was he needed to convey but this is the emergency department and things rarely go according to plan. 

You have a strong suspicion about what's going on with his wife but how it happened is very much unclear. He says he searched the house looking for empty pill bottles, including the trash can. He checked the medicine cabinet and while there wasn’t time to do a full inventory, the narcotics were undisturbed.

Normally this is very valuable information from a family member if there is a report of an overdose. EMS will often look for empty bottles and bring anything they find to the emergency department. In this case though, I'll tell you there's nothing in your medicine cabinet that's causing smoking stools.

“Does she work,” you ask

“Yes,” he says. 

“What kind of work does she do?”

“She's a chemist.”

Hmm that's never good in a suicide attempt. “What kind of chemistry? Where?” 

“In a munitions factory.”

Uh-oh. I don't personally know all of the chemicals and toxins in a munitions factory, I think it's safe to say it could be anything and everything, especially stuff that's really bad for you. 

Smoking stools was a big enough clue, a munitions factory pretty much seals the deal in my opinion. This is a tough one if you're not a medical professional but it is time to pick your poison. Question 2 Is it?

A.    VX gas

B.     Sulfur mustard

C.     White phosphorus

D.    Nitroglycerin

The answer is C. This is white Phosphorus. An extremely dangerous, very life-threatening toxin. If you ingest white phosphorus, it causes nausea, vomiting, diarrhea, and abdominal pain and everybody's favorite test question, smoking stools. It also has a strong odor of garlic. That's what we were smelling in her room not from garlic in a meal. More on what White phosphorus does in a minute. Now that we know what happened we need to jump immediately to treatment. 

Question 3. Should we pump her stomach, ie gastric lavage? 

A.    Yes

B.     No

We toxicologists spend a lot of time debating the merits of GI decontamination in various types of patients and for various types of toxins. In the old days, as I'm sure you know, everybody's stomach would be pumped in the ER immediately after an overdose. We no longer subscribe to this theory because the gastric lavage tube is really large and causes complications, including aspiration and esophageal perforation. So these days we reserve gastric lavage for potentially life-threatening exposures. Does white phosphorus count? Absolutely.

The second criteria for pumping someone's stomach is evidence of a recent ingestion, meaning you have to have a reasonable suspicion the toxin is still in the stomach. I should probably clarify that gastric lavage is a very large tube. Think the size of a small garden hose that goes down your nose or mouth and into your stomach. The tube is then hooked up to suction with the hopes of suctioning out the toxin. If however the toxin has moved further down into the intestines, then the lavage tube won't be able reach to suck it out regardless of how potentially lethal it might be. 

How long do things stay in the stomach? It's pretty variable, we usually have to make an educated guess. About an hour is a general rule of thumb though it might be less for things that are quickly absorbed, like liquids, or longer for things that are slowly absorbed and delay gastric emptying, like Diphenhydramine or Benadryl.

The husband reports he spoke to the patient on the phone several hours ago and she was fine so I think it's safe to assume that this was a recent ingestion. I'll tell you right off the bat it's controversial whether or not to do a lavage after white phosphorus exposures. So if you answered A or B, you were right. Some sources absolutely recommend it and others report little benefit and potential harm.

One potential harm is a particular complication occurring after lavage tube placement, that as far as I know, only occurs with white phosphorus ingestion. That's question number 4, is it?

A.    Spontaneous combustion.

B.     Esophageal perforation.

C.     Increased absorption

The answer is A. You heard me right. There is actually a risk of spontaneous combustion. For real not a joke. If the white phosphorus combusts, you could potentially burn the patient as well as the staff members (i.e. the person putting in the lavage tube). Lavage tubes can’t increase absorption and as I said earlier can cause esophageal perforation but this is due to the tube itself and not related to the specific toxin. 

Let's talk about what white phosphorus does. After considering the harm, we'll come back and decide what to do about gastric lavage.

First I should say there are different types of phosphorus: white, red, and yellow. Red phosphorus is used in matches. That's the red you see on the match head. There's been a recent resurgence of toxicity related to red phosphorus because it's used in methamphetamine production. When you heat it with iodine, a part of the process of making methamphetamine, the by-product can be phosphine gas, which is a pulmonary irritant. Yellow phosphorus causes liver failure. But the most dangerous form by far is white phosphorus.

What happens after someone eats it? We don’t know exactly how it works, but it gets inside and poisons cells, including the endoplasmic reticulum and mitochondria, where energy is made. Systemic toxicity from white phosphorus results in electrolyte disturbances, including low calcium and high phosphate. Several case reports note arrhythmias, including ventricular fibrillation, likely due in part to hypocalcemia. Acute liver and kidney injury can occur. 

Clinically, there are three phases. The first phase occurs within 24 hours after ingestion. It’s exactly what our patient is having: nausea, vomiting, diarrhea, and abdominal pain. How do you get smoking stools? It’s white phosphorus that wasn’t absorbed in the gastrointestinal tract, coming out the other end, being excreted in the stool. The patient poops it out, it’s exposed to oxygen and starts to smoke. In phase 2 at approx. 48 hours, the patient is asymptomatic and appears to be improving. Unless you’re checking their lab tests, you'll see the liver function tests start to rise. Phase 3 is survival or death. Some critically ill patients have survived ingestion after liver transplant. 

Cases from the 1930s and 40s suggested a 50% mortality rate after ingestion. With modern medical care it's much less. A series of patients ingesting firecrackers in Ecuador, showed a fatality rate of about 6%.

Is there an antidote for this lethal toxin? 

No, the treatment is supportive and that's why we have to come back to the issue of gastric lavage. If we do a gastric lavage and remove some white phosphorus, it might be a lifesaving intervention. But as I said before risky. Why? What's inside the lavage tube when you put it down in the stomach. Air, i.e. oxygen, causing spontaneous combustion. While I wasn't able to find reports of this actually happening, it is definitely a possible reaction. 

I'd be cautious about lavaging any patient with white phosphorus toxicity but if you decide the risk-benefit analysis favors it, the recommendation is to keep the tube filled with water to prevent introducing oxygen into the stomach.

White phosphorus ingestion is actually pretty rare, especially in the US where there are a lot of restrictions on its use. It's banned in firecrackers, for example. In countries outside the U.S,It's used as a rodenticide and is still used in firecrackers, which is why, as I said earlier there are cases of toxicity after ingestion.  

By far the most common form of exposure worldwide to white phosphorus is dermal exposure. Why? Unfortunately, it’s used as an incendiary weapon.  As I said, White phosphorus explodes when coming into contact with water. In fact, Phosphorus isn't found in its elemental form in nature because it's so reactive. When it does explode, it creates a large amount of white smoke, the reason it's used in flare guns. 

It's used in incendiary bombs, which cause horrific burns, due to a combination of thermal and chemical injury. The burns penetrate deeply into the skin, deep enough in some cases for white phosphorus to be absorbed systemically.

Gastric lavage isn't the only way white phosphorus puts the hospital staff at risk. If a patient comes in with dermal exposure (i.e. burns), the staff can come into contact with the white phosphorus and suffer burns themselves so decontamination is extremely important in these cases. Specifically external rather than internal GI decontamination, like lavage. For any patient who may even potentially have been exposed to white phosphorus, it is extremely important to make sure all the staff is wearing a gown, gloves, and a face shield.

Even if the patient is really sick, the first step is decontamination to keep the staff safe and to keep the patient from ongoing exposure. For example if there is residual white phosphorus on the patient's clothing, they can keep getting burned. Clothing should be removed, presumed to be contaminated, and placed in water-filled, tightly sealed storage containers. Phosphorus is minimally reactive with water making this the best way to store it. For example when used for industrial purposes it's stored in water to prevent contact with oxygen and subsequent combustion. Bandages that are removed from the patient have to be considered incendiary and stored in the same fashion. Even the patient's body fluids are a risk so the vomit and diarrhea are considered hazardous substances and there is a risk of fire.

Once you decontaminate the patient, the next step is copious irrigation with water or saline to remove any remaining white phosphorous from the patient's skin. Even this can be dangerous to health care workers and needs to be done with caution because pieces of burning phosphorus from wounds have flown up onto health care workers. White phosphorus can really stick to the skin and the burns. Some recommend using a woods lamp, essentially a black light, which will allow phosphorescence, illuminating residual toxin in the wounds. 

            The burns by white phosphorus are pretty horrific looking and I say this as a person who has taken care of hundreds and hundreds of burn victims. Ideally the patient would be treated in a burn unit if the wounds are extensive. Dermal burns can be lethal. If the burn is large enough, leading to systemic absorption.

            Back to our patient. You admit her to the intensive care unit, advising the ICU staff on PPE precautions and treating both vomit and stool as potentially hazardous incendiary compounds. The patient's liver function tests rise dramatically. The transplant team consults and lists her for transplant; however by day 6 her liver function begins to stabilize. After another week in the hospital her liver function tests return to normal. She's seen by psychiatry, who recommends psychiatric admission once stable for further treatment of depression.

            She admits to the psychiatrist that she obtained white phosphorus from her work in the munitions factory and ingested it in an attempt to kill herself. This is a fictional case, as are all our cases, to protect the innocent. But it is based on real poisonings. As always in this episode we're leaving out many details in case someone listening wishes to harm themselves or someone else. If you are having thoughts of wanting to hurt yourself, please know that help is available and you can call the Suicide and Crisis Line at 988.

White phosphorus has an important occupational history. It was initially used in "strikeless matches," which became very popular in the late 1800s. Because white phosphorus is so incendiary, as we've been saying, you can strike it against anything and it'll light. You don't need a special strip like we have on most match boxes today. These were outlawed in the early 1900s. Why? Because of the horrific complications suffered by the workers. 

The symptoms started with tooth and jaw pain followed by tooth loss, abscess and fistula formation. Eventually what happened was complete necrosis of the mandible, i.e. the jawbone. I cannot imagine the excruciating pain of having a rotting, foul-smelling, dying bone in your mouth. It became known as phossy jaw. 

X-rays of the phossy jaw bones have a very characteristic appearance. It looks like they're worm-eaten, almost like the jaw turns into a pumice stone with holes. Eventually after publicity and protests, laws were passed forcing matchmaking companies to transition to use of red phosphorus. This requires a strike to strike the match on like we have today and was much more expensive, though much less toxic. 

Phossy jaw is not gone. Interestingly enough there's a common medicine we use today that's toxic to the jaw. It's bisphosphonates. You may know what this is. It's a classic category of drugs we use to treat osteoporosis. And interestingly enough, osteonecrosis (i.e. death of the jaw) is a rare but possible complication.

            Phosphorus is often used in fertilizer and while this may not sound super exciting, I have to tell you this is one of the craziest facts I've ever come across in this podcast. In ancient times people noted that crops grew better in the presence of bones and so for a long time bones were dug up, ground up, and then sprinkled on fields as fertilizer. Ultimately it was determined that the phosphate from the bones was the useful component.

            Question number 5. The Battle of Waterloo is packed with bones.

A.    True

B.     False

This is false and you're not going to believe the reason why. You know about the Battle of Waterloo, of course, the high-water mark and the end of Napoleon. More than 10,000 men died at this battle in one day. Not surprisingly Archaeological investigations have been ongoing since 2012. Do you know how many skeletons they've discovered? Two full skeletons Two! 

That's it. 

How did they miss the skeletons of the other ten thousand people? They didn't. It's because the bones aren't there. They were dug up and sent back to England to be turned into fertilizer. Really you cannot make this up.

It's pretty gross to imagine dead bodies being ground up, scattered across the fields, and then incorporated into the food that you eat. Not surprisingly the bones in Europe started to run out so then people started looking to guano (i.e. bat poop) as a fertilize. Guano is high in phosphorus, Like bones.

Phosphorus was called the Devil's Element when it was discovered by an alchemist in the 1660s due to its dangerous and combustible nature. The alchemist was attempting to make gold, apparently, by boiling his own urine. Rather than gold he got a yellow waxy substance with a phosphorescent green glow. So he named it Phosphorus after the Greek words for light bearer.

            Combustion isn't the only danger posed by white phosphorus. As I said when it's in water, it's not combustible; however when it gets into the water supply, you may not be surprised to hear it can cause serious problems. For example it built up in Lake Erie. This caused an increase in algal blooms, which we've talked about in previous episodes. They can kill wildlife, birds, and even pose some danger to humans. You've probably heard that laundry detergent isn't great for the environment and the reason for this is the phosphorus that's in it.

            The last question in today's podcast is: What book was written about the pollution in Lake Erie?

A.    The Lorax by Dr. Seuss.

B.     Silent Spring by Rachel Carson

C.     Love Canal a Toxic History by Richard S. Newman

Follow the Twitter and Instagram feeds both @pickpoison1 for the answer. Remember, never try anything on this podcast at home or anywhere else. 

Thanks for listening. It helps if you subscribe, leave reviews and/or tell your friends. Transcripts are available at pickpoison.com. 

While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Until next time, take care and stay safe

Answer: A the Lorax. I also didn't know that Dr. Seuss wrote The Lorax about Lake Erie. It was green due to algal blooms and pollution from phosphorus. After the Clean Water Act was passed it was cleaned up.