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Dr. Marsha Ford on Poison Centers and Coordinating Crisis Care

Poison Centers and Coordinating Crisis Care

In the 1930s, pediatrician and toxicologist Jay Arena began collecting data on poisoning cases and discovered that the lead cause of death for children was poisoning. “Children are naturally curious,” says Marsha Ford, emergency physician, medical toxicologist, and former president of the American Association of Poison Control Centers. “At the time, there was no such thing as a child-resistant cap.” Dr. Arena, the first director at Duke University’s Poison Control Center, later developed what we know now as the child-proof safety cap alongside the Plough Company (renamed Merck & Co., Inc. in 2009), a U.S. pharmaceutical company and manufacturer of children’s aspirin. The company’s “candy aspirin” was chewable, orange-hued, and flavored to appeal to young children, which it did, resulting in spikes in aspirin deaths among preschoolers. 

Poison centers, notes Dr. Ford, grew organically over time, starting with the first one at St. Luke’s Medical Center in Chicago in 1953. Pharmacist Louis Gdalman, one of its founders, had developed a toxicology information system stored on index cards and, later, microfiche. “The Poisindex [poison index] was later moved to local databases—we received CD upgrades every three months—and now it’s stored on the cloud,” says Dr. Ford. Today, IBM owns the index.

Today, there are 55 poison centers. Calls are answered 24 hours a day, 365 days a year by specialists in poison information, called SPIs. “They’re the frontline of the centers and are usually either nurses or pharmacists,” says Dr. Ford. However, SPIs can also be physicians, physician assistants, or toxicologists. Each center is capable of handling nearly all exposure cases. Not only because of the specialists’ expertise but also because they have constant access to the Poisindex, which lists a few hundred thousand chemicals, natural products, and drugs, as well as management protocols. “The Poisindex tells you what to expect and also gives recommended treatments.” Each center also has its own management guidelines for the most critical, serious cases specialists are likely to encounter.

If a specialist needs further guidance, they can connect to another poison center. For example, decades ago, Dr. Ford had a caller who’d been exposed to paraquat dichloride, an herbicide—one she was familiar with but hadn’t yet had a case involving it. So she reached out to a poison center in Minnesota with experience addressing similar cases. “They’d developed a specialized expertise because they’d handled many calls involving paraquat.”

Similar to the 988-National Suicide Prevention Lifeline, calls to the nationwide poison center number (800.222.1222) triage by area code. However, many people have cell phones with an area code different from where they live, or they might be traveling. Organizations like NAMI and Vibrant Emotional Health, which runs 988-Lifeline, have pointed out that geolocation would improve routing accuracy—and thereby response—by matching people to the nearest 988 call center and local resources. On May 24, the FCC held a forum on 988 geolocation. 

Dr. Ford, the director of the North Carolina Poison Center at Atrium Health in Charlotte from 1997 to 2014, says most calls the center received were from people in North Carolina. “But if someone with a North Carolina area code is elsewhere and calls the nationwide toll-free number, they’ll still get routed to the North Carolina poison center.” She says former colleagues have shared that they’ve repeatedly and unsuccessfully tried to get telecom carriers to route calls based on billing address instead of area code. “The mobile companies have not yet made this a priority.”

Also, similar to 988-Lifeline, poison centers can stabilize most calls and divert people from the emergency department. The call specialist will collect data immediately, including the caller’s name, address, whether the caller is the patient or calling for someone else, the patient’s age, symptoms, and exposure. “Most of the time, the person ingested something,” she says, “but sometimes, it’s an inhalation, or they got something in their eye or on the skin.”

More than half of unintentional poison exposures in 2020 involved children five years old and younger. “Many callers are parents,” says Dr. Ford. The call specialist will ask the parent what the child is experiencing and how long ago the exposure was. Often, the specialist will be familiar with the toxin and next steps, but if not, they’ll look it up in the Poisindex to determine the clinical effects and what’s considered a toxic amount. The database also includes how to manage the exposure and what sort of decontamination is needed, if any. “If the toxin is in the eye, the parent might need to run slow-moving water from the faucet over the child’s eye.” 

Poison centers have moved away from recommending activated charcoal and syrup of ipecac. “It’s not thought to be very efficacious in most cases,” says Dr. Ford, “and sometimes the treatment is worse than the ingestion.” Throughout the call, the specialist is also trying to get a feel for the caller and whether they’re able to address the issue at home. “They’ll also ask how far the caller and child are from the nearest emergency room and if they have transportation.” 

In most cases, the exposure isn’t dangerous. “The child can usually remain at home, and we make at least one follow-up call to ensure all is still okay.” Specialists will also tell callers to call back if symptoms worsen. However, some cases are more dangerous than they might appear. For example, even if a child seems fine, specialists will send a child who’s gotten into a family member’s diabetes medicine straight to the emergency department. “Their blood sugar could dangerously drop,” says Dr. Ford. 

Poison centers also partner with hospitals to ensure coordinated care, regardless of whether the patient gets to the emergency department by ambulance or car. For instance, Dr. Ford had a case where a three-year-old had eaten an anti-inflammatory, analgesic product that included methyl salicylate (wintergreen leaf), a chemical closely related to aspirin. “The mom called and said the child appeared fine, but we realized the ingestion had the potential to kill the three-year-old in a matter of hours.” The specialist told the parent to hang up and call 911. However, when emergency medical services arrived on the scene, they didn’t understand the gravity of the situation. “The amount of exposure had been small, but we leaned on them to take the child to the emergency department.” However, the emergency physician similarly wasn’t aware of the seriousness of the exposure.

“That’s when I got involved,” says Dr. Ford. “There’s always a doctor in toxicology backing up the specialists.” She told the doctor it was a life-threatening aspirin overdose, and the hospital quickly transported the child to a tertiary care hospital in the eastern part of North Carolina. Dr. Ford called the flight team’s medical control doctor, shared the complications, and called the pediatric kidney specialist at the receiving hospital. “It was a Friday afternoon,” she says.” “I told them not to go home, not let their team go home, and said they’d likely have to dialyze the child, which they did have to do.” The three-year-old experienced complications during the night, but by the following day, he was out of danger. 

“If not for that kind of coordination, the child would have died.”

Call data from each local poison center is uploaded to the National Poison Data System. This web-based system automatically updates in near real-time, roughly every six minutes. The system is the data repository for all 55 centers and allows poison centers to identify local, regional, and national trends like mass poisoning events, overdoses, and suicide attempts and deaths. For example, in 2020, out of 388,765 human exposure cases, 18.3% were intentional, including “suspected suicide,” “misuse,” and “abuse.”

With 988 now live, Dr. Ford emphasizes that coordination and partnership need to take place not only with 911 but also with EMS, emergency departments, and poison centers. “The 988 call centers must have local relationships and understand the site capabilities in the area.” For example, EMS or a poison center might get a call about a suicide attempt, an exposure that isn’t dangerous toxicologically, but where the first responder or specialist could link the person to 988. “That way, the patient could be evaluated over the phone by a suicide hotline specialist and get the care they need.”