THE MATTHEW ELLENHORN LECTURE
Medical Toxicology: Past, Present, Future: A Very Personal Overview*
Lewis R Goldfrank
New York University
New York, NY
Int J Med Toxicol 1998; 1(4): 22
What is the Ellenhorn Lecture? - 1998; 1(1): 6
See also 1999 Ellenhorn Award Lecture - 2000; 3(2): 3
When I began my medical school education almost thirty-five years ago, Medicare and Medicaid had not become law and the total health care bill for the nation was 1% of what it is today. There were no training programs in medical toxicology or in emergency medicine. A few poison centers had been established, but there were no Departments of Emergency Medicine; in fact, there were no Medical Toxicology or Emergency Medicine specialty organizations.
As a first year medical student, I visited what was literally a single emergency room and one night observed a resident treating a patient with a heart attack in pulmonary edema with rotating tourniquets; Cardiac Care Units where CPR and electrical defibrillation were performed represented a recent innovation not available in most hospitals. At that time many physicians were still uncertain whether alcohol withdrawal resulted from alcohol abstinence. At that time delirium tremens had a 15% mortality rate.
On a shift during the first week in September 1998, the junior emergency medicine resident, supervised by the chief resident cared for a patient with a myocardial infarction who received a tissue plasminogen activator. On the same day a patient with life threatening ethanol withdrawal was initially managed by the emergency medicine resident, admitted to the intensive care unit while the medical toxicology fellow and a board certified medical toxicologist supervised the patient with the absolute presumption of the patient’s survival.
The use of this clot lysing agent and the survival of patients with DTS were only recently dreams much like the development of teams of emergency physicians, and the specialty of medical toxicology. What surprises me most about my career in medicine is not simply that medical toxicology and emergency medicine have grown exponentially and emerged as respected medical specialties, but that these are specialties in which practitioners never tire of the variety and complexity of clinical problems and the web of psychosocial forces at work in people’s lives. These are specialties that challenge us to keep learning new things and to genuinely help people. Most of all I am proud that medical toxicology and emergency medicine have served faithfully as society’s health care delivery and public health safety net; and that we have gained such enormous popular support.
But we must address the fact that we spend an inordinate amount of time as health care providers on things that we shouldn’t have to concentrate on in the first place.
My reflections today will focus on where I have seen progress, how you and I have achieved this progress and what we can do to continue that progress.
I believe that we can only succeed as toxicologists in our specialty through the integration of public health measures in each component of our work: in our clinical practice, our organizations, our education and our research.
When I was a young physician, I saw caustic injuries to the oropharynx and esophagus every month.
Why don’t I see them today? Previously children had access to NaOH containers with very high concentrations of strong base and there was no attempt to inhibit inspection by a naturally curious child. Several critical actions took place:
- The maximal concentrations commercially available were diminished.
- Child proofing was begun when in 1970 Congress enacted the Poison Prevention.
- Packaging Act (PPA) which authorized the United States Consumer Product
- Safety Commission (CPSC) to require the use of special resistant packaging for toxic substances in and around the house.
- Cap and closure engineering occurred.
- Warning signals were placed on containers.
- Parents were educated about the "dangers under the sink."
- Special child proof locks were developed for kitchen and bathroom counters.
When I was a young physician, I saw hydrocarbon aspiration pneumonitis several times a month. Why don’t I see that today? We made several observations and took several critical actions:
- Those bottles of lemon polish are now in spray form.
- Many alluring advertisements were criticized and withdrawn.
- Many of the consumer product labels that were inaccurate and contained inappropriate suggestions for treatments were withdrawn
- Many bottles have improved warning labels; some are child proofed.
- The use of kerosene heaters has diminished.
When I was a young physician I frequently saw children with lead poisoning. In the late 1970’s more than 80% of children had blood lead levels > 10 g/dL. Although today more than one million children have levels high enough to affect intelligence and development adversely, less than 10% of children have blood lead levels > 10 g/dL. There are so many wonderful reasons why this pernicious effect on children – only recently seen as an insurmountable problem –is being effectively approached. Many are attributable to the focus of toxicologists, pediatricians and environmentalists.
- The Department of Housing and Urban Development has begun to remove home lead from aging housing.
- The CPSC has removed lead from toys and house paint.
- The FDA has worked to phase out lead soldered cans.
- The EPA has worked to phase out leaded gasoline.
- The medical community has focused on the problems of behavioral and learning disabilities attributed to lead.
- Individual communities have worked on lead screening, abatement and education.
When I was a young physician, I saw childhood burns from excessively hot tap water several times a month. Why don’t I see that today? We have made critical observations that have led to:
- Protective engineering advances such as maximum thermostat controls
- And substantial educational efforts
When I first started working in Emergency Medicine I saw dental caries in almost every mouth. Why don’t I see that today?
- The fluoridation of water has become routine.
- The understanding of the potential benefits and the capacity to control potential risks of fluorine have been enhanced by the efforts of environmentalists, toxicologists, dentists and pediatricians.
When I began my career, I saw horrendous vehicular crashes every day. The impact of the 1966 National Highway Safety Act to fund ambulances, communications and prehospital personnel training programs through the Department of Transportation had just begun to be appreciated. Why do so many crashes occur without lethal and disfiguring injuries today?
- Seatbelts and/or air bags are routinely available
- Child seats have been placed in almost every car, bus and airplane.
All of these engineering steps in our medical progress have a philosophic trend. The concept of the "Accident" has been replaced by the term "Injury." There is a less fatalistic assessment of our interactions with our environment with a greater allocation of personal responsibility.
When I was a young physician I saw patients with meningitis far too often; I saw patients with tetanus once a month. Twenty-five years ago, one of my coworkers got Hepatitis B every year. Some died. When we worked with patients who used intravenous drugs we feared Hepatitis B, later we feared HIV infections and tuberculosis. Ten years ago, every social worker in my emergency department developed a positive PPD. Some developed active TB. The link between substance abuse, alcoholism, poverty and HIV placed us all at risk. Why don’t these events occur today?
- Legislative actions led to Medicaid and Medicare which have increased access.
- Immunization with remarkable vaccines such as that for Hepatitis B protect the previously unprotected.
- Engineering with new needleless IV systems have begun to reduce risks.
- OSHA Legislation protecting health care workers was established.
- Universal or standard precautions utilizing gloves and improved waste collection was implemented.
- Retroviral post-exposure therapy became available.
- An understanding that alcoholism and HIV are directly linked to tuberculosis and often only effectively treated with special programs such as DOT (Directly Observed Therapy).
- New ED strict triage standards were established for patients with symptoms potentially associated with tuberculosis.
- New ED architectural standards such as negative pressure rooms and 10 air circulations/hour with no recirculated air were established.
- We have focused on the development of programs for intravenous drug users including substance abuse prevention, substance abuse treatment and harm reduction such as methadone maintenance and needle exchange programs.
When I traveled the world as a young man, I received a smallpox vaccination. Why don’t we give those immunizations any longer?
- The public health model of the WHO and UN has changed our world.
- Today when we worry about smallpox it is about biological or chemical terrorism. At the heart of this discussion you will find the poison center, medical toxicologists and emergency physicians.
The Emergency Medical Systems Act of 1973 and its extension in 1976 mandated a systems approach and design to alter delivery modalities. There were seven major clinical categories to develop including behavioral emergencies, burns, cardiac, high risk infants, neurotrauma, general trauma and poisoning emergencies! When I first began to work with Sylvia Micik, David Boyd and a number of you in the room, the national support for poison management, education and prevention was limited. Our ability to show the link between all of the other types of emergencies and poisoning led to a dramatic alteration in funding. These changes altered clinical care and our treatment in the out of hospital setting was revolutionized. The care of patients with alcoholic emergencies is an excellent example.
Why don’t I see Wernicke’s encephalopathy? I used to see it every week. Why don’t I see patients with post hypoglycemic encephalopathy as often today? We have as much alcoholism, but paramedics and emergency physicians routinely give Thiamine and 50% dextrose to patients with altered levels of consciousness. Clinical leadership from the ED with an understanding of medical toxicology altered the clinical course of these patients. The toxicologic education about alcoholism, thiamine, and hypoglycemia has diminished morbidity and mortality from these disorders in the prehospital and emergency settings.
When I was a young physician I saw numerous adults die of heat stroke every summer and many poor die of hypothermia every winter. Today, we have:
- Heat alerts emphasizing the protection offered by armories, air conditioners and ice.
- Cold alerts emphasizing the protection offered by shelters, heat and clothing for the disenfranchised.
We talk about the care of the homeless, the psychiatric patients, the risks of drugs that affect the hypothalamic – thalamic axis. We have stopped an epidemic.
In the early 1980’s a single toxicologic emergency associated with non-seasonal heatstroke altered the level of support and importance of medical toxicologists and emergency physicians in the medical and legal communities.
A patient was admitted and examined by an intern and a resident after being brought to an emergency department with agitation, fever, chills, myalgias, and arthralgias. Her medical history included psychiatric treatment for stress and a recent tooth extraction and earache. She was taking phenelzine, oxycodone, and erythromycin. On admission her temperature was elevated to 39.7° C (103.5° F) and she had orthostatic pulse and blood pressure changes.
The young woman’s private attending physician declined to come to the hospital. The resident made a diagnosis of "viral syndrome with hysterical symptoms," obtained blood cultures, and prescribed acetaminophen for fever and meperidine for agitation and shivering. The intern was called when the patient became restless and disoriented, and, rather than evaluate the patient, she ordered physical restraints and haloperidol by telephone. When that patient became more agitated and febrile (42° C axillary [107.6° F], the intern was again called; she ordered, by phone, a cooling blanket. Four and one half hours after admission the patient experienced a respiratory arrest and died.
The cause of death was unclear, but infection and drug reaction or interaction were implicated. Meperidine is known to react adversely with phenelzine and traces of cocaine were found in the serum. Whatever the cause, respiratory and cardiovascular arrest resulted from inadequate treatment of a hyperthermia (nonseasonal heatstroke).
The New York State Health Department concluded that unsupervised house officers should not care for patients in emergency departments and that there should be limits on the number of consecutive hours an emergency physician worked. The Health Department also felt that computerized systems to identify drug interactions should be utilized. This experience helped me develop my perspective on the special role of medical toxicologists in emergency medicine and emergency physicians in medical toxicology. This experience established my absolute commitment to the development of both specialties and to the employment of numerous individuals who have been trained in both specialties.
When I was a young physician agitated young males died in police custody routinely. Why doesn’t that occur today?
- They don’t go directly to police precincts any longer.
- They are initially brought to hospitals.
- Vinyl body bags were replaced with mesh to allow heat dissipation.
We established links between the Health Care Providers and Public Safety agencies. These collaborative relationships with the police emergency services have saved lives and resulted in a shared educational process. That EDP [emotionally disturbed person] is considered under the influence of a toxin until proven otherwise. The police have taught us about violence awareness and thereby limited the risk to health care providers.
When I was a young man, there were days when those with chronic lung disease and asthma could not venture out into the streets due to the smog. In Donora, Pennsylvania in 1948 twenty people died and thousands became ill. In London in 1952 four thousand deaths occurred. Why don’t we see that today?
- The EPA has changed automobile and industrial emissions standards.
- Health environmental alerts are routine.
- The practice of preventive, occupational and environmental medicine has increased dramatically and has been intimately linked through our Board of Medical Toxicology.
Many of these events led the earliest leaders of medical toxicology to form the American Association of Poison Control Centers in 1958, the American Academy of Clinical Toxicology in 1968 and the American Board of Medical Toxicology in 1974.
My personal service and association with the American Academy of Clinical Toxicology and American Board of Medical Toxicology gives me a great deal of perspective on Matthew Ellenhorn’s role as a leader, thinker, teacher and role model. I will always be grateful for the opportunity to have worked with him.
I would like to read you some of my views from my valedictory as chairman of the American Board of Medical Toxicology following our approval as a subboard by the American Board of Medical Specialties in September 1992. It was an event of great importance to all of us and my words remain meaningful to me.
The purpose of this Board as defined in its by laws is "to advance the science, study and practice of medical toxicology by evaluating the training and credentials…..and to foster the development of medical toxicology in its provision of emergency consultation, forensic, legal, community and industrial services." Recognizing this purpose I would like to suggest that we have achieved a substantial success.
In these remarks I refer to the leadership of the American Board of Medical Toxicology and its membership of the past seventeen years with great respect. I have been counseled by and worked along side many of the leaders of this organization such as: Helmut Redetski, Fred Lovejoy, Bill Robertson, Charles Becker, Barry Rumack, and the current officers, Bill Banner and Paul Pentel. These individuals have provided a continuity of purpose and a dedication to the pursuit of excellence in medical toxicology.
Our organization has grown dramatically from a few visionaries devoted to the field of medical toxicology to the present approximately 200 committed individuals. Remarkably recognition has been bestowed on our field by the American Boards of Pediatrics, Preventive Medicine and Emergency Medicine and the American Board of Medical Specialties. I will not recount our many scientific contributions to the development of this field, but I will focus on our view of the roads we must travel. I often think of our efforts as Max Planck thought about quantum physics as he earned a Nobel Prize in 1918: "the pursuit of a goal, the brightness of which is undermined by initial failure, is an indispensable condition, but by no means a guarantee of final success."
This board of elected volunteers has served in a curious position. We have often received criticism from our colleagues for having done too little as well as criticism from our colleagues for having done too much. Yet we have volunteered to serve nonetheless because we believe that this work, the development of the field of medical toxicology, must be considered from the point of view of the direct usefulness of this specialty. This development, this commitment to the creation of a new specialty has been supported by the overwhelming majority of our group because we have felt that this strong specialty will ultimately benefit all of society.
I must personally thank all of you especially the executive committees and the varied members of the Board of Directors for your commitment to studying the problem of the future of medical toxicology, for your willingness to develop plans to put ourselves out of business as examiners and to create a more stable environment for future toxicologists trained and supported by the American Board of Medical Specialties.
Those of us who can now feel assured of the prosperity and the future of medical toxicology in our society will by our very acts assure a more difficult future for ourselves, but we can all agree that we are committed to a better environment for our society and better care for our patients of the future. We have assured better recognition of the problems that we have studied.
I was very proud to lead that group and I believe that those leaders have allowed for our rigorous formation which led to the approval of medical toxicology as a subspecialty by the Accrediting Council on Graduate Medical Education (ACGME) in June 1998. The public health, toxicologic and emergency medical events that I have discussed have formed my coworkers and me. I have spent my entire postgraduate career in the public hospitals of the City of New York. When I started working in the South Bronx as the Director of Emergency Medicine at Morrisania City Hospital there were no texts in Emergency Medicine and only a few texts focused on medical toxicology. Certainly none of these texts focused on what I saw in the South Bronx and few texts or journals offered me an evidence based approach to this field. My assignment in the South Bronx was to teach Internal Medicine residents one conference a month on whatever I wanted. In a matter of a few weeks I had seen alcoholic hypoglycemia, methanol, ethylene glycol, heroin, quinine, and salicylates in overdose, yet I could find little information as to the appropriate therapies. Many articles and texts didn’t make sense. I began to write down every question that I was asked about these cases. Shortly thereafter I met a young editor and publisher, Peter Frishauf of Hospital Physician and I began to transcribe my monthly conference into a column for his journal. I began work with my first associate Robert Kirstein, later with Harold Osborn and Eddy Bresnitz, to create these columns in a manner that was focused on history and anecdote, attentive to the curious mind, concerned with practical issues, controversial and reality based and above all in a way that would allow our personalities as evolving emergency physicians and toxicologists to be heard and understood.
When I moved to Bellevue Hospital and the NYC Poison Control Center in 1979 I began work with Neal Flomenbaum, Neal Lewin, Richard Weisman and Mary Ann Howland in the development of our special brand of academic medical toxicology. Several years later Robert Hoffman added his immense skills to our effort as we attempted to link the passion of clinical medicine with the promise of science to solving a few of medicine’s insoluble problems.
With these coworkers we have produced six editions of our text. We have tried to be provocative – to contribute to the advancement of our knowledge, to inspire others, to allow us all to treat patients better and to improve the public’s health. We have been remarkably fortunate to create an environment where we can combine patient care for the truly needy and teaching of diverse types of medical, pharmacy, nursing, prehospital, college and high school students with clinical and laboratory research. Our specialty remains one of the unique opportunities to develop physician-scientist-clinician-teacher roles. It also is an environment where multispecialty interdisciplinary collaboration is valued. Our historic links between pharmacy, medicine, pediatrics, internal medicine, preventive medicine and emergency medicine are the foundation of our immense strength and importance.
Medical toxicology, emergency medicine and health care in general must adhere to the public health model of disease prevention based on a definition far broader than the medical model.
We have an outrageous health care system that permits 11 million children of less than 18 years of age to be without insurance and we allow more than 41 million adults to be without health insurance. And who truly has access?
Yet for many, the problems may be the lack of assurance not insurance. We do invest millions in saving the lives of neonates of single parents only to realize that the mother can’t get day care or education or social support or a job. So what will those children’s futures be?
If we truly practiced health care, we would expand social care. It is essential to change the definition of "health care"
- to participate in public education,
- to enlist community involvement,
- to develop public policy advocacy,
- to initiate governmental action.
The medical model has a minimal impact on the long-term health care of children and adults.
Every effort must be viewed with respect to individual and community needs. The strength of these community relationships is essential for the success of our efforts.
The simplest proposal might be to assure as Dag Hammarskjold, a previous secretary general of the United Nations once suggested that "We’d have no difficulties if everyone were born in Scandinavia".
As we reflect on the lack of human rights in China today, we might also think of the human rights and personal experiences of those patients who come to our emergency departments. How closely are we focusing on the racism, discrimination, and lack of dignity in our patients’ lives? Do we remember that as recently as thirty years ago many emergency departments were still segregated?
Most of our great successes, that I have reviewed are based on the fact that we recognize that health care must be considered far more than each individual’s medical services.
Think how fortunate you are that you are not uneducated, hungry, poor, homeless, or living in foster care. Think about our patients. How many would be in your ED or on your poison center telephone line if each and everyone had a family, a home, two parents, an education, and preventive health care.
I believe that we will treat our vulnerable patients better and make their access more appropriate when we systematically look at each and every patient and ask ourselves: What is the lesion in our public health system that brought this man, woman or child to the emergency department today?
Our only solution is a true social contract for our society. Our great accomplishments have come and will come from our commitment to public health, public policy and universal health care in the context of an educated population, with reasonable housing, social support, opportunity, job training and employment. Public health models emphasize the interconnectedness of our society and it is this concept that leads to our success and reinforces our importance.
The chasm between the computerized statistical elegance of the poison center and the random social chaos of the emergency department must be bridged. Only by an integrated effort can we effectively use the former to assist in developing solutions for the latter.
I don’t expect us to solve all of society’s problems in the poison center or in the ED, but we are the best barometers of our societal failures. If we don’t address the issues, define the problems and suggest solutions they will not be recognized and there will be no solutions. Our communities must understand our roles, our efforts should be linked to the disaster/emergency medicine costs of our society – the essential stand ready costs that some inappropriately call "non productive costs" – but that we understand are critical for a safe and functional society.
It is essential that we rethink our organizational approach to health care as a part of a public health process which is a far more important step than re-engineering our health care market.
I see no commitment to confront our societal ills from those who favor the commercialization of healthcare and medical education. The explosive increases of tuberculosis (particularly multiply drug resistant TB) among the inner city poor and homelessness among psychiatric patients in the 1980’s can be directly attributed to our abandonment of public health measures. The devastating results of employing the cheapest social policies for these patients led to a reinstitution of public health measures to care for TB and homelessness in inner cities in the 1990’s. These experiences must be used as examples of what will happen as health economists seek to curtail the efforts that have led to the obvious remarkable public health advances we see everyday.
The goals of education and clinical practice must be to address societal need not self-interests. Our goals as medical toxicologists and as emergency physicians must be to be compassionate caregivers. We must use science and humanism as the basis for each of our discussions. We must show that poison services have an intrinsic value and our social mission can not be financed optimally in a competitive market place. We should be considered an integral part of the social mission of Academic Health Centers and Health Departments.
Our vantage point (of the world) offers a broader vision than that available to any other physicians. Our mission can be shared by all others devoted to the public’s health. Our educational goals must be to go on as soon as possible beyond that which is taught, to create knowledge, maximize originality and define novel solutions to our problems.
I am proud to have worked beside all of you as we have succeeded in so many areas. I am reminded of John F. Kennedy’s comments in New York City in 1961 as he improved on Teddy Roosevelt’s effort of an earlier time; "the credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood, who knows the great enthusiasms, the great devotions, and spends himself in a worthy cause: who at best, if he wins, knows the thrills of high achievement, and, if he fails at least fails daring greatly, so that his place will never be with those cold and timid souls who know neither victory nor defeat."
The world that I saw in the emergency department in 1963 is very different from the world I see today. The world for all of us and particularly the poisoned patient will be better still in the twenty-first century if we continue to emphasize altruism and humanism while creatively expanding the strength of a public health approach to our problems.
Several of the ideas discussed in this paper were inspired by a speech given by Margaret C. Heagarty, M.D., the Director of Pediatrics at Harlem Hospital in New York City.
Many of the ideas expressed in this speech have presented as parts of my presidential editorials for the Society for Academic Emergency Medicine and the American Board of Medical Toxicology Newsletters over the past fifteen years.
*Presented at the September 1998 North American Congress of Clinical Toxicology, Orlando, Florida.
Int J Med Toxicol 1998; 1(4): 22
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