The Matthew Ellenhorn Lecture
Lessons from Medical Toxicology*
William O. Robertson, MD
Washington Poison Center
Professor of Pediatrics
University of Washington
Int J Med Toxicol 2000; 3(2): 3
What is the Ellenhorn Award? - 1998; 1(1): 6
See also 1998 Ellenhorn Award Lecture - 1998; 1(4): 22
In preparing some remarks for this occasion, I couldn’t help but recall some of the early meetings of the, then, American Association of Poison Control Centers as it met in a small room at Chicago’s Palmer House Hotel. The room itself was provided by the American Academy of Pediatrics – since we had no money to even rent a room. In the late 1950s before the "revolution" that lead to the splintering off of the American Academy of Clinical Toxicology, we would be fortunate to attract 20 people connected with the newly emerging poison centers, plus an occasional pediatric practitioner who would drop in just to see what was going on. In those days, the National Clearinghouse for Poison Control Centers, a federal operation located in Washington, DC, would print up a newsletter that carried the 4-8 abstracts that had gotten discussed at the prior meeting. Virtually any abstract that was submitted was accepted for presentation. Sometimes there were not enough to fill half the day! Such were the early days of clinical toxicology. Times have certainly changed!
It was a 1960 meeting of the American Association of Poison Control Centers (AAPCC) in Chicago when the Cleveland group first announced how gastric lavage had come out a poor second when compared to ipecac-induced emesis in emptying dogs' stomachs, using salicylate as the marker.1 Charcoal wasn't even a player in the decontamination game. It had been used along with magnesium sulfate to promote fecal loss and tannic acid to denature any so-called proteinaceous material. This infamous "universal antidote" was banned from any use at all when tannic acid was found to be so toxic in and of itself.
The next year, I was able to report some data about two widely held beliefs about Syrup of Ipecac. First, that it didn't work. Second, that if it did work, it took too long to do so. Our data clearly showed that both were wrong. We had found that all of the 214 kids we treated with ipecac drank it and 97% of them proceeded to throw up after a delay of some 15 minutes.2 Few of today's clinicians seem to recall that ipecac-induced emesis was being used rather extensively in managing croup. This was in the days before epiglottis scared pediatricians away. For those croupy kids, the process of emesis was really remarkable in almost immediately alleviating the laryngeal spasm so it was surprising to me that ipecac had not been used to manage ingestions.
Shortly after our two presentations, there was an enormous flurry of interest in home management with ipecac. The popular motto was, "Have syrup of ipecac on hand at home and watch the child there for symptoms." In the Seattle community, we were able to report that more than 65% of homes with children less than 10 years of age in them had syrup of ipecac on hand.3 Simultaneously, monumental professional objections arose arguing that such an approach simply wasn't safe. Ipecac, allegedly, put both kids and adults at enormous risk so the opposition claimed. The opposition even petitioned the FDA to remove ipecac from its over the counter status. The FDA did, in fact, knuckle under for almost six months when saner heads finally prevailed and we ipecac proponents were off to the races with a great public relations tool for our emerging poison centers. "Get your ipecac, keep it in your home ,and call us after any suspected or even remotely possible poisoning." Admittedly, that approach really constituted yet another of what I call "Toys for Boys." While no gender slight is intended, it really gave everyone something to do and we all felt better, sometimes even the patient. Most certainly, ipecac was vastly overused since no health care professional worth his or her salt could refrain from doing something or, at least, trying to give the appearance of doing something. That overuse plus the ever-present resistance to home management set the stage for the resurrection and reappearance of activated charcoal. Activated charcoal was strongly advocated by L. Emmet Holt, a famous New York pediatrician, author, and department chair whose own house staff, incidentally, had a policy of never using the stuff until long after he had died.4
I just emphasized my non-refuted hypothesis about charcoal in a letter to the editor in last month's American Journal of Emergency Medicine.5 It is my non-refuted hypothesis that recommending charcoal constitutes a great hook to get patients to come to my hospital, clink the cash register, and makes conscientious health professionals who insist on actually laying hands on all patients very happy. It totally avoids having to figure how to deputize parents or friends to do the monitoring at home. Championing charcoal was a natural for the newly emerging specialty of Emergency Medicine and its policy position in opposition to telephonic medicine thus giving rise to concerns about inherent conflicts of interests lurking behind a number of studies advocating charcoal's purported superiority. But this is only my as of yet non-refuted hypothesis.
As mentioned, my letter had been prompted by Wax and Cobaugh's March '98 report which found that among a sample of 361 EMS patients transported because of a drug overdose, only 218 qualified to receive pre-hospital charcoal. However, none received it although somehow 6 at least got ipecac.6 Their transport time involved only 25 minutes and, of those going to the University Hospital, it was an additional 82 minutes after arrival before they received their charcoal. Note that the Dallas group reported in Abstract #65, a 118-minute delay until charcoal administration in their sample of patients who did not receive it in the field.7 A third group found a 91-minute delay until charcoal administration after arrival at the hospital.8 When we had carried out our ipecac study more than 40 years ago, not a single child waited more than five minutes for his or her ipecac and not a single one rejected the ipecac. Thus, no garden hose lavage was involved as is so common with charcoal today.
Today, the conventional pharmacokinetic wisdom sees time delay until decontamination regardless of whether it's gastric lavage, emesis, or charcoal as being pivotal in predicting any benefit. Time delay is clearly the largest contributor to the variance. As I stated in my letter, absent better evidence than we have today about meaningful acceptability data for charcoal given in the home, during transport, or anywhere else: why bypass ipecac’s potential?
As is obvious, I am still a staunch advocate of using ipecac. I am still looking for the first documented catastrophic case after using ipecac in the face of all those popular contraindications: tricyclic ingestions, delaying NAC for APAP, etc. Proponents of the precautionary principle, it "might," it "may," or it "could" prove harmful have certainly gotten all the media coverage. As a proponent of the contrasting "probability paradigm" e.g. what are the evidence-based likelihoods involved, I am convinced I'm right.
Conceivably, the issue is really moot; overuse of efforts at gastric decontamination shows signs of becoming a thing of the past. No one in his or her right mind would dream of doing anything for ingestion of a mouthful of flower petals or a handful of multivitamins. Today, I am convinced our focus has to be on eliminating time delays whenever it seems likely that decontamination might actually be helpful. Once you have done that, I really don't care which of the three techniques you use as long as your practice outcome data match mine for minimal time delays.
I would like to believe that we have all learned a lesson from the past 40 years of debate on this issue but I'm skeptical that pre-existing bias has been an enormous confounder. On a probability basis, it might have been better to expend our energy elsewhere although I'd hate to think it might have been used for trading even more war stories than we have about acetaminophen instead.
Now let me shift gears to another favorite topic. When one looks at clinical toxicology through the historical retrospectoscope, it gives me concern that over the past 45 years, we in that business have repeated the mistakes of our forebearers in other specialties and that we are continuing to do so. All too often, we have focused on the acute episode. We have been pleased to treat the acute symptoms and we have smiled blissfully when, shortly thereafter, the patient was able to go home. Many times we haven’t asked the question, "Why did that happen?" We’ve asked, "Why did drug A produce X and Y symptoms" but not "Why did the episode itself occur?" You may recall a few years ago that Lewis Goldfrank piqued us all as he described his successful use of naloxone on several occasions for a young woman who was a heroin addict. Finally (as I recall) he admitted her to the hospital only to have her commit suicide by jumping out an upper story window. Dr. Goldfrank acknowledged his feelings of hopelessness and helplessness although he had been so effective managing her acute symptoms with naloxone.
Admittedly, in the early years, we did ask the question "Why?" about those toddlers who got into household poisons and common medicines. Very rapidly, everyone agreed that toddlers learn about the world by exploring it usually with their mouths. While many of us fumed and fussed with the questions of how to hasten excretion of too much salicylate or how to tide over the child with hydrocarbons down the trachea, a few of us and some non-physician behavioralists saw prevention as the ultimate goal. Avoiding the ingestion or inhalation in the first place was clearly the way to go. As a result, educational campaigns such as, "Out of Sight – Out of Reach," drastically improved labeling and public alertness campaigns aimed at the parents or parent surrogates were implemented. One of our Canadian colleagues, Windsor’s Henri Breault, was skeptical after their educational efforts proved so popular but were a total flop in reducing the problem. He went for a non-educational program, child resistant containers, imposing a non-voluntary technologic obstruction between the child and the product. He set his community on fire with his enthusiasm. He sponsored a contest that came up with the palm-and-turn device that took advantage of some new polyplastics to make them work.9
Actually, one of the AAPCC’s founders, Duke’s Jay Arena, must be credited with first pushing the use of safety caps using the snap top type container on St. Joseph’s aspirin back in the 1950's.10 It helped but not all that much. Then Bob Scherz, at Tacoma’s Madigan Army Hospital, with not a penny of support pulled the necessary strings to conduct a trial of usage on the palm-n-turn container.11 When Dr. Scherz’ study proved overwhelmingly successful with a 90% reduction in salicylate ingestions compared to historical controls, Bob went on to single-handedly persuade the various Surgeons Generals of each of the services to mandate the use of safety caps at all military bases. He then attacked and conquered the legislators of the State of Washington and finally got the Federal Government to mandate their use across the country. This is definitely a real success story done on a shoestring by a devoted advocate and is credited as being primarily responsible for the dramatic reduction in deaths from poisoning among toddlers. Poisoning deaths were reduced from 500 a year in 1960 to somewhere around 30-50 over the last few years.
Unfortunately, many toxicologists and poison centers across the country were conspicuous by their absences in gathering supporting data on their local scenes to help make the safety cap program really take off. Our national meetings paid lip service at best to these achievements by way of accepting any abstracts addressing that topic or other preventive efforts. Instead, we have created a "separate but equal" program analogous to what our school systems tried to do to avoid racial integration in local schools for almost a century. As a result, today we have our sessions and they have theirs. Seldom, if ever, do the twain meet -- to the detriment of us all. Conceivably, the pending congressional legislation with its budgetary bonanza will turn all of this around. I am skeptical although programs that have taken place during the NACCT suggest that the bioterrorism billion dollar boom may prove me wrong.
Actually, it has been prevention programs aimed at adults where we have been most remiss. Unfortunately, again, we are not alone on that point. It happens in many fields. Let me elaborate with one special problem - with the issue of drug errors as my target.
In the early 1960's, the staffs of several teaching hospitals published rather simple studies of drug errors on their premises. Surprisingly, some 10% of the drug administrations that occurred in those hospitals had some type of error connected with them. Of course, the majority of errors stemmed from faulty times of administering the drugs, but the "wrong drug" and the "wrong dose" were both significant contributors to the total. Naturally, the various health professional groups involved were particularly adept in pointing the culpability finger at one another as being responsible for the fiasco. One admitted rogue in the whole affair was the plain unmarked white pill (tablet) that so frequently masqueraded for some other medication leading to big mistakes in virtually all institutions. That particular problem led the American Medical Association (AMA) to commission a study on how to overcome the dilemma. Over a three year period, Heffernen and colleagues contrived a very elaborate identification system for all solid medication forms. The system consisted of constructing a 10-digit coding system based on the physical characteristics of the medication itself: the shape, the length, the width, the color, etc. all measured with micrometers and carefully selected with very expensive color plates. An entire issue of JAMA, 157 pages including the costly color plate inserts, was devoted to familiarizing the profession with the authors’ technical accomplishment. Their aim was to totally eliminate the problem of the unknown tablet or capsule, particularly, the "anonymous" plain white pill.12
When that JAMA appeared in 1962, I was medical director of Columbus’ Poison Center. I can recall the sense of relief that came over me when I first saw it. Not only would it be a godsend to the poison center for its unknown tablet ingestions, but it would also go a long way in correcting the proverbial problem of errors with drug refills. Often, the labels on the bottles at the time did not include the name of the drug that was inside or if it were there, it was written in Latin.
I remember glancing through the journal looking for evidence that the system had been tested somewhere. Unfortunately, nothing was reported in the Journal itself and a call to the AMA revealed that not one iota of field testing had taken place before some 360,000 copies had been distributed to physicians all across the country. It seemed impossible to believe, but it was true: no studies in the field of the real world.
I recruited three medical students to test the system. We tested the "device" while timing the minutes involved in identifying the unknowns. Believe it or not, our physician and pharmacist subjects were able to identify less than 30% of the limited sample of unknowns. They also took more than 15 minutes trying to identify each unknown.13 This was a fiasco; a totally useless solution at great cost in terms of dollars as well as reputations.
Fortunately and almost simultaneously, the Eli Lilly Company decided to imprint its entire line of solid medications. The imprint was in part to improve identification, but was also a very effective marketing device. When we tested that technique with the same protocol, we found 99% accuracy was achieved in less than 15 seconds. This was, indeed, quite a contrast in performance.14
Soon, a number of other companies followed Lilly’s example. We were successful in our state in convincing our legislature to mandate the use of imprints. First, the use was on prescription trade name drugs and then, on all generic drugs. Finally, we began to pursue over the counter drugs. At that point, we found ourselves joined by the non-prescription drug industry itself. Its members proposed that we put in a two-year phase-in clause in our law so that, together, we could petition the FDA to make a nationwide rule. In 1993, that finally happened. I mention the year to stress that the whole escapade had taken 33 years to accomplish. So, you may have to be patient to achieve your goals.
Actually, the issue is still in flux. Interpreting an imprint code ideally sees identification of the manufacturer’s logotype and then the manufacturer’s own drug code. It should be feasible for one and all to use. But, as we have demonstrated repeatedly,15 the manufacturer’s logotype, symbol, or code is all too often totally uninterpretable. Even experts can barely achieve a 50% success rate of interpretation. We have urged the FDA, USP and the Pharmaceutical Manufacturers Association to intervene and develop a comprehensive interpretable system, but to no avail as of yet.
For anyone who has taken a look at the drug error issue, the "get rid of the bad professional" paradigm is out of favor; today, the word out there is to correct the "systems errors," for example, with illegibility problems. Our group, along with a number of others, have accumulated persuasive data that shows the results of illegibility have been horrendous, even in the individual poison center. But the only real concerted effort to do anything about it has been to introduce the computer, which, in turn, eliminates handwriting.16 On the basis of a recent time and motion study we have done in our center about Toxicall, the only sure-fire value has been its total success in eliminating all handwriting and the inevitable illegibility that goes with it. In the past, we have not only tolerated bad handwriting but we have also promoted the use of abbreviations and acronyms, all allegedly designed to simplify our intercommunications. Unfortunately, all result in even more errors.
We have worked with colleague hospitals to help accumulate data on these points and now we are working with retail pharmacies to serve as the data gathering points to put all their experiences together to begin proposing possible solutions. All can be tested before being implemented. Pivotal to this move is assuring that the resultant summary records are immune from subpoena for negligence suits. And we have passed legislation to do just that.
I am convinced our centers, their staffs, and all clinical toxicologists should be doing a lot more in this arena especially, given two recent publications on the matter. For example, one overly-hyped JAMA article from last year, indicted drug errors and adverse reactions to drugs as the 4th leading cause of death in the U. S.17 The other, from Lancet, sees that death rate doubling over a 10-year period while drug deaths from homicides, suicides, etc. have all remained remarkably steady.18 Nationally, self-insured physician liability insurance companies have found drug errors to be the second most frequent and the second most costly causes of malpractice suits against physicians.19 Moreover, both a California study in the 1970's and the Harvard Medical Practice study of the 1980's produced data that confirmed the universal problem of in-hospital drug error deaths across the nation.20 While accidental poisoning deaths among children less than 5 years of age amount to less than 30-50 deaths per year, more than 150 in-hospital pediatric deaths stem from drug errors every year across the country. Yet, Dr. Toby Litovitz and her colleagues wrote in this year’s just released annual TESS report that "... two unlikely sites of poisonings, health care facilities ... accounted for 6,311 (0.3%) [of total calls]...."21 It serves to support my contention that many of us have been and still are surprisingly oblivious of the drug error problem. With 400,000 drug administrations a year in one University Hospital and a 10% incidence of drug errors, 40,000 a year from just that one hospital could account for all those exposure calls cited by Dr. Litovitz several times over. Remember, there are more than 5,000 hospitals rather than simply that one to account for the total; not even the tip of the iceberg is being recognized! Clearly, it is time for far more concerted and meaningful action on the part of all of us to really try to do something about drug errors not simply more lip service and more meetings on the matter. We need to see some real action. I would propose we consider declaring a "War on Drug Errors" to quickly replace the infamous "War on Drugs" with, hopefully, more success.
Finally, I would take a moment to add some personal thoughts about our written journal communications. What a time of change this has been over our past century. But is it any quicker today?
Just over a hundred years ago, Wilhelm Roentgen, an Austrian professor of physics, stuck his wife's hand in front of what turned out to be an x-ray unit on the 8th of November in 1895. He wrote it up and submitted his experience to the editor of the Wurzburg Physical-Medical Society's Transactions six weeks later on Christmas Day in 1985. It was published 7 days later on New Year's Day. He was able to distribute reprints that afternoon, an alacrity not even dreamed of today. On the 5th of January in 1896, the x-ray story captured front page headlines in Vienna's leading newspaper and Roentgen's study was able to be replicated in England within a week. The report made it to Edison in this country for the creation of fluoroscopy before the end of March.22 In May, the French used x-rays to search luggage being boarded on railroads. Talk about rapid dissemination of new information! It really set a record never likely to be topped or, at least, so it seemed until the Internet came along a few years ago.
Who knows but, as of today, the whole process might be compressed into a single morning by taking advantage of modern technology, along the lines being promoted by NIH's Harold Varmus' vision of his about to go public Internet based NIH PubMed journal.23 One way or another, what was supposed to be a leisurely pace for progress in science has long since passed. Clearly, it is gone forever if, in fact, it ever really existed. Rush, rush, rush seems to be the motto of the day. One common consequence is that all too often, new information and new data are summarized and transmitted before they have really been converted into meaningful ideas or before they have been adequately thought out. Some of us tend to shoot from the mouth with our mounds of data particularly when we take advantage of today's unedited e-mail.
Even if a message is well prepared, it's always tough to communicate an idea from your context into mine so that it will be optimally interpreted. While speedy communication is a definite plus, it is really a plus only if it strikes the right spot in the brain of the message’s recipient. Without his or her attention, the message is all too easily lost in its entirety. Along that line, next time you're watching TV look at the commercials. See the great lengths the advertising world goes to just to get your attention -- usually, at far more expense than the cost of transmitting the advertising message itself. With your attention, provided it is aimed into the proper context, the message hits home. Absent either the attention or the proper context, it sails off into never-never land.
From my vantage point, I have been extremely fortunate over the years in being able to devote a fair amount of my professional effort into preparing written communications that permit me to try to focus first, on getting the reader's attention and then, hopefully to put my message into his or her proper context. Some articles have been subjected to peer review and some have not. I defy you to try to tell them apart.
Regardless, as Lancet's famous editor, Theodore Fox, once emphasized, he’d "been able to enjoy and thrive on the lively news transmittal function of our technical journals without being saddled with the far more staid and boring archival storage function of the so-called recorder journals."24 In fact, those recorder journals seem to interest only readers going for the bottom of the barrel of knowledge, so to speak, to get what they want or need. Those few have to be highly motivated to pursue what to the rest of us are trivial facts at best. Fortunately, those readers rarely constitute my target audience or the target audience for most of us. And they rarely constituted the target audience for Dr. Fox and Lancet back in 1961 when he proposed to totally eliminate all such recorder journals much to the consternation of the world of science. In their stead, he proposed that you type up your manuscript and submit it to a proper accepting editorial board to pass on its quality, to what was still only emerging as traditional peer review. Only an abstract of the manuscript’s content would ever be distributed with the exception for those few readers with special needs to know. Yes, priority would be assured but tons of paper would be saved. Actually, Fox was simply elaborating on an earlier proposal of J. D. Bernal, a professor of physics in London, back in 1939.
Think about it for a moment, only newspaper journals to read; no more archival or recorder journals to which to subscribe. No journals to pile up and gather dust while generating guilt complexes. Almost unfathomable in 1961 but does it sound so far fetched today? Not at all! This is the very premise of the proposal that Varmus and the NIH are about to implement. Physics has already done it and toxicology is at the very least a logical next step.
Keep that in mind when you sit down to write your next paper. Look in the mirror and ask yourself what is your real purpose. Do you have a message for readers or are you simply documenting some otherwise dull facts and be prepared to have to act accordingly. Update your style so as to get the reader's attention: no passive voice, use the word "I," and keep it simple but without hordes of acronyms and abbreviations. At the very least, the next decade can't help but prove interesting as our language and our journals both continue their evolutions.
Over the past 50 years, our medical journals have already undergone some enormous changes. For example, the mean number of authors per article continues to burgeon being only slightly more than 1.2 when I measured it in the pediatric journals in the middle 1950's. Today, the average exceeds 4 and for certain articles, some published in the NEJM, more than 100 separate authors have been listed. I would seriously question whether they have actually been involved in writing the overall article rather than a miniscule component of it. However, it will be posted on their curiculum vitaes to serve as the coin of the realm toward getting promoted.
Perhaps more notable to all of us has been some happenings of the last year when two popular editors of two prestigious journals have both been terminated. One, George Lundberg of JAMA, was discharged because he was too good at the business side of publishing, allegedly the monkey business side of the business. The other, Jerome Kassirer of the NEJM, was let go because he was not good enough at the business side. He preferred to believe that the business side didn't even exist. What surprised me was that both terminations were just short of being predicted by Ellen Shell's fascinating article in the New York Times a year and a half ago, some six months before either action had taken place.25 Its’ title, "The Hippocratic Wars," was a delightfully tongue-in-cheek spin on the spelling of hypocrisy as opposed to Hippocrates. She portrayed so clearly the individuality of each of the two, now ex-editors, and the enormous impact each had had on his respective journal over the years. In truth, each capitalized on that buzzword of the decade, peer review. I am convinced that both were well aware of the fact that the process of peer review, while worshiped with little short of religious fervor, has yet to be scientifically substantiated as clearly accomplishing its objectives. The ex-editor of the British Medical Journal, Stephen Lock, after taking a year's sabbatical to study the peer review process in the real world of that journal, concluded that he was fortunate, indeed, if he could get a 70% concurrence from his reviewers about the acceptability of any given article.26 But the train of peer review has left the station and is way down the tracks, never likely to be derailed since it serves to protect so well the interests of the insider crowd. Keep peer review in proper perspective. Does peer review really improve the product or is it primarily a form of censorship and who wants to find out?
Frankly, I remain concerned about just who will constitute that board of approving referees for the new NIH journal and what will be their motives? Is it conceivable that some members or those boards just might be motivated to add a little political spin to the publication process? I really mean a little more political spin on the one hand and censorship on the other. Too much spin would be a problem; it could really lead to disaster and at its worst, to a return to the dogmatism of science of the middle ages and of a number of religions today. What bothers me even more is that today in my paranoia I already see some evidence that purportedly objective editorial groups in their publications are applying such political spin and it’s not in the private journals but the public ones. Let me explain by way of an example.
Acknowledging each journal has its own political position, most current journals such as Lancet, JAMA, NEJM, the BMJ, Clin Tox, Vet and Human Tox and the Annals of Emergency Medicine are all famous for usually printing both sides of most of the stories they cover in their news transmittal function. Even if the opposing position is only covered in the Letters to the Editor section, both sides are published. Of course a tad of bias, a little spin, is to be expected but a strictly one-sided point of view is uniformly abhorred. Take a close look at one of the NIH's own current publications, Environmental Health Perspectives (EHP), and ask yourself this question. Does that journal do its best to present both sides of the stories it chooses to cover with their components of uncertainty or do the stories clearly adhere to an obvious political party line? For one, I would expect EHP to try to be even more objective than the so-called commercial journals cited above. However, in my opinion it clearly doesn't measure up. Has it ever used the term "hormonally active agent" as routinely employed by the National Research Council in its publications to express somewhat neutral concerns about that important topic or does EHP rely exclusively on "endocrine disrupters" to communicate its advocacy point of view to its readers? Does EHP at least give the appearance of employing a stable of somewhat bipartisan writers or do its writers unfailingly push the "precautionary principle" point of view on each and every single topic about which they write; whether the subject is MCS, CFS, fragrance issues, PCB's, Gulf War Syndrome, lead, agent orange, dioxins, and so on? If you look at the June 1999 issue and turn to the one page zinger on "Leaders in Lead" or any of its pronouncements about lead over the past 5 years, see if you can find any evidence whatsoever that the CDC and the U. S. Preventive Services Task Force both might just be right when they both recommend abandoning universal testing because, across the nation, blood lead levels in toddlers have plummeted from the 30's in the 1960's to the 20's in the 1970's to way down to less than 5 in the 1990's.27
You name it and if the topic has been covered in EHP, I have concluded you will see a consistently one-sided point of view in its columns. A point of view virtually always pushing more concern, more testing and lower and lower levels of tolerance of chemicals fingered as always being bad for both people and the environment. I would expect such a performance from the newly published Rachel Carson Journal but not from one emanating from the NIH. I agree my point of view is based on following the journal for only five or so years and certainly may suffer from my own pre-existing bias but I don't think so. Check EHP out and decide for yourself. My point is not to seek a change at EHP but to alert all of us to be aware of what just might accompany the arrival of the electronic age of publishing against a background of increasing commitments to evidence-based medicine. I could go on to several other examples but won't; my purpose is simply to stress we will all want to be a bit wary before we put all of our eggs in one publication basket; be it the NIH's PubMed or some rival. The future's too important to be left to chance alone.
Let me conclude by once again thanking all those who were responsible for this award as well as all those friends and colleagues who, over the years, have helped make and continue to make my professional career so enjoyable to me. That latter group just knew this crotchety curmudgeon would bring up the issue of using ipecac and the primacy of time delay in pursuing our mutual goal of gastric decontamination. However, you probably didn't expect my harangue about drug ID, handwriting illegibility, abbreviations and drug errors. It's a vast wasteland today and predictably it will only be worse tomorrow. Remember: the frequency of such errors is a function of 2 raised to the power of the number of drugs being used. Sounds like job security for toxicologists to me, so get involved.
I am certain no one anticipated my diversion into the field of the diffusion of innovation. However, to me, that is the name of the ultimate game of modern day science as opposed to carrying out some trivial observation to the 39th decimal place. After all, we in toxicology have a vested interest in reading or hearing about new things that may make us more effective so keep after the journals to do their jobs to the best of their abilities.
Finally, I am sure that Matt Ellenhorn, were he able to be with us today, would already be approaching the microphone to challenge a lot of these points I've sought to emphasize and to challenge them in a manner that would be advantageous to all of us. That was his forte and remembering that imitation is the sincerest form of flattery, I would urge you all to flatter him by emulating him everyday throughout your careers.
- Arnold FJ, Jr. et al; "Comparison of Gastric Lavage and Induced Emesis in Experimental Salicylate Ingestion", Amer J Dis Child, 1957; 94: 478-81.
- Robertson WO; "Syrup of Ipecac – A Slow or Fast Emetic", Amer J Dis Child, 1962; 103: 136-39.
- Haulman J and Robertson WO; "Syrup of Ipecac in 1993", Drug Safety, 1993; 9: 79-84.
- Holt CE, Holz PH; "The Black Bottle", J of Ped, 1963; 63: 306-314.
- Johnson SB and Robertson WO; "Gastrointestinal Decontamination, Amer J Emer Med; 1999, 17: 494-5.
- Wax PW, Cobaugh DA; "Prehospital Decontamination of Toxic Ingestions: A Missed Opportunity", Am J Emerg Med; 1998, 16: 114-16.
- Keyes C, DeTamble L; "Prehospital Activated Charcoal: A Prospective Randomized Trial (Abstract), Amer J Emerg Med; 1999, 37: 610.
- Kornberg AE and Dolgin J; "Pediatric Ingestions: Charcoal Alone Versus Ipecac and Charcoal", Ann Emerg Med; 1991, 20: 648-651.
- Marjoribanks R; "The Man Who Didn’t Want Children Poisoned", The Windsor (Ontario) News Weekend Magazine; 1967, #38.
- Arena J; Poisoning: Chemistry Symptoms Treatment, CC Thomas, Springfield, IL; 1963.
- Scherz RG, Latham GH and Stracener CE; "Child Resistant Containers Can Prevent Poisoning", Pediatrics; 1969, 43: 84-87.
- Heffernen JJ; "Identification Guide for Solid Dosage Forms", JAMA; 1962, 182: 1145-1302.
- Caldwell JG et al; "Identification of Drugs", JAMA; 1964, 187: 951-953.
- Symonds JK and Robertson WO; "Drug Identification: Use of Coded Imprint", JAMA; 1967, 199: 158-59.
- Smolinske SC and Robertson WO; "Imprint Coding on Solid Medication Forms: Problems in Interpretation", Vet and Human Tox; 1992, 34:170-2.
- Vasudevan P et al’ "Avoiding Medication Mixups: Indentifiable Imprint Codes", West J Med; 1996, 165:352-54.
- Leape LL, Swankin DS and Yessian MR; "Commentaries on Medical Injury", Public Health Rpts; 1999, 114: 302-317.
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*Presented at the October 1999 North American Congress of Clinical Toxicology, La Jolla, California.
Int J Med Toxicol 2000; 3(2): 3
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