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Health: The Politics of Poison

Allowing poison-control centers to close might yield some short-term savings, but in the long run it would be idiotic.

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The Rush Poison Control Center, located in a little room off a hallway in one of the wings of the labyrinthine Rush-Presbyterian-Saint Luke's Medical Center, feels more like a graduate-study carrel than a MASH unit. Reference materials are piled high, a muted radio plays in the background, coffee is always brewing in an adjacent room. Two or three people sit at terminals, quietly answering phones and asking the callers "How many pills are left in the bottle, ma'am?" "At what time did this get in your eye?" "Can you read the label and tell me what was in the capsules?" "Has he vomited since then?" They key the data into their computers and view screens that provide them with information on toxicity, dosage, and antidotes for virtually any poisonous compound.

A call from the intensive-care unit at a community hospital in McHenry County sounds particularly serious. A child has gotten into a prescription drug containing phenobarbital. He was brought to the emergency room, placed in the ICU, and still isn't responding to treatment. The medical team has already pumped his stomach and administered activated powdered charcoal to try to draw the poison out of his body. But he's lethargic, his pupils are dilated, and his heart rate is frighteningly fast.

Tony Burda, a poison-information specialist at the Poison Control Center, takes the call. Burda knows that phenobarbital affects the respiratory and nervous systems, and he recommends an arterial-blood-gas count so the ICU team can measure how well the boy is getting oxygen into his system. If his blood-gas count is too low, the boy will have to be put on a ventilator to help him breathe.

Burda also knows that the combination of ingredients in the drug the boy took can have unpredictable effects on blood pressure, might send it dangerously high or low. He instructs the ICU personnel to monitor the boy's blood pressure carefully and recommends giving him more charcoal as long as there's good intestinal-tract movement and the charcoal will be carried through the child's body and not get impacted.

At this point Burda consults a toxicologist at the Toxikon program, a consortium that includes the occupational-medicine department at Cook County Hospital, the Poison Control Center, and the University of Illinois drug-information center. The toxicologist talks directly to personnel at the ICU and gets the patient's history. By this time the blood-gas count has been obtained, and the toxicologist supports Burda's recommendation that the boy be placed on a ventilator. The ICU team administers several more doses of activated charcoal and continues to monitor his blood-gas levels. Before the day is over the boy is out of danger.

Such mini-dramas are part of the daily routine at the Rush Poison Control Center, one of the most utilized public-health services in Illinois. Last year it received 48,234 calls from people in northeastern Illinois, more than 35,000 of whom had been exposed to a poisonous substance. Most of the remaining calls were from people seeking information or from people who wanted to know whether they were in danger from a substance that turned out to be nontoxic. The need for the center seems clear. But without better funding mechanisms, it may someday be forced to close.

Most cases handled by the center don't need to be treated in a hospital; 72 percent of the 1991 cases were treated over the phone. The center estimates it prevented more than 8,000 costly emergency-room visits that year, saving the health-care system in the state a minimum of $2.1 million.

The Rush center is one of more than 100 poison-control centers in the U.S. In 1990 the 72 centers that participated in a survey set up by the American Association of Poison Control Centers (AAPCC) served 191.7 million people, 1,713,462 of whom were directly exposed to poisons.

This nationwide system is the result of a public-health initiative undertaken in Chicago in 1953. A few years earlier the American Academy of Pediatrics had published a study that showed poisoning was the number-two cause of morbidity--injury, pain, or discomfort--and mortality among children in the U.S. In response, Chicago's medical schools, their affiliated hospitals, and organizations such as the American Academy of Pediatrics and the state's toxicology laboratory started a poison-control project in five hospitals, including Saint Luke's Hospital (this was before its 1956 merger with Presbyterian Hospital). Each hospital was to operate its own internal consulting service, staffed by an in-house poison-control officer, to be used by physicians.

After a one-year trial period the idea rapidly expanded across Illinois and eventually the country. It wasn't long before virtually every hospital was calling itself a poison-control center; at one point about 200 Illinois hospitals were using the term. The AAPCC was established in the late 1950s to collect and monitor data, hold scientific meetings, and give the fledgling health-care enterprise more scientific legitimacy.

Within a few years the number of calls from the general public had outpaced the number from physicians (over 80 percent of all calls now taken by the Rush center are from the public). But some hospitals received very few calls, and it was impossible to monitor the efficiency and quality of all the hospital-based centers. Slowly the idea of regionalization began to take hold. By the late 1950s Rush-Saint Luke's and Illinois Masonic were serving as the two primary poison-control centers in Chicago, though quite a few other hospitals continued to offer at least some services.

By the 1970s most states had recognized the benefit of poison-control centers, and many began to take a more active role in planning and funding them. The Illinois Department of Public Health did not provide money, but it did designate three regions that would be served by three existing centers: Chicago and northeastern Illinois was to be served by the Rush Poison Control Center, northern and central Illinois by Saint Francis Medical Center in Peoria, and southern and central Illinois by Saint John's Medical Center in Springfield.

Regionalization made the system more efficient, but it also put a greater strain on the three hospitals as the volume of calls increased and more staff were needed. The hospitals began to question the cost efficiency of maintaining this public service, and about five years ago the regional center in Peoria was shut down. Within six months the nearby Pekin Memorial Hospital took over the responsibility of supporting a center, but made it clear that without more funding it would not be able to continue indefinitely. Last November that center too closed. Today Illinois has only two poison-control centers: Rush and Saint John's Medical Center. (An animal poison-control center is located in the University of Illinois' veterinary school in Urbana.)

The first thing a poison-information specialist does when a call comes in is decide what the substance is and how much was taken. The caller may be asked to count the number of pills left in a bottle or the number of rat pellets still strewn around the house, or to measure the amount of liquid in a jar or can. Vomiting may be induced at home, or the caller might be instructed to monitor symptoms and call the center back if there's an adverse reaction. In many cases it's sufficient to flush out the mouth or eyes with water, or to put ointment on a skin abrasion.

If a highly toxic substance, such as antifreeze, has been swallowed, the poison-information specialist will recommend that the person go straight to the nearest emergency room. The specialist will call an ambulance if necessary, and will also call ahead to the emergency room to let the staff know a poisoning case is coming in and to consult with them over the phone.

Essential to this process is something called the Poisindex, which is a computer-software package developed by Micromedex, a Denver-based corporation that specializes in computer and microfiche drug and poison information systems. It contains more than 500,000 individual product entries for drugs, plants, and chemicals. It also outlines the clinical effects of poisons; treatments, including appropriate laboratory examinations and known antidotes; the dosages known to be fatal and tolerated; the available forms in which the toxin may be found, including brand names and general categories such as cleaning fluids, pesticides, etc; and a pharmacology and toxicology section to outline how the poison works on a cellular and molecular level. Also included in the Poisindex are citations and articles describing available data on different substances from clinical trials, studies, and other sources.

Most poison treatments are rather prosaic: inducing vomiting with ipecac, a substance derived from the South American ipecacuanha plant that irritates the stomach and usually causes vomiting within 15 minutes; pumping the stomach; or administering activated charcoal, common charcoal pulverized into a fine powder, which absorbs organic materials and is mixed with water or a cathartic like sorbitol.

Some poisons have specific antidotes: Vitamin K for anticoagulants like warfarin; Narcan for opiates or narcotics; antivenin for snakebites. Other poisons, such as barbiturates and many other medications, can be dealt with only by watching for symptoms and treating them when they appear. The vast majority of poisonings do not end in death. Nationwide in 1990 there were only 612 deaths--0.036 percent of the total.

Connie Fischbein, a veteran poison-control specialist who's been at the Rush Poison Control Center for approximately eight years, says the most common poisoning cases treated by the center involve children who get into household chemicals and plants. "In winter we get a lot of cough and cold preparations," she says. "In the summer we get a lot more of the outdoor plants, things like nightshade berries and mushrooms. And a lot of bee stings at the end of the summer.

"Cleaning products are fairly common--bleaches, dishwasher detergent. Some things that many people aren't aware of. If you mix bleach with other chemicals, bleach is very reactive. If you mix it with acid--a toilet-bowl cleaner or an acid drain opener--you get chlorine gas; if you mix it with ammonia, you get chloramine gas. And they're both very strong respiratory irritants. They can be coughing for several hours; sometimes you'll have coughing for about 24 hours. They can usually be watched at home. If a person has asthma or bronchitis or some kind of underlying respiratory problem, it can be more serious.

"Another thing kids get into are multiple vitamins with iron. Iron is corrosive to the GI tract, and it also causes disturbances in the acid-base chemistry of the body. It can cause shock and loss of blood pressure. Every day we get calls about multiple vitamins with iron.

"Tylenol causes liver toxicity. We get a lot of calls about kids getting into the children's preparations. Generally we don't see too much of a problem because there's not that large of a quantity in the bottles. Children apparently are more resistant to the liver toxicity than adults are."

Newell McElwee, an epidemiologist in the hospital's department of medicine and a consultant for the center, says the prevalence of young children in the center's caseload reflects national data. "Consistently around 65 to 70 percent of poison-center cases are children five years old or younger. Most of them are just general accidents that occur primarily in ages one and two. Younger than that, they're usually not very mobile, and once they hit three the rate starts dropping down. Children are just curious. The route of exposure is typically ingestion."

McElwee also points out that suicides make up a significant number of poison-control-center cases. In 1990 in the U.S. there were 116,400 suicides or suicide attempts reported by the AAPCC, 6.8 percent of all reported cases.

Today financial pressure threatens all of the state's poison-control centers, even the one at Rush. A good poison-control center handles most cases over the phone, so it doesn't attract patients, and their money, to the hospital where it's located. Hospitals maintain their poison-control centers largely for the publicity--any PR sent out by a center will probably prominently display the name of its host hospital. A poison-control center is also a way for a hospital to further its traditional mission of providing for the health and welfare of its community.

Few hospitals, however, can afford to be totally altruistic. Most poison-control centers across the country receive funding from outside sources, such as their state departments of health. But there has been no state funding for Illinois centers since the late 70s, when $10,000 start-up grants allowed each center to install 800-number phone lines.

These centers depend on their host hospitals, but when economic times are tough hospitals tend to retrench. Even a large not-for-profit institution such as Rush, with its long history of community service and substantial caseload of poor patients, has had to pay more attention to the bottom line. Peter Butler, vice president of administrative affairs at Rush-Presbyterian-Saint Luke's Medical Center, says that for now the Poison Control Center appears safe. That, however, could change. "It's the kind of thing that hospitals ought to be doing for their community. Maybe that's why we hang onto it. It is a line item in the budget for which there is no offsetting revenue, so we have to rely on other patient-care revenue to help subsidize it--about $300,000 a year in direct expenses, not to mention the space and things like that.

"We're right in the middle of [the budget-review process]. I don't see it going. It depends how we're looking six months from now. In terms of reconciling this budget for next year it's still in. But if we need a mid-course adjustment in our budget next year, then it'll be right back up for consideration."

Given the current statewide financial crunch, it's unlikely that any new money would come from the state Department of Health. So the Poison Control Center came up with a novel idea to augment the funding it gets from the hospital. Jack Lipscomb, the center's director, explains: "Consider that poison control is essentially an emergency telephone information service. In that respect anyway, it's not unlike 911. We looked at how 911 is supported, and that was a surcharge on monthly telephone bills. It spreads across as large a population base as possible, therefore keeping any one group or individual's costs as low as possible."

Higher telephone bills? That might seem like a losing proposition, but Lipscomb has been doing some research that seems to indicate it might fly with the public, especially when compared to other possible means of support, such as increased state revenues, which could mean higher taxes. "A lot of people say nobody wants new taxes," he says. "That's true. We have been surveying people--we've started in the last month or so. We're calling people at random. The vast majority all say they think they're already paying for it out of their tax dollars, and they're very surprised when they find out they're not.

"We ask them, given that there is no public-sector funding at all, would you be willing to support an eight-cent-a-month increase on the phone bills? And so far most of them--about 80 percent is my rough estimation at the moment--say they would. These are people called at random. We're not talking to people that have used the service.

"A lot of times we've gotten the comment, 'Well, I wouldn't notice an eight-cent-a-month increase on my phone bill.' Ninety-six cents a year to pay for a poison-control service, to always have it there and available. Sometimes one of the arguments against support was, 'Well, I don't think I'll ever have to use the poison center--why should I pay for it?' Most people don't ever think they'll have to use 911. But I haven't been hearing complaints about what they're paying for 911 services, and they're often paying anywhere from 50 cents a month to a dollar."

But this solution to the center's financial worries will have to wait. At the urging of Lipscomb and other advocates, a bill has been introduced in the state legislature that would mandate that the director of the Department of Public Health and the director of the Department of Agriculture designate regional poison-control centers. This bill, sponsored by Louis Lang and Howard Carroll, both Democrats from Chicago, would require the health department to designate either two or three regional poison-control centers for human poisoning cases; the Department of Agriculture would be required to designate a center for animals.

This legislation would allow the two departments to set operating standards and monitor the centers' quality. However, it does not provide for funding. The word from the governor's office is that the administration would oppose the telephone-bill surcharge idea because it would be considered a new tax. This means that even if the state mandates the existence and location of poison-control centers in the future, there's no guarantee they'll be adequately funded.

Most regional poison-control centers, according to Newell McElwee, handle about 20 calls for every 1,000 people each year. In Chicago that works out to about 140,000 calls per year. In addition, the AAPCC suggests that a regional poison-control center should serve between one and ten million people, and there are approximately seven million people in the metropolitan Chicago area. So theoretically the Rush Poison Control Center should be able to deal with 140,000 calls. But it handles only a little more than a third that number, largely because most people don't know it exists. Yet the center doesn't have the money to aggressively publicize itself.

What's more, it doesn't have AAPCC certification, the only way a regional center can show it's adhering to AAPCC standards. That would help it attract and hold on to good personnel as well as boost public confidence in its work. The center also loses out on federal funds that the AAPCC sometimes allocates to centers that are certified.

To qualify for AAPCC certification, the center would have to have a full complement of AAPCC-certified, dedicated staff--personnel hired and trained to be poison-information specialists--available 24 hours a day. But of course the center doesn't have the money to hire full-time staff 24 hours a day. Its full-time staff are on duty only from 7 AM to 11:30 PM. The rest of the time the phones are answered by the pharmacists, who are also responsible for patients at the hospital.

Yet the volume of calls continues to increase along with community requests for educational materials and information. At some point the center may be unable to meet the demand and may be forced to close.

If either of the two poison-control centers in Illinois closes down, the entire system would probably collapse. Lipscomb explains: "Our call volume right now is about double Springfield's call volume--we're beyond capacity. So now [if the Rush center closes], you triple Springfield's call volume, which in essence is going to nearly triple their costs. If they're actually going to truly handle these calls, they'd have to more than double their staff--triple their staff essentially--add on new phone lines, everything. Or keep it the way it is, and those lucky few that can get through without a busy signal get help.

"Or what's more likely, Saint John's would probably turn around and say, 'Why should we be paying to cover everybody in the state? We're getting nothing out of it.' It would collapse then. If Saint John's closed down and everything tried to funnel into here, we'd collapse. Because Rush has essentially said, 'We can't afford to keep increasing the budget year after year.' If there's any expansion, if there's any increase in services, it's got to come from elsewhere."

The irony of course is that if the poison-control centers closed, health-care costs across the state would very likely increase. Emergency-room visits would soar, and we'd probably see more poisoning cases needing more intense, expensive intervention.

Then there are what Newell McElwee calls the unmeasured benefits of a poison-control center. "We reassure people when there's really not a problem. So it prevents the disruption of people thinking that something bad is going to happen, and people going through the experience of going out to County or wherever and spending the entire evening in an emergency department. So there are a lot of intangible benefits to poison-control centers." And of course these worried people would go to an emergency room, adding further unnecessary costs.

Peter Butler, vice president of administrative affairs at Rush, is still optimistic about the Poison Control Center's immediate future, but he sounds fatalistic about the longer term, pointing to policymakers' attitudes toward prevention, early intervention, and cost savings. "My fear is it kind of takes a notice to the public that we're going to drop it to get the attention. And it may come to that. Preventive medicine, things that make real good sense, that give people access to good information over the phone, is just not something that always gets funded. The things that tend to get dropped often are the things that perhaps even help save cost rather than create cost to the public."

Art accompanying story in printed newspaper (not available in this archive): illustration/Will Northerner.

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