Archive for the ‘Medical History’ Category

Do they Have Gastroenteritis or Antimony Poisoning?!

Friday, January 7th, 2011

Hey all, it’s ERP from erstories.net. Haven’t done a guest post in a while but here ya go.

Recently there has been a huge uptick of visitors to my ER violently ill with vomiting and diarrhoea.  They (the CDC) thinks it is Norovirus, but that got me thinking.   We see episodes of this sort of thing so often that we almost turn off our brains as clinicians.  We say “you have a virus” before the patient has finished telling us the full story.  We blindly order Zofran, IV fluids and check some electrolytes.  If they feel better after a bolus of fluids and they tolerate some liquids, they go home.  Quick and easy.  Anyway, I got to thinking, what if something else is going on?  Something weird or random (I know I am a geek like that). Something sinister?   During such outbreaks, it would be easier to avoid detection if you were poisoning someone.  This thought got me back to one of my favourite murder-mystery/science books, the Elements of Murder by John Emsley.  You may remember when I blogged here a while back about the cause of death of Napoleon.  My interest in this subject was piqued by reading this book.

Anyway, if you want to poison someone (not that I would advocate such a thing), the way to do it is to do it SLOWLY.  Don’t give a huge lethal dose since that will trigger suspicion that one was poisoned. Also, don’t use things that have very distinctive toxidromes, such as alopaecia.   This includes radioactive stuff like Thallium and Polonium – 210.   If  you give small doses of things that give more common, run of the mill symptoms (such as vomiting and diarrhoea) that are easily mistaken for things like GI viruses, most MD’s won’t be the wiser.  If you are offing  your great-great grandmother to collect her inheritance or life insurance, no one will bat an eye when she kicks it.  The idea is not to trigger an autopsy or official medical examiner evaluation.   Of course, in this day and age, it is much harder since random deaths of young healthy people will almost invariably trigger an investigation even if it occurs over time. Still, I was thinking about this when I saw a 70 year old lady with N/V/D with dehydration, abdominal cramps, low grade fever, mixed in with  about 5 others I had seen with the same thing during a shift.   Perhaps she was rich and some evil nephew could not wait for her to bite the bullet naturally.  Maybe the poisoner was some evil genius with access to all sorts of nasty stuff?

That got me back to my Elements of Murder book and I read about Antimony, the element with the symbol Sb and an atomic number of 51.  It’s  not something that’s usually lying around these days like it was from the 1500’s to the early 20th century, but it is still around in industrial applications and still can be used in a some forms therapeutically to treat some parasitic infections.   There are some problems with using Antimony to poison someone, mostly that unless the body is cremated, it stays detectable in the corpse nearly forever. Thus the key is to avoid an autopsy.  The advantages of it however are that it causes vomiting, headaches, cramps, and sweating – hence it used to be used to treat fevers.  This lady that I saw pretty much had all this – as did many others that I saw last week.  Just giving her small recurrent doses which would be perceived as a relapse over time, and eventually levels would build up to lethal levels where it blocks anticholinesterase enzymes and causes cardiac arrest.   Now, if I were to suspect this poisoning, I could administer chelating agents like Dimercaprol and the patient would likely survive, so the key is to get the patient poisoned during a big Norovirus outbreak when I have the blinders on.

There were some famous murderers that used Antimony, usually in the form of James’ Powder or Tartar Emetic.  One victim’s case that I found pretty interesting was that of Wolfgang Amadeus Mozart. His death at age 35 in 1791, at the height of his creative genius was officially attributed to “Military Fever”, an archaic term no longer used that could represent many real conditions – infectious or otherwise but may in fact really be Antimony poisoning.    There are many other theories about his death that you can read about (head trauma, Trichinosis, complications of Rheumatic fever), however there seems a real possibility that he was poisoned.  Antimony seems to make the most sense (over Arsenic which would be much more common) due to his symptoms of raging fever, vomiting,depression, and severe edema of the extremities and abdomen from renal failure.   He also exhibited a rash (which my lady fortunately did not have) that has been observed in known cases of poisoning.  The theory is that the composer was treated with Antimony for “melancholia” or severe depression (saddled with stress and debt, this would not be surprising) by his doctor  (ironically Antimony was used to treat this but often CAUSES more depression!) and apparently he was pretty sensitive to it.   When he got more ill and appeared to be febrile (“Military Fever” again) he got more Antimony (and some Mercury which is also nasty stuff) until he succumbed 15 days later, leaving his final composition, the Requiem Mass, unfinished.

Some consorts reportedly came forward much later stating that they had poisoned him on purpose, but the evidence seems to point strongly to yet another case of historical medical malpractise!  Back then, you could do what you and most of medical establishment thought was right, and kill someone unintentionally.  If I could go back to virtually any time before the US Civil War, I would tell people to avoid doctors like the plague!  Meanwhile, my lady felt better after her treatment and I discharged her with an Rx for Zofran – which I subsequently realised might contribute to her death if she were being slowly poisoned with Antimony (since expelling the compound from one’s body is critical in avoiding absorption of acutely deadly doses).  Well, lets just hope she had that virus and get back to work clearing the board.

What Will They Find?

Thursday, August 12th, 2010

Catching up on the news and saw an article about a construction crew in Flint, Michigan that was expanding the hospital emergency department when they came upon two time capsules buried deep within Hurley Hospital.

At least one of the time capsules is more than 100 years old.

I had a bunch of humorous ideas for what I thought they’d find inside.

What do you think will be in there?

A Classic Dr So-and-So Patient

Saturday, September 26th, 2009

ERP from ERstories.net  here again today and tomorrow… You know, WC needs a weekend off now and then…..

Why is it that certain doctors (usually primary care) attract a certain subset of patients? Our community is very heterogenous but I still find that several MD’s have tapped into certain subpopulations whether intentionally or unintentionally. Often, I find myself guessing (usually correctly) about who a patient’s doctor is before asking them. Clues like the med list, the last name, the insurance (or lack of it) they have, and PMH all give clues. I chuckle to myself when I ask them who the MD is and find I am correct. For example:

One doc seems to have about 90% of all the living Holocaust survivors in the US as his patients. (and he was not one himself) – usually on BP meds and Coumadin for Afib.

Another guy seems to have only patients with chronic pain, nebulous psychiatric diagnoses, and poorly controlled hypertension and diabetes. They often have Medicaid (which is honourable of him). However, even those with private insurance tend to be extremely challenging to deal with. Most are on Oxycontin, Wellbutrin, benzos, and Metformin.

One group sees only super rich entitled people who never have serious emergencies. However they often seem to have diagnoses of fibromyalgia and IBS way above the national prevalence. Hmmmm. Usually on Cymbalta, Xanax and something for chronic diarrhea.

One guy sees 90% patients from South America with no insurance – but they all have money and pay him cash. Often on random drugs they purchased on their last trip to Columbia.

One woman has a large non-English speaking, Russian population. They always seem to have some major issue going on. Often on no meds despite the acute MI they are having.

Another guy who is Asian seems to have all the really sick Koreans and Chinese in the area. Usually they are on dialysis and have a med list a mile long.

Another Asian doctor seems to only have the healthy ones. They tend to be on ziltch.

Of course none of this really matters since they ALL eventually become my patients! But thankfully they don’t REMAIN my patients until their next visit when I am on!

Surgery Circa 1930

Saturday, September 19th, 2009

A subscription to Wired Magazine is about the best ten bucks I spend every year.

A recent post on their blog shows some wild videos from 1930s British archives demonstrating brain surgery, removal of a large ovarian tumor, sterile technique, and how to deliver a baby by Caesarean section. Probably not something to watch if you have a weak stomach.

The baby coming out of the C-section is looking a little floppy to me, by the way. Also strange to think that the baby being delivered – if alive – is almost 80 years old now.

Whiskey Prescriptions and the Prohibition Act

Thursday, February 28th, 2008

Scalpel made a suggestion to post pictures of some of my medical memorabilia, so I figured “what the heck.” I have a couple of other rants ready to post, but figured I’d give everyone a break from my craziness for a day or so.
One of the historical displays I have in my office is about the Prohibition Act. I purchased some old alcohol prescriptions off of eBay a while ago. I also purchased some a lot of old medication labels. Then I did some research on the internet about Prohibition. I printed out the information below and put it all in a frame that is now hanging on my wall. Some facts, including those about the pharmacist and drug store, came from the person who sold the prescriptions to me, so I can’t vouch for the accuracy of those facts.
I made this display long enough ago that I don’t have the sources for what I wrote, so don’t blast me if what I have down there isn’t precisely accurate. If you have some other interesting facts about prescribing alcohol during the Prohibition, feel free to add them in the comments.
I left the prescription and medication label at high resolution, so they may take a minute to display. If you click the images, you can download copies that should print out pretty well. I removed the last name of the patient on Photoshop.



By the 1830s, the Temperance Movement had turned increasing public attention toward abstinence from alcohol. Temperance societies nominated their own candidates – “DRIES” — to serve in public office. There were over 1.5 million DRIES in 1830 and they were known to write the letter T next to their names on membership rolls, hence the term “Teetotalers.”
According to “Alcohol, Hygiene and Legislation,” written in 1915 by Dr. Edward Huntington Williams, “we should expect to find that all human beings have an instinctive craving for such substances as alcohol, tea, coffee, tobacco, or narcotic drugs.” Dr. Williams considered drinking to be inevitable for certain mentally impaired persons:

The vast majority of persons do not crave excessive quantities . . . in case of the dipsomaniac, we have, theoretically, a person whose brain structures are weakened in a certain part, just as in any other form of mental unsoundness. Indeed, this is the generally accepted view of modern clinicians — that the inebriate is a person whose brain is structurally different from that of the normal man.

What originally began as a Temperance Movement became a Prohibition Movement when the Anti-Saloon League declared war on any alcohol consumption. On January 16, 1919, less than a year after the end of World War I, the Prohibition Act became the 18th Amendment to the US Constitution.
The National Prohibition Act, also known as the Volstead Act after the Minnesota congressman who sponsored it, passed on October 28, 1928 despite Woodrow Wilson’s veto. After 36 states ratified this Amendment, the new law officially took effect. Penalties were strict for breaking this new law. Selling alcohol without a permit could bring up to five years imprisonment and fines as high as $10,000!
Fortunately, for many there was a loophole. The law prohibited sale of alcohol, but did not criminalize the possession of alcohol. Further, sacramental wines and alcohol prescribed by a physician for medicinal purposes was also excluded.
In order to avert the law, proprietors manufactured medicinal agents containing high amounts of alcohol in order to comply with the law. These included:spirt-of-nitre.jpg
which contained up to 100% alcohol with a sprinkle of herbs, and
Nostrums in which other medical agents – sometimes narcotics – were added to highly concentrated alcohol in order to intensify intoxication from the liquor.
The creation of new “medicinal” agents was so common that from 1914 to 1930, there were 287 preparations registered with the United States Internal Revenue Department that contained from 30 to 90 per cent alcohol. These “medications” were created to cure ills such as rheumatism, nervousness, kidney ailments, dyspepsia and “biliousness.”
For those wine or whiskey connoisseurs, there was always the option of seeking out a physician for a legal prescription.
The prohibition prescription was found hidden in the basement of Krause’s Drug Store, in Covington, Kentucky. Krause’s Drug Store opened for business in 1899. When alcohol became illegal in 1919, prescriptions for “medicinal liquor” became more popular. Krause’s Drug Store was known locally as “The Bootleg Drug Store” because the owner had a “No Questions Asked” policy when it came to filling these prescriptions. He also kept a still in the basement of his pharmacy. Many pharmacists refused to fill liquor prescriptions, instead referring the patients to Mr. Krause. Krause’s store was open on Thanksgiving, Christmas, New Year’s Eve and New Year’s Day — he was never too busy to fill a prescription for “medicinal liquor”!
The Prohibition cat-and-mouse game came to an end in 1933. By that time Franklin Roosevelt had launched the “New Deal” to invigorate the US economy. On December 5, 1933, the 21st Amendment to the US Constitution repealed the Prohibition Act.

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