POISON CONTROL & the INTERNET by Bill Bakaitis

Recent technological innovation has changed the way that many of us work with Poison Control calls. In many ways it is now a quite different experience than it was even a few years ago. I want to describe some of those changes, try to highlight some of the benefits as well as problems, and offer suggestions that might be helpful for those of us who volunteer for this type of work.

I first began assisting in identifying mushrooms for the NY State Poison Control Network in 1984 responding to a call made at the Glassboro New Jersey meeting of the Northeastern Mycological Foray.  At the time one hospital center (in Nyack NY) handled most of the mushroom poisoning calls north of New York City, and they often operated under difficult circumstances. The calls came in from a wide area; the staff was small and most knew very little about mushrooms. One critical bottleneck was the availability of only a few mycologists, often professionals with a deep but rather narrow expertise, who were available for consultation. John Haines, the New York State Mycologist at the time, used the forum at Glassboro to attempt to recruit amateurs in an attempt to fill this need.

Within days of volunteering I received my Baptism under fire as I responded to a referral and went to a local hospital to attempt identification of a mushroom eaten by an experienced mushroom collector. It turned out to be a Destroying Angel, Amanita virosa complex, misidentified as an edible.  The patient, a Registered Nurse in her 60's was in the recurrent symptom, third day, stage of the Amatoxin sequelli. Her husband, an MD, was also an experienced collector. At my request he returned to her collecting site, gathered some mushrooms, and brought to the hospital several specimens of the mushroom he thought she had eaten. They sat beside her on the bed stand, in a plastic bread bag, mute testimony to the magnitude of her error.  Both husband and wife were sure that death was immanent.

The attending Physician of the Critical Care Unit stood by perplexed and helpless. After I took the specimens to the lab, scrounged around for some Hydrochloric acid and conducted a confirming Meixner test, he confessed to me that he hadn't the slightest clue as to what to do next. .He said he was trained to fix broken bones, burst arteries and failing hearts, but mushroom poisoning was entirely outside his scope of training.  He was asking me for advice.   

Whew! What had I gotten myself into here?   I called the Poison Control center with my observations.  At the time the communication technology in place was the telephone and a line from the Poison Control center was connected to a printer in the hospital.   Based upon my ID, they sent a medical protocol to the hospital.  The printer clattered away, the paper advancing letter by letter, line by line, cog by cog, page after page. I left as the Doctor and Poison Center Specialist were discussing the case on the telephone as the printer clicked and clacked in the background. 

Returning to the Patient's room, I was able to spend some time with the couple. They were preparing for the worst and were desperate for whatever information I might be able to offer. An hour or two was spent answering all of their questions and concerns as honestly as I could. The gist  of  what I had to say was that monitoring of vital signs and appropriate treatment interventions would guide the hospital staff. Various strategies were available as different stages of the sequelli presented themselves. Based upon what was reported in the latest text I had read, death was quite rare where reasonably healthy adults had access to modern medical facilities.   

The patient did recover, albeit with some damage to her heart, liver and kidneys. And she did go on to collect and eat mushrooms, brave heart that she was.  But for me, and the point of this article, was that this case was instrumental in defining the role I saw for myself in this process at the time.  That role has changed over the years. I can loosely refer to those changes as pre and post internet. Let me explain.

PRE INTERNET POISON CONTROL WORK: 

As the case above illustrates, immediate, tangible face to face, personal contacts were one of the more salient features of the Poison Control consultation for me in the past. 

For starters, I was able to personally handle the mushrooms, either at the hospital or at my home. I could turn them over in my hand, feel the texture, taste, smell, look at various features under the microscope, and subject the tissue to various reagents.

In addition, personal relationships were developed with the ER and Poison Control staff. Within months of the case described above, a set of training seminars with the PC staff at Nyack Hospital was initiated. Among other issues, staff members and a small cadre of volunteers were recruited and/or trained in field identification of mushrooms. 

I vividly recall one poison specialist trained during our forays who would personally taste various insects, plants and mushrooms. At first I thought him odd or slightly mad, with his intriguing Italian accent and twinkling eye, but as I got to know him I realized there was method to his madness.  Many if not most of the cases he dealt with involved oral ingestion by children.  He needed to be able to understand at their level the tastes they described and to make his judgment calls in part from those descriptions. In this light his oddity became delightful child's play and his comments about taste or smell developed a richness and authority that would ever after command respect.

In order to more promptly deal with the quandary faced by physicians dealing with their first, and perhaps only mushroom poisoning case, a list of references and protocol sheets were prepared to be handed to the Physician at the Hospital or to those who would bring the specimen to my home for identification. 

As it turned out, one of the most valuable things I was able to do was to help the patient (and to a lesser degree, the Physician) understand what she or he was likely to experience.  In case after case they expressed great relief at being able to have the chance to talk about what was happening to them and to have straight answers to their questions and concerns.

An even greater personal involvement was evident when it was a family member who would bring the mushroom, and their child, the usual patient, to my home.  At the time my young daughter would take it upon herself to bring out some of her toys to share with the child while I pondered the mushroom, or piece thereof brought to me for identification. The ensuing rapport could not have been greater.

And finally, from the personal contacts and experiences with the hospital and PC staff I came to learn which towns in my area were reporting cases of mushroom exposure. I would then go into these communities to deliver mushroom identification courses and to encourage participation with local mushroom associations.

Throughout, it was the personal contact with the mushroom, the patient, and the professionals that was central to these experiences. 


POISON CONTROL WORK IN AN INTERNET AGE:

By way of contrast, during 2007, I responded to twenty or thirty calls involving mushroom exposures, yet of those, I actually handled a mushroom only once:(An Amanita delivered to my home from a distant hospital by a tag team of Police Officers, the last one a State Trooper wearing latex gloves, with the mushroom double bagged inside a sealed plastic tub and driving with his windows open so that he wouldn't get high from inhaling any fumes given off by the mushroom. Curious, isn't it?))

Because of technological changes, almost all of my referrals today come from an abstract distant location, delivered from a revolving set of professionals and staff, with a wide array of skills and knowledge followed by images of varying degree of value piped to my mobile location and displayed onto the screen of my laptop computer.

History will show our recent technological revolution to be complex and redundantly interconnected, but as it affected the process described here changes to the telephone services seemed to come first.

In New York State, the area Poison Control Center with which I had done most of my work was decentralized.  A common statewide 800 number was established and from the first, calls were shunted to local hospitals close to the point of patient initiation.  At about the same time 'Call Forwarding' became a routine service available to private telephone subscribers. This meant that a Land Line could be set to ring through to wherever the owner stipulated. In my case that was the Hudson Valley of New York during the academic year and the mid-coast of Maine in the summer.   Those with reliable cell phone service have even greater options.

Concurrent with these changes, and central to it, was the widespread availability and use of the internet, along with the power of broadband, wireless, and powerful search engine technologies.  So ubiquitous are these changes that we need to be reminded how recent they are:  So useful their utility that we also should be reminded that they are not infallible and come with flaws.

Errors of fact on the internet, for example, are legion. The most obvious examples are on unjuried pages such as blogs, dot coms, dot orgs, various Wikis, 'Open Source' pages and advertisements.  Imagine my surprise, however, when preparing a talk on Amanita I clicked on one of the most authoritative medical sites available to find an error of deadly proportion. It involved the mistake of confusing the Meixner test for Amatoxins with the Amyloid reaction of spores to Meltzer's reagent.  

I emailed the Doctor in charge of the web page who immediately set about trying to trace and correct the mistake. Since he copied me on the emails to his staff I learned, as he did, that this mistake was carried forward from another medical journal of equally high repute.  As most of us by now know, once sent to the World Wide Web, information can never be completely recalled or corrected, and there are undoubtedly medical personnel out there right now who have the incorrect information in a data base on their office computers. 

This rapid 'viral' spread of internet information carries implication for the most innocuous of exchanges.  When I opted for Call Forwarding on my home phone, I sent an email to the Poison Control centers with which I had been working, informing them of  the fact that I would be available if needed and inviting them to share my number with those in need of knowing.

Soon I began to receive calls from throughout the United States including one from the west coast forwarded apparently from the orient. (That one came with an unsolicited image asking for an opinion of its identification. I had none, but later came to suspect that the image was probably of Pleurocybella porrigens, as a number of Asians with impaired immune functioning had succumbed to toxic reactions from this species at about the time this image was wending its way through the web.  It wouldn't surprise me to hear from others who also received the same solicitation.)

But, in a computerized internet age, why not respond to distant referrals?  I began to accept those that came from legitimate poison control centers in the Northeast, the only area for which I am comfortable making such determinations.   Calls in 2007 came from Maine, Vermont, New Hampshire, Massachusetts including Cape Cod, Rhode Island, Connecticut and New York. That is quite an area, but the scope has provided some generalizations which are comforting.

Some things have not changed. For example, from wherever the calls have come, I have found the staff at the Poison Control Centers to be superb. They are professional and easy to work with.  They generally try to find someone close to the case for their referral, moving out in a logical fashion to more distantly located mycologists if none are close at hand, or if their 'regular' consultant is on vacation or otherwise unavailable.  They are aware of the limitations imposed by third party observations and the difficulty of making determinations from images sent to computer screens. (More about this later)  To a person they have been knowledgeable, personable, and easy to talk with.  

Equally familiar was the type of referral. The vast majority of calls I have received involved toddlers and children who handled, mouthed, or chewed upon mushrooms.(+) All but two * such cases involved generally benign mushrooms, the most concern being for those toddlers who handled Panaeolus (Psathyrella/Panaeolina) foenisecii. Again, no change in the pattern I had come to expect from local calls.  Comforting too that these 'grazers" often located choice edibles (Pleurotus ostreatus) or otherwise interesting mushrooms.  (Rhizopogon sp.) Were only the rest of us so good.

[* The most dangerous one was independently identified by a friend of the family, prior to presentation at the ER as Amanita gemmata/crenulata.  The friend turned out to be a NAMA member who had in the past worked as a consultant for Poison Control. I know her and accepted her ID without further involvement.  The second involved an immature Scleroderma citrinum that was missing only a very small (5mm) portion.]

[(+) This pattern of exposure is confirmed by the data of Northern New England Poison Control Center where 64% of the 227 mushroom exposures reported to them in 2006 involved children aged five years and under.]

I was also reminded of how mushrooms often fruit over a wide area at the same time, and how knowledge of this fruiting pattern can help in identification. Consider the following.

On the afternoon of September 25th, 2007, I received three referrals within a five hour period: One from southern Coastal Maine, near the New Hampshire border, followed by one from inland near Augusta, the State Capital, concluding with one from Burlington Vermont, in the Lake Champlain Valley near the Canadian border.   All three cases involved children who collected/handled/ate Gyrodon meruliodes.  The specimens were variously described as chanterelles, brackets or tree ears and some of the images were terrible, but coming so clustered the clearest images and descriptions were useful in interpreting the more confusing.  And once I had a tentative description I was able to speak with the parents and inquire about the trees in the area where the child collected the mushroom.  In two of the three cases Ash was mentioned as the only tree.


UNRESOLVED ISSUES/ SPECIFIC REMEDIES: 

Over the past few years several problems specific to internet ID work have been recognized. Described below, they warn us that we might best handle them with specific procedures. 

Since the parties will almost always be operating at a distance it is important for everyone to share email addresses and telephone numbers as the case progresses.  I begin by exchanging these with the Poison Control specialist and then with the hospital ER staff when I call them.

By far the most troubling aspect of the "long range" ID work has to do with the quality of the images transmitted from the hospital. The worst images almost always come from cell phones.  Often the images are quite blurry. Sometimes the color is very off.  The scale and proportions are at times easily distorted. The experience for the mycologist attempting identification can be frustrating at best and terrifying when one considers that a small life might be at stake.

Last summer I emailed several other mycologists who also do consulting work and asked about their experiences using these internet images.  The responses were quite varied, running the spectrum from those who refused, to those who embraced the technology.

Consider the concerns raised by Dominick Laudato, a longtime consultant from Long Island, who is very hesitant to use internet images for several reasons.  He points out that at times the differences between edible and toxic species are so similar that images alone cannot distinguish between the two -Lepiota rachodes and Chlorophyllum molybdites was an example he cited.  Also, as he points out, the range of variation within a single species can be so great that an image from one part of the spectrum might not be recognized as belonging to the taxon, even within field guides where excellent photography of ideal types is attempted.  The task becomes more problematic when less than perfect images must be identified without cues offered by the field context. And on a pragmatic point he offers "Having taught as well as practiced nursing, I feel that the nurse has enough to do caring for the patient load w/o having to photograph mushrooms in a manner that would provide a quality photo that could be used for ID purposes."

The response of Michael Beug, (who receives the Mushroom Poisoning Reports for NAMA) on the other hand is typical of the more positive end of the spectrum.   He reports that "… the ability to share images via the web has really improved my ability to give advice compared to the old days when I had to rely on verbal descriptions of the mushroom - when I have had both an image and a verbal description I have often marveled on how different the mushroom appeared from the descriptions that I had been given … There have been times when the images did not show the detail needed for a reasonably confident identification. However, over-all I have usually been able to rapidly assure someone that they have nothing to worry about in the long run. In a few cases, the images have alerted me to potentially serious poisoning."

Greg Marley, President of Mushrooms for Health, and computer savvy editor of The Coastal Newsletter (current issues available frominnrneuf@midcoast.com) has spent some time thinking about this problem, particularly the poor images transmitted by cell phones. He has offered specific, well thought out suggestions to the Poison Control Centers he works with.  Among these are the  "…consideration of hospital EDs purchasing and having on hand a digital camera with capability of macro imaging and at a megapixel level above 5.0 . This type of camera can easily be found for $200-$300." He further suggests "storage of camera and transfer cable (both in a ziplock bag) with scheduled drugs in the ED. This enables close supervision to prevent loss or theft and a clear understanding of where the camera will be found when needed. All nursing and clinical staff would have access to the camera 24/7 and since staff count and log the scheduled drugs at each shift, they would be reminded of the location of the camera at regular intervals. Ideally, there would be staff (or a staff position) identified to be trained to use the camera and transmit images by email. Many likely already have the requisite knowledge." 

Without high quality images, Greg is very reluctant to continue to attempt identification from images so transmitted.  Many will agree with him. 

Unfortunately those of us on the receiving end of the images have little control over the Hospital Emergency Room procedures.  On the other hand, the problems of using images alone to make an ID (cited above by Laudato and Beug) while on target are fortunately subject to our modification.  I attempt to handle this problem by using all of the communication channels open to me.

I begin, for example, by having the ER staff member attempt to describe the mushroom, and then, after the unprompted description revisit that description with a set of guided questions probing details that might have gone unrecognized.   I also ask to speak with the patient or parent about their description and observations of the mushroom. Not only do their descriptions of the very same mushroom frequently differ from those given by the hospital staff, but they  almost always provides information unknown to the staff member.

The parents or patient, for example, can describe the trees and shrubbery in the yard or area where the mushroom was collected. They will be able to say if the mushroom brought in was the actual mushroom eaten, or one growing in a nearby area. They might know if it were "on the tree", or "on the ground next to the tree".  In the case of the Rhizopogon referred to earlier, the parents were able to describe the child picking the mushroom not from the yard, but from the compost pile that had just been delivered to the yard by a contractor, a bit of information that explained how a child's thin bare hand could uncover hypogeal fungi.  And of course real people can describe the texture, feel, and smell of the mushroom.

Following these interviews I direct the staff member to take very specific images that I need to attempt identification of this specific mushroom. I may ask for a shot of the underside and exposed parts (if any) of the mushroom. In some cases, such as small puffballs, I ask for a vertical section.

It sometimes takes hours for images to arrive in my email inbox. Indeed, some never get through. This problem has also been noted by other mycologists consulted for this article.  I now provide three email addresses for the images to be sent. (Free email accounts are available from a wide variety of sources. Yahoo and AOL are two.)  As a backup I will also have exchanged telephone numbers and email addresses with the parents and hospital staff.

If I have a tentative ID, particularly if the images sent are of poor quality I might have the staff attempt a Google Image search while on the phone together.  Quite often the family will use their own camera to send images better than those sent by the hospital. Or they might call with newly discovered/realized relevant information.    If I suspect Amatoxins I will suggest a Meixner Test at the Hospital. This often causes problems as the Physician and staff is usually unaware of this test.  As described earlier, in the past I would bring informational sheets with me when I visited the hospital; for an ID.  I am now considering preparing a set of links to web pages for easy reference. 

In some cases I will consult with other mycologists for confirmation of my ID's. This is easily done by including them on the email address line. So far we have always agreed.

It is crucial to keep in touch with the Poison Control Center at every stage of the way. It is they, after all, who will provide the information necessary to guide the treatment. Since time delays between initial contact with the hospital, formulation of a tentative ID, receipt of images, possible calls for additional information, final ID with degree of confidence etc. are common I will telephone with a status report at critical junctures.  This allows the PC Center to more sensitively shape their advice to the hospital.

The personal contact with the family has never failed to be golden. The assistance in the identification process has been very productive. In addition, family members, almost to a person, express relief in being able to discuss aspects of their case with an interested mycologist and in understanding what is happening as the ID process proceeds beyond the bounds of the hospital.  Frequently they, and extended members of the family, will call or email days later with their heartfelt thanks.

Unfortunately, the same cannot always be said of the hospital staff. Although the vast majority are professional, helpful, and personal, some appear quite threatened by a stranger questioning them over the telephone. Occasionally the referral process has either bogged down or has ground to a halt. In one case the intransigence or lack of comprehension on the part of a staff member became so counterproductive that the family members themselves took over and were able to rescue the referral process. In this case simply being there, in person, allowed the family to understand the limits of the staff member of this small hospital, to then intercede, ask for direction, and to quickly and skillfully photograph and transmit images that allowed me to identify the mushroom and resolve the case. 

It is hard to imagine such difficulty ever occurring when the consultant is on a first name basis with the doctors and staff at local hospitals. Hopefully this problem will remain quite rare as we evolve to deal with an internet community of unknown staff in remote locations. 

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There often comes a time in the life of those of us who collect mushrooms for our own purposes where we cross a threshold and become amateur mycologists.  For some that threshold brings with it a desire to give back to a community that has supported us in our endeavors. We may take a leadership role in a local mycological association, teach a course to beginners, or volunteer to assist in the identification of mushrooms for the poison control networks across the nation.  The technology now in place can be very helpful in dealing with the later choice, even for those Luddites, like me, who have come to these changes late and reluctantly. The technology cannot supplant the personal experience one can bring to the task, but given the chance, it can augment it.  

I have tried to describe some of the techniques that have been helpful to me when dealing with those referrals involving the transmission of internet images from distant locations.  I hope that others might find some of this useful, and might respond with other suggestions.  Such a dialogue can only help to improve our collective efforts.

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PROTOCOL SUMMARY

HANDLING INTERNET REFERRALS OF MUSHROOM IDENTIFICATION FROM POISON CONTROL CENTERS

UPON FIRST RECEIVING THE CALL

1. Take notes beginning with date and time.

2. Exchange telephone numbers and email addresses with the referring staff member.

3. Get the name of the patient, and Doctor at the Hospital where the patient is.

4. Get whatever information was presented to the Poison Control Office.

CALL THE HOSPITAL

1. Exchange telephone and email addresses with the Hospital staff. Get their description of the mushroom and status of the patient.

2. Speak with the Patient and or family member. Get their description of event, mushroom. Exchange telephone numbers and email addresses.

3. Provide more than one email for the images to be sent.

4. Request specific shots from a high quality camera.

UPON RECEIVING THE IMAGES

1. If of poor quality, request a better set of shots.

2. If uncertain of ID can you 

a. rule out certain toxic species?

b. share images/info with another consultant?

c. offer tentative ID and ask family/staff to compare with published photos.

d. have the Hospital conduct a Meixner test?

3. If a potentially deadly mushroom is suspected advise the hospital and PC that the mushroom be sent to a mycologist for confirmation.

REPORT BACK TO ER AND PC

1. Give immediate telephone response.

2. Follow up with email.

You are also encouraged to fill in an online report to the North American Mycological Society (NAMA) poison case registry:http://www.namyco.org/toxicology/email_report_form.html