"Nothing is easier than self-deceit. For what each man wishes, that he also believes to be true."-Demosthenes, Third Olynthiac

What is the most dangerous place in the world? Is it an infectious disease storehouse or a commercial fishing boat off the coast of Alaska? I think it's under your kitchen sink. On my last inspection of that area in my house, I found no less than two metal cleaners, dishwasher detergent, Drano and some spray that kills fleas on pets-all lethal poisons in their own right. Poisons can ruin your day faster than a bad round of golf. Clearly, homes harbor agents that can subtly manifest themselves in deadly ways. Let's examine this month's case for an example.

Scenario

On an otherwise quiet day, dispatch sends you and your partner to a call for an "Adult male vomiting. 325 Michael Lane off Rubin Blvd. Time out: 1310." Splendid, you think. Why are we tying up an ALS unit on this call? Where are the BLS units? As you arrive on scene, you're directed to the rear of the house and discover why your ALS crew was called-an unresponsive elderly man actively vomiting in the middle of his garden.

As you immobilize the patient's C-spine, begin suction and prepare him for intubation, your partner obtains a quick history. The patient's wife explains he had a bypass operation several years ago and has a weak heart. He takes digoxin, Lasix and Slow-K. He went out to the garden an hour ago, and when she called him in for lunch he didn't answer. She found him and called 9-1-1.

Your partner tells you the patient is incontinent and has diarrhea. You notice the patient's pupils are constricted and his eyes are tearing profusely. The patient's heart rate is 45. At this point, your patient becomes apneic and cyanotic. You successfully intubate him with his head in a neutral position and begin bagging him. The patient has some wheezes in his lung fields, and the end-tidal CO2 detector indicates your tube is in the trachea.

The ECG demonstrates sinus bradycardia at a rate of 45. Blood pressure is 80/46, and you obtain venous access. You start the IV in the right antecubital and administer saline solution.

Your back-up BLS unit arrives and finds an empty bottle near the patient in the tomato plants-a bottle of Malathion. They also find the sprayer he was using. You and your partner correctly decide the patient is likely experiencing organophosphate poisoning and normal poisoning treatment won't be effective. You call medical control and present the patient condition to the doctor.

The doctor agrees the patient has all the symptoms for organophosphate poisoning. You learned to remember these symptoms with the acronym SLUDGE: salivation, lacrimation (excessive tearing), urination, diaphoresis, gastrointestinal motility and emesis. The medical command physician orders 2 mg atropine via IV bolus and asks you to monitor the patient, repeating the dose every 20 minutes until the symptoms disappear.

You begin transport to the receiving hospital. The transport proves uneventful, and the patient improves somewhat after you repeat the atropine dose during the ride.

In the hospital, the physician administers another antidote for this particular poisoning, pralidoxime (Protopam). He explains it activates cholinesterase, an enzyme that reverses the poison's effects.

Discussion

You check back on the patient later in the week and learn he had a smooth recovery and was discharged after a few days. A week after his discharge, he and his wife stop by your station to drop off several pounds of tomatoes from their garden as a thank-you gesture. (They've washed them, of course.)

Although we tend to think these particular toxidromes occur only on farms in the hinterlands, poisonings can occur in the most urban of settings or in places you might not otherwise suspect. The trick to assessing a poison victim is really no different from that of any other patient. Often, you need to suspect a problem in order to recognize it. A baseball manager once said the most important quality a ballplayer can have is something that can't be coached-speed. I believe the most important quality an EMS provider has is something that can't be taught-suspicion. We can easily teach folks the skills, but it's much harder to make them suspicious.

Paul Werfel, NREMT-P, paramedic program director for the University Medical Center at State University of New York, Stony Brook, may be reached via e-mail at pwerfel@epo.hsc.sunysb.edu.

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