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One of our biggest clients is the local psychiatric hospital because a good chunk of the facility is rehabilitation and addiction management. Lately, there’s been a population of patients who were coming up positive on the amphetamine drug screen but we have never been able to find anything that could explain it in the confirmations. This is not the most bizarre thing because amphetamines are very volatile so if you have a tiny concentration in the urine, you might lose it in the extraction (which contains dry down steps).
However! One day we got a box full of homemade cigarettes from the hospital which were taken from an “entrepreneur” who was selling them to patients and we were asked to do extractions on them to see if maybe we could find this mystery amphetamine or cross-reactant. (Unrelatedly, I thought the surgeon general’s warning sticker is a really charming touch)
We tried a number of extraction methods but never did find the amphet. In fact what surprised me was the fact that, compared to commercial cigarettes, these were actually really clean!
So I have an interesting case of environmental toxicology.
One of the local hospital’s neonatal ICUs has been suffering from an outbreak of bloody diarrhea. Obviously the first thing they suspected was some sort of infection, so they recruited an epidemiologist to puzzle it out, but they quickly ruled out both bacterial and viral infections.
We got a bunch of water samples from them for trace elements analysis and it came back negative. But we also got some baby bottles from them and they had really high zinc levels, so they suspected something is leaching from the bottles.
We then got a bunch of urine samples from the babies and indeed the zinc levels are through the roof.
We asked the clinical toxicologist if this could be related and indeed, high zinc levels can be a cause of bloody diarrhea. Imagine that.
When samples come into our lab and there is any possibility that they can turn into medical-legal issues (eg, impaired at work, related to a crime, but usually drug facilitated assault), we will not run them. In the case of assault, our toxicologist will phone the ordering doctor to tell them the sample has been sequestered and the patient must lodge a complaint with the police so that they can seize the sample and test it in a lab that allows the result to stand up as evidence in court. That is a matter of protecting the victim.
Once upon a time, we were naive and even though the requisition requested rohypnol (flunitrazepam) and the appropriate red flags went up, the GP lied to us and told us that it was clinical, not medical legal, and he was concerned it was contributing to her tremors so we should definitely do the test.
It is a benzodiazepine and our mass spec method is not really good at detecting benzos. Flunitrazepam is also a very low dose drug so our chances of finding it were spotty at best. So we ran it on the gas chromatograph which is no where near as specific as a GSMS but had a method developed for other benzodiazepines. To make things even more sketchy, we don’t and never really had a fully developed method for date rape drugs and the test was tailor made for this one time use by our lab scientists. Our big mistake was performing the test and sending out the report with “Flunitrazepam suspected.”
Several days later, the lab was getting calls from the woman’s lawyers. As it turns out, her husband was drugging her and taking advantage of her, but our results cannot be used outside of a clinical setting, especially not a result like that one. The police ended up seizing the sample anyways. The consequence was that we had used up a good portion of the sample and it took the forensics lab months and months to work out a method that could run the small quantity.
Good news is he was tried and convicted in the end. And also that we learned our lesson.
I feel as though I have reached a new level of gross in the specimens we receive. Nothing quite as horrifying as kidney worms though. The other day as I was walking past the extraction bench for the GC mass spec, I noticed a very distinct alcohol odor. When I looked over, there was a sample cup full of greenish chunky vomit.
Someone had requested an alcohol level on puke.
Alcohol levels are actually done on the GC headspace, not the GCMS. Instead of sampling the extract, the instrument makes use of the volatility of alcohol and samples the space above the sample. The result is a much cleaner and easy to interpret chromatogram. That being said, they don’t have a method in place for extracting vomit (That is more the Medical Examiner’s Office’s domain) and we had to reject the request.
Our GCMS doesn’t do levels and is a qualitative method. Reason being is that 99.9% of our samples are urine (sometimes serum/plasma and syringe contents) and knowing how much of a drug is in the urine literally tells you nothing. It won’t tell you how much the person took, nor when they took it, not if they are a regular user or not, not even if it has any relevance to their clinical presentation (if overdose is suspected).
Something all toxicology labs have but don’t advertise is their stock of drug standards that they use for building drug libraries on our instrument, reagent preparation, and controls. Getting even a single ampoule (1mg/mL) involves lots of hoops since the bigwigs need to feel comfortable with people having a freezer full of ultra pure, ultra concentrated (street)drugs.
So, after 8 months of hard lobbying and everyone signing their life away, we finally got approved by the federal government and got our hands on drug standards for desomorphine, better known on the internet for its hype in Russia under the name Krokodil.
You may also be interested to know that its ion profile on the mass spec is shockingly similar to dextromethorphan, the cough syrup.
When we send results, the laboratory information system sometimes automatically appends reporting comments to help physicians interpret the results.
Recently, a new comment has attached itself onto Benzodiazepine results on the drug screen saying that Oxaprozin (AKA DayPro) can produce false positive results for up to 10 days. This is strange because the benzo screen was supposed to be pristine but apparently this new fangled drug will cross react in the assay.
How that comment came to be was interesting.
Our esteemed toxicologist (who often donates his body to such pursuits), took four days worth of this prescription medication at maximum dose and collected his own urine to throw on the cobas analyzer and, lo and behold, was positive for benzodiazepines for 10 days.
And thus a reporting comment was born.
Lately I have been working on transitioning to a new position in Toxicology, which is less of a toxicology department now that it has basically adopted all the labour intensive expensive tests for the lab, almost all of which are some form of chromatography with long, painful manual extraction processes.
On my first day I was greeted with a request for a cannabinoid confirmation on a newborn (literally newborn).
It came back strongly positive and we reckon mom decided to smoke some marijuana to help with her pregnancy. I hope it was worth it to her knowing that her baby is quite possibly going to have neurodevelopmental problems.
Unfortunately, this kind of experience will be par for the course in the new position, as we will get a lot of addicts (to harder drugs) who give birth to poisoned babies.
Well, it’s been a while since I did a case study because I never think to remember things like these, but let’s do another.
A 36 year old male with a history of alcohol abuse is found lying in a pool of vomit at home by his mother. He was apparently drinking heavily for the last 24 hours and was now unresponsive to painful stimuli. He had a grand mal seizure (45s long) followed by two shorter ones. His pupils were fixed and unreactive, so he was given IV Narcan (opiate antidote, did nothing), dextrose (volume expander), vitamin B12. He also showed signs of brain swelling so he was given IV mannitol.
If you were the physician, what would you order STAT for this patient? Remember that the only tests that should ever be requested stat and not routine are ones that will affect the course of treatment for the patient right then and there, so it is important to be judicious. That means no “drug screen” for you.
Once in a while we get thrown a curve ball and get specimens from people who don’t need any clinical direction anymore.
Today, I received a vitreous fluid specimen from a 15 year old boy who was killed in a bike accident—a huge bummer in and of itself. They wanted to know if alcohol was involved.
Basically, eyeball fluid is a good specimen for post mortem ethanols because the levels are pretty stable and bacteria don’t have an easy time mucking things up in there (as they tend to in a lot of specimen types).