A Charmed Life

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“Happy New Year!” The Marston household was filled with jubilation that another crazy season was in full swing. Steven and Marsha Marston and their four children, Steven Junior 15, Margaret 13, Elizabeth, 4, and baby Sophia, just 6 months, had spent the last five days together, snowed in as occasionally happens in rural Alaska.

It had been an especially lovely Christmas this year and all the children were especially attentive to Sophia. Both Steven and Marsha consider themselves blessed to have children that got on so well. Steven Junior and Margaret both had volunteered to babysit at any time. Nevertheless, it was Elizabeth, only 4, who had formed a special bond with little Sophia.

The New Year was filled with promise. Marsha, a nurse at the healthcare center, had been promoted in September, and the family made good use of the extra income at Christmas. Steven, who ran the only filling station and auto repair facility in town, had remarked at the enormous number of baby toys that Sophia had accumulated in such a short amount of time. Even so, the baby paid little attention to squeaky toys, rattles, or stuffed animals. Instead, she was attracted to anything shinny, a fact that’s annoyed her sister Margaret to no end. Margaret had begun to collect jewelry in the form of bracelets, charms, and necklaces. Whenever she would hold Sophia, she had to be careful because the baby would grasp onto anything shiny. And of course, she had to taste it. Margaret was constantly wiping baby drool off herself. More annoyingly, off her charms and rings

230 miles south, as the Eagle flies, in the city of Nome, Mark Prescott, a recent Ph.D. graduate in epidemiology, was settling into his second week at the office of public health. Dr. Prescott had specialized in chronic diseases, and although familiar with infectious diseases, it was certainly not his area of interest. Still, the office required familiarity with all forms of disease, and Dr. Prescott had begun to familiarize himself with the most common occurrences here in Alaska. A native of Southern Louisiana, Dr. Prescott had not so much as had a cold until he began college in Maryland. Now, here in the bleak mid-winter of Alaska, the darkness and cold were beginning to make him doubt his choice of deployment.

At the Marston home, January 14 started out as a normal day. Breakfast was always hectic, as Steven had to open the shop at 6 AM, while Marsha had to be at the clinic for 7:00. Sophia had not woken up at her usual time, usually between four and 5 AM, and Marsha asked the children if someone could go in and get her. Elizabeth went in to wake the baby. Now, nearly a week later, Marsha remembers her daughter’s voice when she called to her mother “something is wrong with Sophia”.

Something did seem to be odd with Sophia. She was awake, but she was not crying. She was not really doing anything. Aside from drooling, which she always seemed to do. Her eyes were open, but she just stared as if she was watching something far away. Marsha picked up the baby, and quickly scanned her from head to toe. There did not seem to be anything wrong. Nevertheless, she sensed that something just was not right. That is when Marsha felt the first seizure. Marsha asked the older children to put away the breakfast dishes and she bundled up Sophia, put her in the car seat, and headed for the clinic. In the clinic parking lot, Sophia began to vomit. The clinic was not what might be called a “hospital” but for the 4,2000 residents of the town and nearby area, it had always been sufficient. The emergency room doctor, David Siegel, M.D., examined the baby carefully, yet could find nothing obviously wrong, aside from some nausea. Infection had been ruled out, as Sophia had no abnormal temperature. If anything, actually seemed a little cooler than normal for an infant. As Dr. Siegel turned her over to listen to chest sounds, her back arched against his hand, her legs and arms rigid. Sophia had another seizure.

Sophia’s blood pressure was checked and rechecked, and was within normal range. A monitor was brought in and Sophia’s heart rate, oxygen saturation, and pulse rate were monitored continually. She was breathing ok, and her pulse rate was normal. Aside from that, however, nothing seemed normal. Sophia now began to have diarrhea, and Dr. Siegel had the nurse on duty begin IV fluids to help prevent dehydration. For the first time that morning, Sophia began to cry. By the time Steven had made the 10-minute drive to the clinic, Sophia had her third seizure. He sat with Marsha as the doctor question them about diet, formula, and breast-feeding. Steven, sitting stiffly in the plastic chair, looked out the window and saw the weather had changed again. A slight breeze that morning had changed into a strong southerly wind that kicked up the falling snow. At this point, neurological causes were suspected. Having exhausted other possibilities, Dr. Siegel asked if anyone in either family had epilepsy. The answer was a simple and straightforward “no”.

A life flight to the trauma center in Nome had been called in. And cancelled due to weather conditions. A flight would be made as soon as the wind died down and visibility improved. Dr. Siegel doubted the baby would survive long enough to get there. It was during the question and answer that the monitor alarm first sounded. Her pulse had risen sharply. Sophia was in pain. Unable to diagnose the cause of the symptoms, Dr. Siegel was uncomfortable treating for a seizure disorder, particularly without any family history of epilepsy. Dr. Siegel felt powerless as the duty nurse came into his office to tell him Sofia’s eyes looked jaundiced. Her liver was in danger.

The nurse grabbed a clean diaper for Sophia, and reported to the doctor that the urine was dark brown indicating blood. Now her kidneys were involved. This was not epilepsy. It was also nothing that Dr. Siegel had seen or even heard of before. Dr. Siegel made a phone call to the public health office in Nome in hopes of discovering if any new infectious diseases or reemerging infections had come to their attention. The woman who answered the phone reported nothing unusual. A few dozen cases of influenza, but aside from that, nothing at all. In fact, things had been oddly quiet for a January. She asked Dr. Siegel if he wanted to speak to the epidemiologist. Dr. Siegel then explained Sophia’s symptoms, however, Dr. Prescott was of little help. Nothing fit, and Dr. Siegel hung up.

Dr. Prescott went to lunch that noon with the case of the sick baby on his mind. He had not pursued infectious disease epidemiology because that would mean working primarily with children, and worse, their parents. From the arguments against vaccination to the number of reactionary un-scientific beliefs that were becoming the norm in America, Mark Prescott wanted no part of it. As he walked against the stiff breeze and blowing snow, he muttered aloud the idiocy of moving to Alaska. He had barely tolerated the winters in the Northeast. Stomping the snow off his new snowmobile boots, Dr. Prescott chose a booth in the back of the restaurant and sat down. Not all of his books had been unpacked, and his magazine and journal subscriptions had yet to catch up to him. He chose at random a magazine from the pile on a table in the corner and sat down. After ordering a cup of coffee and a toasted cheese sandwich, he sat back and thumbed through the pages with only half interest. Just as Sandy, the waitress he saw on most of his trips to the restaurant was pouring his second cup of coffee, Dr. Prescott stopped and starred at the glossy photo in the magazine. He realized he was talking aloud when he said, “That’s it!” “What’s it, Doc.” The waitress asked?

Not waiting for his lunch, Dr. Prescott ran all the way back to his office, slipping and falling twice. “God I hate snow.” He asked the secretary to get the doctor who had called back on the line. Hurry. She asked him what was going on. In the magazine, there was an appeal for supporters of some charity providing food and education for children in some third world country. What had focused his thoughts so suddenly was the image in the background. It was a dark and depressed looking shop, and the sign over the door read “Minerals for Sale.”

When Dr. Siegel answered the phone, Dr. Prescott had to force himself to speak slowly. Had the baby’s symptoms improved? No. Any changes? Yes. Now there was liver and kidney involvement. Did the family live near any gold or silver mines? A quick response from Steven and Marsha came back. No. Puzzled, Dr. Prescott next asked about the family’s drinking water. They had a well, but the water had always tested fine. Excellent in fact. Dr. Prescott asked how long the family had lived in their present home. Nearly 12 years. At this point, Dr. Siegel asked Dr. Prescott what he was thinking. “It must be environmental” he replied. The symptoms sounded like some form of heavy metal poisoning. Nevertheless, the usual environmental causes were simply not there. Did the baby have pierced ears? This was a pet peeve of Dr. Prescott’s about parents, one of many if he were honest. The answer came back. No. Dr. Prescott thought for a moment. He felt so sure. Maybe he was wrong. As he was about to hang up the phone, Dr. Prescott asked if here were any other children in the home. Had any of them been ill recently? Again, the answer was no. One last question: had any of the children gotten any jewelry for Christmas? Any small metal toys? Anything imported?

Marsha responded that she had purchased some new charms for her older daughter’s bracelet. Where had she gotten them? Marsha replied she had picked them up from one of the discount stores in the mini-mall in Nome when she was visiting her sister. Dr. Prescott asked Dr. Siegel if he had x-rayed the baby’s abdomen or thoracic regions. Dr. Siegel remarked that he had not because the problem seemed neurological. They would be looking in the wrong place. “It is not neurological” Dr. Prescott commented. “Use an x-ray not an MRI,” he continued. “If I am right, you will see that the baby has ingested something metallic, and I suspect if it came from a discount store it’s made in China.” Although some manufacturers in China had received much bad press for the use of lead in children’s toys, they had found a cheap replacement that is even more toxic: cadmium. Cadmium is a lustrous, silver-white, ductile, very malleable metal that can be easily shaped into small jewelry items. Like bracelet charms. Dr. Siegel assured Dr. Prescott that no MRI would be used, as the clinic did not have one. Sophia was taken across the hall and an x-ray of her abdomen showed nothing unusual, but the thoracic x-ray showed a small, entrapped, opaque object. Dr. Sigel used an endoscope to confirm. Lodged in Sophia’s esophagus was a small oddly shaped object. It was about the size of a dime. The surgeon was called, and the charm was surgically removed. An IV of Calcium Disodium Versenate was started before surgery, and at 90 min intervals. Dimercaprol was administered over the next 4 days. Calcium, iron, and vitamin C were administered daily and by the morning of day 5, Sophia seemed back to normal. Any lasting developmental problems would not be known for several years, but the ingestion is thought to have occurred on January 13, and the charm was removed on the 14th, so both Dr. Siegel and Dr. Prescott hoped there would be no lasting damage. Sophia was allowed to go home on January 21st.

Blood tests had confirmed the presence of cadmium. A byproduct of zinc production, cadmium has been used as a pigment in paint, and corrosion resistant plating on steel. Some cadmium compounds were used to stabilize plastics before its toxic properties were fully known. Today, most cadmium poisoning occurs from jewelry manufactured in China. It is predominantly marketed to kids for its cheap cost and malleability.

The charm that Sophia had swallowed, Rudolph the Red-Nosed Reindeer, was sent to the Office of Public Health. It measured at 91% cadmium. It was made in China. Baby Sophia it seems led a truly charmed life.

 

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