Arsenic case causes terrorism procedure shift

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A year after somebody used arsenic to poison the Sunday after-service coffee at Gustaf Adolph Evangelical Lutheran Church in New Sweden, most of the victims have resumed normal life activities.

“People here are just trying to move on,” said Caribou family physician Carl Flynn, explaining why residents might be reluctant to return calls from the press. “Some are having a harder time than others.”

While the tiny Aroostook County community goes about the quiet business of healing its own, the rest of the state – the whole country, really – owes a debt of gratitude to the people of New Sweden and the health care system that responded to their crisis.

The incident sparked one of the most dramatic public health interventions in Maine’s history, testing the system’s ability to deal effectively with a small-scale but intense crisis. Maine not only passed that test with flying colors, according to state health officials, but the case also prompted a critical change in the management of federal bioterrorism funds.

“My heart goes out to the people of New Sweden,” said Dr. Dora Ann Mills, director of Maine’s Bureau of Health. “They’ve endured a great tragedy.” But Mills said the incident vividly demonstrated that “criminal – or terrorist – attacks can happen anywhere in the world, including rural Maine.”

Before the poisoning, Mills said, states were not allowed to use federal bioterrorism funds to create local stockpiles of antibiotics and chemical antidotes such as the ones that saved the lives of most of the New Sweden victims. Instead, federal administrators planned to create regional caches of emergency supplies, pledging to have them delivered to any facility in the region within 12 hours of an identified need.

That wasn’t quick enough for Mills. “With chemical poisonings, you need that antidote ASAP,” she said in a phone interview Tuesday morning. “We decided we should create and manage our own stockpiles.”

So months before the New Sweden arsenic case, Maine found different funding to order an array of medical disaster supplies. When the incident occurred, the supplies were in storage at Maine Medical Center in Portland, awaiting dispersal to nearly every community hospital in the state.

Early on that fateful Monday morning, within an hour or so of emergency department physicians in Caribou and Bangor floating a tentative diagnosis of arsenic poisoning, supplies of the lifesaving antidote were en route by air to the patients who needed them.

As it turned out, some patients were so badly stricken that the standard antidote, administered as an injection into a muscle, could be only partially absorbed. Doctors worked with the state’s poison control center at MMC to locate a more effective intravenous form that had to be flown in from California. It took the better part of a day. The ready availability and early administration of the first antidote is credited with saving lives and minimizing damage to victims’ internal organs.

Mills said administrators from the federal Department of Homeland Security reviewed Maine’s response a few weeks after the crisis was stabilized and recognized the benefit of having a supply of the antidote near to hand. A subsequent revision of federal bioterrorism guidelines encouraged states to create their own stockpiles.

“It is because of New Sweden that states are now allowed to use federal bioterrorism funds for emergency stockpiles,” Mills said.

Mills also credits the state’s recent investment in basic conference-call technology – made possible through bioterrorism funds – with fostering the communication that made response both speedy and effective.

Dr. Anthony Tomassoni, medical director of the Northern New England Poison Control Center at Maine Medical Center, said Maine is now better prepared than many states for incidents of chemical or biological poisoning, with “starter doses” of antidotes and antibiotics stashed at 30 hospitals around the state.

Staff from the center will be working with physicians, emergency responders and other medical providers to furnish ongoing education and support for treating future incidents, Tomassoni said.

The recognition that a similar event could happen again may be the greatest lesson from New Sweden, he said.

“Things like this can happen in a place like Maine,” he said. “This really represents a loss of innocence.”

Of the sixteen parishioners who drank the bitter brew that Sunday morning, one man – 78-year-old Walter Reid Morrill – died. The others suffered a range of life-threatening responses including kidney and liver dysfunctions, blood clotting disorders and severe breathing difficulties. Four of the victims had to be maintained on life support for several days at Eastern Maine Medical Center in Bangor, and several underwent repeated dialysis to detoxify their blood until their internal organs recovered.

Although all of the patients had ingested the same poison from the same sources, their responses varied considerably. Some had consumed more than others, some had significant underlying conditions, and some had waited longer for treatment.

“These were some of the sickest people I’ve ever taken care of,” said Dr. Thomas Kandra, a critical care specialist at EMMC. “There’s so little data available on treating acute arsenic. We were all trying to learn as we went along.”

Kandra, who has practiced in Bangor since 2000, has only praise for the health care system that responded to the arsenic poisonings – doctors in Caribou who first suspected something other than common food poisoning, consultants at the poison control center who responded promptly to the tentative diagnosis, pharmacists who researched the intravenous treatment option, laboratory staff who compiled reams of data, and nurses who provided emotional support to families as well as expert bedside care to victims.

“The response of the [health care] system was incredible,” Kandra said. “I now have complete confidence in this system.”

Bangor primary care physician Toby Atkins was supervising medical interns in the emergency department at EMMC when news came in of the sudden onset of the mysterious illness up north.

For Atkins, communication was key. “By the time the first patients got here, we had a tentative diagnosis of arsenic poisoning. By the time we realized we had an epidemic, we were already trying to standardize treatment so we wouldn’t have to reinvent the wheel for each case,” he said.

“All the staff were equally at sea,” he said. “Nobody had any more experience than anyone else. The communications were very good. There was a real bond between the specialists, the doctors up north, the consultants and the primary care people.” Atkins said professional support and consistency of treatment allowed him to attend to some of the profound emotional and psychological needs of the victims and their distraught families.

“There was a great deal of uncertainty. People were wondering what their lives would be like if they survived the poisoning,” he said. “There was also a profound loss of trust. This church was such an important institution in the community. I don’t know if that can ever be restored.”

Physician Carl Flynn, who, along with colleague Dr. Daniel Harrigan, was recently honored for his role in treating many of the victims at Cary Medical Center in Caribou, said many of his patients are having difficulty coping with the emotional aftershock of the poisoning. “Some of them feel violated, some of them are still looking for answers,” he said. In general, he said, the older victims and those who were more seriously affected have had the hardest time coming to terms with the experience.

Seven of the victims are Flynn’s regular patients, so he has firsthand knowledge of their long-term physical and emotional recovery from the acute arsenic episode. “I can say that no two patients are having the same problems,” he said. “If they were, we could draw some conclusions and develop interventions for them as a group. But medicine is never that neat.”

Instead, he said, people are exhibiting a range of complaints, some of which are in clear response to the trauma of the arsenic poisoning and others that may or may not be related.

“That’s the trouble with something like this,” Flynn said. “Any time these people have any kind of medical problem, the question now will always be ‘Is it related to the arsenic?'”

Responders to the New Sweden arsenic poisonings are collaborating on a case study that they expect will be published in a major medical journal within a few months.