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					                    “Chemical Mysteries in the ER”
                                    Tim Graham
                                  Roosevelt H.S.
                            Wyandotte, Michigan
                          tsgraham@hotmail.com
NBC’s ER is a television drama…use the drama to engage your students. The small
investment is always worth it because it opens up a wonderful opportunity to
present the scientific content.

DVD #1 includes the following chapters:

       1. methemoglobin / methylene blue (2:57)
       2. HCl vs. HF (3:51)
       3. ethylene glycol (2:39)
       4. water toxicity (1:50)
       5. tooth enamel / anorexia (1:43)
       6. lead exposure (6:30)
       7. huffing CCl4 (4:35)
       8. strychnine poison (6:15)
       9. CO poisoning (15:00)
       10. cigarette smoker (1:10)
       11. urine prank / methylene blue (1:10)
       12. teenage drinking (13:00)
       13. Wilson’s disease (9:30)

Episode Synopsis:

1. ER episode #90 “Suffer the Little Children” Methemoglobinemia. (Season4)
Carter's diagnosis of the cyanotic child with methemoglobinemia was good except for
one major point--in any case of cyanosis, an arterial blood gas is one of the first tests to
order, not one done after later conferring with the attending he did do a good history for
cyanosis--he asked about medications, asthma history, and any congenital heart disease.
He knew where the family was. He worried about pulmonary embolus, and carbon
monoxide. Once methemoglobinemia was figured out, he went through the ways to
acquire it. Then the treatment is methylene blue. (Related article, “A Well-Known
Chemical Demonstration to Illustrate an Unusual Medical Mystery.” Fenster, Harpp,
and Schwarcz, Journal of ChemEd, Vol.74 No.4 April, 1997) Story about the “Blue
Fugates.”
Notes:




2. ER episode # 89 “Of Past Regret and Future Fear” Hydrofluoric acid exposure.
(Season4) Exposures of as little as 2.5 per cent of the body surface to concentrated
hydrofluoric acid (HF) may be fatal. Survival after major HF exposures is facilitated by
aggressive emergency management which includes wound irrigation, subeschar injection
of calcium gluconate, monitored supplementation of serum calcium, and prompt wound
excision carried out as an emergency procedure. (Related article, “An Invisible Fire.”
Discover, Vol. 17 No. 4, April, 1996.)

Notes:




3. Episode #43 “A Shift in the Night” Antifreeze/Ethylene Glycol
Poisoning.(Season2) A kid swallows antifreeze, but the hospital is out of ethanol to treat
him with. Rather than risk the kid having brain damage and renal failure, Mark has Carol
treat him with bourbon, left in a shopping cart out in the hall by someone. Ethylene
glycol poisoning--Suspect if patient OD'ed on something, appears drunk or agitated, and
alcohol and tox screens are negative. Will be acidotic and have a high anion gap.
Neurological symptoms appear, followed by renal failure when calcium oxalate crystals
deposit in kidneys. (Ethylene glycol is metabolized to oxalic acid.) Antifreeze has
fluorescein added so it can be easily identified. Treatment is with ethanol slows down the
metabolism of ethylene glycol (alcohol dehydrogenase) and allows the body to fully get
rid of the oxalic acid. Dialysis is also used in severe cases. (Related ChemMatters
articles, “Antifreeze Antidote”, October, 1996 and “Good Science Gone Bad.”, October,
2004.)

Notes:




4. ER episode # 68 “Make a Wish” Water Intoxication/Hyponatremia. (Season3).
Carter treats Harry Smith, a man who lost control of his car and ran into a pole. DUI
seems apparent, but there's no alcohol in his breath or in his system. Carter finds out that
Harry was on his way to a job interview, and that his mother was relieved that the police
didn't find out about the marijuana in his car. Suspecting that Harry may have tried to
drink massive amounts of water to clean out his system, Carter runs a sodium test and
discovers that the patient did indeed have water intoxication. (See recent hyponatremia
death in the news… “Woman drinks so much water she dies”, AssociatedPress, January,
2007--- A woman who competed in a radio station's contest to see how much water she
could drink without going to the bathroom died of water intoxication, the coroner's office
said Saturday. Jennifer Strange, 28, was found dead Friday in her suburban Rancho
Cordova home hours after taking part in the "Hold Your Wee for a Wii" contest in which
KDND 107.9 promised a Nintendo Wii video game system for the winner.) Related
ChemMatters article, “Sports Drinks…Don’t Sweat the Small Stuff.” February, 1999.

Notes:




5. ER episode #71 “Something New” Bulimia/Tooth Enamel. (Season4) Laura
Quentin, the girl with bulimia, was self inducing vomiting. Dr. Corday looked at her
teeth and "saw" characteristic erosion of the enamel that is caused by stomach acid.
(Related ChemMatters article, “Toothpaste.” February, 1986.) Anorexia/Bulimia…
Both are eating disorders but bulimia is characterized by binge eating and then purging.
A typical clinical diagnosis might include the evaluation of tooth enamel. The additional
acidity in the mouth due to purging erodes enamel. This is an equilibrium system.
Calcium hydroxyapatite dissolves in an acidic environment according to the following
equilibrium equation:
            Ca5(PO4)3OH (s)   5 Ca2+(aq) + 3 PO4 3-(aq) + OH 1- (aq)

   Fluoride: (0.7-1.2 ppm in drinking water)

Water fluoridation in the United States owes its origin in part to the research of Dr.
Frederick McKay, who pressed the dental community for an investigation into what was
then known as "Colorado brown stain." In 1909, of the 2,945 children seen by Dr.
McKay, 87.5% had some degree of stain or mottling. The Colorado stain was a high
concentration of fluoride ions in the region's drinking water (ranging from 2 to 13.7 ppm)
and areas with lower concentrations had no staining (1 ppm or less…to put this
measurement in perspective, 1 ppm is equivalent to 1 inch in every 16 miles.). In a
historic moment in 1939, the first public proposal that the U.S. should fluoridate its water
supplies was made not by a doctor, or dentist, but by Gerald J.Cox, an industry scientist
working for a company threatened by fluoride damage claims and burdened by the odious
expense of disposing of tons of toxic industrial waste. Cox began touring the country,
stumping for fluoridation.(10) Dean would go on to carve out a nice career for himself as
the "father" of public water fluoridation. He became the first dental scientist at the
National Institute of Health, advancing to director of the dental research section in 1945.
After World War II, he directed epidemiological studies for the Army in Germany. When
Congress established the National Institute of Dental Research (NIDR) in 1948, Dean
was appointed its director, a position he held until retiring in 1953.(11) In his post at the
NIDR, he was to oversee the first clinical trial of fluoridation (1945) in an American city,
Grand Rapids Michigan.(12).


Interesting Note: Forensic scientists are searching for human remains at notorious
California site of Charles Manson family. (MSN.com, 3/16/08) Arpad Vass and Marc
Wise, senior researchers from Tennessee's Oak Ridge National Laboratory, were
readying the first of the instruments they'd brought, capable of chemically detecting
evidence of decades-old human bodies. It was a hand-held device shaped like a gun.

"It's a crude sniffer," said Vass. "It gives us a quick indication of areas we want to come
back to."

The machine detects fluorinated hydrocarbon compounds, one of the approximately
400 types of volatile organic compounds emitted by human bodies during
decomposition. Focusing on these compounds is important because Vass believes
they're formed as the fluoride added to urban drinking water is released after
death.
Their presence helps differentiate a human bone from bones from wild animals,
explained Vass, who has spent years developing a decomposition odor database using
bodies donated to the Oak Ridge lab.

Notes:




6. ER episode # 110 “Rites of Spring” Lead Poisoning. (Season5) Carter diagnoses a
toddler with lead poisoning. Carter shows the results to Antoine (student) in the lab.
Carter notes that the toddler is also anemic, and that poor children, who have inadequate
diets and live in older buildings, are at risk for both lead poisoning and anemia. Later
Carter finds Antoine outside talking to friends. Carter tells him that he shouldn't socialize
on job. Antoine tries to explain but Carter won't listen, saying that he doesn't care, but
he's trying to give Antoine advice for future jobs. Later Antoine's friends bring in another
baby with lead poisoning. Antoine had recognized the risks, and told them to bring the
child to Carter. Antoine asks Carter if he can stay for the testing, and Carter agrees.
(Related ChemMatters articles, “Nightmare on White Street.” December, 1996,
“Poisoned.” December, 2005, and “Bling Zinger.” April, 2006.)

Notes:




7. Episode #152 “Survival of the Fittest” Hufffing Carbon tetrachloride(Season7) .
The fire department chief tells Mark that the school bus is not contaminated. Luka takes
Emily, a young, gum-chewing girl into the ER; she complains of nausea. Mark spots the
same three troublemakers who tormented Stuart, leaning on a car smoking cigarettes. He
tells them to get inside. The hoodlums on the bus have been huffing solvents; it turns out
that they had forced Stuart to inhale them too. Luka and Mark decide that they need to
find out exactly which solvent. Mark locates the three young thugs (Bo, Toby and Eric)
fooling around with the equipment in an exam room. He bluntly asks what they were
huffing, and the three pretty much ignore him. He bluffs that solvents have appeared in
their blood tests, and that further tests will be done if they don't give him details. He
chooses Bo to go first. In another room, Mark and Malik bring out all kinds of
threatening looking equipment and tell him that they will label his blood with a
radioactive marker and then re-inject it into him and do a nuclear scan. Terrified, Bo
finally blurts out that it was carbon tetrachloride, a common spot remover. Mark tries to
get Bo to give him contact information for his parents. He tells Bo that he is in liver
failure and in need of a transplant. Bo's persistent huffing has destroyed his liver. (Clark
Staten, Executive Director Emergency Response & Research Institute) A little
known but deadly problem is lurking in almost everyone's garage, cabinet, and cleaning
closet. The source of this emergency is for sale in most convenience and grocery stores in
every suburb in America. This menace takes hundreds, and maybe thousands of youthful
lives each year. Most people have no idea of the magnitude of the issue. It has been
declared one of the "gateway substances" that leads to the use of "harder" drugs. The
source of this scourge is inhalant abuse, a phenomenon commonly known as “huffing”. A
typical inhalant abuser is 14-16 year old, can be of any race or ethnic origin, probably
abuses inhalant substances with one or two friends, and doesn't understand what he or she
is "getting into", according to Catherine Macintyre of the International Institute of
Inhalant Abuse. Macintyre says that one of the biggest problems involving this
burgeoning issue is the fact that most people don't even recognize that there is one. There
are more 1,400 known substances that are categorized as capable of being abused by
inhalation. They include hydrocarbons, nitrites, anesthetics, alcohols, and halogen
compounds. Some typical name-brand substances that have been frequently abused are;
airplane glue, Scotchgard, Pam, carbon-tetrachloride, gasoline, paint thinner, Butane,
"White-Out" correction fluid, color markers, and other items too many to mention.
According to the National Institute of Drug Abuse (NIDA), while abuse of several other
drugs may be declining among younger people, inhalant abuse appears to be increasing.
Dr. Neil R. Rosenberg, a neurologist from the Colorado Neurological Institute at the
Swedish Medical Center in Denver, Colorado, was quoted in the Chicago Sun-Times as
saying; "They do it because either it's not illegal or there's a law that nobody knows about
or enforces . . . and because it's available". Rosenberg says that Illinois is one of only four
states that have laws prohibiting inhalant abuse. Ms. Macintyre, who helps Dr. Rosenberg
to study the neurological effects of inhalant abuse, says that most of the substances that
are abused are entirely legal to obtain and possess and that they are "cheap" to purchase.
She says that many adult's unfamiliarity with the abuse properties of inhalant substances
also contributes to the attractiveness of them for youngsters. Most of the products are
readily available and can be purchased at any neighborhood hardware, hobby,
convenience, or grocery store. Often, teen-agers are abusing inhalants, almost in front of
a parent or teacher, without their knowledge. Macintrye also says that youths of today
abuse potentially toxic substances because they "like the high" or feeling of euphoria that
is produced by them. She also says that most teens do not recognize the physical dangers
that are associated with inhalants. Lastly, Macintyre fears that inhalant abuse has become
the "In Thing" to do in some neighborhood high schools, and that "peer pressure" will
prompt others to experiment with it. Carbon Tetrachloride (CCl4):
Drugs continue to be taken off the market due to late discovery of hepatotoxicity. Due to
its unique metabolism and close relationship with the gastrointestinal tract, the liver is
susceptible to injury from drugs and other substances. 75% of blood coming to the liver
arrives directly from gastrointestinal organs and then spleen via portal veins which bring
drugs and xenobiotics in concentrated form. Several mechanisms are responsible for
either inducing hepatic injury or worsening the damage process. Many chemicals damage
mitochondria, an intracellular organelle that produce energy. Its dysfunction releases
excessive amount of oxidants which in turn injures hepatic cells. Activation of some
enzymes in the cytochrome P-450 system such as CYP2E1 also lead to oxidative stress.
Injury to hepatocyte and bile duct cells lead to accumulation of bile acid inside liver. This
promotes further liver damage. Non-parenchymal cells such as Kupffer cells, fat storing
stellate cells and leukocytes (i.e. neutrophil and monocyte) also have role in the
mechanism.


Notes:




8. Episode #120 “Humpty Dumpy” (Season6) Strychnine Poisoning/ Alzheimer’s.
Mark is called to neurology concerning Dr. Gabe Lawrence. When he arrives, Gabe is
undergoing an evaluation. When he has trouble identifying a couple of objects, Gabe
becomes frustrated with his inability to find the words. Mark talks with Gabe after the
tests, and tells Gabe that he has called his son. While Dr. Lawrence objects, he slowly
comes to the realization that he will need help in order to join a clinical trial to treat his
Alzheimer's. Dr. Lawrence decides the clean out his locker while awaiting the arrival of
his son to pick him up. Noticing Gabe sitting in the hallway, Carter asks for his assistance
when he is unable to diagnose a trauma patient. Dr. Lawrence suggests a course of
treatment for strychnine poisoning, which saves the patient's life. (Related ChemMatters
articles, “Nightmare on White Street.” December, 1996, “Poisoned.” December, 2005,
and “Bling Zinger.” April, 2006.)

Notes:
9. ER episode #216 “Blood Relations” Carbon Monoxide poisoning. (Season10) An
entire family comes to the emergency room due to carbon monoxide poisoning. (Related
ChemMatters article, “The Silent Killer.” February, 2005.)

Notes:




10. Cigarette Smoker Idiocy.

Notes:




11. Urine/Methylene Blue Prank: Methylene blue is often used as a urinary antiseptic
in the treatment of urinary tract infections. It is also used as a diagnostic agent because of
its blue staining properties. SIDE EFFECTS: Nausea, stomach upset, diarrhea, vomiting
or bladder irritation may occur. This medication causes the urine, stools and possibly skin
to turn green-blue in color. The discoloration will disappear when the medication is
stopped. DO NOT TRY THIS ON YOUR STUDENTS.

Notes:
12. ER episode # 112 “Responsible Parties” Teenage Alcohol Abuse. (Season5) Three
teenagers on their way to their prom are brought in following a car accident. Justin was
the driver; he ran the car into a telephone pole. The car caught fire and Justin managed to
pull his friend Travis from the back seat. Justin has minor burns; however, Travis has
third degree burns over most of his body. Travis' sister Shannon was in front seat, she has
a spinal injury and is unable to move her legs, other than wiggling her toe. Travis' date,
Melissa, was also in the car, however the paramedics were unable to find her. The police
ask Mark to get a blood alcohol level on all the kids, especially the driver. They were at a
pre-party where the parents were serving beer. Mark goes in to talk to Justin. He has a
fractured rib and some burns on his arms from rescuing Travis. Mark tells Justin that his
blood alcohol level was .09. Justin cries and tells Mark he didn't mean for this to happen.
Justin's parents arrive, and Justin tells him that the accident occurred when he was
changing a CD in the car. Travis' parents are still about forty minutes away, and they
won't be able to wait that long. Carter asks Lucy to call the neighbors to see if they have a
car phone. They do, and Lucy brings Travis a phone so he can talk to his parents. Mr.
and Mrs. Mitchell, Travis and Shannon's parents arrive. Mark tells them that Shannon
had surgery, and could loose function below the waist. He also tells them that Travis is in
the burn unit, being kept comfortable. There is only a twenty- percent chance of survival
for Travis. Mrs. Mitchell collapses sobbing. Elizabeth goes to check on Shannon. She
still can't feel anything below the hip. Risks of Underage Drinking: The costs of alcohol
abuse are tremendous in both human and economic terms. The National Institute on
Alcohol Abuse and Alcoholism (NIAAA, a part of the National Institutes of Health and
Human Services) reports that each year, more than 100,000 deaths in the U.S. result from
alcohol-related causes. NIAAA and the National Institute on Drug Abuse estimate the
economic cost of alcohol abuse and alcoholism to be $148 billion annually. Underage
alcohol use is associated with injury and risk-taking. Perhaps the most familiar risks have
to do with driving. Young drinkers are over-represented in drinking driver deaths. Even
when their blood alcohol concentrations are low to moderate, teen drinkers are involved
in automobile accidents at higher rates than older drinkers.
(www.ftc.gov/reports/alcohol/appendixa.htm)


Notes:
13. ER episode # “No String’s Attached” Wilson’s Disease. Wilson's disease causes
the body to retain copper. The liver of a person who has Wilson's disease does not
release copper into bile as it should. Bile is a liquid produced by the liver that helps with
digestion. As the intestines absorb copper from food, the copper builds up in the liver and
injures liver tissue. Eventually, the damage causes the liver to release the copper directly
into the bloodstream, which carries the copper throughout the body. The copper buildup
leads to damage in the kidneys, brain, and eyes. If not treated, Wilson's disease can cause
severe brain damage, liver failure, and death.

Wilson's disease is hereditary. Symptoms usually appear between the ages of 6 and 20
years, but can begin as late as age 40. The most characteristic sign is the Kayser-Fleischer
ring—a rusty brown ring around the cornea of the eye that can be seen only through an
eye exam. Other signs depend on whether the damage occurs in the liver, blood, central
nervous system, urinary system, or musculoskeletal system. Many signs can be detected
only by a doctor, like swelling of the liver and spleen; fluid buildup in the lining of the
abdomen; anemia; low platelet and white blood cell count in the blood; high levels of
amino acids, protein, uric acid, and carbohydrates in urine; and softening of the bones.
Some symptoms are more obvious, like jaundice, which appears as yellowing of the eyes
and skin; vomiting blood; speech and language problems; tremors in the arms and hands;
and rigid muscles.

Wilson's disease is diagnosed through tests that measure the amount of copper in the
blood, urine, and liver. An eye exam would detect the Kayser-Fleischer ring.

The disease is treated with lifelong use of D-penicillamine or trientine hydrochloride,
drugs that help remove copper from tissue, or zinc acetate, which stops the intestines
from absorbing copper and promotes copper excretion. Patients will also need to take
vitamin B6 and follow a low-copper diet, which means avoiding mushrooms, nuts,
chocolate, dried fruit, liver, and shellfish.

Wilson's disease requires lifelong treatment. If the disorder is detected early and treated
correctly, a person with Wilson's disease can enjoy completely normal health. (Related
JofChemEd article, “When Drug Molecules Look in the Mirror.” Thall, Edwin, Vol.3
No.6, June, 1996. “Mirror Molecules.” ChemMatters, April, 1989. “The Horror and
Hope of Thalidomide.” ChemMatters February, 1997.,)



Notes:
References:

http://www.digiserve.com/er/episodes/

http://www.tnt.tv/title/?oid=115576

High quality downloads of ER seasons #1-4 are available from Amazon Unbox Video at
$1.99/episode.

				
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