Dead Weight

A three-year-old develops abdominal pain, constipation, profound lethargy, and a sudden seizure after a family gathering. The crucial clue appears in an unexpected place—and points toward a mysterious Civil War artifact. Along the way, discover what movies get wrong about gunshot wounds and how one toxin may have influenced the Roman Empire.

This is Pick Your Poison. I’m Dr JP. ER doctor. Toxicologist, and unapologetic lover of all things poison. Want to know how you can be poisoned by a Civil War artifact? What do movies always get wrong about gunshot wounds? What toxin has been implicated in the fall of the Roman Empire?
Stay right here to find out.
This is an interactive story.
Will our patient live or die?
It's up to you and the choices you make.
Your phone is ringing.
Today's episode starts with a phone call. It's your cousin shouting frantically into the phone. You can't understand a word she's saying. After several minutes you finally understand, her a child - a three year old- is sick. He’s So lethargic she can barely wake him up. The phone conversation is not making any headway and the child sounds sick. Rather than try to get more information on the phone, you tell her to meet you in the emergency department. In real life of course you Probably wouldn't take care of a family member, but this is fiction so you're the doctor.
In the emergency department you enter the room. Your cousin is sitting on the stretcher, holding the child in her arms. He doesn't move or even open his eyes. You get a gown and ask her to get him undressed. He doesn't really react As she does that either. The nurse tells you the vital signs are as follows: Temperature: 98.6°F or 37°C, heart rate is 120 Beats per minute, blood pressure is 90/45, respiratory rate 25, with an oxygen saturation 100% on room air. Essentially normal for his age.
This is not the child you just saw one week ago At the Family Labor Day party running around, And jumping off the diving board. That child probably would have been jumping off the bed and racing around on the stool.
The family was gathered at your grandfather's house, The kids enjoyed the pool. Your grandfather Showed off new additions to His collection of Civil War memorabilia. and Reminisced about re-enactments At Gettysburg to anybody who would listen.
He told you stories about Hospital tents with piles of amputated limbs. All cut off without the benefit of anesthesia. Is this true or false about the lack of anesthesia?
True
False
Actually be false. Contrary to public opinion of limbs being sawed off with men biting on leather straps. In most cases anesthesia was used In surgeries during the Civil War.
You asked mom what happened. She said the day following the party he complained of abdominal pain. She thought he'd probably eaten too many sweets. He developed some constipation a few days after, but was having bowel movements.
She took him to see the pediatrician, who didn't find anything worrisome. She thought maybe he was coming down with a virus until this morning. Not only did he not wake her up at 6:00 in the morning, as usual, when she went to wake him up, he was extremely lethargic and barely rousable. That's when she called you and brought him to the emergency department.
She says, He's not had a fever, no cough, congestion, or runny nose. No vomiting or diarrhea. No one else in the house is sick. He's not having pain with urination. Some bumps and bruises of a rambunctious child but no significant traumatic injury, like a fall.
He doesn't have any medical problems, Take any medicines other than the stool softener she gave him a few days ago and no allergies to medicines. You ask if he could have gotten into any medicines in the house. She says it's unlikely As they're stored in medicine cabinets, which he can't reach. You some skepticism about this, seeing the way he was climbing fences At Grandpa's house. That said even if he could climb up on the counters, she probably would have noticed spilled or opened bottles of medicine had he gotten into something.
You move on to the physical exam. He is extremely lethargic. In this age group all kids are watching what you're doing. Many of them will cry. He doesn't even open his eyes. Even when the nurse puts in an IV, he only gives a short weak cry.
No external evidence of head injury, ie no Bumps or cuts on his head. His neck is normal, no stiffness. His pupils are equal and reactive to light. His heart and lungs are clear. He grimaces a little when you press on his abdomen. He is able to move all of his Extremities though very weakly and he's barely lifting them up off the bed against gravity.
Okay so now what? Despite having normal vital signs this is a pretty worrisome case because he looks very sick. One of the things you can never forget about pediatric patients is that they can look relatively well and suddenly crash, meaning their vital signs look good until they look awful. This is because most kids have strong healthy physiology so in most cases they can compensate for a lot of problems. Until it's too late.
The nurse holds up the tubes of blood she has drawn, putting in the IV, and asks you what orders you want. Certainly basic labs as well as a lactate and blood cultures to look for infection. A chest X-ray and urine specimen would be important for the same reasons. It might be worth doing flu and COVID swabs not because this is likely, but to exclude them as possibilities because probably somebody will ask you to.
What about a head CT Did I hear you say, "Good question"? You'd have to debate the pluses and minuses. In an adult we probably get one right away. In children we try to be more cautious about radiation exposure. If you want the head CT, I don't think that's unreasonable. I might wait until we have some basic labs back but at this point either answer is right.
This is a difficult case. We have a definitely abnormal child without a lot of history or physical exam findings to point us in the direction of what's causing this. You're pretty worried, both as a family member and as a doctor, about this kid. You call pediatrics, who agrees with your management so far and says, "Let's get the results from these tests back and then we can consider a head CT and a spinal tap If nothing turns up."
You hang up the phone and move on to your next patient the victim of a dog bite who has a serious laceration. You're halfway through Stitching the laceration on the woman's leg when you hear a commotion. You ignore it, staying focused on the procedure. A colleague puts their head in and says, “Sorry to interrupt, I know you're suturing but the three-year-old is seizing. Do you want me to give order some benzos until you finish?
Your fist clenches around the needle driver in your hand. This is not a good development. Yes you say thanks. You tell him the child's weight so he can dose the medicine to stop the seizures appropriately. You finish up the last four stitches, apologize to the patient, and rush back to your cousin's room. Your colleague ordered intravenous lorazepam (i.e. Ativan), and by the time you get back to the room the seizure stopped.
If you listened to the last episode, we talked a lot about seizures so I'm going to keep this brief. Seizures are definitely not uncommon in pediatric patients. Febrile seizures are actually fairly common but our patient didn't have a fever so we can't attribute this to that. Certainly people can have new-onset epilepsy. We never know this in the emergency department with the first seizure but it's always possible. Mom says there's no family history of seizures, making this less likely but definitely not impossible. After a seizure, as we discussed before, people can have what's called a postictal state where they are confused, tired, or lethargic but New onset epilepsy certainly doesn't explain being sick for several days.
What about something like meningitis or encephalitis? He doesn't have a fever or a stiff neck. In addition mom says he's vaccinated, which dramatically reduces the risk of bacterial meningitis. You can have encephalitis without all of those findings and certainly encephalitis can cause seizures so it's a possibility. I think we need to consider Doing a spinal tap. You asked the nurse to expedite the head CT, which we should do before going any further.
This isn't a neurology podcast. It's a toxicology podcast so let's get right to potential toxins. Again if you want to hear more about this, please listen to the last episode Short circuit. The bottom line is there are tons and tons and tons of toxins that can cause seizures. In fact if you've listened to any episode whatsoever, you know that the endpoint of many toxins is seizure, coma, and death. Also you don't need me to tell you that kids can get into all sorts of stuff at home. Mom doesn't think he got into anything but In a case like this where we have no idea what's happened it is still worth asking what medicines are in the house. You ask about prescription medicines. She says no. She and her partner don't take anything. She denies illicit drugs in the house. The child hasn't gotten into any alcohol. And that's a good reminder of something we need right away. We need a finger stick to make sure that this child doesn't have low blood sugar. The nurse tells you it's normal. What about over-the-counter medicines you ask? She says they have Acetaminophen (i.e. Tylenol), Ibuprofen (i.e. Motrin), Diphenhydramine i.e. Benadryl, and Melatonin.
Question # Could this be an over the counter medicine overdose.
Acetaminophen
B-ibuprofen.
Diphenhydramine (i.e. Benadryl)
Melatonin.
None of the above.
The answer is E. None of these fit exactly. Melatonin does come in gummy form, Making them appealing for toddlers to eat. He is lethargic, which goes along with that. There is some debate as to whether melatonin can cause seizures but it doesn't typically do so in overdose. Also, It’s short-acting and doesn't cause someone to be sick for days even after an overdose.
What about acetaminophen or ibuprofen? You know that acetaminophen causes liver failure rather than seizures and ibuprofen causes nausea and vomiting in overdose but not much else, at least acutely.
What about diphenhydramine? This is a good thought. It definitely causes seizures and overdose. It definitely causes lethargy, What's missing though are the other features of anti-cholinergic toxicity, including a rapid heart rate and blood pressure.
What about other household things causing seizures? I hate to list things cocaine and methamphetamine as household items but sadly That's the case in some places. Children can get into the Symptomatic drugs and have a seizure, but again the vital signs don't work. Also you really don't think your friend and her partner are using drugs.
Organophosphates like pesticides could certainly cause it, But the vital signs don't fit and your friend says she has an apartment with no yard and no garage. Essential oils in concentrated forms can cause seizures. She denies having these in the house.
As the nurse wheels the boy, the toddler, down to radiology You sit down at your Computer and scroll through his results. The lab work is unremarkable, no sign of infection. Electrolytes, liver and kidney functions are normal. No signs of infection in the urine. You pull up his chest X-ray To check for infection there. After the image loads, you suck in a sharp breath. Since he’s a small three year old, the X-ray caught the upper part of his stomach, Along with the answer to this case. There's a round object in his stomach, approximately the size of a quarter. It's time to pick your poison.
Is this:
A. Lead toxicity
B. Toxicity from a magnet
C. Button battery toxicity
Answer: A lead toxicity. You have an idea about what the toxin is before you can identify the toxin itself. Now that you see it in the stomach, you realize that his symptoms fit perfectly with lead toxicity. Specifically acute lead toxicity.
Button batteries Causing Burns in the esophagus and gastrointestinal tract if ingested, which doesn't fit here. Magnets can be toxic if there's more than one magnet swallowed. They can click together and cause bowel obstruction or pressure necrosis of the bowel wall, Dangerous but it doesn't fit here.
So lead toxicity. This is a huge topic, especially in pediatrics. There are pediatricians, toxicologists, and all sorts of other experts who devote their entire careers to treating and researching these topics. I want to try to keep this succinct and stay on track because I want to talk about some really cool historical stuff, in the Roman Empire, related to lead in a few minutes and Nobody has all day.
So first there's acute and chronic lead toxicity. Our patient has acute toxicity but chronic lead toxicity is more common and so I want to say A little about it. It's when patients get exposed from, say, eating pain chips. The symptoms can be very insidious, occurring slowly over weeks to years, and thus very difficult to diagnose Difficult even for parents to tell and this is the reason why Pediatricians screen for lead levels on a regular basis. You can see abdominal pain and constipation. It can cause anemia (i.e., a low blood count) but what we really worry about and the reason we're really screening for it are the neurocognitive changes that lead exposure causes. Meaning changes in the brain. Children with chronically elevated blood levels can lose nine IQ points. There's six times less likely to be able to read and seven times more likely to drop out of high school, which is pretty astonishing if you think about it. There are two times more likely to have ADHD. And the behavioral changes persist even in adulthood. They're more likely to have a lower socioeconomic status in adults and more likely to be arrested for crimes. So screening is one of the Many really important things pediatricians do.
Okay now this is acute lead toxicity as I said. This happens over days to weeks rather than months to years. Similarly it can cause abdominal pain and constipation but anemia is much less likely because the anemia takes a longer time to develop. What we worry about most with acute lead toxicity is high lead levels causing lead encephalopathy. What's that? Encephalopathy means a problem with your brain. With lead encephalopathy specifically children become lethargic and have an altered mental status. They can have seizures. Ultimately coma and death can occur. Unfortunately Your cousin's symptoms fit exactly. You don't know what that foreign body is in his stomach but you're willing to bet it contains lead.
You order a blood lead level, which in most hospitals will come back in a few hours. An hour later you get the results. His blood lead level is 100 mcg/dL. You suck in a breath when you see it. This is extremely, dangerously high. A normal blood lead level should be under five and we worry about effects of toxicity even at ten.
What do we do now? Well there are two things we need to accomplish: 1. First is to remove the source of the lead toxicity. 2. Second is to treat the lead exposure that's already occurred. It's a safe assumption that the foreign body in his stomach is the source of the lead. You call the pediatric gastroenterologist, who Listens to the case, takes a look at the X-ray, agrees, and tells you they'll do an emergent endoscopy to remove the foreign body. From his Stomach.
Moving on to number two. We need to treat the lead that's already been absorbed into his body, reflected by the lethally high lead level. How do we treat lead toxicity? That's question number .
A An antidote?
B Chelation
C dialysis
The answer is C. We don't have a specific antidote for the treatment of lead toxicity, But we can chelate the lead out of the body and it does work. Dialysis in general is not good at removing heavy metals. What exactly is chelation? Well it's when you give a medicine that can bind to the heavy metal, thereby inactivating it until it is excreted from the body. You could imagine it as a sort of cage Surrounding the lead and Keeping it from Binding to anything and causing further damage.
The treatment of lead toxicity is another huge topic that we could spend multiple episodes on and again I'm going to sum it up with some generalizations rather than get into the weeds and bore you to death. First, treatment of lead toxicity, including recommendations and blood lead level cutoffs, varies between adult and pediatric protocols. Second, different types of key leaders are available in different countries. As one example there are differences between medicines approved in the U.S. and Europe.
Blood lead level concentrations are used as one parameter because lead toxicity does correlate well with levels, unlike with some other toxins. And the second parameter is symptoms. Patients who are more symptomatic require more intensive treatment than those who are less symptomatic Even with similar levels.
Focusing on children, a mild elevation of the blood lead level is considered a level under 50, you can expect some mildly impaired thought processes, subtle changes in behavior and fine motor skills. Moderate elevation is generally levels between 50 and 70. You may see impaired hearing or impaired growth, irritable behavior, decreased interest in playing, intermittent abdominal pain and vomiting. Levels above 70 are considered severe. This is the range where we become concerned about encephalopathy, which is manifested as altered mental status, bizarre behavior, loss of developmental skills, seizure, and coma. In chronic toxicity you can have anemia.
As I said we take both the blood lead level and the symptoms into consideration in deciding who to treat in general. If the blood lead level is under 45 then the treatment is really to remove the lead, whether it's stopping the child from eating paint chips, removing them from an environment where lead is high in the soil, etc.
With blood lead levels of 45-69 in a child with mild symptoms, they would be treated with oral chelation. In the US this means a medicine called succorer or DMSA. For levels above 70 or children with severe symptoms, definitely anybody with encephalopathy, then we usually treat with both intravenous and intramuscular chelation. In the U.S. This means calcium-sodium EDTA given intravenously, as well as dimercaparol, also called British antiluosite (I'll tell you why in a second), or BAL given intramuscularly.
Does it work? Yes it works so well that the combination of the two drugs can drop lead levels by 50% in just 15 hours. Over the course of two to three days the lead level will drop by about 75 to 80%, which is pretty amazing if you think about it.
Just for reference in adults typically blood lead levels under 70 aren't treated. Since adults' brains aren't changing as much, higher levels can be tolerated in the short term.
So this sounds great, right? I have to tell you that chelating patients with lead toxicity is a lot harder in real life than it sounds like in textbooks. First succimer smells like sulfur. People hate taking it. Then it makes them smell like rotten eggs so they hate taking it even more. The course is usually days, sometimes weeks. And this can result in patients not taking it as prescribed, Causing fluctuations in blood lead levels
Think that's bad? Well dimercaprol can be even more difficult. From a pharmacologic standpoint it's very difficult to dissolve. They use thick oily peanut oil to dissolve it in. This means it can't be given to patients with peanut allergies. It also has to be given as an intramuscular injection, meaning the person has to get a shot every four hours for days. Adult patients don't love this and you can imagine the situation with the pediatric patient.
Another issue that always confounds toxicologists and pediatricians when treating blood lead levels are fluctuations in the lead levels. These occur frequently for several reasons. First is re-exposure. Sometimes a person is admitted to the hospital, treated, and blood lead levels go down. They're switched to oral chelation with succorer to continue at home. If the exposure wasn't identified, they might be re-exposed if the exposure was coming from the home or the workplace. This might cause the blood levels to go back up.
Blood levels can still go up even if the exposure was removed and the patient is taking the succimer exactly as prescribed. Why? There's something called the lead sink. What is it? That's question number
A. 1. Lead continues to be absorbed from the stomach.
2. Someone is poisoning them.
3. Blood leaching from the bones.
The answer is C. Lead can actually leach out of the bones Back into the blood, once the blood lead level goes down. Why does blood get into bones? Well chemically it looks like calcium and as you know your bones love calcium. Same with lead.
If you have lead in your body, it will be taken up into the bones. Pediatrics asks you to X-ray your cousin's arms. Seems like a weird request, right? He hasn't fallen and doesn't have joint pain. but the reason for this is to determine acute versus chronic exposure. If you've been chronically exposed to lead, as I said, tyou can actually see Where the bones took it up it X-ray. There are bright white lines called lead lines.
Our patient is definitely sick. He's definitely symptomatic and he definitely has lead encephalopathy so you You order IV calcium disodium EDTA and intramuscular dimercaporal injections. He gets admitted to the Pediatric Intensive Care Unit.
After your shift finishes you go up just in time to see the endoscopy. After your little cousin is sedated, the gastroenterologist passes a tiny endoscope down into his stomach, Maneuvers the camera around until the swallowed foreign body Comes into view. As soon as you see it, you know exactly what it is, Even before he pulls it out. It's a Civil War-era musket ball. These are almost completely made out of lead. It's pretty big compared to your cousin's little stomach and seems to have gotten stuck.
While we wait for the chelation to do its job, let's talk about some cool stuff associated with lead toxicity. First bullets. With our dark humor we jokingly refer to gunshot wounds in the emergency department as acute lead toxicity. Question number six: Bullets are removed from most gunshot wound victims.
True.
False.
The answer is actually false and I'm sorry if you answered true. That answer kills me every time because it's one of my most hated movie misconceptions: digging bullets out of people who've been shot. I've treated hundreds, if not thousands, of gunshot wound victims and I've never dug a single bullet out of anyone because we don't do this in the emergency department. Why? Because cutting open the person and digging out the bullet most often causes more harm than good. There are a few exceptions to the rule. One of them is if the bullet ends up in a joint. Or if a bullet migrates into a joint.
Why does this matter? Bullets are made of lead obviously but if the bullet is left in skin or muscle, the lead stays in the bullet and nothing happens. However your joints are extremely acidic and if the bullet migrates into the joint then the acid causes the lead to leach out. Patients can and do become lead toxic as a result. The other place that's very acidic is, of course, your stomach and that's why our cousin was having so much trouble. Had the lead musket ball passed through his gastrointestinal system and he pooped it out in a few days, he probably honestly would have been fine. Because it stayed in the stomach, the acid from the stomach continually leached out the lead, kind of like a delayed release pill.
Lead on the periodic table can be hard to find if you don't know what you're looking for because the chemical symbol is PB. Lead toxicity is often called plumbism. Why? Well this has to do with ancient Rome. The Romans used lead pipe for plumbing and that's how it got its name.
Excavations of bones from ancient Rome show very high lead levels and there is a distinct difference between bones of patricians and bones of enslaved people. The patricians have high lead levels. The enslaved people don't. What's the difference. There was a relatively high amount of lead in the water. There was also lead in the air from smelting and other things. Had lead levels been coming from environmental sources then you would imagine that everybody should have had the same exposure. The answer is a lot more interesting than environmental exposure. There was lead in the wine in ancient Rome. Not accidentally but put there intentionally.
Everybody knows Romans loved wine. In fact it is estimated that adults in ancient Rome might have drunk as much as 5 L of wine a day. Specifically they liked sweet wine. How did they make it sweet? Well they didn't have sugar or corn syrup. Those are new world items. They did have honey but given the copious amount of wine people consumed, it would be difficult and expensive to make that much honey.
What did they do? Well they sweetened the wine by adding syrup called sap, made from grapes. Grapes were boiled down into a syrup, specifically in lead-lined pots. Grapes become vinegar and vinegar plus lead results in lead acetate, also called lead sugar. The Romans then put Sapa in their food and their wine to sweeten it, resulting in extremely high blood levels. It's estimated that sap contains 29,000 ppb of lead. Compare that to what's considered safe in water today, which is 10 ppb. By some estimates patrician Romans may have had lead levels as high as 50 mcg/dL.
And some historians have suggested that lead toxicity was the cause of the fall of the Roman Empire. Is this true? It's definitely a fun topic to think about. Well first let me tell you some of the other symptoms of chronic lead exposure. It can cause a huge number of symptoms, including Fatigue, headache, irritability, Impaired concentration, memory loss, mood swings, intellectual disability, tremor, peripheral neuropathy and extremity weakness. Also, infertility, increased infant mortality.
Historians have questioned whether Roman emperors exhibited symptoms of lead toxicity. Caligula was described as having disorders of intellect. He was known to have seizures. He definitely had psychosis. Claudius was described as having weak limbs and unsteady gait, a tremor, and mental instability. Nobody knows for sure but certainly some of the descriptions do fit with lead toxicity. As it declined, emperors developed erratic decision-making and suffered from Infertility, leading to further speculation as to whether or not lead toxicity itself caused the fall of the Roman Empire. Leg toxicity certainly could have contributed to lower IQs, unstable mental status, and reduced fertility. However it doesn't totally explain things like weakening of the central government, attacks from barbarians, et cetera. It's pretty cool to think it might have contributed though historians doubt it’s the only explanation.
Most lead toxicity in the United States occurs from children eating paint chips. Lead paint has been banned for use in houses since 1978 so we see it in children living in older housing stock in the northeastern part of the United States or some areas of California. Other sources include pottery with lead glazes. If you've ever bought a ceramic pot that says "don't eat out of this", that's likely the reason. Spices from outside of the United States, Turmeric is common. It can be made up again from outside the US, like kohl eyeliner. Supplements have been found to contain lead.
Environmental exposure of course, like drinking water, most recently in Flint, Michigan. In developing countries many, including children, are at risk in areas where smelting and mining occur.
Occupational exposure is not uncommon. One interesting one is employees at firing ranges. Because there are so many bullets if they don't take appropriate PPE precautions, they may have Develop lead toxicity.
Another interesting topic is leaded gasoline. Tetraethyl lead was put into gasoline to avoid knocking sounds coming from the engine, resulting in massive environmental contamination. It was phased out in the U.S. in the late 1970s and since that time the average IQ of American children has risen by nine points.
During prohibition not only methanol might have been in your moonshine but lead. Why Because car radiators were used as stills to make moonshine in those days were made of lead.
We've talked about lead toxicity but actually we haven't talked about the mechanism, how it actually occurs. We don't know all the details But it affects multiple pathways and parts of the body. It can cause reactive oxygen species. These are highly reactive and bind to receptors, proteins, and DNA, causing cell malfunction. As I said before, it acts like calcium and is taken up into cells instead of calcium. In addition to bones this can have a big effect on neurotransmitters in the brain, Contributing to encephalopathy. It inhibits heme synthesis, causing anemia.
Not only is the history of lead toxicity interesting but so is the history of the chelators we use to treat it. Succimer was invented in England, in 1949 to treat cystosomiasis, a parasitic infection. In China it was discovered to lower blood lead levels, ultimately resulting in FDA approval in the US in 1991. Even more interesting, is dimercaprol or as it used to be called, British Anti-Lewisite. Why the old name? At the start of World War II, the British were extremely concerned about the Nazis using Chemical Warfare use of chemical warfare. One of the concerns was the use of arsenic gas called lewisite. Researchers at Oxford discovered this compound as an antidote, Thus the name British Anti-Lewisite. It was later found to be useful for chelation, including not just arsenic but mercury and lead.
Treatment of lead toxicity is already complicated As I said earlier but recently has become more Difficult as the only American manufacturer of dimercaporal filed for bankruptcy, leading to severe shortages in the U.S. Another chelator called DMPS is used in Europe however it's not FDA approved here. It is legally made by compounding pharmacies, and is useful For lead toxicity but isn't currently recommended for lead Encephalopathy
Back to our patient. The PICU team repeats a blood lead level later that evening and thanks to removal and chelation it drops precipitously, And because it's acute rather than chronic toxicity, it's not in his bones and it stays down. By the next day he's back to his rambunctious self and fortunately is discharged from the hospital with no permanent neurocognitive Deficits. At the next family party you make sure Grandpa has the Civil War musket balls locked up in a way from the children. This is a fictional case, as are all our cases, to protect the innocent. But it is based on real poisonings.
That brings us to the last question in today's podcast. There's a very interesting study in England in 1975, when leaded gasoline was still prevalent, showing the average amount of lead on post-mortem exam was 165 mg (i.e., the weight of a paper clip).
How much lead was found in men diagnosed with lead toxicity, i.e., the equivalent of how many paper clips was it?
The equivalent of three paper clips
Ten paperclips
100 Paper Clips
Follow the X and Instagram feeds both @pickpoison1 for the answer. Remember, never try anything on this podcast at home or anywhere else.
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While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Until next time, take care and stay safe.
QA Answer (last question in transcript): 3 paperclips is enough to cause toxicity!