METH TASK FORCE FORGES FORWARD

One of the issues the local Meth Task Force has been working on for several
months is the development of a standard protocol for emergency room
treatment of children found in homes where methamphetamine has been
produced. Dr. Bob Ellison of the Appalachian District Health Department
brought the discussion a step closer to resolution last Friday by
presenting suggestions for immediate care and clinical evaluations.As a
prelude, Ellison reviewed the potential effects of chemical exposure from
meth production: skin and eye irritation, burns and respiratory effects
such as cough and asthma. Long term effects can include liver, spleen and
kidney damage, respiratory difficulties, delayed speech and language and
possible neurological damage.

Ellison told the group that his clinical evaluation and testing suggestions
did not constitute a protocol but that he was simply presenting guidelines
based on available information that might not be appropriate for every
child. He suggested that physicians obtain a complete medical history and
perform a complete physical exam (including developmental and neurologic
screens, respiratory system evaluation, vital signs and evaluation for
signs of abuse/neglect) within 12 to 24 hours for children found in meth
dwellings. Ellison's suggestions for clinical evaluations include liver and
kidney function tests, electrolytes, complete blood count, glucose, urine
drug screen (within 12 hours), oxygen saturation/pulmonary function tests.
Ellison suggested that doctors also consider a heavy metal screen.

Ellison endorsed the task force's established procedure of immediately
sending a child from a meth home to the hospital emergency room to be
checked, saying that such an evaluation is in the child's best interest. He
also suggested that such an evaluation could also be carried out in a
primary care physician's office, but task force member and forensic
toxicologist Dr. Andrew Mason raised concerns about using private providers
in lieu of the emergency room. Mason noted that a private practitioner
would not have the necessary decontamination facility available and pointed
to problems with consistency (both in terms of what tests are run and what
laboratories are used to process the samples and interpret the results) and
the potential for problems in maintaining the appropriate chain of custody
for evidence. Consequently, the task force was in agreement that children
will continue to be taken to Watauga Medical Center.

Discussion then turned to the advisability of conducting an additional test
- - of the hair - on children to determine chronic exposure. Because of the
way methamphetamine is eliminated from the body, complete elimination can
occur on average in 2 to 4 days, subject to a number of variables, and the
urine screen therefore might be negative even in cases of relatively recent
exposure. In such cases, the hair sample would then provide the only avenue
for determining if the child had been exposed to meth during the hair's
growth period. But the hair test is expensive, , Mason said - easily double
the $40 to $60 cost of a urine screen and the confirmation test necessary
for the results to stand up in court - and may not be necessary.

Mason pointed out that neither the urine test nor the hair test has any
value from a treatment perspective because the ER doctor will be treating
the child's symptoms. The two principal reasons for determining a child's
exposure - whether through a urine screen or a hair test - are for
prosecutorial purposes and to substantiate abuse and neglect.

Following discussion, task force members agreed that hospital personnel
will collect both hair and urine samples from all children as a fail-safe
measure because of the unlikelihood of additional opportunities to obtain
them. However, the hair may not need to be tested. As Mason pointed out, if
the urine drug screen is positive for methamphetamine, ordering the more
expensive hair test is unnecessary because a positive urine screen provides
acute proof of exposure. If the urine screen is negative, however, and DSS
suspects exposure, a hair sample will be available to send to the
laboratory if the child services or prosecutorial team decides the evidence
is necessary. Mason told the group that the hair test can only confirm
chronic exposure, but not the number of exposures or the strength. Mason
will train hospital personnel in proper hair sampling techniques.

Chad Slagle, treatment worker for DSS Child Protective Services, said that
DSS will continue its practice of having a routine, visual physical
examination done for each meth-premises child after 30 days.

The task force then turned to a discussion of a draft field assessment
protocol that Mason had prepared to help determine the need for onsite
decontamination before the child is transported to the emergency room.
Mason's checklist includes four specific signs that indicate the need for
decontamination: visible residue or stain, powders, liquids or solids on
skin, clothes or shoes; detectable, unusual odors; visible dermal injuries;
and possession of chemicals, solvents or products. The checklist also
includes a catch-all item for other indications of contamination.

Mason explained that any affirmative answers to the questions on the
checklist indicate the need for onsite decontamination. "This checklist is
a one-way gate," Mason said, "and in my mind, this automatically means the
need for the child to be transported by ambulance." Task force members
agreed that even if the checklist does not indicate the need for onsite
decon, the child's clothes and shoes will still be removed before transport
to the hospital. All task force members received copies of the draft
checklist for review and further discussion at the January meeting.

Some of the task force members had attended and participated in - as panel
members and presenters - a DSS director's meeting in Asheville the day
before, and Mason and Slagle summarized the highlights for the rest of the
group. From Doug Campbell, chair of the state's epidemiology department,
they learned that the state still has no standards for determining the
degree of contamination of a meth lab site nor any standards for
remediation and cleanup. Campbell said that the department had compiled a
list of suggestions for cleanup, but when Slagle asked him if he would
testify in court that premises cleaned according to those guidelines would
be safe for children, Campbell said no. As a result, Slagle said, "they
realized how urgent this information is for all of us." The lack of
contamination measurement and remediation standards has been a problem for
DSS from the beginning, and the task force's interim solution is to
prohibit children under DSS custody from returning to a home in which a
meth lab was located.

Slagle said that the meeting also highlighted the problems other counties
are having in coming to grips with the meth problem as it reaches their
jurisdictions. Slagle cited lag times in treatment for meth users and
miscommunication between agencies as difficulties reported by other
counties that Watauga County has avoided through the formation of the
interagency task force. Slagle said that the Watauga County team was not
permitted to present the task force's protocol at the director's meeting
because the protocol has not been sanctioned by the state, but that
representatives from other counties were eager to obtain copies to use as a
blueprint for developing their own response plans. Slagle said that both
Buncombe County and the state epidemiologist's office expressed interest in
sending representatives to Watauga County's task force meetings to gain
additional information and insight.

The final topic of discussion at last week's meeting was the protection of
home visitation workers, an ongoing task force concern. Jim Flowers
suggested that all home visitors obtain and use the home safety review that
Erica Mann developed as part of the SAFE Kids at Home program. Flowers said
that the checklist gives him the opportunity to check every room in the
home and that he does the safety review before beginning any new home
treatment. In addition, Boone PD Officer Tom Redmond pointed out that home
visitors should be alert to any onset of respiratory difficulties that
could indicate the presence of toxic irritants, and Mason added that the
State Bureau of Investigation's Van Shaw had warned that "if you start to
get a headache, there's probably something there and you probably want to
get out." Mason continued by saying that home visitors should think in
terms of the potential for irritants if they notice the onset of symptoms
such as runny nose, burning skin and itching eyes.

The next meth task force meeting is scheduled for Friday, January 9, from
1:00 to 3:00 p.m. in the DSS conference room.