Toxicology Lab team keeps up with technology and the times seeking answers to patient care mysteries

Toxicology group

(From left) Dr. Uttam Garg, Clint Frazee, Mike Kiscoan and Jeff Knoblauch in the Toxicology Lab.

Don’t let the head-bending multisyllabic words – atomic absorption spectrophotometry, ultra-high performance liquid chromatography, hematofluorometer, mass spectrometry – get in the way of what you really need to know about Children’s Mercy’s Toxicology Lab, and why it is a genuine point of pride.

Instead, know that what began 50 years ago with one chemist, little more than a couple of crude instruments and handwritten data with carbon-paper copies, is today the only full-service clinical and metabolic toxicology laboratory in the region, expanding as well into biochemical genetics, and playing a crucial, life-saving role in patient care at CM and beyond.

Where other hospitals have auto-analyzers that screen only 10 to 12 of the most common drugs, the Children's Mercy Toxicology Lab has 15 support staff and analysts who know how to use the state-of-the-art instrumentation. They can accomplish everything from drug screens on toddlers who’ve gotten into parents’ pill bottles, to checks on patients’ lead and Vitamin D levels, to metabolic tests that answer questions about a baby’s failure to thrive.

“We are the only clinical laboratory in the area that performs comprehensive drug screening and metabolic testing to help in the diagnosis and treatment of overdoses, poisonings and patients with metabolic disorders,” said Uttam Garg, PhD., DABCC, FABFT, FAACC, Division Director of Laboratory Medicine.

“We help fill in the blanks and solve the mystery,” added Clint Frazee, NRCC (CC,TC), MBA, who’s been the lab’s Clinical Supervisor since 2002. “The investment in advanced instrumentation allows us to perform very sensitive and specific testing for the presence and concentration of drugs that many other hospitals are unable to do.”

And they can do it quickly.

“Rapid diagnoses can be a matter of life or death for children,” Dr. Garg said, adding that even in less existential circumstances, the toxicology talent and technology at CM making early diagnosis possible can reduce the length and cost of a child’s hospital stay.

That was then…It’s a far cry from 1968, when the late Vernon Green, PhD, a professor of pharmacology at the University of Missouri Kansas City, was recruited to establish a toxicology consulting service and laboratory at Children's Mercy. Even with just one chemist and meager equipment, it broke ground as one of just a few such services in the country, publishing articles in medical journals and developing a computerized poison control center which later became the basis for similar resources nationwide.

“Early on, assessing lead levels was one of our toxicology laboratory’s primary activities,” Clint said. “Leaded gasoline was still in use in the 1970s and lead paint exposure was more common. In fact, Kansas City is still considered a ‘hot spot’ for higher risk of lead poisoning because of the potential for leaded paint in older homes.”

Toni Sheffer (pictured left), MBA, MT(ASCP), CSSGB, now Administrative Director of Lab Services, joined Children's Mercy in 1981, and remembers a time before computers, when data was hand-written with carbon copies – one set each for the patient chart, the lab files and the billing department. When she became computer supervisor in 1988, Children's Mercy’s computer system filled a room on the top floor of what is now the Annex building on the Adele Hall Campus, where she hauled large disks storing lab data that required daily change.

By the early 1990s, when Toxicological Biochemical Analysts Mike Kiscoan, NRCC-TC, and Jeff Knoblauch, NRCC-TC, joined Children's Mercy, the lab staff had grown to six employees plus a director. Mike and Jeff are the longest-tenured chemists in the Toxicology Lab, and have experienced growth in its volume of work (“at least 10 times,” they estimate) and stature as advances in research and instrumentation have made it possible to solve increasingly complex mysteries with ever-greater precision.

This is now…Clinical toxicology remains the core of the Children's Mercy Toxicology Lab. But with today’s state-of-the-art technology and the expertise of the lab’s 15 chemists, biologists, medical technicians and support staff, their work has expanded into biochemical genetics – the study of inborn errors of metabolism that can cause a range of birth defects and metabolic disorders.

A sampling of the work they now undertake for Children's Mercy patients as well as patients and clients throughout the region:

Comprehensive clinical and forensic drug screen testing (including blood and urine tests for the Kansas City, Missouri, Police Department, and other police departments in the Kansas City area).
Meconium drug screens, to assess maternal drug use.
Organic acid, amino acid and acylcarnitine profiles as follow-up to abnormal newborn screening– Children's Mercy’s lab is one of four designated centers in Missouri for confirmation of abnormal results in statewide newborn testing.
Therapeutic drug monitoring – “We test for what’s supposed to be there to determine compliance,” Jeff said.
Testing of immunosuppressants for transplant patients, steroids panels for hormone abnormalities, catecholamine metabolite as indicators of neuroblastomas.
Testing for levels of lead, serum copper, zinc, Vitamin D2 and D3.
Confirming sleep-study patients are free from sleep-altering drugs.
Checks to maintain levels of pentobarbital used in induced coma.
Following kiddos born with phenylketonuria (PKU) with a home sample collection kit, developed by the toxicology team, that allows routine monitoring without requiring parents to bring the child to the hospital for blood draw.
Detect organic aciduria such as methylmalonic and propionic acidemia, amino acid and fatty acid oxidation disorder – all of which (and more) fall under the heading of determining why a baby is not developing as it should.
And continue to publish when the opportunity presents itself. “The lab has now published more than 100 articles!” Dr. Garg said.

Their work is labor-intensive, but the investment of time and talent pay off in precision. “We don’t just spin samples,” Mike said. “It’s true chemistry.”

“Our work can affect people’s quality of life,” Jeff added, noting that even when it’s not a life or death situation, their findings can influence insurance and parental custody decisions as well as diagnoses and treatment.

Looking ahead The pace of change only accelerates. New equipment, new genetic discoveries and new treatments all require the Children's Mercy Toxicology and Biochemical Genetics Lab to stay several steps ahead.

“The designer drug market is huge,” Clint said, offering just one example. “There are so many compounds now, and as soon as one is identified and legally controlled, a smart chemist modifies the chemical structure to make a similar non-controlled drug. Keeping on top of that is challenging.”

But because Children's Mercy is the only clinical laboratory in the area to have the latest technology enabling quick identification and specific measurement of a broad range of compounds, it’s a challenge they can meet, Dr. Garg said.

“We’re proud of our laboratory, its history and the services we are able to provide our patients here at Children's Mercy and throughout the region.”

Learn more about The Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation at Children's Mercy.