Once the diagnosis was established, the next problem was encountered. Several
of us, using the Internet and other online databases, searched the literature
for the optimum method of removing thallium from the body. A number of methods
were cited; but to xicologists at the New York and Los Angeles Poison Control
Centers felt that the most effective treatment was that of administration of the
dye Prussian Blue (ferric ferrocyanide) and renal hemodialysis, with addition of
potassium chloride. Then came the problem of obtaining the Prussian Blue (a
common industrial chemical which was eventually found in China). Underlying this
difficulty was the fact that, once again, advice from "outsiders" was suspect by
the Chinese.
Finally, after many phone calls, faxes, and other communications (the doctors
at PUMC would not deal with the students, who had Internet connections),
including the involvement of the patient's family (several of whom were known
political figures locally) , the Prussian Blue-hemodialysis regimen was started
on May 5, 1995, this almost one month from the initial proposal of the diagnosis
of thallium intoxication and some forty days after the patient had lapsed into
coma and had become apneic.
I wish that I could report a "happy ending" here. The patient responded
rapidly to the treatment, and, within 15 days after the institution of
treatment, the patient's thallium levels in blood, urine, and cerebrospinal
fluid had decreased to near-zero (a lthough certain other tissues, such as nails
and hair, will retain the metal for many weeks and will slowly "leach out").
Sadly, the patient's neurological condition has not improved to a significant
degree. She now has been partially weaned from the ve ntilator, and seems to
recognize her parents; but she does not as yet have full consciousness, nor does
she exhibit much in the way of voluntary or purposeful activity. The long period
of brain intoxication in this case appears to be the reason for her l ack of
further progress to date and the prognosis for recovery remains guarded.
In recent years, there has been geometric growth in the use of online
communication in medicine. The new field of "Telemedicine" is rapidly being
advanced in the developed countries, with computer review of case histories,
imaging studies (many of which are digital in their native form), and other
medical data becoming almost "routine" in making judgments, for example, as to
the transport of seriously ill or injured patients to tertiary medical centers.
In our own area, patients are transported on a dai ly basis, from small
facilities out in the "hinterland" to major urban medical centers. Physicians at
outlying hospitals have, through a simple computer/modem connection, access to
specialists and centers with advanced technology. The growing use of ISDN
(Integrated Services Digital Network) telephone lines has made the transfer of
complex information, including full-resolution MRI and CT scans, into a rapid
and seamless procedure. The global Internet renders such "connectivity" a
relatively inexpensive reality to be enjoyed by health care professionals and
patients throughout the world.
Despite this availability of technology (and, in the case of this unfortunate
student), however, the finest advances in global communication cannot surmount
centuries of tradition and cultural differences. In this case, the cultural
differences delayed im plementation of the large volume of collective knowledge
which was brought to bear on behalf of a young woman; and sadly in this
instance, was probably "too little and too late". As with other problems in this
world, it still comes down to the "human fac tor".
As we advance the cause of "Telemedicine" and other interactive technologies,
we must never lose sight of the fact that, behind these wonderful machines are
the minds and hearts, and prejudices, of the human beings who run them. It is in
this "human aren a" where we need to place our educational emphasis, so that the
marvels of the modern digital age can be used for the advancement of our species
and of the world as a whole.
AUTHOR'S NOTE:
This paper is dedicated to Zhu Lin, the 21-year-old student who is the
subject of the case report. Acknowledgement is also gratefully made to John W.
Aldis, M. D. (U. S. State Department); Xin Li (telemedicine fellow at UCLA
Medical Center); Dr. Ashok Ja in (USC Department of Emergency Medicine and Los
Angeles Poison Control Center); Dr. R. Hoffman and his colleagues (New York City
Poison Control Center); Dr. David Bullimore (University of Leeds, England); and
the myriad other people who labored on behalf of a young woman, critically ill
halfway across the world.
of us, using the Internet and other online databases, searched the literature
for the optimum method of removing thallium from the body. A number of methods
were cited; but to xicologists at the New York and Los Angeles Poison Control
Centers felt that the most effective treatment was that of administration of the
dye Prussian Blue (ferric ferrocyanide) and renal hemodialysis, with addition of
potassium chloride. Then came the problem of obtaining the Prussian Blue (a
common industrial chemical which was eventually found in China). Underlying this
difficulty was the fact that, once again, advice from "outsiders" was suspect by
the Chinese.
Finally, after many phone calls, faxes, and other communications (the doctors
at PUMC would not deal with the students, who had Internet connections),
including the involvement of the patient's family (several of whom were known
political figures locally) , the Prussian Blue-hemodialysis regimen was started
on May 5, 1995, this almost one month from the initial proposal of the diagnosis
of thallium intoxication and some forty days after the patient had lapsed into
coma and had become apneic.
I wish that I could report a "happy ending" here. The patient responded
rapidly to the treatment, and, within 15 days after the institution of
treatment, the patient's thallium levels in blood, urine, and cerebrospinal
fluid had decreased to near-zero (a lthough certain other tissues, such as nails
and hair, will retain the metal for many weeks and will slowly "leach out").
Sadly, the patient's neurological condition has not improved to a significant
degree. She now has been partially weaned from the ve ntilator, and seems to
recognize her parents; but she does not as yet have full consciousness, nor does
she exhibit much in the way of voluntary or purposeful activity. The long period
of brain intoxication in this case appears to be the reason for her l ack of
further progress to date and the prognosis for recovery remains guarded.
In recent years, there has been geometric growth in the use of online
communication in medicine. The new field of "Telemedicine" is rapidly being
advanced in the developed countries, with computer review of case histories,
imaging studies (many of which are digital in their native form), and other
medical data becoming almost "routine" in making judgments, for example, as to
the transport of seriously ill or injured patients to tertiary medical centers.
In our own area, patients are transported on a dai ly basis, from small
facilities out in the "hinterland" to major urban medical centers. Physicians at
outlying hospitals have, through a simple computer/modem connection, access to
specialists and centers with advanced technology. The growing use of ISDN
(Integrated Services Digital Network) telephone lines has made the transfer of
complex information, including full-resolution MRI and CT scans, into a rapid
and seamless procedure. The global Internet renders such "connectivity" a
relatively inexpensive reality to be enjoyed by health care professionals and
patients throughout the world.
Despite this availability of technology (and, in the case of this unfortunate
student), however, the finest advances in global communication cannot surmount
centuries of tradition and cultural differences. In this case, the cultural
differences delayed im plementation of the large volume of collective knowledge
which was brought to bear on behalf of a young woman; and sadly in this
instance, was probably "too little and too late". As with other problems in this
world, it still comes down to the "human fac tor".
As we advance the cause of "Telemedicine" and other interactive technologies,
we must never lose sight of the fact that, behind these wonderful machines are
the minds and hearts, and prejudices, of the human beings who run them. It is in
this "human aren a" where we need to place our educational emphasis, so that the
marvels of the modern digital age can be used for the advancement of our species
and of the world as a whole.
AUTHOR'S NOTE:
This paper is dedicated to Zhu Lin, the 21-year-old student who is the
subject of the case report. Acknowledgement is also gratefully made to John W.
Aldis, M. D. (U. S. State Department); Xin Li (telemedicine fellow at UCLA
Medical Center); Dr. Ashok Ja in (USC Department of Emergency Medicine and Los
Angeles Poison Control Center); Dr. R. Hoffman and his colleagues (New York City
Poison Control Center); Dr. David Bullimore (University of Leeds, England); and
the myriad other people who labored on behalf of a young woman, critically ill
halfway across the world.
