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ACUTE ARSINE POISONING
1433
of great clinical relevance, though the Swiss workers claim to have found it in the blood of burned patients. It is not produced in scalded skin and so would play no part in one of the commonest forms of thermal injury in man. Perhaps the most provocative aspects of this study, and those which warrant independent investigation, are the demonstration that animals can be protected against normally lethal burns either by passive immunisation with antitoxin IgG or by active immunisation with sublethal doses of the toxin, and the finding that sublethal doses of the toxin increase susceptibility to pseudomonas wound invasion. Relevant to this second finding may be the release into the blood of burns patients of a cytotoxic antigen which acts
directly
on
lymphocytes.1o
STUDENTS AS PATIENTS MosT of the best teachers in medical school spend much of the day in bed, and students often hesitate In the usual system medical to approach them. students and doctors encounter the sickness role only from the outside, and have little direct insight into the patient’s experiences and needs. Where a student is assigned to specific patients, he has an opportunity to follow a patient and observe how the different functions of the hospital can combine in the interest of the individual patient. With luck, he may, for perhaps the only time in his career, become aware of the deficiencies of the system of medical care from the point of view of the patient. There are more direct ways to bridge the gap. Simpson 11 has proposed that " It would ... be beneficial for most students, where two this can be arranged, to be seen personally at different hospital outpatient clinics as an ordinary patient, and ... to be admitted to a ward of his own for a couple of days ". Similarly, for example, by attempting to spend some days in a wheelchair, or even on crutches, a student could learn more about the realities of physical handicap than the most skilful lecturer could hope to convey. At the 1974 scientific meeting of the Association for the Study of Medical Education, in Edinburgh, K. Cox reported a response to this suggestion at the University of New South Wales, Australia. It had been found that, despite reasonably high, motivation to get involved in clinical medicine after three preclinical years, students rarely entered the wards except when on structured teaching sessions with a clinical tutor. Discussions with small groups of students revealed some of the factors the students described as inhibiting them from approaching patients. These included many aspects of insecurity and unfamiliarity with the ward and ward routine, uncertainty about the new hierarchy in which they were now placed, embarrassment when undressing patients, fears they might dry up when talking to patients, and discomfort at feeling that they were invading the patient’s privacy with nothing to offer in return. A special workshop was devised to help the students to understand the ...
hospital
i !
10. 11.
Hakim, A. A. Experientia, 1973, 29, 865. Simpson, M. A. Medical Education: A Critical Approach. London, 1972.
feelings of patients in hospital, and to understand how the hospital ward functions. As part of this process, students were admitted to hospital with a range of simulated maladies. They were admitted via casualty in the usual way, and were treated as normal patients, including being taught on and having routine investigations such as X-rays and E.C.G.S. The emphasis was not on the student’s simulating the features of a particular illness, but on his experiencing the concomitants of the management of such a condition. Thus, for instance, the student with " head injury " experienced regular observations of pulse, bloodpressure, pupil size, and arousability all night; the " eye injury " has both eyes bandaged; the " asthmatic " has breathing exercises; and the student scheduled for " bowel surgery " is put on a fluid diet and intravenous infusion. The students and staff involved thought highly of the experience. Valuable group discussions ensued, and a change of behaviour was seen. Students entered the wards and engaged with patients more readily, and (especially those who had needed to be most dependent upon others during their admission) became more attentive to patients and prepared to spend more time with them. Planning for the workshop, involving as it did prolonged discussions across different hospital departments and levels of seniority, led to useful improvements in communication.
ACUTE ARSINE POISONING AFTER two cylinders of arsine (AsH 3) leaked in the hold of the containership Asiafreighter, 17 crewmembers were admitted to hospital, 4 seriously ill (last week one was still very sick). The toxicity of
arsine-which was once tested as a possible chemical in a well-timed article by Fowler weapon-is reviewed and Weissberg.1 The gas is colourless and nonirritant, and smells of garlic. Symptoms come on 2-24 hours after exposure to as little as 3 p.p.m., and the main damage is to blood and kidneys. Abdominal pain (with liver tenderness), dark-red’ urine, and jaundice are typical presenting features. At this stage there is a Coombs-negative haemolytic anaemia, with much haemoglobin in both plasma and urine; leptospirosis, malaria, paroxysmal nocturnal hsemoglobinuria, and poisoning by other agents are possibilities, but arsenic in the urine will usually clinch the diagnosis. By the third day, acute oliguric renal failure may have supervened, and in fatal cases this is the usual cause of death. The renal tubules are extensively damaged; later there is regeneration of tubular cells with thickening of glomerular basement membranes, so that renal function may remain deranged. Acute and severe poisoning is treated by exchange transfusion and, where there is renal failure, by haemodialysis. Dimercaprol has been tried, but its efficacy is uncertain. Evidently, the gas on the Asiafreighter was to be used in the manufacture of transistors. Fowler and Weissberg believe that the burning of fossil fuels with high arsenic content may make arsine poisoning more common. 1.
Fowler, B. A., Weissberg, J. B. New Engl.J. Med. 1974, 29, 1171.
of great clinical relevance, though the Swiss workers claim to have found it in the blood of burned patients. It is not produced in scalded skin and so would play no part in one of the commonest forms of thermal injury in man. Perhaps the most provocative aspects of this study, and those which warrant independent investigation, are the demonstration that animals can be protected against normally lethal burns either by passive immunisation with antitoxin IgG or by active immunisation with sublethal doses of the toxin, and the finding that sublethal doses of the toxin increase susceptibility to pseudomonas wound invasion. Relevant to this second finding may be the release into the blood of burns patients of a cytotoxic antigen which acts
directly
on
lymphocytes.1o
STUDENTS AS PATIENTS MosT of the best teachers in medical school spend much of the day in bed, and students often hesitate In the usual system medical to approach them. students and doctors encounter the sickness role only from the outside, and have little direct insight into the patient’s experiences and needs. Where a student is assigned to specific patients, he has an opportunity to follow a patient and observe how the different functions of the hospital can combine in the interest of the individual patient. With luck, he may, for perhaps the only time in his career, become aware of the deficiencies of the system of medical care from the point of view of the patient. There are more direct ways to bridge the gap. Simpson 11 has proposed that " It would ... be beneficial for most students, where two this can be arranged, to be seen personally at different hospital outpatient clinics as an ordinary patient, and ... to be admitted to a ward of his own for a couple of days ". Similarly, for example, by attempting to spend some days in a wheelchair, or even on crutches, a student could learn more about the realities of physical handicap than the most skilful lecturer could hope to convey. At the 1974 scientific meeting of the Association for the Study of Medical Education, in Edinburgh, K. Cox reported a response to this suggestion at the University of New South Wales, Australia. It had been found that, despite reasonably high, motivation to get involved in clinical medicine after three preclinical years, students rarely entered the wards except when on structured teaching sessions with a clinical tutor. Discussions with small groups of students revealed some of the factors the students described as inhibiting them from approaching patients. These included many aspects of insecurity and unfamiliarity with the ward and ward routine, uncertainty about the new hierarchy in which they were now placed, embarrassment when undressing patients, fears they might dry up when talking to patients, and discomfort at feeling that they were invading the patient’s privacy with nothing to offer in return. A special workshop was devised to help the students to understand the ...
hospital
i !
10. 11.
Hakim, A. A. Experientia, 1973, 29, 865. Simpson, M. A. Medical Education: A Critical Approach. London, 1972.
feelings of patients in hospital, and to understand how the hospital ward functions. As part of this process, students were admitted to hospital with a range of simulated maladies. They were admitted via casualty in the usual way, and were treated as normal patients, including being taught on and having routine investigations such as X-rays and E.C.G.S. The emphasis was not on the student’s simulating the features of a particular illness, but on his experiencing the concomitants of the management of such a condition. Thus, for instance, the student with " head injury " experienced regular observations of pulse, bloodpressure, pupil size, and arousability all night; the " eye injury " has both eyes bandaged; the " asthmatic " has breathing exercises; and the student scheduled for " bowel surgery " is put on a fluid diet and intravenous infusion. The students and staff involved thought highly of the experience. Valuable group discussions ensued, and a change of behaviour was seen. Students entered the wards and engaged with patients more readily, and (especially those who had needed to be most dependent upon others during their admission) became more attentive to patients and prepared to spend more time with them. Planning for the workshop, involving as it did prolonged discussions across different hospital departments and levels of seniority, led to useful improvements in communication.
ACUTE ARSINE POISONING AFTER two cylinders of arsine (AsH 3) leaked in the hold of the containership Asiafreighter, 17 crewmembers were admitted to hospital, 4 seriously ill (last week one was still very sick). The toxicity of
arsine-which was once tested as a possible chemical in a well-timed article by Fowler weapon-is reviewed and Weissberg.1 The gas is colourless and nonirritant, and smells of garlic. Symptoms come on 2-24 hours after exposure to as little as 3 p.p.m., and the main damage is to blood and kidneys. Abdominal pain (with liver tenderness), dark-red’ urine, and jaundice are typical presenting features. At this stage there is a Coombs-negative haemolytic anaemia, with much haemoglobin in both plasma and urine; leptospirosis, malaria, paroxysmal nocturnal hsemoglobinuria, and poisoning by other agents are possibilities, but arsenic in the urine will usually clinch the diagnosis. By the third day, acute oliguric renal failure may have supervened, and in fatal cases this is the usual cause of death. The renal tubules are extensively damaged; later there is regeneration of tubular cells with thickening of glomerular basement membranes, so that renal function may remain deranged. Acute and severe poisoning is treated by exchange transfusion and, where there is renal failure, by haemodialysis. Dimercaprol has been tried, but its efficacy is uncertain. Evidently, the gas on the Asiafreighter was to be used in the manufacture of transistors. Fowler and Weissberg believe that the burning of fossil fuels with high arsenic content may make arsine poisoning more common. 1.
Fowler, B. A., Weissberg, J. B. New Engl.J. Med. 1974, 29, 1171.