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Update (11/29): Status of patients from the JCO Criticality
RADSAFERS,
I am sorry I have not kept you updated last few days. I have just returned from
the Radiological Society of North America conference in Chicago. As you are
aware from other updates, Mr. A suffered heart attack on Saturday, 11/27. The
medical terms used in updates on Mr. A on 11/27 and 11/28 were very difficult
and I was unable to translate them adequately.
Several people wrote to me that the unknown word "bi ri ru bin" in blood of Mr.
A (11/22 update) is "bilirubin," a reddish yellow pigment C33-H34-N4-O6, residue
of broken down red blood cells (particularly the heme group). It is that yellow
color you see in jaundiced kids. It is also responsible for a bruise's color.
Excess of it usually can be dealt with by sunlight. Thank you to all of you who
wrote to me.
Valerie Putman's (INEEL) most recent JCO Criticality Summary (11/30/99) gives
revised dose estimates as 9.06, 4.96, and 1.19 Gy for Mr. A, B, and C,
respectively. I will make the change. I will also stop updating condition for
Mr. C. No explanation for revised dose estimates given.
Tosh Ushino
ICN Dosimetry
tushino@icnpharm.com
==========================================================================
RBC = Red Blood Cell WBC = White Blood Cell BP = Blood Pressure
Temp = Temperature Pulse = Pulse Rate Resp = Respiration rate
CRP = C-reactive protein
Mr. A: 9.06 Sv
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11/22/99 17:00
BP: 140/97 mm Hg, Pulse: 122/min., Resp: 16/min., Temp: 37.6 C
Continuing with sedative and ventilation. Some recovery of renal function, and
increase of bilirubin value in blood also stopped. WBC count in small blood
vessels is 5,100/mm^3. Radiation damage to intestine and skin is extremely
critical problem. Because of this, the patient requires massive amount of fluid
and blood products transfusion daily. Continuing problem with large volume of
fluid seeping out from the areas of injuries due to radiation burn. To reduce
fluid loss, we have again transplanted cultured human skin tissue. The volume of
stool in diarrhea has decreased, but blood in bowel has worsened. The source of
blood is thought to be the festering areas of injuries in small and large
intestines due to radiation burn. Volume of fluid in stomach of unknown origin
increased.
Treatment Direction: Covering small areas of radiation burn area at a time with
cultured human skin . Prevention of infection of areas with radiation burn.
Continue ventilation management, infection prevention, nutrition management,
continued transfusion management, and detailed total body management.
Others: Currently, blood pressure, pulse rate and other vital signs remain
somewhat stable, but the overall condition is very critical, requiring continued
vigilance.
11/23/99 17:00
BP: 143/82 mm Hg, Pulse: 127/min., Resp: 18/min., Temp: 38.0 C
Continuing with sedative and ventilation. Further recovery of renal function.
WBC count in small blood vessels is 4,800/mm^3. Radiation damage to intestine
and skin is extremely critical problem. Because of this, the patient requires
massive amount of fluid and blood products transfusion daily. Continuing problem
with large volume of fluid seeping out from the areas of injuries due to
radiation burn. To reduce fluid loss, we have again transplanted cultured human
skin tissue. No large change to volume of blood in bowel (505 gm from midnight
to 4:00 PM). The source of blood is thought to be festering injuries due to
radiation burn. Volume of fluid in stomach of unknown origin is increasing.
Treatment Direction: Attempting to stem blood loss through intestine. Covering
small areas of radiation burn area at a time with cultured human skin . Continue
ventilation management, infection prevention, nutrition management, continued
transfusion management, and detailed total body management.
Others: Currently, blood pressure, pulse rate and other vital signs remain
somewhat stable, but the overall condition is very critical, requiring continued
vigilance.
11/24/99 17:00
BP: 155/98 mm Hg, Pulse: 120/min., Resp: 20/min., Temp: 38.6 C
Continuing with sedative and ventilation. WBC count in small blood vessels is
4,400/mm^3. Radiation damage to intestine and skin is extremely critical
problem. Because of this, the patient requires massive amount of fluid and blood
products transfusion daily. Continuing problem with large volume of fluid
seeping out from the areas of injuries due to radiation burn. Increase in volume
of blood in bowel (2,720 gm from midnight to 4:00 PM). The source of blood is
thought to be festering areas of injuries due to radiation burn. Volume of fluid
in stomach of unknown origin is increasing.
Treatment Direction: Attempting to stem blood loss through intestine. Covering
small areas of radiation burn area at a time with cultured human skin . Continue
ventilation management, infection prevention, nutrition management, continued
transfusion management, and detailed total body management.
Others: Currently, blood pressure, pulse rate and other vital signs remain
somewhat stable, but the overall condition is very critical, requiring continued
vigilance.
11/25/99 17:00
BP: 141/88 mm Hg, Pulse: 114/min., Resp: 20/min., Temp: 38.9 C
Continuing with sedative and ventilation. WBC count in small blood vessels is
5,200/mm^3. Radiation damage to intestine and skin is extremely critical
problem. Because of this, the patient requires massive amount of fluid and blood
products transfusion daily. Continuing problem with large volume of fluid
seeping out from the areas of injuries due to radiation burn. We have again
transplanted cultured human skin tissue. The volume of blood in bowel decreased
(655 gm from midnight to 4:00 PM). The source of blood is thought to be the
festering injuries due to radiation burn. Volume of fluid in stomach of unknown
origin is increasing.
Treatment Direction: Attempting to stem blood loss through intestine. Covering
small areas of radiation burn area at a time with cultured human skin . Continue
ventilation management, infection prevention, nutrition management, continued
transfusion management, and detailed total body management.
Others: Currently, blood pressure, pulse rate and other vital signs remain
somewhat stable, but the overall condition is very critical, requiring continued
vigilance.
11/26/99 17:00
BP: 124/80 mm Hg, Pulse: 128/min., Resp: 20/min., Temp: 39.0 C
Continuing with sedative and ventilation. WBC count in small blood vessels is
5,900/mm^3. Radiation damage to intestine and skin is extremely critical
problem. Because of this, the patient requires massive amount of fluid and blood
products transfusion daily. Continuing problem with large volume of fluid
seeping out from the areas of injuries due to radiation burn. We have again
transplanted cultured human skin tissue provided to us from other university.
The volume of blood in bowel worsened (990 gm from midnight to 4:00 PM). The
source of blood is thought to be the festering injuries due to radiation burn.
Festering wound in duodenum is also suspected be the source of blood. Volume of
fluid in stomach of unknown origin is increasing.
Treatment Direction: Attempting to stem blood loss through intestine. Covering
small areas of radiation burn area at a time with cultured human skin . Continue
ventilation management, infection prevention, nutrition management, continued
transfusion management, and detailed total body management.
Others: Currently, blood pressure, pulse rate and other vital signs remain
somewhat stable, but the overall condition is very critical, requiring continued
vigilance.
11/27/99
- Today, at 7:02 AM, suddenly there was (heart fibrillation???) and patient
suffered cardiac arrest. Heart massage and artificial respiration commenced
immediately, and medication was provided. Heart resumed normal function at 8:14
AM after five electric shocks.
- At 10:00 AM, BP: 102/66 mm Hg, Pulse: 150/min., Resp: 27/min.
- Due to prolonged lack of circulation, we are conducting evaluation of central
nervous system function.
- The result of the 6:00 AM blood sample gas analysis showed no abnormality.
- The cause of cardiac arrest is unknown. No abnormality to heart was found. No
indication of high level of inadequate respiration. Involvement of (???reflex of
nerves through blood vessels???) strongly suspected.
- We will continue with evaluation of central nervous system function and
support of overall condition.
11/27/99
- 4:30 PM: circulation relatively stable. With medication, BP: 115/71 mm,
Pulse: 150/min, Resp: 25/min (breathing on own).
- Maintaining breathing on own and there is reflex reaction to light.
- Since there is low volume of urine, patient will be on dialysis machine
continuously.
[***Various tests were conducted and several possible cause of cardiac arrest
were ruled out. Unable to translate the possible causes they explored. They
suspect that due to some problem in liver, there was low level of oxygen in
blood, which caused some sort of erratic nerve reflexive response, and sudden
lowering of blood pressure and subsequent cardiac arrest.***]
- Drainage of water in stomach, circulation, respiratory function evaluation,
aggressive treatment.
11/28/99 17:00
- 4:00 PM: Circulation remaining relatively stable. With medication, BP: 154/98
mm, Pulse: 128/min, Resp: 28/min.
- Some improvement in respiration.
- Breathing on own and there is reflexive reaction to light, CNS function is
maintained.
- Since there is low volume of urine, patient will be on dialysis machine
continuously.
- Liver function deteriorated This is suspected to be due to cardiac arrest.
- Radiation damage to intestine and skin remains a critical problem.
- Blood in stool decreased, and the severity also decreased (440 gm from
midnight to 4:00 PM). Bleeding is observed using tube inserted into stomach
through nose (550 gm from midnight to 4:00 PM). This is thought to be from
festering wound in stomach and duodenum.
- Continuing problem with large volume of fluid seeping out from the areas of
injuries due to radiation burn.
- Because of this, the patient requires massive amount of fluid and blood
products transfusion.
- Patient continues to remain in critical condition.
11/29/99 17:00
BP: 151/92 mm Hg, Pulse: 121/min., Resp: 25/min., Temp: 37.7 C
Continuing with sedative and ventilation. WBC count in small blood vessels is
12,700/mm^3. On dialysis machine continuously. Liver function has deteriorated
to the point where there is essentially no liver function. Radiation damage to
intestine and skin remain extremely critical problem. Because of this, the
patient requires massive amount of fluid and blood products transfusion daily.
Continuing problem with large volume of fluid seeping out from the areas of
injuries due to radiation burn. volume of blood collected through tube inserted
into stomach increased (1,285 gm from midnight to 4:00 PM).
Treatment Direction: Continue massive volume of transfusion and continue with
dialysis. Continue ventilation management, infection prevention, nutrition
management, continued transfusion management, and detailed total body
management.
Others: With medication, blood pressure, pulse and other vital signs remain
relatively stable, but due to inadequate liver function, increase in bleeding
observed, becoming even more critical to maintain vigilance.
Mr. B 4.96 Sv
-------------------------------------------------------------------------
11/22/99
Fever and inflammation reaction continuing. Exhausted and drowsy. No major
change to skin condition and evaluation data.
BP: 124/74 Pulse: 130/min Temp (peak): 38.6 C WBC count:
12,580/mm^3 Hemoglobin: 8.4 g/dl
11/24/99
No major change.
BP: 148/88 Temp (peak): 38.0 C WBC count: 14,150/mm^3
11/25/99
BP: 141/88 mm Hg Pulse: 114/min Resp.: 20/min Temp: 38.9 C
Continuing with sedative and ventilation. WBC count in small blood vessels is
5,200/mm^3. Radiation damage to intestine and skin is extremely critical
problem. Because of this, the patient requires massive amount of fluid and blood
products transfusion daily.
11/16/99
With steroid medication, fever and inflammation improved. Feeling of exhaustion
strong. Some improvement observed in damaged skin. No major change to
examination result.
BP: 150/100 Pulse: 120/min, Temp (peak): 38.3 C WBC count:
12,100/mm^3 Hemoglobin: 8.6 g/dl
11/29/99
With steroid medication, fever and inflammation improved. Although skin of
entire body affected, improvement observed beginning to be large area of damaged
skin. Damaged to liver function thought to be the result of medication observed.
BP: 140/92 Pulse: 116/min, Temp (peak): 38.3 C WBC count:
16,620/mm^3 Hemoglobin: 8.8 g/dl
Bilirubin: 3.6 mg/dl
-------------------------------------------------------------------------
Toshihide "Tosh" Ushino, CHP Tel: (800) 548-5100 x2413
Product Development Manager Fax: (714) 668-3149
Dosimetry Div., ICN Biomedicals, Inc. Email: tushino@icnpharm.com
3300 Hyland Ave., Costa Mesa, CA USA 92626 tushino@hotmail.com
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