“Doctor, um, I have a boy who has consumed nitrous benzene; he is blue. What do I do? Can you come quickly?”
If you are like me, you probably have never heard of the compound. It typically is used as a paint thinner and solvent. The formulation the boy intentionally took, following a dispute with his father, is used as a plant stimulant.
The boy, who is 16, married, and a father to a young infant, took the plant growth stimulant following a dispute. He was intoxicated at the time. After the ingestion he went to his uncle and disclosed what had happened. They induced vomiting with a soap water slurry. The patient was brought to the hospital.
None of us knew how to manage this case. I was on call for medicine. It is said that the only thing you are taught in medical school are methods to rapidly look up questions in a text book. While this isn’t entirely true, there is a lot of truth to this saying as we are taught how to take clinical facts and rapidly reason through treatment scenarios.
The main treatment for this type of poison is a chemical called methylene blue. The chemical converts methemoglobin – the chemical state of hemoglobin incompatible with carrying oxygen – to hemoglobin. The manifestation of methemoglobinemia is profound cyanosis, this patient looked blue.
Once we read that methylene blue was the treatment of choice we opted to recommend referral to a larger center in Kathmandu. However, calling the poison control number in Kathmandu yielded disappointing news: there is no methylene blue in the country! Okay, so what do we do? Well, Dr. Molé, an emergency medicine physician, recommended that we call a poison control center in the US to seek additional assistance. This young boy will be forever indebted to the kind staff at the Rocky Mountain Poison and Drug Center in Denver, CO. For the next 1.25 hours I spoke with the toxicologist and her staff to devise a treatment plan. What materialized saved this boy’s life – praise be to God!
The boy was admitted to the ICU. We intubated him for airway protection. He was provided supportive care. The only treatment options available to us were to infuse new blood into his body and to remove a corresponding volume of toxic blood. This is technically called exchange transfusion but due to lack of equipment we had to modify how it was performed. Ascorbic acid, vitamin C, and riboflavin, Vitamin B2, can also be used to treat methemoglobinemia. Thankfully these vitamins were available.
This young man, his name is Raju, is alive today because of Scheer Memorial Adventist Hospital and God’s providence and grace. He should have died. We told the family he would not live. We told them it would only be by divine intervention that he would live and not be neurologically damaged. Our chaplains prayed over Raju every day!
Our God – the one and only living God of this universe – intervened in Raju’s life! It is awesome and humbling to see God at work!
Written by Jonathon Thorp, MD MBA, Internal Medicine