Sir,

Referring to the paper published in the Jan 2010 issue on telemedicine [1], it would be, no doubt, of immense utility to the vast majority of impoverished population who do not have access to specialized medical care. But, it may lead to some disastrous consequences if we are not careful of certain things. We wish to narrate one such case, which we encountered recently.

A three-yr-old girl was admitted to our hospital with features of vomiting, ataxia, shock and dehydration. Her parents revealed the following history on detailed questioning.

The child was operated for aqueductal stenosis about 3 yrs back in a specialized center in South India. She was discharged from there in a satisfactory condition and was under follow up through a telemedicine centre situated in her native city run by the treating institute. About 7 days prior to admission to our hospital, she developed two episodes of generalized convulsions for which they reported to the telemedicine centre. The centre prescribed phenytoin syrup to the child. But, unfortunately, it was prescribed in milligram format ( 30 mg–15 mg–30 mg). The prescription format was downloaded and the parents were asked to give the medicine in terms of milliliter (30 ml–15 ml–30 ml). It may have been due to an oversight at some level as usually the drugs are prescribed in terms of actual volume to be given in milliliters. The child received phenytoin at such a high dose with the resultant consequences leading to admission in our hospital. The serum phenytoin was tested and it came out to be 35.22 μg/dl (22 μg/ml). Fortunately, child improved on symptomatic management.

The purpose of this communication is to remind the fellow clinicians to keep these caveats in mind while depending on telemedicine to avoid the disastrous consequences as has happened in the above incidence.

References

1. Singh M, Das RR. Utility of telemedicine for children in India. Indian J Pediatr. 2010;77(1):73–5

Author’s reply

Sir,

We are thankful to the authors for bringing out such an instance. It is always prudent do a double check on the doses etc. One is aware of such occurrences even in the wards where wrong orders are written. In fact it is a failure of the prescribing practice rather than telemedicine. In fact, presence of an electronic medical record gives proper documentation of the event. However, it is always recommended to conduct a videoconference for two way communication in complicated cases.

Meenu Singh

Additional Professor of Pediatrics,

In Charge Pediatric Pulmonology,

Site Director, South Asian Cochrane Network,

Coordinator, SAARC Telemedicine Network,

PGIMER. Chandigarh. 160012.

India