Wednesday, January 6, 2016

Sabbatical . . .

The last 100 days, I thought of taking a break from my blog . . . I hope the break is over. Part of the reason for the break was laziness.

Now, as I mull over what caused my laziness, part of the answer was that I did not seem to get a break from the routine work. Considering into fact that blogging was taking quite a lot of my time after the change in my work environment, I came to the conclusion that the first thing that I should forego was blogging.

While at NJH, my friends used to ask me when I got the time to blog. And the answer was in between the surgeries. There would not be time to go home and take a break, but there would be time to write a blog. Outpatient was not as busy with a better doctor patient ratio.

However, Kachhwa has been different. We see the same number of patients, but has a poor doctor patient ratio - which makes things different. 

So, major issues we had to grapple with over the last year at Kachhwa - 

1. Tuberculosis
2. Malaria
3. Systemic Hypertension and Diabetes
4. Care of the Elderly
5. Snakes bites which is of course coming down since winter is on . . . 

Shall write in detail about each of them . . . 

Well, the ultimate reason on why I took back to blogging. One of my friends retorted that the reason for my silence seems to be the perceptible change in environment within the country on putting across opinions and facts . . . 

As doctors, we are scientists and to voice out facts and our opinions on issues pertaining to healthcare is our mandate. Well, one could stifle them, but that would be at a heavy price . . .  

I hope I get the time to write . . .

Before I sign off, a small prayer sent to me by one of my seniors, with a small addition from my father in law -

May God bless us with discomfort at easy answers, half-truths and superficial relationships, so that we may live deep within our hearts.

May God bless us with anger at injustice, oppression and exploitation of people, so that we may work for justice, freedom and peace.

May God bless us with tears to shed for those who suffer from pain, rejection, hunger and war, so that we may reach out our hands to comfort them and turn their pain into joy. 

And may God bless us with enough foolishness to believe that we can make a difference in this world, so that we can do what others claim cannot be done, to bring justice and kindness to all our children and the poor. 

And we pray for the gift of endurance to withstand all the above, such that inner transformation will happen to us all. 

Wishing you all a blessed 2016  - - - 

Monday, August 31, 2015

Referred by a Jhad Phuk

Couple of weeks back, we had a young boy wheeled in. It was late evening, just after we finished our outpatient work.

The history was that of a bite at dawn while he was sleeping on the floor. The boy had seen the snake slightering off into the dark but could not identify it.

As is common practice, he was taken to the jhad phuk who did his chanting and gave some medicine. He proclaimed that the boy was free of any poison and therefore sent him home. The family did not make much about the snake bite and took him home.

At home, our dear friend started to feel quite funny. He noticed that he was having difficult keeping his eyes open as well as there was a funny feeling on his throat. He thought that it must be something which he ate that got stuck in his throat. By the time, school was over late afternoon, he realised that something was grossly wrong with him.

The parents linked the symptoms to the snake bite which he had early morning and took him again to the witch doctor. The witch doctor did his mumbo-jumbo and then proclaimed that it does not look like a snake bite, rather it looks like a Bengal Monitor bite. He washed his hands off the patient and asked them to take him to a proper hospital.

After a visit to one more jhad phuk, they arrived at KCH - a full 13 hours after the bite.

It was a very obvious neurotoxic bite. I conveyed the diagnosis to the relatives and gave the option of treating or taking to a higher centre. Well, you may be surprised that I gave them the option to take to a higher centre. The reason was that there was a very portly and goon looking gentleman among the bunch of relatives who argued with me that it was not a case of snake bite.

He told me that the jhad phuk whom he went was a very famous witch doctor and his success was 60-70% - which meant that 30-40% died! That gave me enough ammunition to discredit the jhad phuk – I told him that the jhad phuk will have a better success rate if he left the patient alone, because of 100 bites, only 15 bites would be those with envenomation and of that too only 4 will die without treatment.

The printed material on snake bite which we had prepared recently was a great help. I was glad that there were couple of our previous patients who had come for dressing of their cobra bite wounds who supported my view.

Ultimately the family decided to stay at KCH and allow ASV to be given. Thankfully, he recovered well overnight. However, the surprising thing was that the next day night, his mother and elder sister also sustained snake bite and come to us straightaway. Thankfully, there were no signs of envenomation in both of them.

Recently, we've had been having discussions about how to manage snake bite. There are quite a few people who believe that it should be according to identification of the culprit snake. However, I believe that the approach should be based more on the clinical presentation. The case of the chameleon bite and this case is ample evidence in support of a syndromic approach. 

After 48 hours in the hospital, the young boy was ready for discharge. Although it was a krait bite, he ended up with a bandage as the quack had made quite a few deep incisions around the bite site. 

It was quite heartening to see the relatives thank us for opening their eyes on how the witch doctors exploit poor village folk.

Monday, August 10, 2015

Unusual bite - 1

One advice we give to village folk to prevent snake bite is to avoid sleeping on the floor and rather using a cot. I've even seen advice to use a mosquito net to prevent snakes from getting inside the cot.

However, Mrs. Guddi did all of it. But still ended up with a bite. The culprit snake got onto her cot which was covered with a mosquito net and bit her. 

She came to us about 10 hours after the bite.

The family had killed the culprit snake and brought it along with them. 

It was not their mistake that they came late. They had gone elsewhere where ASV was available. 

Since I've started my service at Kachhwa, it is very obvious that hardly anybody in the nearby healthcentres have any idea about ASV usage in snake bite. Mrs. Guddi received 3 vials from elsewhere and when she reached us she was on the verge of going into respiratory depression.

Thankfully, Guddi managed without mechanical ventilation.

It was a joy to see the young family playing with their little child the day before discharge.

However, please note that there is evidence which supports the use of bednets to decrease incidence of snake bites.