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.

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. 

Girgit

Muskan, this little 8 year old girl in the snap appears all set to break into a dance if some music is put on. As one of my colleagues put it, smiles like this one can really take the stress off a very very busy day.

There is more reason for Muskan to put so much of a smile. Muskan came to us more than a fortnight back after having been bitten by a chameleon in her aunt's house where she had gone for a visit. The problem was that after the chameleon bite, she started to feel very weird.

She had a funny feeling in her throat and she found it difficult to open her eyes.

Her father was a sensible man and brought her to the 'bite hospital' which is us. My colleague received her in emergency and she told him that she was bitten by a girgit – that's the word for a chameleon.

Dr. Ao did not feel that things were okay. He called for a second opinion and while I was repeatedly asking her if she was quite positive that the culprit creature was a girgit, it was very obvious that the ptosis was worsening.

I told my suspicion of a cobra bite to the relatives. They wanted to know about the costs involved and was reluctant to give Anti-Snake Venom. To buy time, I told them that I'll start off with a small dose and see how things progress. However, as our staff got the ASV ready, she went into a respiratory arrest and we had to put her on mechanical ventilation.

Muskan immediately after the intubation. I got the snap to use later if there were medicolegal issues. Notice the bite mark with black surrounding skin. Incidentally, when I photographed here on one of the review days, she was wearing the same dress which she wore the day she got bitten. 

Things became easy for us. Very soon, she was receiving treatment for cobra bite. 

With the ASV, atropine and neostigmine, she was conscious, breathing on her own and talking after 3-4 hours. I again asked her about the animal that bit her – girgit was the answer.

By now, her bite site had swollen up quite a bit and it was obvious that it was a cobra bite.

The next day, Muskan narrated on how she had turned to take some rotis which was kept on a window sill and as she turned after taking the food, she saw a chameleon sitting beside the plate of rotis, which lunged at her and bit her on the upper part of her right arm. That narration was difficult to believe as chameleons are quite timid creatures and they run for their lives when they see someone.

However, Muskan was the first of our two patients who misidentified the animal that bit them.

About our second patient, in the next post. And I can assure you that it is hilarious. 

First Aid in Snake Bite

On the opposite side of the leaflet on Preventing Snake Bites is the First Aid which is to be done in case of a snake bite.

The pictures here have been taken from the website - http://www.she-india.org/snakebite-first-aid/ where it is attributed to the Nisarga Vidnayan Sanstha. Unfortunately, our printers did not add the acknowledgement for the cartoons when the final printing was done although it was there in the final proof. 

The English translation of the leaflet is as follows - 

1. Keep the patient calm and reassure him. Please note that 70% of snake bites are caused by non-poisonous snakes and of the rest 30%, only half of them would have features of envenomation.

2. Keep the patient quiet. Don't move the site of the bite. If the bite is on the arm, put a splint. If on the leg, splint the limb and don't allow the patient to walk. There is no advantage of putting a tight tourniquet proximal to the site of bite, rather it would do harm.

3. Go as soon as possible to a hospital which has ASV available. Use whatever means of transport is available.

4. It is harmful to put nicks or cuts on or around the bite site. It is also not advisable to wash the wound. Both these practices ensures that the venom spreads fast all over the body.

5. Please note that even after you reach the hospital, treatment with Anti-snake venom is started only when signs/evidence of venom envenomation is noted. It is dangerous to inject Anti-snake venom without signs/evidence of envenomation.

6. It is good to be kept under medical observation for 12-24 hours after the bite. There are some snakes like Krait where the symptoms of envenomation may be observed only after 6-24 hours.

7. It is better to keep a snake bite victim nil per orally until the doctor allows to eat orally.

8. Please remove ornaments like rings, bangles, wrist bands etc. if any near the bite site as swelling of the bite site can cause problems with their removal later.  

Please feel free to use the material to print your own 'first aid for snake bite' leaflets. However, as noted above, you'll need to take permission to use the cartoons.

Preventing Snake Bites

Couple of weeks, staff at KCH helped to put together a leaflet on preventing snake bites . . .

The cartoons have been done by Mrs. Blodwen Shankar.

The English translation is as follows -

1. When you go out of home at night, please use a torch or some other light source. If you don't have a light source, use a rod to tap the ground heavily as you walk.

2. When you cut grass or pick vegetables or fruits from a bush, use a small stick to probe the place and clear the vegetation where you'll place your hand.

3. When you collect dry leaves or twigs from the floor, use a stick to probe the place from where you'll pick the leaves/twigs.

4. When you remove anything from your attic or machaan or the shelves of your home, use a torch and stick. Be vigilant about snakes hiding there. Don't put your hand or feet into a dark area without looking.

5. Keep your surroundings clean. Don't allow rats to thrive inside your home. Dirty and unkempt surroundings encourage breeding of rats which in turn attracts snakes.

6. There is a higher chance of your being bitten by a snake if you sleep on the floor.

7. Don't grow plants near windows and doors. If you have climbing/creeper plants climbing onto your house, snakes can enter your home with ease.

8. When you move about in areas with dense foilage, use a long stick to clear the vegetation as you move. Boots, full pants and full sleeves shirt can help you avoid fatal snake bites

Please feel free to use the above material. You can contact me at jeevan53@gmail.com for the cartoons in jpeg format. 

On the backside of this leaflet was also information on first aid to be given in case of snake bite. That would be my next blog post . . . 

Snakes galore

The last week was quite busy. We had about 20 patients brought in with snake bite. We lost Shivam couple of days back. By God's grace, only 8 of the 20 patients had evidence of envenomation. Interestingly, nine of the 20 patients brought the culprit snake, 7 of them dead snakes and two alive ! ! !. 

Here are the snaps of the snakes brought . . . I'm glad that none of the snakes were non-venomous . . .

This is a baby cobra which bit a 30 year old lady. Thankfully, there were no signs of envenomation. 

This is a krait which bit a lady who was sleeping on the floor. Again, there was no envenomation. 

This bit a 25 year old man on his toe. Again, no envenomation

I thought this was a wolf snake. This is live. The local experts say it is a krait. The 35 year old lady who was bitten by this snake had some sore throat and dizziness for about 12 hours which settled over time. There was no ptosis. We kept the patient on observation for 36 hours and discharged her. No ASV was given. 

A cobra who bit a prominent person of a village about 40 kilometers away. Mr. Phekku, 60 years old came in about 2 hours after the bite after the customary visit to the jhad phuk. He was on mechanical ventilation for about 2 days. He is doing fine now. We gave him the maximum possible dose of 20 vials ASV. Interestingly after we told the family that the culprit snake could be in the enclosed space where he was bitten, the family hired couple of snake charmers who caught the snake live and brought it to the hospital for identification. God only knows if this was the culprit snake or one which the snake charmers got out of their kitty and show cased it. 

Another krait. Again, the victim did not have features of envenomation. 

This snake bit a 40 year old lady from a nearby village. She was brought in almost 12 hours after the bite. She had ptosis and respiratory distress. She maintaind saturation without need of intubation. Her ptosis resolved after 10 vials of ASV.

A 3 feet long cobra which bit a 50 year old man inside his flour mill. It was wrapped around one of the machine parts which he was cleaning. He came in within 15 minutes. Initially, they did not know what snake it was. Later, when we told the relatives that considering that the bite happened in a room, the snake could still be lurking inside, the searched and found it out and killed it. Interestingly, within few minutes of the snake being brought in, the patient started developing ptosis and throat discomfort. He responded well to ASV and got discharged aftr 48 hours. He needed only 10 vials of ASV.  

Another krait brought in by a patient who was bitten on the leg. Again, no features of envenomation. 

It is quite interesting that only one patient out of the six who brought in the dead krait had features of envenomation whereas two out of the three patients who brought a cobra had features of envenomation. Please note that there were 11 other patients who came with bites from unidentified snakes. 5 of them had features of envenomation and we had to give ASV. 

And, we finished about 100 vials of ASV in 3-4 days, including 50 on a single day . . . 

More, in the next posts . . . 

Dear Citizens

Someone had forwarded this message to me in my WhatsApp. I thought that it was good enough to be posted in my blog . . . Honestly speaking, I don't know that source. I thought that it was worth exploring . . . 

Suggested REFORM ACT OF 2014

1. No Tenure/No Pension: Parliamentarians collect a salary while in office, but should not receive any pay when they're out of office. 

2. Parliamentarians should purchase their own retirement plans, just as all Indians do. 

3. Parliamenarians should no longer vote themselves a pay raise. Their pay should be linked to the CPI or 3%, whichever is lower. 

4. Parliamentarians should lose their current healthcare system and participate in the same healthcare system as the Indian people.

5. Parliamentarians with tainted records, criminal charges and convictions, past or present should be summarily banned from the parliament and fighting election on any pretext or the other. 

6. Parliamentarians should equally abide by all laws they impose on the Indian people. 

7. All contracts with past and present Parliamentarians should be void effective 1/1/2015. The Indian people did not make this contract with them. Parliamentarians made all these contracts for themselves. 

8. Serving in Parliament is an honor, not a lucrative career. The founding fathers envisioned citizen legislators, so ours should serve their term, then go home and back to work. 

Neyyar Dam Trail

Snaps of a mini trail in Neyyar Dam. Quite welcome greenery . . .

Dangers of searching revisited

We had one more snake bite victim who got bitten just because she did not look at where she was putting her hand. Being a adolescent girl in a rural Indian household, she was doing her chores as part of the routine of her household. 

Arti was in charge of rolling out rotis every day morning. 

It was just another routine day which ended up being a nightmare for her and the family. For along with the wooden slab and rolling pin, which were used to flatten the lumps of wheatflour dough, was a krait which must have been attracted to the cool environment of the wood in a hot Indian summer. 

Arti put her hand into the pile of vessels which also contained the wooden slab and rolling pin. The bite was not painful. She did not develop symptoms immediately. First it was a difficulty in keeping her eyes open, which was followed by a funny sensation in the throat. 

It was dawn when she was bitten, but by the time she reached us it was late evening. Her condition was so bad that she could hardly breath. She needed mechanical ventilation. 

However, she was lucky to be weaned out within 48 hours. 

Well . . .  another warning about putting your hands into spaces without looking if there is danger lurking. 

Arti with her parents just before discharge . . . 

I was wrong

I hope the post, Krait Attack - 3 is fresh in your mind. 

Mr. Dinkar has recovered well, although he has a very badly infected bite site. 

Today, as we took rounds, Dinkar and both his sons walked in quite excited. The younger son explained that they managed to kill a large snake inside their home last night. And they attributed that snake to have bitten Mr. Dinkar. 

They had even taken snaps of the dead snake on their cell phone. 

So, Mr. Dinkar was bitten by a cobra. Dinkar says that he is postive that this was the same snake that bit him. He clarified that the white marks which he told was not like that of a krait. He told us that the white marks one can see in the snap were what he was talking about. 

So, that explains the badly infected wound. However, I don't know how to explain the fact that we had given him ten doses of Atropine/Neostigmine and he had not responded. Instead, he took 6 days on mechanical ventilation before he came around. 

I just cannot imagine Dinkar and his large family living with a large cobra inside their home. 

Dinkar's younger son heard a peculiar noise coming from the dark corner of their home as he woke up to switch off the electric motor which was pumping water into their fields. . Only after he woke up his elder brother did they realize that the noise was the hiss of an angry snake who was cornered. It was quite obvious that both the brothers realised soon that this must have been the culprit who injured their father and brought them much misery over the last month. And now, it was threatening to bite both of them. 

They had no other option but to kill the snake. They were so angry that they chopped off it's head and after taking the snaps cut it up into pieces and burnt it. 

I think Dinkar's family was lucky that nobody else was bit unlike the family in Rajasthan whose story appeared in the news recently. 

Is it really worth?

It was only today that a senior colleague and mentor wrote about love, care and concern showed by relatives of patients who've quite serious illnesses, especially when they come from not-so-well off backgrounds, both in terms of intellect and finances. 

In fact, we have a snake bite victim suspended between life and death . . . 

We were quite surprised that the parents brought this 8 year old boy who was bitten by a snake almost a day back . . .  20 hours to be exact. 

Shivam was playing in front of his home when he was bitten at around 6 pm last Monday. Neither his parents nor his friends saw the snake. It was with quite difficulty that they realized that Shivam was bitten by a snake . . . 

Shivam is intellectually disabled. He does not talk much and is known to be 'weak brained' by everyone in the village. He hardly speaks. And that was the exact reason nobody found out about the snake bite. 

It was only when Shivam started to develop breathlessness that his parents realized that something was amiss. Somehow, Shivam conveyed to them that he was bitten by a snake. In addition to the breathlessness, he started to have discomfort of the throat, which he conveyed well to his parents. 

Now, by the time, his parents realized that their son was bitten by a snake it was late morning the next day. As was the custom, they went to the wich-doctor, popularly called jaad-phuk. It was obvious that he could do nothing. 

By the time, Shivam reached KCH, he was desaturating and it was obvious that he needed assisted breathing. Being a child, we had our challenges. Our ventilator had conked off after being hooked to Dinkar. All the patients who came after Dinkar were manually ventilated. 

It's past 48 hours since he is intubated and being mechanically ventilated. And through this 48 hours, he had quite a many challenges, which I shall narrate in a later post. 

Today, sometime late evening, we realised that Shivam's sustained some amount of mechanical ventilation injury. There was subcutaneous emphysema - air under the skin. He's already had 3 changes of his endotracheal tube. 

His saturation is maintained well. We hope that he'll make it inspite of the subcutaneous emphysema. I've previously had couple of patients who went into this condition. One did not make it . . . the second one did . . . 

We request prayers for Shivam. 

I'm so encouraged to see Shivam's parents constantly at his side encouraging and chiding him to hold on. Do realize the entire family has been pitching in by manually bagging him. Manual bagging for 48 hours is no small thing . . . 

I wonder if a more well off family would have shown such care. I've at least seen in one instance when a well off family decided not to care when a major illness affected their mentally challenged son. 

Once more . . . request prayers for Shivam . . . 

If you ask me . . . it is really worth caring and making our utmost effort to save Shivam . . . for we are all made in God's Image . .  .

Brought Dead . . .

Patients who are brought dead are a common sight in most hospitals. KCH also sees an average of 3-5 patients every week day who are brought dead. 

Yesterday, we had a little boy of about 4 years who was brought dead after getting bitten by a snake. 

In June, I kept count of about 10 patients who were brought dead after being bitten by a snake. My estimate is that half of the people who are brought dead without any explanation are snake bite victims. The 10 patients I kept a count of does not include the latter group. 

Now, about the little boy. He was bitten by a black snake at around 12 pm yesterday. Couple of men saw the snake were definite that it was not a krait. The boy became unconscious as the family was on their way to consult the witch doctor. By the time they reached the witch doctor, the boy was presumed dead. Even the witch doctor declared him dead. 

As it was nearing evening, the family wanted to do the last rites and therefore took the body to a nearby river for cremation. As they laid him onto the wood and started preparing for the cremation, someone noticed that his limbs were moving and then someone declared that he could hear the heartbeat. 

Out they took the body from the timber platform and rushed . . . not to a hospital . . . yes . . . to another witch-doctor who was much more famous. This witch doctor declared that he was alive and started treatment. The treatment included pouring ground herbs into his nose. Nothing happened.

That was when someone told about KCH. The witch doctor also gave them hope that chances are better if they took the boy as soon as possible to Kachhwa. 

We were wide awake treating another snake bite victim who was on mechanical ventilation when a huge crowd of people walked in with the little boy. It was around midnight . .  . a full 12 hours after the snake bite . . .

One look and it was definite that the boy was long dead. After the customary examination, we declared him dead. Dilated and fixed pupils, a dry clouded cornea, absent heart beat . . . mouth filled with vomit . . . both nostrils stuffed with a ground herbs . . . bloated abdomen . . . there was no doubt . . . 

The relatives could not believe. They told me that the witch-doctor told them that there was some machine we had that could resurrect dead snake-bite victims. Trying to respond to these guys was mind-boggling. They lingered around for more than half an hour. 

At last, relatives of other patients intervened and convinced them that there was no point. I thank God that there were three snake bite victims who had recovered well at that point of time and their relatives were willing to talk and reason out. 

I never knew the full story till they left. After they left, few of the young men who intervened told me the above story. They also commented that this was not uncommon for them to hear such accounts. I also could believe it . . . I hope you remember the story I posted from one of the local newspapers in Jharkhand last year about a dead snake bite victim who was exhumed after burial not once but twice at the insistence of witch doctors . . . 

An ethical dilemma . . .

A 55 year old gentleman had come to us with seizures and hemiplegia about a month back. The arrival of this guy into emergency department was quite dramatic. He was quite a huge guy and he was throwing up multiple episodes of seizures. However, his seizures responded well to routine anti-seizure medications and a CT Scan of the brain showed multiple lesions suggestive of neurocysticercosis with perilesional inflammation. 

He was put on Albendazole, steroids and anti-seizure medication. 

Last week he came for review. As I talked with him, I inquired quite casually if he rode any vehicles. I expected him to say that he did not ride any. 

Instead he asked me why I asked him that question. I told him that while he is on the medications, he cannot drive any vehicles.

He started to sob. He told me that he had been a driver all his life. That was the only job he knew. He had been having seizures since the last 10 years and was thrown out the job from many places as he developed seizures in the middle of his driving. 

It seems nobody told him that it could be healed, although he would have needed to retrain for another job. In fact, when he came to us first time last month, his family had bluffed to us that it was the first time he got seizures. 

Yes . . . a life time of seizures . . . no proper treatment, investigations . . . 

Once his sobbing stopped, I asked him on what he did now for a living . . . I was shell shocked by the answer. 

He was a school bus driver. He reasoned that being a school bus driver, his working hours are much lesser. And therefore, the chance of getting a seizure was low. He was of the opinion that the history of long standing seizures was because of long working hours as a driver . . . That was what many of the quacks whom he consulted for his seizures told him.

I tried to reason with him that being a patient with history of seizures on regular medication, and that too with multiple neurocysticerosis lesions in brain, it would be a hazard for a whole lot of people including school children. 

He started to weep. He told me that it was with much difficulty that he got this job. He and his wife did not have any support from their daughters, who were all married off in far away places. His job was the only source of income . . . 

I knew it was not easy . . . 

Now, what do I do? Give it to him in writing that he cannot drive. Call the school for which he worked and tell them that it was dangerous to have this guy as a driver for their school bus . . . Tell him, that I could recommend him for a job . . . but then, he only knew to drive . . . 

The Danger of Searching

As Mahesh took lunch he was looking forward to play cricket with his friends soon. In spite of his father urging him to eat slow, he ate fast. One of his friends was already in front of Mahesh's home. He reminded Mahesh to bring the ball when he comes to play. 

Mahesh knew very well where he kept the ball after the previous day's play. He had rolled it under his bed where it would be safe among couple of sacks of wheat from the winter harvest. 

Soon, he was through his lunch. He could not see where he was supposed to search. As he groped the wheat sack searching for the ball, he felt a searing shot of pain on his left hand. Something had bit him. Then, he saw it. It was a black snake. 

He screamed for help. His parents rushed to him and he told them that a snake had bit him. 

As in most of rural India, the natural response was to rush him to a witch doctor. That's what everyone does. However, Mahesh's father knew quite well about the mission hospital 15 kilometers away which was good at managing snake bites. 

After some time at the witch doctor, the father took the initiative to bring Mahesh to us. By the time, Mahesh reached KCH, he had already stopped breathing and he only had his heartbeat. Dr. Krupa had him intubated in no time. 

With anti-snake venom being infused and Injection Atropine and Neostigmine being regularly given, we expected him to come out of respiratory paralysis soon. Considering the description of the snake given by the father as well as the massive amount of swelling at the bite site, we could easily come to the conclusion that it was a cobra bite. 

However, Mahesh did not respond to treatment till about almost 24 hours when he showed signs of recovery. Once he slowly regained consciousness, the progress was quite fast. 

But, he had the major issue of some serious cellulitis affecting the bite site. He is on regular dressing and as soon as we have our surgeon return from vacation, we would be looking at the possibility of a skin graft. 

Mahesh with his dad . . . 

Now, a major learning point from patients like Mahesh is about avoiding snake bites by always looking at where you place your hand or feet especially if it is a blind spot. It is quite common to see snake bites where the victim was rummaging for something without looking at where he or she was putting the hand. 

Krait Attack - 3

(There was a change in the snake involved after about a month after the patient was admitted. This was ultimately not a krait bite, but rather a cobra bite)

Since the setback we had with a krait bite patient since the Lord gave us success with 3 successive krait bite victims couple of weeks back, I was quite depressed. 

It was only today, I remembered about our third patient. 

I'm sure I would remember Mr. Dinkar the rest of my life. When Dr. Ao called me to see Mr. Dinkar for the first time sometime three weeks back, my heart sunk in despair. 

The  reasons - the guy weighed more than a 100 kilograms. The second - he hailed from a very well off family in the neighbourhood. They could afford to take him to the best hospital in the nearby city. But, the problem was he was totally out - Glasgow Coma Scale of 3 and not even a gasp for air. I could only admire Dr. Ao for successfully intubating him. 

Mr. Dinkar lay without any movement for a full 72 hours. Then, he slowly started to move his fingers, then his hands. We tried to extubate him, but was unsuccessful three times. His body was too huge to take the burden of his own respiration. 

To make matters worse, our Newmon ventilator collapsed shouldering the burden of ventilating him. It was the untiring efforts from his family and friends that he was kept breathing for almost a week. Since then, we've given orders for a new Newmon machine. 

The most amazing thing for Mr. Dinakar was the fact that he suffered a cardiac arrest when his endotracheal tube got blocked couple of days after his admission. We had to do a cardiac compression for more than 2 minutes before got the heartbeat back. 

It was relief to see him come out without a bed sore after being quite paralyzed for almost 10 days. Once the endotracheal tube was out, the recovery was quite fast. 

Mr. Dinkar with his two sons. The day he was bitten, his elder son (on the right in the snap) had just reached Mumbai.
He had to rush back to attend to his father. Dinkar lost quite a lot of weight during his stay.
He looks thin here because of the way the snap was taken. 

Unfortunately, he developed quite a bad infection at the bite site. We suggested that he be shown to a surgeon at one of the specialty hospitals at Varanasi. I hope the wound heals soon. 

Now, a very interesting thing about how Mr. Dinkar got the snake bite.

Mr. Dinkar usually sleeps outside his house in a open shed during the summer. Since it rained a bit, he decided to sleep inside his house on a cot. And that night, he got bitten. The culprit snake had climbed onto the bed and bit him. 

Mr. Dinkar's son told me that the floor of the house was only paved with bricks because of which lots of holes were there and mice lived in them. So, most probably the snake was also living in one of the rat holes. 

Lesson learnt from Mr. Dinkar's case - - - 

- KRAIT BITES CAN ALSO RESULT IN SEVERE CELLULITIS. IN FACT, THIS IS ONE OF THE ONLY TWO CASES OF KRAIT BITES I'VE SEEN WHICH ENDED UP WITH CELLULITIS AT THE BITE SITE

- DON'T LOSE HEART WITH KRAIT BITES. THEY MAY LOOK ALL DEAD FOR QUITE A FEW DAYS. THERE IS ALL CHANCE OF THEM MAKING IT.

- FAMILY SUPPORT IS VERY ESSENTIAL FOR MANAGING SNAKE BITES IN RESOURCE POOR SETTING

- IN ADDITION TO SLEEPING ON A COT, HAVING WELL PAVED FLOORS WITHOUT CHANCE OF ALLOWING HOLES/CREVICES IS ESSENTIAL TO PREVENT SNAKES FROM TAKING SHELTER INSIDE HOMES. 

Just to keep you informed, we have our hands full with snake bite victims since the last few days. In fact, as I write this, I've three patients into whom Anti-Snake Venom is flowing of which one of them is on mechanical ventilation. Shall be writing on each of them .. .. .. So, stay tuned.

PS: Later, we found out that the culprit snake here was not a krait, but rather a big cobra. Read about the change in snake involved by clicking here. 

Classic

I belong to that breed of doctors who graduated just as medicine was making a transition from a clinical art of questioning and examining a patient to arrive at a diagnosis to the present high tech investigation driven practice of medicine. 

At Medical College, Trivandrum where I graduated, we had some astute professors in almost all the specialties who drilled us into the rigorous routine of taking a proper history and doing a detailed examination to arrive at a diagnosis. I do not want to take the names of my teachers as I would end up doing injustice to some whose names I could end up missing. 

I write this as last week I got to see a patient who had a classical finding on clinical examination. 

I was not the primary clinician for this elderly man. 

As part of our training of working in resource poor environments, many of us in such settings end up doing ultrasounds on a regular basis. I do at least 5 ultrasounds per day which could stretch to 15 a day. 

So, there was this gentleman, a wizened man of more than 70 years, who stretched on the ultrasound table. Although, I had not examined him, I usually ask questions about the complaints and try to make small talk to ensure that the patient is comfortable. 

The guy had vague abdominal discomfort. However, as he pulled up his shirt, I was in for a surprise. There was well defined fullness in this right hypochondrium. I was taught that a major diagnosis to be ruled out when you see a fullness in the right hypochondrium was Carcinoma Gallbladder - the swelling was better seen than felt. 

Well, that was the classical teaching. I don't know whether it still stands today. 

Of course, ultrasound confirmed the dreaded diagnosis. Few snaps of the ultrasound pictures which I did not take well in the dim lit room. 

I'm proud and thankful to my teachers who took pains to help us arrive at diagnoses using our senses than the technology available, which was expensive and hardly available for the poor. 

The Monsoon arrives

The monsoon arrived at Kachhwa yesterday. Of course, it was a welcome relief from the heat . . . However, it caused quite a lot of damage, including the cancellation of the Prime Minister Mr. Narendra Modi's visit to Varanasi . . .

As usual, it was quite pleasant inside the campus. Snaps of our home and the inundated garden . . .

Death by krait bite

Last Wednesday, early morning, at around 6:30 am, we had a patient wheeled in with a krait bite. Our JD, Dr. Krupa had her intubated in no time and Anti-Snake Venom was flowing into her veins in no time. 

However, as similar to many krait bites, she was taking her own sweet time to come out of ventilatory support. She had already received 10 vials of ASV. Then, ASV was still going into her veins even today. 

She was however not an easy patient. For some reason, we could not sedate her well. Midazolam and Haloperidol are the only sedatives that we use here. From Saturday morning, she was insisting on being extubated. In fact, we extubated her twice over the last 36 hours. But, she could not breathe even with the endotracheal tube inside. 

I saw her last alive at around 5:30 today (Sunday, the 28th June). I tried to wean her out of the mechanical ventilation (being given manually as our ventilator has malfunctioned). She went into desaturation. 

I received a call at around 11:30 pm today (Sunday, the 28th June) that she had stopped breathing. Our JD on call, Dr. Ao was already there trying to revive her. It was obvious what has happened. She had developed surgical emphysema. Most probably, she had developed a pneumothorax or her endotracheal tube developed a perforation in the trachea. It was too late. Her pupils were already dilated and fixed. 

If I remember, this was the second patient I encountered in my career who developed a surgical emphysema during mechanical ventilation and died. The first one who was a snake bite victim. 

I agree that our ventilation facilities are lower than the optimum for state of the art care of such patients. But then, we cannot afford high end ventilators where we transfer costs to the patients. 

Another note on this lady. On Saturday morning, the relatives had come saying that they cannot afford any more treatment. We agreed to cap the bill to 15,000 INR whatever be the costs involved. When I told that, their bills had already reached about 20,000 INR and they had paid only 9000 INR. They told us that the for the rest of the 6000 INR, they would have to borrow money. 

It was because they had come to us that the costs were so low. 

We lost our first patient of the season who came to us with snake bite. 

It is a major blow to our morale. We should not have lost her. He family had brought her within 4 hours of the bite which happened while she was sleeping. They had taken her to two witch doctors before bringing her here. 

Pray that the family would be able to bear the loss . . . 

Issues of the Heart

Few days back, one of my senior colleagues shared an article on how deaths from heart attacks have dramatically come down in the United States. However, as I read it I know very well that only a minuscule of patients in our country who suffer a heart attack would ever undergo emergency angioplasty.

Angioplasty - that's the name given to the way they save the heart by opening the blocked artery by pushing in a catheter, inflating a tiny balloon and inserting a stent which will keep the artery wall patent. And this has to be done fast . . . very fast. 

Take the example of 2 patients whom I saw in emergency over the last couple of days at KCH. We worked fast to ensure that both the patients are referred to a higher centre. When we referred, the minimum we expected was that both the patients would be given Streptokinase to dissolve the block in their coronary artery. 

The first patient, a 38 year old mother of three with well documented anterior wall myocardial ischemia, was prescribed Aspirin, Atorvostatin and Clopidogrel and sent back home. 

The second patient was a 60 year old gentleman with typical symptoms of Myocardial Ischemia. He did not have typical features on ECG, but since the symptoms were typical, we referred him. Couple of days, the relatives came back saying that he had a heart attack with elevated enzymes. 

The guy was luckier as from the prescription, it seems that he got low dose heparin. 

There are 2 aspects. 

The first is the cost involved in treatment. The latter patient incurred a cost of 60,000 INR for treatment at the cardiac specialty centre he went to for a 3 day stay. No small amount for a middle class family, leave alone for the majority of my fellow citizens. 

The second aspect being the number of intervention cardiologists available in the country. I wonder if the total number of intervention cardiologists in the whole country is even a 4 digit number.

The third aspect is about where you'll be treated. The first patient was seen by cardiologists in a public healthcare set up. The second patient in a private tertiary cardiology care centre.

When we look at it - Yes . . . there's a lot of people dying out there or more than that getting debilitating heart damage due to ischemic heart disease, all because of high costs and non-availability of specialists. 

Well, the future looks bleak in a country which is still grappling with maternal deaths, children dying of diarrhoea and respiratory tract infections, tuberculosis and malaria. 

As for the time being the best option for us remains - 

1. Healthy eating habits

2. Good exercise

3. Control of risk factors such as diabetes and hypertension. 

From the policy, we would need to see - 

1. If thrombolysis treatment can be authorised in primary care.

2. Short courses for medicine consultants in the public health secondary care institutions to do angioplasties.

Till those happen, the 3 cardinal rules to have a healthy heart remains the best option in the country . . .