Sunday, July 12, 2015

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 . . . 

Monday, July 6, 2015

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. 

Friday, July 3, 2015

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 . .  .


Thursday, July 2, 2015

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. 

Wednesday, July 1, 2015

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