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 . . .