Wednesday, July 1, 2015

Krait Attack - 3

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. 

Tuesday, June 30, 2015

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. 

Monday, June 29, 2015

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 . . .