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 . . . 

Krait Attack - 2

Prameela went home after quite an uneventful period of admission in the hospital. However, Prameela was an eye-opener about why many snake bite victims are already dead when they reach the hospital.

Prameela reached last Sunday late evening. She was just alive. Gasping for breath with secretions flowing out of her mouth and nostrils, she would have been a goner if the family was late by another fifteen minutes in bringing her.

Prameela was bitten about 15 hours back, sometime before dawn. Her family members had woken up hearing her scream and caught the intruder which had bit her – a 2 feet long krait. Beliefs demanded that the krait be taken to a safe place and let free. The family was more concerned about setting off the snake free than about Prameela who was bitten.

They took the snake quite far away, deep into the jungle to release it which took them about 4 hours. By the time they came back, Prameela was not feeling well with feeling of something in her throat and abdominal pain. It was about 6 hours after the bite that Prameela was taken to a hospital.

At the hospital in the district headquarters, Prameela was administered intravenous fluids and some injections, the total cost of which was only 600 INR, which means she was not given Anti-Snake Venom. As Prameela’s condition appeared to worsen, someone suggested that she be brought to us.

We had to intubate her immediately. And she was in the ventilator for a good 48 hours. Thankfully, her recovery was quite fast.

Now, the worst part of any snake bite is what hit us next - The cost of treatment.

Prameela ended up with the requisite 20 vials of ASV. It was obvious that the total costs were much beyond the reach of the family. With tight budgets this year, we also were finding it difficult to write off bills. The family came to us begging for charity. We could not afford to give more than a 5% charity on the bill which was raised, which already gave her a charity of around 20%.

This is one of saddest parts of any snake bite. It is the rural poor who are the most affected. Since the last 3 years, the cost of Anti Snake Venom has risen by about 200%.

I feel that there are 2 solutions to the problem.

The first solution would be make ASVs freely available in all government facilities as well as designated facilities like ours which have a reputation for snake bite management. Closely linked to this would be efforts to decrease cost of making the ASVs.

Till that happens, patients such as Prameela would be dragged down the poverty hole by snake bites . . . 

Lessons learnt - 

1. TRADITIONAL BELIEFS CONTINUE TO BE A HINDRANCE TO TREATMENT OF SNAKE BITE VICTIMS. 
2. THE ONSET OF RESPIRATORY PARALYSIS CAN BE DELAYED BY AS LONG AS 15 HOURS IN KRAIT BITES. 
3. COST OF CARE IS A MAJOR ISSUE WITH SNAKE BITE CARE. 
4. KNOWLEDGE OF CARE PROTOCOLS FOR SNAKE BITE VICTIMS ARE VERY POOR AMONG DOCTORS

The patient I mentioned in the previous post, Alokita gave consent to be photographed and her story to be shared in my blog . . .

Alokita with her parents

Back to square one

Over the last 2 weeks, we were on the move once again and are now based at a small mofussil town in Eastern Uttar Pradesh, about 300 kilometers from Palamu region. We’re not quite sure about the future, but for now, we would be based at Kachhwa Christian Hospital, Kacchwa, Mirzapur District.

We are about 50 kilometers from Varanasi or Banaras. In fact, the river Ganges is just 2 kilometers from where we are now.

Coming to the hospital, it serves the small town of Kachhwa. I shall write about the place in a later post. The best part of my first week was a 30 year of mother of two who was brought in gasping after she got bitten by an unknown snake. She was almost dead.

Our team got her intubated and resuscitated in no time. Considering that she did not have swelling over her bite site, we were quite sure that it was a krait bite. We had ASV pumping into her veins in no time. And what did we have for the mechanical ventilation?

I could not believe my eyes when I saw the machine. It was the same one; the war horse we had at NJH when we reached there in 2010.

The Newmon ventilator did a wonderful job for about 24 hours before she ran out of steam.  The relatives did manual ventilation for about 8 hours before the machine started to work again.

Thankfully, the lady could be weaned from the ventilator by 48 hours. Unfortunately, we discovered that she had some amount of brain damage, which may have occurred during the period of cardiac arrest (We do not know on how long she had not been breathing. The relatives told that she stopped to breathe about 5 minutes before we intervened.).

Our patients would definitely benefit if we had one more Newmon ventilator. It costs about 80,000 INR now (1350 USD, 820 GBPs, 1050 Euros) and the people here know where the machine can be purchased.

More on the clinical exploits at Kachhwa and about the place in a later post . . . 

A 'big' snake bite . . .

Yesterday, we had a lady being wheeled into casualty. She had been bitten by a viper about 12 hours back. She had a swollen leg and couple of bite marks. However, she was very cold. And we could not get a pulse on her. She was in shock. 

One of the relatives told me that she was bitten by a baby python. They had brought the snake!

I was sure that there was envenomation. She had difficulty breathing although her saturation was normal. 

I got 2 vials of ASV going into her along with the intravenous fluids and decided to take a look at the snake which was kept outside. 

Thankfully, it was a killed specimen. And what did I find . . . 

Yeah, a really big viper . . . 

So much for people misidentifying snakes . . .

Surprisingly, her clotting time was normal. However, the urine output was on the lesser side. The creatinine was 1.57 mg%. I gave her Anti Snake Venom according to the low dose protocol. 

It's 36 hours now. She's done well so far. The urine output is on the rise. Tomorrow, we shall repeat the S. creatinine. And if that is fine, she should be going home. 

Focus . . . Snakes and snake bites . . .

Last week, NJH was part of a group of hospitals who were invited by the Christian Medical College, Vellore to look into snake bites and their management . . .

I leart quite a lot of things. It was a privilege to rub shoulders with who’s who in herpetology. Romulus Whitaker, Gerry Martin, Dr. Oommen V Oommen, Dr Bawaskar, Dr Punde . . .quite a lot of big names in the field.

Yesterday, I was talking to my staff in Community Health and Development about how fast we draw conclusions without looking into evidence.

Over the last month, I had put up the post on the clientele we serve at NJH. And later something about neurocysticercosis and their cause. Regarding the former topic, quite a good number of our staff thought that we serve a higher number of poor. I got quite a number of feedback about the ‘new information’ they received in the post on neurocysticercosis.

The common aspect about snakes and snake bites are the myths that surround them.

Couple of the myths that I harbored for long were given the boot after the meeting.

The first one . . . I was under the impression that a venomous snake bite late in the night or early daybreak would be less venomous compared to a bite in the evening. The reason . . . the snake would have already spent it’s venom on a prey and therefore a lesser amount only would be available to inject into the next victim. The same logic applying to snake bites on two consecutive victims by the same snake. The second victim would have lesser venom injected thereby causing lesser envenomation in the second victim.

The venom is the saliva of the snakes. Even after a biriyani, you’ll continue to secrete saliva if there is ice-cream after that. Similarly, the snake would continue to secrete the venom irrespective of the fact whether it had a prey before biting a victim.

The second one . . . a non-poisonous snake in your backyard means no poisonous snake in the same area. Absolutely wrong. Any snake seen means more snakes in the area. It was reported that it is not uncommon for a venomous and non-venomous snake to share the same hole!!! I remember someone tell me that it is not good to kill a non-venomous snake as it’s place in the habitat may be taken by a venomous one.

There is nothing like a territory for a snake. . . the way they have for tigers etc.

The third one . . . which is quite frightening. I used to believe that use of chemicals such as phenol would help keep out snakes. And after we had couple of snakes inside the house during our first year at NJH, we’ve not seen them inside after we started to regularly use phenol to wipe the floor. In fact, there is no evidence to support the fact that snakes dislike phenol. However, snakes don’t like clean places. They love dirt and areas with things like papers, leaves etc. piled up. The fact that snakes are not entering the house is because of cleanliness that accompanies a daily wipe with phenol and not the smell of the chemical.

However, the best ones . . .

Kindly see the snap below. The blue bordered regions are places where a proper taxonomy of existing snake species has not been done. Quite an exciting thing for mission hospitals in North India such as ours as we can be base for quite a lot of work on getting to know more about these creatures.

The final straw . . . The snap below. Kindly note the thing written in red. This is the number of vials of antivenom that will neutralise the maximum possible venom that is injected during a bite of the concerned snake.

The question is now going to be about how WHO has come up with a protocol of 20 vials to be used for any sort of snake bite. . .For units such as NJH, this has major implications . . . as a low dose protocol should theoretically be enough to salvage viper and krait bites . . .

We’re quite excited of the future . . . we could be part of path-breaking research on snake bite syndromes and their management.

Pray for us . . . 

RSBY Success Story . . . But . . .

On the 24^th of last month, MDO, a 20 year old young man was searching for some thing in his house late in the night, when he was bitten by a krait on his hand. As is the prevalent practice, his relatives summoned a local faith-healer who assured them that everything was alright.

However, as time passed, the father realised that something was amiss. MDO was not able to breathe properly and was looking very sleepy.

NJH, being very near to his home and one of his cousins being a chowkidar in the hospital – the family rushed MDO to NJH.

On arrival at NJH, Dr Johnson attended the call. MDO was hardly breathening and was bluish all over. There was no response to stimuli and his pupils were mid-dilated and hardly reacting. MDO was intubated and was put on the mechanical ventilator. The relatives were explained about the very small chance of survival. It was about 1:00 am of 25th August. 

Meanwhile, our chowkidar, Mr. Jamuna who was MDO’s cousin told us about the RSBY Smartcard (Rashtriya Swasthya Bima Yojana) the family had. It was brought immediately and was promptly blocked for treatment of snake bite.

It was only recently we were having a discussion of snake bites being covered under RSBY as there was a major increase in costs of Anti-Snake Venom (ASV).

Since, we were yet to come to a conclusion on the increase in ASV costs, we decided to treat him fully under RSBY.

By the 25^th morning, when I came for rounds, MDO’s pupils were fully dilated and fixed. There was no reaction till about 26^th afternoon.

He was in the ventilator for 80 hours. And intubated for 104 hours. 120 hours of Acute Care admission. . . 30 B-type oxygen cylinders . . . 20 ASVs - the cost of which alone is 13000 INR

MDO is getting discharged today. The problem was that his total bill had come to a whopping 45000 INR and RSBY was going to pay us 10500 INR.

MDO with his father

We’re not sure on how to approach this. The family is ready to pay us 7500 INR more. But, as per RSBY policy we are supposed to be giving cashless service. I’ve sent a mail to our Insurance Providers explaining about our predicament. I hope that they would respond positively.

The interesting part is that we have 3 more patients in the ward with krait bite. And all of us are in some part of their ventilatory support . . . I’m glad that we have 2 ventilators . . . But still, we’ve to refuse all patients who could end up needing a ventilator since yesterday . . .  eclampsias, snake bites, severe pneumonias etc . . .

The recent increase in cost of ASV make it quite difficult to treat snake bite victims under any protocol of snake bite management under RSBY. I hope that the concerned authorities would take note and do the needful . . . 

(Consent to publish the photograph and the story has been obtained)

Start of the new season . . . Snake Bites . . .

Summer has started and patients with snake bites are back. Over the last one week, we had 3 patients - first one with viper bite, and the other 2, cobra bites - both of them coming over the last 2 days. 

The second patient, and the first cobra bite victim, a middle aged lady who was bitten yesterday night had come sometime early morning yesterday. She was hardly breathing and was in a total neuromuscular paralysis. It seems they had been trying black magic (locally called 'jhad phuk) to remove the poison all through the night. 

Early yesterday morning, someone suggested that she be taken to NJH for treatment. 

She had to be intubated immediately and started on mechanical ventilation. She responded quite well and was out of the ventilator within 2 hours after having received 10 vials of the anti-snake venom. By evening, she was sitting up and we kept her for observation overnight. She has some local swelling which would take some time to subside. 

Well, she is a milestone patient for us as she has been treated completely free under the RSBY.

The third patient, a young girl with an unknown bite came sometime late afternoon today. The diagnosis was very obvious - either a krait bite or a cobra bite. The clotting time came out normal. Therefore, cobra bite. In went 10 vials of the anti-snake venom and she was soon on her way to complete recovery. 

However, I should tell you a bit more about the little girl. She had been bitten sometime early morning. She came straightaway to the district hospital. She was kept there for about couple of hours although a diagnosis of snake bite was made. And at around 1 pm, she was referred to Ranchi. Someone suggested that they try out NJH. And that's how they reached here. 

It is unfortunate that the district hospital has no facilities to keep ASV, when the prevalence of snake bites are quite high in the region.