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. 

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. 

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 . . . 

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. 

Pediatric ICU

It is not even one week since I received a call from a prospective pediatrician for NJH about the pediatric workload at NJH. Well, this post is sort of an answer . . . 

Today's patients in the Acute Care Unit . . .

Bed Nos. 1: 3 year old boy, AA. Admitted with complaints of one day history of fever, multiple episodes of seizures and altered sensorium since today early morning. We had to intubate him and mechanically bag him within minutes of his admission. The diagnosis - Meningoencephalitis with aspiration pneumonia. The boy is quite sick.

Bed Nos. 2: LK, a 9 year old girl, who was sick with fever since 4 days. Since today morning, he had multiple episodes of seizures. The diagnosis - Meningoencephalitis with aspiration pneumonia. Her condition is better than AA, but needs oxygen to maintain saturation although she is not intubated. 

Bed Nos. 3: 9 year old girl, NK, who came on the 3rd August after a krait bite. She has been intubated since. By God's grace, her condition has improved quite a lot. Weaning off the ventilator would take some more time.  

Bed Nos. 4: 20 year old young lady, KK, who had a cobra bite at around 3 pm yesterday and was brought around 8 pm after going through the customary rituals of 'jhad-phuk' and couple of visits to other hospitals. We had to intubate her within minutes of her arrival . . . She continues to be on the ventilator. To make matters worse, she has a bad ischaemia of the site of the bite - Right middle finger - which most probably needs amputation. The only adult patient now in the ACU. 

Bed Nos. 5: 16 year old boy, who was bitten by a krait on 2nd of August. He has also been on the ventilator since admission. Dr. Roshine plans to take him off the ventilator sometime later today. 

Bed Nos. 6: 10 year girl, BK, admitted today morning with the history of fever since 8 days, headache and vomitting since 3 days and couple of episodes of seizures since yesterday. Lumbar puncture is suggestive of a tuberculous meningitis.

So, 4 out of 6 patients in ACU are children, another one is a teenager. That provides the answer to the prospective pediatrician . . . 

The things to be thanked for . . . all the 6 patients are sick and it was such a relief to see all of them hooked onto multipara monitors. Thanks to all those who helped us to get to this state of affairs. 6 multipara monitors, 1 full fledged ventilator, 2 anesthesia ventilators, 2 syringe pumps . . .

The sad thing was to see little AA being manually ventilated . . . However, you know, there are no ventilators of any type other than those we have for a radius of almost 150-200 kilometers. 

Of course, many more things to be done before it would become a full fledged ICU . . . more on that in the next post . . .