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

Medicines for all - DPCO

Couple of years back I had written a post where I commented about thenon-availability of cheap but effective medicines in the general market. The drug is question at that time was Hydrochlorothiazide, which is the first choice drug for uncomplicated systemic hypertension.

Recently, quite a few medicines were brought under the Drug Price Control. This means that the government has fixed prices for quite a lot of drugs. This resulted in drugs becoming more affordable. 

Many of us had expected problems for some time. We did not face any problems in the beginning.

However, now we are faced with a major issue. Over the last 2 weeks, we’ve a shortage of commonly used medicines. The list my store clerk sent reads – Injection and Tablet Hyoscine (Buscopan), Tablets and Injection Frusemide, Asprin tablets, Normal saline nasal drops, Salbutamol Tablets, salbutamol Inhaler, Injection Benzyl Peniciline (Crystalline Penicilline)and Injection Haloperidol.

All the above are quite commonly used medications. And also quite cheap.

And the latter is the exact reason they are not easily available.

‘No margin, sir’, the supplier says.

However, the pharmaceutical companies have come out in droves against the order.

A side effect of this issue . . . comparatively expensive medicines are easily available in the market. We were surprised recently to see even quacks prescribe medicines such as Cefpodoxime.

Unfortunate . . . but true. How long will it take for the government and now the judiciary to realize that the pharmaceutical industry can make a mockery of science . . . and that too medical science.

I’m sure about what is the latest on this. One of my friends told me that the industry has gone to the court and the DPC list is stayed. However, my suppliers tell me that after DPC, their margins have come down a lot. There were also news reports about this few days back.

My take on the matter is that the healthcare community needs to take a very strong stand against this move of the pharmaceutical companies. 

Managing diarrhoea . . . Complicating things

Yesterday, I was taking rounds when I came to a little boy, 11 months. He looked irritable and took my presence with much protest. I wondered why he should be admitted. 

The case sheet showed - 'Loose stools: 3 days. Being managed elsewhere. Baby has no relief'. 

There is no history of fever or any difficulty in feeding. There was couple of episodes of vomiting which has since settled . . .

I was interested in the 'management elsewhere' - 

And these were the list of medicines the little child was on - - -

1. A combination syrup of Salbutamol and Guiphenasin: 5 ml three times a day. 

2. Inj Ceftriaxone and Tazobactum - twice a day

3. Resicadrotil drops - 20 drops twice a day

4. Syr. Colistin Sulphate - 3 ml thrice a day

5. Inj Amikacin - one injection a day since the last 3 days

6. Neopeptine drops - 20 drops at night

7. Promethazine + Paracetamol syrup: 5 ml thrice a day

8. Ofloxacin + Metrogyl syrup: 5 ml thrice a day

9. Probiotic powder (Lactobacillus)

10. Dicyclomine drops: 5 drops thrice a day

11. Syrup Loperamide: 2 ml when needed

Well, I wonder if the little boy needs food at all . . . There would be no space in his little tummy after he's taken all those syrups . . .

This is the knowledge many of our doctors have about managing diarrhoea. 

You don't want to miss anything - so hit all the bacteria you've heard about or use all the antibiotics whose name you've heard of . . . I'm sure that if they had heard about any anti-virals, that would have also been started. . .

Below is a snap of all the medicines . . .

The worst part of the prescription. There was no Oral Rehydration Solution at all. . . If the doctor had added ORS to the prescription, that would have made it 12 medicines to treat a case of diarrhoea. . . 

We've stopped all medications. The baby's doing well . . . 

Tuberculosis . . . continuing to ravage . . . and helped on . . .

Over the last couple of weeks we've had reports of a new form of tuberculosis which the government refuted within a surprisingly short interval.

Today morning, in OPD, I had three new patients who were all partially treated tuberculosis. All very similar histories which found common ground in an article I read recently. I'm not very sure on whether their sputums will yield acid fast bacilli as almost all of them had been on some form of tuberculosis treatment. And none of them have had any trace of government medicines in them . . .

Well, tuberculosis is not an uncommon diagnosis in NJH. In fact, we are a tuberculosis unit which cater to one third of the district. Today and tomorrow, our Medical Officer is on a training course of diagnosis and management of Multidrug Resistant Tuberculosis. 

The patient I wanted to tell about is TT, a 17 year old young man admitted into our ward. We diagnosed TT to have miliary tuberculosis on the basis of his symptoms and Chest X-Ray. But TT was already on treatment for Tuberculosis from a private practitioner. He was put on a sub-optimal dosage of a combination therapy of Rifampicin, Ethambutol and Isoniazid. No Pyrazinamide . . . 

But, what interested me more was the number of other medicines which TT was on. I've tried to take a photograph of all the medicines put together. 4 of the medicines are multivitamins which totally cost about 30 rupees per day. Then, there is a cough syrup. One strip is Diethylcarbamazine . . . and then he has been on regular daily intravenous injection of Amoxyciline and clavulanic acid as well as on a combination of oral Ampicillin and Cloxacillin. 

It is unfortunate. There has much written on unethical and spurious medical prescriptions written by quite a lot of our fellow practitioners. It is not uncommon to see even well qualified and well known doctors write so lengthy prescriptions. Of course, there is a lot of money to be made. But, the ultimate question is about the cost poor people like TT or the other 3 patients whom I had seen in outpatient today pay? ? ? 

Essential Drugs

Recently, there has been reports of a major study which brought out the fact that cheaper effective drugs are not being used to combat non-communicable diseases in the country.

Although I did not read about this study in 'The Lancet', I’m reminded of the umpteen number of patients that I see with very expensive medicines given for diabetes and hypertension. Couple of hours back, one of the patients’ bystander, BBM whom I discharged today came to me very discretely and wanted to know if the patient needs to continue the drugs which she is taking from elsewhere. I was a bit taken aback as during admission we had asked the patient about previous treatment being taken. The relatives had replied in the negative.

She was admitted with septicemia and urinary tract infection. The treatment has been quite expensive for the family.

Now, here was a relative of the patient whom I had not seen before standing in front of me saying that she had diabetes and hypertension and she was on quite a lot of treatment. She had 3 different medicines for her hypertension, 3 other medicines for her diabetes, one drug for lowering cholesterol, one for lowering triglycerides, couple of vitamin tablets and two drug to prevent platelet aggregation. The total cost of her medicines for one day was about 60 rupees. It was only 3 months since she has started on the treatment and the family was already feeling the pinch.

If you thought that she must have been a very obese lady looking very sick, you are mistaken. She was quite fit and when she got discharged she looked quite fine. Her blood pressure was normal throughout admission and her random blood sugar was a bit on the higher side. We were planning to do a FBS/PPBS sometime during admission which we missed out.  

Well, I did not know what to say to this man. First of all, this family had not mentioned anything about her medical problems during admission and now they want me to take a decision on whether she should continue on her present medicines, almost half which I've no idea about.

BBM was already discharged. Her blood pressures were normal. I’ve asked the family to bring her in after about a week where I would be checking her FBS/PPBS and other parameters. I hope that I would be able to start bit more simple medicines for her when she comes back next week and enable to make her treatment more affordable to the family.