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. 

Snakes galore

The last week was quite busy. We had about 20 patients brought in with snake bite. We lost Shivam couple of days back. By God's grace, only 8 of the 20 patients had evidence of envenomation. Interestingly, nine of the 20 patients brought the culprit snake, 7 of them dead snakes and two alive ! ! !. 

Here are the snaps of the snakes brought . . . I'm glad that none of the snakes were non-venomous . . .

This is a baby cobra which bit a 30 year old lady. Thankfully, there were no signs of envenomation. 

This is a krait which bit a lady who was sleeping on the floor. Again, there was no envenomation. 

This bit a 25 year old man on his toe. Again, no envenomation

I thought this was a wolf snake. This is live. The local experts say it is a krait. The 35 year old lady who was bitten by this snake had some sore throat and dizziness for about 12 hours which settled over time. There was no ptosis. We kept the patient on observation for 36 hours and discharged her. No ASV was given. 

A cobra who bit a prominent person of a village about 40 kilometers away. Mr. Phekku, 60 years old came in about 2 hours after the bite after the customary visit to the jhad phuk. He was on mechanical ventilation for about 2 days. He is doing fine now. We gave him the maximum possible dose of 20 vials ASV. Interestingly after we told the family that the culprit snake could be in the enclosed space where he was bitten, the family hired couple of snake charmers who caught the snake live and brought it to the hospital for identification. God only knows if this was the culprit snake or one which the snake charmers got out of their kitty and show cased it. 

Another krait. Again, the victim did not have features of envenomation. 

This snake bit a 40 year old lady from a nearby village. She was brought in almost 12 hours after the bite. She had ptosis and respiratory distress. She maintaind saturation without need of intubation. Her ptosis resolved after 10 vials of ASV.

A 3 feet long cobra which bit a 50 year old man inside his flour mill. It was wrapped around one of the machine parts which he was cleaning. He came in within 15 minutes. Initially, they did not know what snake it was. Later, when we told the relatives that considering that the bite happened in a room, the snake could still be lurking inside, the searched and found it out and killed it. Interestingly, within few minutes of the snake being brought in, the patient started developing ptosis and throat discomfort. He responded well to ASV and got discharged aftr 48 hours. He needed only 10 vials of ASV.  

Another krait brought in by a patient who was bitten on the leg. Again, no features of envenomation. 

It is quite interesting that only one patient out of the six who brought in the dead krait had features of envenomation whereas two out of the three patients who brought a cobra had features of envenomation. Please note that there were 11 other patients who came with bites from unidentified snakes. 5 of them had features of envenomation and we had to give ASV. 

And, we finished about 100 vials of ASV in 3-4 days, including 50 on a single day . . . 

More, in the next posts . . . 

Dangers of searching revisited

We had one more snake bite victim who got bitten just because she did not look at where she was putting her hand. Being a adolescent girl in a rural Indian household, she was doing her chores as part of the routine of her household. 

Arti was in charge of rolling out rotis every day morning. 

It was just another routine day which ended up being a nightmare for her and the family. For along with the wooden slab and rolling pin, which were used to flatten the lumps of wheatflour dough, was a krait which must have been attracted to the cool environment of the wood in a hot Indian summer. 

Arti put her hand into the pile of vessels which also contained the wooden slab and rolling pin. The bite was not painful. She did not develop symptoms immediately. First it was a difficulty in keeping her eyes open, which was followed by a funny sensation in the throat. 

It was dawn when she was bitten, but by the time she reached us it was late evening. Her condition was so bad that she could hardly breath. She needed mechanical ventilation. 

However, she was lucky to be weaned out within 48 hours. 

Well . . .  another warning about putting your hands into spaces without looking if there is danger lurking. 

Arti with her parents just before discharge . . . 

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. 

Is it really worth?

It was only today that a senior colleague and mentor wrote about love, care and concern showed by relatives of patients who've quite serious illnesses, especially when they come from not-so-well off backgrounds, both in terms of intellect and finances. 

In fact, we have a snake bite victim suspended between life and death . . . 

We were quite surprised that the parents brought this 8 year old boy who was bitten by a snake almost a day back . . .  20 hours to be exact. 

Shivam was playing in front of his home when he was bitten at around 6 pm last Monday. Neither his parents nor his friends saw the snake. It was with quite difficulty that they realized that Shivam was bitten by a snake . . . 

Shivam is intellectually disabled. He does not talk much and is known to be 'weak brained' by everyone in the village. He hardly speaks. And that was the exact reason nobody found out about the snake bite. 

It was only when Shivam started to develop breathlessness that his parents realized that something was amiss. Somehow, Shivam conveyed to them that he was bitten by a snake. In addition to the breathlessness, he started to have discomfort of the throat, which he conveyed well to his parents. 

Now, by the time, his parents realized that their son was bitten by a snake it was late morning the next day. As was the custom, they went to the wich-doctor, popularly called jaad-phuk. It was obvious that he could do nothing. 

By the time, Shivam reached KCH, he was desaturating and it was obvious that he needed assisted breathing. Being a child, we had our challenges. Our ventilator had conked off after being hooked to Dinkar. All the patients who came after Dinkar were manually ventilated. 

It's past 48 hours since he is intubated and being mechanically ventilated. And through this 48 hours, he had quite a many challenges, which I shall narrate in a later post. 

Today, sometime late evening, we realised that Shivam's sustained some amount of mechanical ventilation injury. There was subcutaneous emphysema - air under the skin. He's already had 3 changes of his endotracheal tube. 

His saturation is maintained well. We hope that he'll make it inspite of the subcutaneous emphysema. I've previously had couple of patients who went into this condition. One did not make it . . . the second one did . . . 

We request prayers for Shivam. 

I'm so encouraged to see Shivam's parents constantly at his side encouraging and chiding him to hold on. Do realize the entire family has been pitching in by manually bagging him. Manual bagging for 48 hours is no small thing . . . 

I wonder if a more well off family would have shown such care. I've at least seen in one instance when a well off family decided not to care when a major illness affected their mentally challenged son. 

Once more . . . request prayers for Shivam . . . 

If you ask me . . . it is really worth caring and making our utmost effort to save Shivam . . . for we are all made in God's Image . .  .

Krait Attack - 3

(There was a change in the snake involved after about a month after the patient was admitted. This was ultimately not a krait bite, but rather a cobra bite)

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.

PS: Later, we found out that the culprit snake here was not a krait, but rather a big cobra. Read about the change in snake involved by clicking here. 

Death by krait bite

Last Wednesday, early morning, at around 6:30 am, we had a patient wheeled in with a krait bite. Our JD, Dr. Krupa had her intubated in no time and Anti-Snake Venom was flowing into her veins in no time. 

However, as similar to many krait bites, she was taking her own sweet time to come out of ventilatory support. She had already received 10 vials of ASV. Then, ASV was still going into her veins even today. 

She was however not an easy patient. For some reason, we could not sedate her well. Midazolam and Haloperidol are the only sedatives that we use here. From Saturday morning, she was insisting on being extubated. In fact, we extubated her twice over the last 36 hours. But, she could not breathe even with the endotracheal tube inside. 

I saw her last alive at around 5:30 today (Sunday, the 28th June). I tried to wean her out of the mechanical ventilation (being given manually as our ventilator has malfunctioned). She went into desaturation. 

I received a call at around 11:30 pm today (Sunday, the 28th June) that she had stopped breathing. Our JD on call, Dr. Ao was already there trying to revive her. It was obvious what has happened. She had developed surgical emphysema. Most probably, she had developed a pneumothorax or her endotracheal tube developed a perforation in the trachea. It was too late. Her pupils were already dilated and fixed. 

If I remember, this was the second patient I encountered in my career who developed a surgical emphysema during mechanical ventilation and died. The first one who was a snake bite victim. 

I agree that our ventilation facilities are lower than the optimum for state of the art care of such patients. But then, we cannot afford high end ventilators where we transfer costs to the patients. 

Another note on this lady. On Saturday morning, the relatives had come saying that they cannot afford any more treatment. We agreed to cap the bill to 15,000 INR whatever be the costs involved. When I told that, their bills had already reached about 20,000 INR and they had paid only 9000 INR. They told us that the for the rest of the 6000 INR, they would have to borrow money. 

It was because they had come to us that the costs were so low. 

We lost our first patient of the season who came to us with snake bite. 

It is a major blow to our morale. We should not have lost her. He family had brought her within 4 hours of the bite which happened while she was sleeping. They had taken her to two witch doctors before bringing her here. 

Pray that the family would be able to bear the loss . . . 

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

Krait Attack - 1

Since last Sunday, we had 3 patients with krait bites. On analysing the 3 patients, it is very interesting that we saw almost all varied features of krait bites. 

Krait is known as 'the dirty snake' or the 'mysterious snake' among the big four in India - the other three being Russel's viper, cobra and the saw scaled viper. In fact, krait bites have baffled clinicians with it's varied presentations. A cursory google search yields varied and many a time contradictory findings across the regions where krait bites are seen. 

Let me go to the first of three patients we had to treat this week - all of them needed ventilation. 

The first patient, we'll call A. As she went to take water from a handpump, she had put her foot into a puddle of water and she felt something wiggling under her leg. She had pulled out her leg and she did not feel any pain. Later, she developed some sort of a funny feeling of her legs giving way and a sore throat. Her parents attributed it to a fever she had couple of days back. She had mentioned about the snake which grazed her feet. 

The parents were wise enough to bring her to the hospital. By the time she reached, she was gasping with a falling oxygen saturation. It was not difficult for my colleagues to diagnose a neurotoxic snake bite. Within no time, she was intubated. 

And she slept for a full 3 days without any sign of life except for her heart beat and sluggishly reacting pupils. In addition, she had high blood pressure readings which did not respond to any anti-hypertensive medication as well as high grade fever which did not respond to Paracetamol or other NSAIDs. 

It was difficult for her parents to accept that it was a snake bite. In between they suggested that her condition had something to do with her fever couple of days back. To convince the parents, we did blood tests which all came out to be normal. 

On the fourth day, she showed signs of arousal. She slowly started to move her eyelids, fingers and toes. And by Friday morning, she was off the ventilator. However, even today, she had only Grade 4 strength of her muscles. Today (Sunday, the 14th June, 2015), 

It was good she was off the ventilator on Friday as we had another krait bite patient on Friday midnight. More on the next patient in my next post. 

Now, lessons on krait bite from this patient. 

- A BITE MARK NEED NOT BE PRESENT ON A KRAIT BITE VICTIM. 

- THE RELATIVES NEED TO BE WARNED ABOUT PROLONGED PERIODS OF VENTILATORY SUPPORT WHICH COULD BE ASSOCIATED WITH COMPLICATIONS 

- THE HIGH BLOOD PRESSURE AND FEVER ARE COMMONLY SEEN FEATURES OF KRAIT BITES. 

- IF YOU SUSPECT KRAIT BITE, ENSURE THAT FACILITIES ARE AVAILABLE FOR INTUBATION AND VENTILATION. Our experience shows that we do not need high end machines for ventilation. Because of cost constraints, we use the Newmon Ventilator, which we used at NJH too. At a cost of around 80,000 INR, it is much more affordable for smaller hospitals in comparison to high endventilators which is more than 10 times costly. 

Look out for the next post, which should as soon as our second patient comes out of coma . . . A third patient has just come in and got intubated. As the second patient is hooked on the only ventilator that we have, the third patient is being manually bagged. Pray for them . . . 

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 . . . 

Almost missed . . .

Couple of days back, we got a patient who came in late into the night with vague complaints of abdominal pain and weakness of the limbs. 

He was already seen at multiple places where diagnoses of all sorts were made. 

The history was that JPJ, a 40 year old man woke up at around 3 am in the morning with severe abdominal pain. He was immediately taken to the hospital where the doctors could not come to a conclusive diagnosis.

The relatives took him to a total of 3 places . . . over a period of about 18 hours. 

The snaps of the prescriptions are given below . . . 

Please note the diagnosis - Pulmonary edema with acidosis with cerebral malaria. 

The patient had investigations like widal and chest x-ray

By God's grace, somehow Titus who was on duty suspected that JPJ had a krait bite. There was ptosis. 

In addition to the complaints of abdominal pain and weakness, the team noticed that his respiration was becoming labored. 

After discussions with the rest of the team, we sort of convinced the family that it looked like a snake bite. 

Within no time, he was gasping. We had him hooked onto the ventilator. 

With ASV on flow, he made a slow recovery. After 2 days, we thought that he was ready for extubation. On extubating, we discovered that his larynx was all swollen up. It was only a miracle that we could get him re-intubated. 

The relatives were quite agitated. They just could not accept the fact that he was doing good and suddenly had deteriorated. It was then that we realized that the family was quite well off and had the required good connections in Ranchi. 

After quite a lot of discussions, we told them of the futility of trying to shift him to Ranchi without a mobile ventilator. After quite a bit of conference with the relatives with the help of couple of doctors in Ranchi, the family decided that they stay back. 

He was on the ventilator for 2 more days. 

Today, Dr. Roshine told me that he is doing good and would be going home soon. 

A strong reminder to all of us on how a krait bite can turn out to be. With no bite marks, it is quite a tough task for the clinician to come to a diagnosis. And more difficult to explain to the relatives. If JPJ had come to us early in the morning, we could have also made all sorts of diagnoses. 

It was a lesson for all of us . . . regarding krait bite presentation . . . and how misleading can the history be. 

In addition, a strong affirmation for our service and a glowing example of how NJH continues to be the only lifeline for people like JPJ in this part of the country. 

Glimpses of possibilities

Yesterday, Titus called me to say that they ran out of ventilators for patients. 

There were 4 patients who needed a ventilator at the same time. And with the the nearest ventilator 80 miles away, there was no other choice than to manually ventilate using a bag.  

Patient A, a 25 year old lady who came with unknown poisoning. She came with seizures and later had a respiratory arrest. She was on the ventilator for almost a day before she was weaned out.

Patient B, a 17 year old young man with organophosphorus poisoning. He was gasping when he came in. He  obviously took the second ventilator. 

Patient C, a 48 year old man who came in with a krait bite. In spite of being started on a high dose ASV, he went into respiratory arrest. When Mr. C came in, B and C were already in the ventilator. Mr. C was manually bagged for around 12 hours, when we felt that Patient A could be weaned out. 

Patient D, a 9 year old girl who came in gasping after a krait bite. She was intubated immediately and was bagged till Mr. B was out of the ventilator. 

Then, there was a patient E, a 12 year old girl who was rushed in from the local village after a krait bite. We gave her an option to go to a higher centre. They have rushed her to Ranchi. 

We did not have a bag to ventilate her if she had a respiratory arrest. Even, we were not sure of starting ASV as we did not have a bag to ventilate (2 patients were being manually ventilated) if she had an anaphylaxis. 

Such a situation puts us in a position where we need to seriously ask questions about expanding our resources - - both in terms of infrastructure and qualified personnel. 

To start off things, we eagerly wait for Dr. Roshine, the medicine consultant who'll join us on the 22nd, the coming Saturday. 

Critical Care . . .

Something for which I was never prepared when I joined NJH in June 2010 was the amount of critical care work which I would end up doing.

Having a background in Community Medicine (Public Health), it was a challenge to get into using ventilators, managing pulmonary edema, rupture uteruses, cerebral malaria. More of a challenge since my last year in the Christian Medical College, Vellore was spent among the Jawadhi tribal community trying to convince them to come for antenatal check-ups, getting them to run small scale income generation programmes, conducting mobile health clinics etc.

From an healthcare institution point of view, NJH was quite peculiar.

Situated in the middle of a heavily forested area along a National Highway linking Ranchi with Gwalior, one would have expected hardly much of a crowd. Yeah, we do not get much of a crowd. The routine cases of malaria, enteric fever and normal deliveries are dealt by the motley crowd of quacks and dais in the villages.

So, if you come to our outpatient, you may think that there is not much work. But our repertoire of cases will put a Medical College to shame. You want to know, what we have in our 6 bedded Intensive Care Unit now. Here’s the list –

1.    A young man who’s survived a krait bite. He was in the ventilator for about a fortnight. Then he went into pulmonary edema. He’s slowly on his way to recovery.

2.    A young lady who went into pulmonary edema following eclampsia. She lost her baby. We had very little hope of salvaging her.

3.    A middle aged woman with organophosphorus poisoning. Again, we were not very sure of getting her alive. She had drunk too much of poison. She’s also slowly recovering.

4.    A little girl with partially treated meningitis. Still not very sure of what the outcome will be.

5.    A young man who’s just come in with a clinical diagnosis of cerebral malaria. For him to be admitted, we had to shift out a young lady who had a molar pregnancy. She had a hemoglobin of 2 gms%. By God’s grace, we could do an evacuation and she’s doing ok.

6.    An elderly lady with a very bad pneumonia. She has already been managed at Ranchi.

Then there are 3 more patients with severe malaria who are waiting in the General Ward. I would have wanted them also to be under close observation. In addition, there is a young lady with bad obstetric history (G6P5L1D4) having severe pre-eclampsia at 28 weeks who’s refused to go elsewhere.

I can only pray that there is no patient with rupture uterus or eclampsia coming in during the next 24 hours.

Well, what do I want to convey?

Critical care is something that we in mission hospitals need to look at very seriously. Traditionally known to be bastions of surgical care, there has been a major shift.

The major reason being that very few hospitals are interested in critical care and when there are facilities for critical care, it is too expensive for the common man.

So, along with palliative care, geriatric care, care of HIV AIDS etc . . . something very unusual is being expected from us in the form of critical care.

However, the ultimate question is about getting committed young men and women to serve alongside us.

A Rupture Uterus and a nagging Snake Bite . . .

Two patients bothered me as I woke up today morning. 

The first was SD, a lady with a rupture uterus. SD had a Cesarian section couple of years back. But, as has been the case with many of our other patients, nobody told her that her next one should also be an institutional delivery. We had lost our previous patient, AD with a rupture uterus following a previous Cesarian section. 

SD’s pain started early morning yesterday. She was being managed at home. They decided to take her to the nearest district hospital, where she reached at around 6 pm yesterday. From the district hospital, they asked her to be referred here.

SD reached NJH at around midnight. It was an obvious rupture uterus with a dead baby. And the family was so poor. They did not know what to do. Till morning they did not go anywhere. They did not know what it took to arrange blood. To make matters she was also in sepsis.

Sometime around morning, couple of our staff agreed to donate blood. And we proceeded with the surgery.

The mother is doing well. We hope she will recovery without problems.

The best part about SD was that she had a referral letter . . . 

The second patient I was quite concerned about was Loric Singh, who has been in the ventilator for more than couple of weeks. He was on the road to recovery till today morning, when he started to deteriorate because of which he had to be put once again into the ventilator. 

I was thinking aloud of whether it could be something else which bit him.

That was when the bystander told me that the type of krait which bit him was of a very poisonous nature. I told him that I thought all kraits were of the same type. Then he told me that the snake had been kept safe with the family back in his village. A very common custom in the region, where the snake is caught and kept alive till the victim is cured or dead.

I enquired if it is possible to bring the snake.

The snaps of the snake are below.

The villagers know this a ‘ghadait’ . . . a coarser version of ‘krait’. It is the elder of the krait . . .  a very old krait. Some claimed that it was a different species.

However, on closer examination, it is evident that it is a krait.

However, according to many of our staff from the villagers, it is commonly believed that a ‘ghadait’ bite is always fatal. One of the elderly villagers told me that he does not know anybody who has survived a ‘ghadait’ bite.

Something new . . .  An elderly krait has a more potent and lethal venom than an young krait . . .

Would appreciate your comments . .  .