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 . . . 

Rare Poison

May is usually a lean month for the hospital. 2 reasons - - - It is very very hot. It's auspicious wedding season. When patients come to NJH in May, it is only if they are very very sick. Obstetric patients try their best to deliver at home. If they arrive into labour room, it is usually when there is a complication. 

The largely empty Acute Care Unit

Yesterday, there was a little girl, 3 year old PD who reached the hospital unconscious. 

The history was that PD had eaten the seeds of a tree locally called 'Bahera'. She had gone to sleep for the night and then never woke up. It seems that these seeds were usually eaten by children. However, it was well known that one should not consume much of these seeds. It seems that PD had eaten too much. 

Seed brought by the parents for identification

We looked this up. Bahera is Terminalia bellirica. 

After the parents discovered that she could not aroused, they took her to the local Primary Health Centre. She was kept there till the evening after which the parents decided to bring her to NJH. 

On arrival at NJH, PD was gasping and was desaturating. We had got her intubated and she is being mechanically bagged. It is 24 hours since she got admitted. Her pupils are mid-dilated and fixed. She is maintaining saturation.

We're not sure on how to go ahead. 

Please pray for PD. 

An unusual presentation

JO was a 15 year old jovial boy who suddenly took up sick with fever about a month back. He was sick for almost 2 weeks and was treated successfully elsewhere. After discharge, JO’s father noticed that his son was not his former self. He suspected something was wrong.

His suspicion turned out to be true within a couple of days, when JO became unconscious gradually. Even his family did not take the way he became unconscious seriously as it looked more of JO becoming more and more sleepy over the day.

When JO was wheeled into our Acute Care, he was hardly breathing. JO had something very bad in his brain. He was running a high fever and had anisocoria. We had to do a CT Scan. But, JO was hardly breathing on his own.

After almost 2 days of mechanical ventilation, we could wean out JO from the ventilator. Considering the sort of diagnoses that a young boy with anisocoria can have, we were anxious for the CT Scan Brain. With a backup for ventilation, we rushed him to the nearest town for the CT Scan.

The CT Scan showed a hypodense area in the periventricular white matter of the right temporal region.

After he returned, the anisocoria stayed. However, a fundoscopy did not show any features of a raised Intracranial Tension. With a guarded prognosis, we took a decision for a lumbar puncture. The family readily agreed . . . in fact, we had not given them even a day for their JO to survive.

Lumbar puncture was suggestive of a partially treated bacterial meningitis with a higher protein levels than usual. Considering the long history of the illness, we took a decision to come to a diagnosis of Tuberculous Meningitis.

JO has responded well to anti-tuberculosis treatment. However, he’s yet to be completed fit for discharge.

We’re blessed to be a blessing in the life of JO and his family. Kindly pray that this young boy will be completely healed. 

Clueless . . . and a miracle

This is about MK, the little girl about whom we were quite clueless. 

We're so thankful to all who prayed. It was a joy to watch Rev. Maxwell David and his wife, Sr. Snehalatha who came for a week of spiritual retreat, pray for this little girl. 

From a medical point of view, we explored all the possible diagnosis . . . and quite a few of us believed that this girl has Obstructive Sleep Apnea. Unfortunately, we could not resort to any blood investigations as she was so chubby to get any blood sample. 

As mentioned earlier, we gave fluids through an intra-osseous line. And she was mechanically bagged for more than 2 days. 

Here is MK ready to go home after her period of admission. 

All glory and praise to our Lord and Saviour, Jesus Christ . . .