Poison . . . wrongly identified

Yesterday afternoon, we had an unconscious middle aged lady wheeled into emergency. She was gasping and had allegedly taken some poison.

The relatives identified the poison as Furadan, a carbamate poison. However, our attending doctor was quite knowledgeable to question the involved poison as Furadan. There was no characteristic violet color discolaration of the tongue or stomach contents. And there was no smell. And most important, there was tachycardia, no constricted pupils or increased secretions.

She had couple of seizures before reaching hospital. We had already started midazolam and phenytoin. As we tried to intubate her, she had more seizures. All her teeth were in the worst side of decay and couple of them got removed during intubation. And she had a short neck. Ultimately, we had to give her scoline to get complete relaxation.

With her on the ventilator, we had to find out the real poison. We placed our bets on Endosulphan. We had already seen couple of endosulphan poisonings over the last year. And the presentation was quite similar.

Titus had already asked the relatives to get a bottle of the offending poison.

The relatives brought the poison. We asked one of them what it was. The answer was ‘furadan’.

It was quite disconcerting. What was being passed on as ‘furadan’ was ‘endosulphan’, one of the most toxic of all poisons in the world.

The lady has improved well over the last 24 hours. We could extubate her by today morning.

She should do well.

However, the fact that highly toxic pesticides like ‘endosulphan’ is commonly available and is being unknowingly used by farmers is very concerning. 

Marathon Cesarian sections . . . almost all MNMs

The start of the last weekend was quite hectic one. . . By standards of many big hospital, it may not be that hectic. . . But for us, it was quite a busy time. . . Not only for us, for each of the patients involved it was a close brush with death . . .  all of them mothers delivering babies. I thought I'll share each one of them. To make things easy, I've put it in a table. 

Name	Time and date of surgery	History	Final management and comments
RtD	20th july, 11:00 am	Previous LSCS, had come for ANC on 20 june, Hb: 8 gm%, never bothered to arrange blood	Boy baby, apgar 9 and 10. Had waited almost a day for the blood
SMD	20th july, 12:36 pm	Obstructed labour since previous day 8 pm	Boy baby, apgar 6 and 10. Almost a rupture
MD	20th july, 2 pm	Primi at 40+6 with labour pain since previous night. Later obtained history of leaking 4 days. Irregular fetal heart.	Girl baby apgar 8 and 10. Well off patient – did not go to Ranchi.
AF	20th July, 3:14 pm	Labour Pains since yesterday afternoon and leaking, short 136 cm, obstructed labour	Sick girl baby, apgar 1 and 4. Died later, Almost a rupture
KD	20th July, 5:24 pm	Prev LSCS  with  and Hb 8 gm%	Dead girl, Hysterectomy for placenta percreta
RnD	21st July, 2:17 am	G4P3L2D1, pedal edema 2 weeks, headache followed by seizures 2 pm, 20th july	Baby boy, apgar 6 and 10. IUGR
SrD	21st July, 3:30 am	Short primi, pedal edema > 2 weeks, was having labour pain since 12 pm on 20th July, BP 140/100. Urine alb 4+	Cervix edematous and head high, inadequate pelvis – lscs, boy baby apgar 3 and 7. Gr 3 Meconium Stained Amniotic Fluid

We lost 2 of the 7 babies. But we could have lost all the 7 as well as few of the mothers. The major challenges we faced - 

1. Availability of blood. 

2. Patients not following advice given during Antenatal Care. 

3. Ignorance of leaking per vagina as an indication for coming to hospital

4. Previous Cesarian section patients appears to be so ignorant about the fact that they need to have an institutional delivery

5. As we conversed with MD and AF's relatives, we realised that relatives have come to the conclusion that they have conceived girls. Especially, MD could have taken her easily to a higher centre. 

The weekend was thankfully not as busy as it threatened to become. . . 

However, do remember little GS, a little 6 year old girl who had come with a viper bite on her hand. Compartment syndrome has set in her hand very badly. 

I tried my best to refer the little girl, but without much response from the parents. We did a fasciotomy in the morning. Only tomorrow we shall know how much better it is going to be. . .

Then we had 4 kids who came in with accidental pesticide poisoning. 

After all the weekend rush, today was very quiet. Most probably on the occasion of a local festival . . .

And one more word of prayer for BD, who has delivered a baby at her home yesterday evening who came in with a retained placenta. On arrival, her hemoglobin was a paltry 2.4 gm%. The relatives have arranged blood just few minutes back. Shishir and Titus would be trying to do a manual removal of placenta within the next couple of hours. . . .Please pray that she will make it . . . It is almost similar to the case of SD who survived almost a identical history with a hemoglobin of 1 gm% ! ! !

Pesticide poisoning . . . A point

The last 2 days, I had a very unique problem with 2 patients. 

The first one was a young lady who had come in unconscious since the last 24 hours and was being managed elsewhere. There was no definitive diagnosis. From the history and examination findings, there were only 2 possibilities. . . It was either a pontine bleed or an organophosphorus poisoning. 

The relatives vehemently denied the possibility of a poisoning. 

As she was not breathing well, we had her intubated in no time. While intubating, we noticed that there was quite a lot of secretions in the airway. 

Nothing much happened initially. We had given the option of a referral which the relatives were not very much interested in.

We weighed the options and started off her on Atropine to which she amazingly responded. By today morning, she was sitting up and it was quite heartening to see the sight . . .

 Later today, a little boy came in gasping, frothing from the mouth and with pin point pupils. He had eaten some poison which was kept on the window ledge. Here, the parents were sure on what was eaten. . . For me, it was pure organophosphorus. He responded to the same management which we gave for the former lady except for the ventilation. 

This is the fourth or fifth time that patients have come in after ingesting poisons accidently (at least from the history). I remember one of them which I thought was homicidal. 

I remember being taught that free availability of poisons is one of the major causes of accidental and self inflicted poisoning in most of the Asian countries where it is common.

When the parents of the boy showed me the sachet of the poison, it was not difficult to realise the reason on why accidental poisoning is something we need to consider seriously when patients come unconscious to our emergency rooms.

Below is the snap of the sachet.

A common practice in India to decrease the cost of purchase of many an item, sachets such as these are quite a dangerous thing. Taken out from their original packing, these poisons are repacked into unlabelled packets. I showed it to couple of our staff who use pesticides for farming purposes. I asked them about the poison. They did not have any idea other than that it was very good to kill houseflies. 

The shiny substance inside the sachet is quite attractive for children. Many a time I've seen liquid pesticides repacked inside empty cough syrup bottles. Last year, we had one young man who claimed to have unknowingly drank Malathion which was stored inside a cough syrup bottle. He was lucky to have made it alive.

In the prevention of pesticide poisoning, one of the concepts being promoted is to ensure that purchase of pesticides be monitored and there is community based storage of pesticides. Of course it is important. However, more important is the need for public awareness not to store it outside their labelled bottles or sachets and not to sell or store pesticides in loose unlabelled packets.

Well, regarding the first patient, the lady - I got a history from her that she was having headache and she had taken some medicine which was given to her long ago. . . She does not remember anything after she took that medicine. My hunch is that she has taken some organophosphorus poison which was kept in an unlabelled bottle. In fact, we had got the history of a headache from the husband . . .from which we had kept the probability of a intracranial bleed -  a pontine hemorrhage because of the pin point pupil . . .

So, any unconscious patient from now on . . . we would be looking at possibilities of poisoning seriously.