Heights of Ignorance

If you search my blog, there is a post with a similar title written on September 3, 2013.

I was aghast at finding a similar report in our local newspaper few days back.

Below is the clip.

The headline screams - Superstition: Buried dead body of girl exhumed on instructions from traditional medicine-man. Medicine-man claims that dead girl will live. 

The news report is about a family who lost their 6 year old daughter after a snakebite. After the dead body of the girl was buried, a traditional medicine-man turned up who claimed that the girl is not dead, but alive. The family readily exhumed the dead body. However, when the family shifted the body for witchcraft, the local temple priest declared that the girl was dead. 

The incident happened in Kankari village, which is 11 kilometers from the Palamu district headquarters of Medhininagar, previously called Daltonganj. 

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.

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. 

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 . . . 

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 . .  .

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 . . . 

A different snake . . .

About a week back, we had a young lady of 16 years brought to Emergency Room in a supposedly comatose state after a snake had coiled around her leg. The patient alone had seen the snake and had told relatives before she became unconscious that the snake did not bite her.

There were no obvious bite marks and it was not difficult to come to a conclusion that she was well conscious although appearing a bit drowsy. She also seemed to have a ptosis which on careful examination was not there. The clotting time was normal. 

The only issue was a low blood pressure reading of 80/40 mm Hg. We gave her some intravenous fluids and she did not respond to that. And we concluded that this was her normal blood pressure. Later, we found out that there were problems in her family and we diagnosed her as having an acute conversion reaction – a psychological response to difficult situations.

We gave her a small dose of anti-depressant. However, she did not seem to do fine. She continued to remain drowsy. She could communicate when we called her. She could even walk to the toilet without help. She also narrated to us that she was taking some ayurvedic drugs for her psychological condition.

The next day being a Sunday, we could do any investigations. Her condition remained the same.

On Monday, we sent a battery of tests – complete blood count, liver function and renal function.

Her total count came as 1200/cu mm with a predominant lymphocyte picture. Hemoglobin and platelets were normal. The liver and renal function also came as normal.

There were only two major things that we were looking at – either a blood dysgracia most probably secondary to her ayurvedic medications or a haematological malignancy.

We referred her to a higher centre.

This is the second time that I’ve come across a suspected snake bite being diagnosed with something else more serious. The previous time was 4 years back at NJH, when we diagnosed disseminated tuberculosis in a patient who came with an unknown bite. 

Searching for help . . .

The country celebrated it's 68th Independence Day today. Over the day, we had stark reminders of how languished many of our fellow countrymen are. 

The first reminder we had today. 

Around 4:30 pm today, we had a young boy being wheeled in. He was dead. 

Although brought in a Maruti Dezire by a well off guy, it was very evident that the boy hailed from a impoverished background. The history - - he was bitten by a krait at around 4 am today morning. For quite some time, they were doing witchcraft (jaad-phuk). Then someone suggested that they take the boy to a hospital. 

Someone told of the good hospital that was at Tumbagara village, in Palamu who offers good treatment for snake bite. Off they set from Tilouthu town searching for our hospital. 

Do search in google maps. Tilauthu is how it is spelt in google maps. Tilauthu to Satbarwa is whooping 165 kilometers. For those of my friends from Kerala, that is more than the distance from Kottayam to Trivandrum. 

I wonder how they missed the fact that Tilauthu to Varanasi was the same distance and the road was much better. Varanasi has big hospitals and the famous Banaras Hindu University which has a Medical College. Nearer is Gaya which also boasts of a Medical College. 

When the group drove from Tilauthu to Satbarwa, they traveled through 3 districts. They had started off at around 8 am today morning. On the way, someone advised them of a more powerful wizard in a place called Japla. So they went to Japla. They left Japla at around 2 pm to reach NJH at 4:30 pm. 

Now, if you look at the map, you see that Tilauthu and Japla are on either side of the Sone river. Initially I thought that that the family somehow crossed the Sone river to Japla. But, that was not the case. The family had reached Chattarpur at around 10 am on the way to NJH, when someone gave the advice about the wizard in Japla. 

So, they actually took a detour to go to Japla. The family claimed that when they left Japla at 2 pm the boy was breathing. 

If the family had straightaway come to NJH, maybe we could have saved the boy. 

But, the incident brings to the fore the sad state of healthcare available to many of the communities around us. And of course, the ignorance about snake bite and its treatment. 

Hope at least by next year's independence day, lesser lives will be lost to snake bites . . . 

Heights of ignorance

Below is a news item which was quite prominent in our local daily. For those who don't know Hindi, I've written up a summary of the news. 

The story is that of a lady who died of a snake bite. She was buried. 

Then, the body was exhumed and witchcraft done to resurrect her. 

Not once . . . but twice. Yes, the body was exhumed twice. First, by the husband's family and later by the parents of the lady. 

Amazing . . . Isn't it? 

Fatal viper bites

Over the last 2 days, we’ve had 2 patients with viper bite with whom we had major issues of clinical care.

The first was 50 year old SD, who was bitten by a viper sometime in the evening. By the time she came, she was pouring out quite a lot of blood. And then, she was in shock. We started her off on Anti-Snake Venom.

After which, she went into a refractory shock, which was totally unresponsive to Dopamine or Adrenaline. She was ventilated for almost 24 hours. At last she passed away today morning, after her heart became totally unresponsive to any medications.

Within a couple of hours came the next patient with a viper bite - a 15 yr old girl from the nearby government school. She was promptly started off on ASV. However, as time passed, she started to deteriorate. Her clotting time was prolonged. She was already bleeding from her gums and nose when she arrived.

She appeared to be going into myocarditis. She went into a respiratory arrest. We hooked her on the ventilator. But, soon, she was bleeding profusely from her gut. Her nasogastric tube brought out copious amounts of blood. Then, we realised that she was going into pulmonary edema.

One of the major issue which we’ve faced with the anesthesia ventilator is the inability to give high pressure ventilation which is needed in condition like pulmonary edema.

Over the last couple of weeks after Roshine joined us, we have been planning to invest in a full fledged adult ventilator. It’s quite expensive for us. And considering the situations of power supply and oxygen procurement, we need to think twice before such an investment twice.

But, we’ve been quite unanimous in our acceptance of the need for a full fledged adult ventilator. The approximate cost for a low end adult ventilator will be about 650,000 INR which will include transport from the place of purchase.

We request help from people who would interested to support this endeavor. Below is what we dream to have. 

You have the unique chance of being history as this would be the first full fledged ventilator in this whole region . . . the next ventilator to the east is in Varanasi which is about 300 kilometers away, the north, Gaya which is about 200 kilometers away, Ambikapur (200 kms) to the south and Ranchi (130 kms) to the west. The total population we would cater would be about 5 million.

(PS: The 15 year old girl passed away today morning)

A 'big' snake bite . . .

Yesterday, we had a lady being wheeled into casualty. She had been bitten by a viper about 12 hours back. She had a swollen leg and couple of bite marks. However, she was very cold. And we could not get a pulse on her. She was in shock. 

One of the relatives told me that she was bitten by a baby python. They had brought the snake!

I was sure that there was envenomation. She had difficulty breathing although her saturation was normal. 

I got 2 vials of ASV going into her along with the intravenous fluids and decided to take a look at the snake which was kept outside. 

Thankfully, it was a killed specimen. And what did I find . . . 

Yeah, a really big viper . . . 

So much for people misidentifying snakes . . .

Surprisingly, her clotting time was normal. However, the urine output was on the lesser side. The creatinine was 1.57 mg%. I gave her Anti Snake Venom according to the low dose protocol. 

It's 36 hours now. She's done well so far. The urine output is on the rise. Tomorrow, we shall repeat the S. creatinine. And if that is fine, she should be going home. 

Focus . . . Snakes and snake bites . . .

Last week, NJH was part of a group of hospitals who were invited by the Christian Medical College, Vellore to look into snake bites and their management . . .

I leart quite a lot of things. It was a privilege to rub shoulders with who’s who in herpetology. Romulus Whitaker, Gerry Martin, Dr. Oommen V Oommen, Dr Bawaskar, Dr Punde . . .quite a lot of big names in the field.

Yesterday, I was talking to my staff in Community Health and Development about how fast we draw conclusions without looking into evidence.

Over the last month, I had put up the post on the clientele we serve at NJH. And later something about neurocysticercosis and their cause. Regarding the former topic, quite a good number of our staff thought that we serve a higher number of poor. I got quite a number of feedback about the ‘new information’ they received in the post on neurocysticercosis.

The common aspect about snakes and snake bites are the myths that surround them.

Couple of the myths that I harbored for long were given the boot after the meeting.

The first one . . . I was under the impression that a venomous snake bite late in the night or early daybreak would be less venomous compared to a bite in the evening. The reason . . . the snake would have already spent it’s venom on a prey and therefore a lesser amount only would be available to inject into the next victim. The same logic applying to snake bites on two consecutive victims by the same snake. The second victim would have lesser venom injected thereby causing lesser envenomation in the second victim.

The venom is the saliva of the snakes. Even after a biriyani, you’ll continue to secrete saliva if there is ice-cream after that. Similarly, the snake would continue to secrete the venom irrespective of the fact whether it had a prey before biting a victim.

The second one . . . a non-poisonous snake in your backyard means no poisonous snake in the same area. Absolutely wrong. Any snake seen means more snakes in the area. It was reported that it is not uncommon for a venomous and non-venomous snake to share the same hole!!! I remember someone tell me that it is not good to kill a non-venomous snake as it’s place in the habitat may be taken by a venomous one.

There is nothing like a territory for a snake. . . the way they have for tigers etc.

The third one . . . which is quite frightening. I used to believe that use of chemicals such as phenol would help keep out snakes. And after we had couple of snakes inside the house during our first year at NJH, we’ve not seen them inside after we started to regularly use phenol to wipe the floor. In fact, there is no evidence to support the fact that snakes dislike phenol. However, snakes don’t like clean places. They love dirt and areas with things like papers, leaves etc. piled up. The fact that snakes are not entering the house is because of cleanliness that accompanies a daily wipe with phenol and not the smell of the chemical.

However, the best ones . . .

Kindly see the snap below. The blue bordered regions are places where a proper taxonomy of existing snake species has not been done. Quite an exciting thing for mission hospitals in North India such as ours as we can be base for quite a lot of work on getting to know more about these creatures.

The final straw . . . The snap below. Kindly note the thing written in red. This is the number of vials of antivenom that will neutralise the maximum possible venom that is injected during a bite of the concerned snake.

The question is now going to be about how WHO has come up with a protocol of 20 vials to be used for any sort of snake bite. . .For units such as NJH, this has major implications . . . as a low dose protocol should theoretically be enough to salvage viper and krait bites . . .

We’re quite excited of the future . . . we could be part of path-breaking research on snake bite syndromes and their management.

Pray for us . . . 

Mixed bag of happenings . . .

The whole of this week has been quite peaceful at NJH compared to preceding weeks. The reasons are manifold . . . First of all there were couple of bandhs, which put us on tenterhooks. Then there was a spate of festivals starting off with the Viswakarma Puja, going on to Teej, then Ganesh Chaturthi and today Karma Puja . . . Still, it was amazing that we crossed 100 patients almost every day. 

The biggest miracle last week was VO, the young man who was in the ventilator for almost 6 days. The amazing thing was that he survived a brief period of time when our oxygen cylinders ran out on account of the bandh. It is quite heartening to see him sitting up today morning as I went for rounds.

VO along with his father . . . 

Later towards the end of last week, our Ophthalmologist's grandson who was born after a high risk pregnancy became sick with unexplained episodes of hypothermia and later hypoglycemia. He was referred to a higher centre where he's on his way to recovery. We praise God. 

Today morning, we had a 10 year old boy coming in with a history of 5 days fever. Below is a snap of his investigation report. 

The family had an RSBY card . . . unfortunately, the boy's name was not on the card. However, considering that he was from a neighbouring village, we offered him free admission. Unfortunately, before I could talk to the relatives, the parents too the child home. I hope he makes it.

The family of the young boy is the reason why there has to be a robust public healthcare system. In spite of the fact that we are able to give subsidized treatment to a certain extent, the poverty of our country is such that quite a large portion of our population would be left out if we don't have a system where healthcare would be easily accessible both in terms of distance and affordability.  

We have the daughter in law of our retired staff admitted with Preterm Premature Rupture of Membranes at 31 weeks and a baby in transverse lie and intrauterine growth retardation. It is much more than what we can handle . . . but the family is absolutely sure that they don't want to take her anywhere else.  Please pray for the family and the young lady . . . 

The best part was that we could finish finalising our calendar for the year 2013 . . . And the day I went to finalise the printing of the calendar, we had a total of about 200 patients in outpatient. 

It has been busy, sometimes disappointing, but ultimately a very fulfilling week of serving . . . Sorry, it's only half the week over . . . There's 3 more days left. 

RSBY Success Story . . . But . . .

On the 24^th of last month, MDO, a 20 year old young man was searching for some thing in his house late in the night, when he was bitten by a krait on his hand. As is the prevalent practice, his relatives summoned a local faith-healer who assured them that everything was alright.

However, as time passed, the father realised that something was amiss. MDO was not able to breathe properly and was looking very sleepy.

NJH, being very near to his home and one of his cousins being a chowkidar in the hospital – the family rushed MDO to NJH.

On arrival at NJH, Dr Johnson attended the call. MDO was hardly breathening and was bluish all over. There was no response to stimuli and his pupils were mid-dilated and hardly reacting. MDO was intubated and was put on the mechanical ventilator. The relatives were explained about the very small chance of survival. It was about 1:00 am of 25th August. 

Meanwhile, our chowkidar, Mr. Jamuna who was MDO’s cousin told us about the RSBY Smartcard (Rashtriya Swasthya Bima Yojana) the family had. It was brought immediately and was promptly blocked for treatment of snake bite.

It was only recently we were having a discussion of snake bites being covered under RSBY as there was a major increase in costs of Anti-Snake Venom (ASV).

Since, we were yet to come to a conclusion on the increase in ASV costs, we decided to treat him fully under RSBY.

By the 25^th morning, when I came for rounds, MDO’s pupils were fully dilated and fixed. There was no reaction till about 26^th afternoon.

He was in the ventilator for 80 hours. And intubated for 104 hours. 120 hours of Acute Care admission. . . 30 B-type oxygen cylinders . . . 20 ASVs - the cost of which alone is 13000 INR

MDO is getting discharged today. The problem was that his total bill had come to a whopping 45000 INR and RSBY was going to pay us 10500 INR.

MDO with his father

We’re not sure on how to approach this. The family is ready to pay us 7500 INR more. But, as per RSBY policy we are supposed to be giving cashless service. I’ve sent a mail to our Insurance Providers explaining about our predicament. I hope that they would respond positively.

The interesting part is that we have 3 more patients in the ward with krait bite. And all of us are in some part of their ventilatory support . . . I’m glad that we have 2 ventilators . . . But still, we’ve to refuse all patients who could end up needing a ventilator since yesterday . . .  eclampsias, snake bites, severe pneumonias etc . . .

The recent increase in cost of ASV make it quite difficult to treat snake bite victims under any protocol of snake bite management under RSBY. I hope that the concerned authorities would take note and do the needful . . . 

(Consent to publish the photograph and the story has been obtained)

The Occult . . . The Paradoxes of Indian Healthcare - Part 3

India has always been associated with the occult. And you may be surprised that the myriad religions, the thousands of gods and goddesses Indian culture is associated with has nothing to do with this. Irrespective of religion, caste, economic status . . . people depend on the occult for healthcare . . . 

Today, I came across 3 patients who tried it out . . . and it's usually the case for the conditions involved. 

The first was a young boy who had an acute episode of seizures in the morning. The relatives brought him straightaway to hospital. After the seizures was controlled, the brought in one of the local exponents of black magic to throw out the evil spirit from the boy. Our staff had quite a tough time dealing with the relatives as they were quite well off. 

The second patient was not that lucky. Bitten by a cobra early morning today, the family had been subjecting him to all mumble jumble till about afternoon when they realised that he may do better in a hospital. He arrived at around 5 pm at NJH. There was no respiratory effort. There was a faint heartbeat. From our previous experiences with cobra bites, Titus commenced CPCR . . . then he realised that it may not of any use. The pupils were already dilated. 

The third patient was also a snake bite victim, a young girl with viper bite, who came in more than a day after the bite with a very bad compartment syndrome. Dr Nandamani did a fasciotomy only to find out that one part of the leg was already badly gangrenous. 

We were sure that the chances of her going into a below knee amputation was quite high. We referred the girl. 

Unfortunately, the parents were too poor to take the girl elsewhere. However, I did not want to manage a potential high risk surgical condition without the surgeon around. They promised to take the patient elsewhere next day. Sometime later that evening, I found out there was a commotion in the Acute Care where the girl was admitted. 

It seemed that the family had arranged for a 'witch-doctor' to come and do sorcery on her. I chased them out. Later, I found out that couple of my staff were also involved in arranging the witch-doctor. I called them and asked for an explanation. However, they denied any involvement. I did not have any evidence. However, later, I found out that they had initiated a discussion with few other staff on the reasons why I should have allowed them to do the sorcery. 'The doctors are anyway referring, so what is the big thing about the relatives trying out jaad-phook (black magic) for their daughter'. . . that was the justification. 

It was shocking . . . unfortunate, but true. 

The worst aspect of the use of occult is that  most of the diseases where the populace invokes the witch-doctors are clinical conditions which merit immediate medical attention . . . SNAKE BITES, SEIZURES, ECLAMPSIA . . .the major ones we're concerned about. One more disease for which the witch-doctor is consulted is HEPATITIS. However, since it is not an acute condition, we do not hear much about it. 

The amount of money that these witch-doctors make is enormous. 

Considering that modern medical facilities are very much far away in terms of accessibility, availability and affordability, it would take quite a lot of effort to turn away the common man from these money mongers. Talking about money mongers, the sadder aspect is that modern clinical practice is also very much in danger of reducing it's practitioners to money mongers . . . which is not much different from our 'witch-doctors'. More about that in my next post on the Paradoxes of Indian Healthcare . . .