SNAKES

It was quite recent that one of my colleagues in a sister hospital informed that he had 11 cobras inside his house and had to kill them. So, I thought that I should put a blog on my experiences with snakes in NJH. I've not seen any cobra, but quite a number of kraits and vipers.

My last encounter with one was couple of weeks back when I went to visit one of my colleague sometime late in the evening. The sight that greeted me as I entered the courtyard was unbelievable. There was a 1 feet long krait sitting directly under the light above the gate and having a feast of insects who were attracted to the light. As I stood watching the spectacle, the fellow noticed my presence. To my surprise, he did not mind me watching him and continued with the feast. However, my paternal instincts convinced that the fellow could be a potential killer and decided to finish him off. So, off came my sandals from my foot and he was dead after 2 sharp blows to his head.

Now, there are few photographs which I took over different times. Hope that I would remember the story behind each one of them.

The first one (on the right) is this 6 feet long viper which one of our nurse-aides killed while returning from the evening ladies fellowship. It was one of the largest vipers that many of us had ever seen, because of which there were quite a number of photo-opportunities for quite a long time. Unfortunately, I was busy with something and managed only couple of snaps.

The second snap is of a pair of kraits (on the left) which we found lodged in one of the crevices behind the doorframe of the ultrasound room. One of the nurses almost got bitten by one of them. It took quite a great deal of patience to coax both of them out of the crevice and kill them. Sorry for the gory picture. We are taught to go for the head. And sometimes I wonder why - especially our chowkidars beat these creatures to such a pulpy mass that identification becomes difficult.

It is not uncommon to hear of snake stories almost every alternate day in the hospital especially immediately after the rains - someone killing a snake somewhere, snake found under the bed, snakes in the toilet, snake coiled around the stove. Then we have the occasional bizzare ones which we hear from patients.

The best one I heard was 2 months back. One of the patients came with cobra bite - not one, but multiple - on the palm of his hand. The story was that the unfortunate victim who was on his way back from work was quite heavily drunk with alcohol and thought that the cobra which was on the road was a good piece of leather which he could use to keep his dhoti in place. Well, you can imagine what would have happened next. He was lucky to have a close friend of his coming just behind him. He was brought quite fast to emergency here. By the time he came, his hand was swollen up like a baseball and we had to go for a fasciotomy to relieve the compartmental syndrome which was setting in. By God's grace, he made a quick recovery.

However, in spite of the umpteen number of snakes we find here - I do not remember of anyone narrating any incident of any staff getting bitten by a snake. Even, yours truly had 3 very close encounters with snakes - kraits being the culprits all the time - the last one where I had stepped on a coiled fellow with my bare feet. How true is the promise we have in Christ where Jesus promises us, his disciples, about the protection we will have from snakes and scorpions (Luke 11: 19).

PEDIATRIC BURNS

VM, aged 4 years was sitting along with his mother on a late April morning. Although winter was long over, the chill in the air was enough for VM's parents to get a fire going to boil water for bathing. VM still complained that it was cold that his mother wrapped a shawl around her son. His mother was busy with all the morning's cooking and other activities. VM's shrill cries caught her attention - her son had accidently gone too close to the fire where water was kept for boiling. The shawl had caught fire. By the time they could put out the fire, the damage was done.

VM along with his parents and little sister lived quite far away from the main town. There was only a single bus service to the village - and it was quite jampacked that very few of the villagers planned to make a trip to town. VM's father worked in the local Catholic school. In fact, it was the association that NJH has with the Catholic dispensaries through the Global Fund Tuberculosis Programme that helped VM to come to us after being burnt.

After VM got burnt, both the parents did not understand the gravity of the situation. They requested the local nurse in charge at the Catholic dispensary to provide them with some burn balm. The nurse got suspicious and asked that she see the burns. She understood that things were quite bad and VM required urgent treatment. Somehow, she convinced the parents to take VM to a good doctor. The parents took VM to various doctors in the nearby town of Daltonganj. They were refused treatment at all places - everybody advised that he needs to go to a higher centre.

This was when, the nurse calls me and asks whether we could take a look at VM. VM arrived at NJH at around 12 pm, about 7 hours after the incident had occured. It was a terrible sight. The boy had burnt both his arms, front of his chest and neck. In addition to dehydration, compartment syndrome was setting in both the upper limbs. I somehow convinced the parents to allow us to do a fasciotomy of both the limbs.

I knew this was going to be a tough case. The boy was in the ward for about 2 weeks - unfortunately, the parents were not willing for a tangential excision and skin grafting. The wounds started to heal on its own. Then, they wanted to go home - and even intensive counselling did not yield any results.

The family left for home. Somehow, we got in touch with them - again thanks to our network through GF TB work - and counselled the family again on the need for regular treatment. Unfortunately, the scars were causing contractures, which thankfully alerted the family to seek medical care. VM has come back to us last week. Nandamani did some amount of contracture release of his limbs yesterday. Kindly pray that the family will be able to understand and heed our advice on further management.

Once more, we have a family where things could have been prevented at various levels. First of all the burns could have been prevented had the parents been a bit careful. The healing could have been faster and more appealing if they agreed for a tangential excision and skin grafting.

NEGLECTED BURNS

Mrs PD never imagined that her habit of alcoholism can put her into so much trouble. As usual, PD had her usual evening binge and was having a good time. She thought that she would do better with one more go of the local drink (Hadiya) when she lost balance and fell backwards on the open fireplace where she was simultaneously cooking food.

The incident was sometime in the first week of June. She was brought to us where one of our medical officers saw her. She was not willing for admission and wanted only some local balm and injections. She went off home with the medicines - not heeding for admission.

She turned up after 3 weeks - saying that the wounds have worsened. And this is what we saw. I don't think I need to describe this grotesque picture of her legs. A part of the major burns is on her buttocks which I did not include in the picture for obvious reasons. I'm not sure if she had put any other local application.

We knew that we had to act fast - escharotomy and skin grafting was decided. We went ahead and wait to see how the grafts have taken. The wounds needed about 3 sittings for total debridement before she could be taken for grafting. The wound over the buttocks were a bit too deep as we could see the schiatic nerve (the main nerve to the leg).

Kindly pray for this lady. We need to work on this lady's life - Alchoholism among village women is a serious issue in this part of the country. Availability of home brewed liquor called 'Hadiya' makes the issue more worse. Pray that we would be able to look at options of having qualified people who would be able to counsel such patients.

PNEUMATIC WAR HORSE - A TRIBUTE TO A SILENT CHAMPION

This piece of blog I write to salute a silent champion and life-saver to many, who completes 5 years of service in our hospital. Her speciality has been to save patients whose respiratory efforts fails following some disease - the most common cases happening following cobra or krait snake bite, organophosphorus poisoning, and eclampsia.

The reason we did not have her till 5 years back was that most of her clan members came at a very high cost. They used to cost something between 700,000-1,200,000 Indian Rupees. They still cost the same. Till her prototype was locally manufactured by an anesthetist. Of course, she would not claim to be able to do the many intricate functions her fellow clan members boast about. But, she could do the most important function which we needed - and that was to ensure that we pump in oxygenated air into the lungs of a sick patient unable to breath.

The cost was about 60,000 Indian Rupees. The design was very simple. I understood it out only recently. It comprises of a wiper engine (the ones we use in vehicles), collapsible corrugated rubber bag and some basic electronic circuits designed to control the extent of collapsability of the rubber bag by which determine the volume of air needed to pump into a patient's lungs. She was called the Newmon Ventilator.

She has stood the ravages of time. Seen couple of surgeons, umpteen number of nursing staff and students, 3 Medical Superintendents and must have saved at least 300 patients. It was only recently that her recent boyfriend - our Engineer - told me that her collapsible bag usually does not last more than 3-4 years. We made the discovery about the bag only recently when she refused to respond to our manevoures and we had to open her up. We've tried contacting her original makers about replacing the collapsible bag, but had no response. In addition, she had her internal wiring bitten away at least couple of times by rats, which again was rectified only by our engineer.

Now, the hospital has become busier - we've realised that we need at least 2 more of her siblings. Since there was no response from her original makers, we scouted elsewhere. And we've found a company in Delhi who makes similiar machines and encouragingly with more functions. However, they cost extra - excluding freight and road tax, it is about 150,000 Indian Rupees. We were planning to buy two new machines - but with the increased cost, we can afford only one as of now, and that too because of kind financial help from churches in England through Dr Colin Binks. FRCS who served NJH from 1981 to 2009.

Neverthless, I salute our Newmon ventilator - who served us well for the last 5 years. With her new friend, the engineer, we have grand hopes of her serving us one more stinct of 5 years.

Arachnid Horror

First of all a warning to those who may not be used to seeing lot of blood and bad wounds.

Little NV (5 yrs) was playing outside his house on evening of the 25th of June, 2011 when he was bit by a spider on his right leg. The spider was a bit larger than the usual ones. His parents did not take take it much seriously - but the leg had turned into a funny colour by the next day morning and it was started to swell up and few blebs developed around the site of the bite. He was taken to the local quacks who gave him some injection and medicines. However, the leg continued to pain and swell.

NV was brought to NJH on the afternoon of 27th June. The snap of his leg is shown here. It looked toxic and the muscle compartments were very tight. We explained to the parents that the leg looks quite bad and we would need to do a fasciotomy to release the tension of the inflammed muscles. To make matters worse, there was evidence that one of the nerves of the leg was damaged. There was foot drop. His parents did not find the prospect of putting incisions over the already discolored and damaged leg, logical as part of the treatment.

We started him on antibiotics, put a splint for the foot drop and started regular Magsulf dressings on his leg. Unfortunately, the leg was becoming worser. The skin started turning into black. Now, the parents somehow gave consent to go ahead with a fasciotomy - however, we feared the worst. More worrying was the black colour of the skin.

We went ahead with the fasciotomy. The skin had by now become completely black. We decided to take off the black skin and plan skin grafting. We've done that in part of the leg - and is waiting with bated breath on the outcome. The only encouragement has been the healthy tissue beneath the ischaemic skin.

I'm sure that not many of such cases would have been seen. It looks more like a snake bite. Had it not been for the piece of leg of the traitor spider carefully kept safely by the parents, we would have definitely put the blame for the same on a snake bite. But, then, there was no systemic signs of any envenomation. However, it is quite difficult to comment on whether the spider bite alone could have resulted in so much damage. The parents had taken him to some local practitioner immediately after the bite. However, he had no systemic problems.

Kindly pray that NV would make a quick recovery - especially that his nerve damage is reversed. We also need the parents to remain patient about the recovery of their son. If they suddenly decide to take him away all our efforts will go to waste.