Our small two bedded casualty was full to capacity, on one bed a pregnant lady in labour pains twisted fitfully surrounded by concerned relatives as sisters while a curtain separated her from a middle aged as lady who’d received an electric shock and lay comparatively still while her ECG was done. The moniter bleeped confident rhythmic heart rates and displayed reassuring oxygen saturations. I surveyed the scene with some satisfaction - investigations were underway, plans for treatment had been made, relatives spoken to. Now I could return to a busy OPD and all the waiting patients there.
The moment I sat down to see the next patient, Sister ran up to me, ‘Ma’am, snake bite aaya hai!’, I asked with trepidation, ‘Ptosis hai?’ to which she replied, ‘Haan ma’am, hai toh!’ The next half an hour played out like a dramatic episode in what could be called an Indian version of the popular American medical saga Grays Anatomy (minus McDreamy). She was brought in to casualty with each arm draped loosely around the shoulders of two men who were struggling to support the dead weight of a person who is fast losing consciousness. Her bindi was askew to one corner of her forehead, and her sweaty face caked with what appeared to be and smelt like, a combination of atta and chuna (lime stone powder) most probably smeared by a ‘faith healer’. She had on a bright stripped orange cotton saree with a parrot green blouse, against which her heaving chest was straining as she gasped for breath. But by far the most striking thing about her appearance was the ominous manner in which her eyelids were half closed, and her swollen upper lip.
I told her to open her eyes, but no matter how hard she tried she couldn’t – this is ptosis (a small but characteristically alarming sign). I tapped her on the shoulder and asked her what happened – the syllables came out slurred, and her tongue kept falling back as she tried hard to swallow back spit. But she couldn’t. She was quickly laid on a trolley for lack of room and hooked to the moniter which bleeped uncertainly as her saturation dropped – 95… 90… 87… 82… 79% she was slowly going to stop breathing on her own. She was rushed to the ICU, cannulised, and given Anti Snake Venom along with antihistamines to prevent a reaction. We breathed a sigh of relief as that was done and prepared to intubate and put her on the ventilator. Even as I gazed at her I saw her slowly blowing up like a red balloon, and I’m not exaggerating one bit. Her lips, eyelids and cheeks were puffy and rashes erupted across her arms and legs. It took me a minute to realize she had developed a reaction to ASV. I was boggled by the irony of it, but there was no option but to continue the ASV and deal with the reaction. Once more there was a scramble for adrenaline and rapid intubation.
Once intubated and stabilized, I had a chance to speak with the relatives. A snake had bitten her on her upper lip (which is why it was swollen) in her sleep at 12pm last night, and she had only been brought to us about 10 hours after the bite. Why did it take so long? I asked. A chorus of answers erupted, ‘We took her to johla chaap (village doctor)!’, ‘…Jhadphook ke liye le gaye the madam (we took her to the witch doctor)’, ‘sarkari aspataal mein bhi gaye (and to the government hospital as well)’. When I asked them for some receipt or prescription they produced a small pitiful piece of paper with an assortment of drugs listed including antibiotics, steroids and every variety of IV fluid. Clearly they’d been swindled of their money and better sense.
In a community which is so steeped in superstition it is extremely hard for us to expect an immediate trust in hospitals which offer ‘angrezi ilaaj (western treatment)’. There are many barriers, cultural, social, religious and definitely financial which need to be overcome in order for such patients to reach us. And by then it’s often too late. Most often it is the poorest of the poor who get bitten by poisonous snakes, either while tilling their maize or rice fields, or while going into the forest to relieve themselves as most villages lack toilets. Yet they can’t afford to get bitten by a snake. The antidote alone costs anywhere from Rs 600-1000 a vial, and we give 10 vials – Rs 6000-10000 for Anti venom alone! Not to mention the cost of transport, ICU admission, moniters, oxygen, ventilation. In which land is this a fair plight? To me it seems like a cruel joke that to those who need it the most, care is not accessible or affordable.
The moment I sat down to see the next patient, Sister ran up to me, ‘Ma’am, snake bite aaya hai!’, I asked with trepidation, ‘Ptosis hai?’ to which she replied, ‘Haan ma’am, hai toh!’ The next half an hour played out like a dramatic episode in what could be called an Indian version of the popular American medical saga Grays Anatomy (minus McDreamy). She was brought in to casualty with each arm draped loosely around the shoulders of two men who were struggling to support the dead weight of a person who is fast losing consciousness. Her bindi was askew to one corner of her forehead, and her sweaty face caked with what appeared to be and smelt like, a combination of atta and chuna (lime stone powder) most probably smeared by a ‘faith healer’. She had on a bright stripped orange cotton saree with a parrot green blouse, against which her heaving chest was straining as she gasped for breath. But by far the most striking thing about her appearance was the ominous manner in which her eyelids were half closed, and her swollen upper lip.
I told her to open her eyes, but no matter how hard she tried she couldn’t – this is ptosis (a small but characteristically alarming sign). I tapped her on the shoulder and asked her what happened – the syllables came out slurred, and her tongue kept falling back as she tried hard to swallow back spit. But she couldn’t. She was quickly laid on a trolley for lack of room and hooked to the moniter which bleeped uncertainly as her saturation dropped – 95… 90… 87… 82… 79% she was slowly going to stop breathing on her own. She was rushed to the ICU, cannulised, and given Anti Snake Venom along with antihistamines to prevent a reaction. We breathed a sigh of relief as that was done and prepared to intubate and put her on the ventilator. Even as I gazed at her I saw her slowly blowing up like a red balloon, and I’m not exaggerating one bit. Her lips, eyelids and cheeks were puffy and rashes erupted across her arms and legs. It took me a minute to realize she had developed a reaction to ASV. I was boggled by the irony of it, but there was no option but to continue the ASV and deal with the reaction. Once more there was a scramble for adrenaline and rapid intubation.
Once intubated and stabilized, I had a chance to speak with the relatives. A snake had bitten her on her upper lip (which is why it was swollen) in her sleep at 12pm last night, and she had only been brought to us about 10 hours after the bite. Why did it take so long? I asked. A chorus of answers erupted, ‘We took her to johla chaap (village doctor)!’, ‘…Jhadphook ke liye le gaye the madam (we took her to the witch doctor)’, ‘sarkari aspataal mein bhi gaye (and to the government hospital as well)’. When I asked them for some receipt or prescription they produced a small pitiful piece of paper with an assortment of drugs listed including antibiotics, steroids and every variety of IV fluid. Clearly they’d been swindled of their money and better sense.
In a community which is so steeped in superstition it is extremely hard for us to expect an immediate trust in hospitals which offer ‘angrezi ilaaj (western treatment)’. There are many barriers, cultural, social, religious and definitely financial which need to be overcome in order for such patients to reach us. And by then it’s often too late. Most often it is the poorest of the poor who get bitten by poisonous snakes, either while tilling their maize or rice fields, or while going into the forest to relieve themselves as most villages lack toilets. Yet they can’t afford to get bitten by a snake. The antidote alone costs anywhere from Rs 600-1000 a vial, and we give 10 vials – Rs 6000-10000 for Anti venom alone! Not to mention the cost of transport, ICU admission, moniters, oxygen, ventilation. In which land is this a fair plight? To me it seems like a cruel joke that to those who need it the most, care is not accessible or affordable.
The picture above is from one of the times a patient decided to bring us the culprit himself to see if it was poisonous or not!
1 comment:
Very interesting read
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