Snakebite envenoming: A visit to India, Vietnam and Myanmar
After a frenetic month in India, Vietnam and Myanmar it is time to stop and think, to take stock and consider the memories etched by the stark reality of how brutal and unforgiving life can be for so many. With the inevitable emphasis on our main purpose to establish clinical trials it is easy to lose the focus on why we are doing it. The WHO estimates that 80,000-120,000 people die from snakebite envenoming every year. We want to make it less.
It is the sheer volume of patients. Christian Medical College (CMC) in Vellore has more than 8,000 outpatients a day. Yes, eight thousand. It is the family who provide the welfare for the 2,000 patients admitted daily. They bring you to hospital where they stay with you and feed you. They look after your basic needs including saying their prayers with you. Cho Ray Hospital in Ho Chi Minh City (Saigon) sees over 1,000 snakebite patients/year and at Yangon General Hospital the on duty team had admitted 133 patients in 24hours. The medical aid organisation Medical Action Myanmar (MAM) had more than 1 million consultations in their 10 clinics in 2018.
It was not just the quiet professionalism of the staff and their enormous expertise founded on huge experience or indeed the high quality of the facilities that appealed. It was the dignified composure of the patients themselves who made the greatest impression. The snakebite patients were almost exclusively simple rural workers making their living from the fields. It would be wrong to use the word impoverished. No loneliness and isolation here eroding the strong supportive sense of family, belonging, and community.
A Cobra makes its mark
Myself and Professor David Warrell came across an elderly lady who had been bitten by a Cobra. She had been sweeping up the yard in the evening twilight. With less than perfect eyesight from advancing years she had failed to spot a Cobra which had taken up its position behind an earthenware pot, anticipating errant rodents, and looking for morsels at the end of the day. The Cobra, feeling threatened by the enthusiastic brush, sprang and bit her on the back of the hand. The family brought her to hospital, a couple of hours away.
A Cobra bite will cause increasing swelling of the hand progressing up the arm. She was given 10 vials of antivenom which arrested many of the worst complications. Cobra venom causes the death of local tissues and after a few days, when the worst was over, the doctors cleaned up her wound in preparation for a skin graft when all the swelling has gone down.
The elderly lady had a strangely distant look on her face. What was she thinking? Yes, a snake bite can take its psychological toll. The pain was under control but the hospital was alien. It seemed to be more than that. I think she was concerned that her role in the family may be threatened. She might become a burden and lose her role to support the family in cooking and cleaning; fearful thoughts for a woman of such apparent dignity.
I am glad to say that the chances of a full functional recovery seemed quite good given the expertise available.
A Krait in the bed
A children’s hospital Intensive Care Unit in Ho Chi Minh City seemed to lack for nothing: all the appropriate high-tech equipment and excellent nurses and doctors who were on top of their work. This was the sort of place which would make a non-medical person quiver and go weak at the knees to see so many seriously ill children whose lives were being supported by advanced technology.
A 9 year old farmer’s daughter had gone to sleep at the end of the day on a mattress on the bare floor at home. She was covered by a net to prevent mosquito bites which are associated with the often fatal Dengue fever. Somehow a 4ft Krait had found an entry place where the net had not been adequately tucked in or perhaps the little girl’s movement in the night had dislodged it. She cried out when she was bitten on the lower leg. Her father responded quickly. He saw what had happened and killed the Krait. When he recognised the tell-tale fang marks on his little daughter’s leg his blood must have run cold as such farming people are well aware of what snakes can do. They also know enough to remember to bring the snake to hospital. It can be identified by the medical staff and the symptoms anticipated.
It was now a race against the clock as the paralysis was slowly and inexorably working its way through the little girl’s body. The eyelids were already drooping. The parents started up the small family motor bike and wedged their ailing girl between them, somehow carrying a 4ft dead snake as well. It was a 3 hour journey into Ho Chi Minh City, much of it on dirt roads.
We saw the family in the hospital where the little girl was on a ventilator. The breathing muscles were paralysed. Numerous monitoring tests had been carried out to detect the severity of the complications of cobra bite: muscle breakdown, cardiac muscle toxicity and kidney injury etc. The family was bewildered and fearful, yet they retained a dignified composure typical of rural farming people.
Can it be imagined how the family felt to see their child in this predicament? One can only hope that the person who tucked her net in for the night is not blaming themselves.
We have heard that the little girl is making good progress, but it can take many weeks to recover fully as the receptors in the gap between nerve and muscle, which enable muscle contraction, have been destroyed and only very slowly re-establish themselves.
-Dr Michael Vaughan, Health Advisor