Thursday, August 14, 2014


Malti was brought in with snakebite. A tribal from a village in Seoni ,was not talking,drowsy and had labored breathing. We pumped in ten vials of anti-snake venom ,gave her neostigmine and atropine, intubated her and taught the relatives to ventilate her with an ambu-bag. She needed ten vials more but financial constraints on the part of the hospital and the relatives did not make it possible. At ten in the morning the nurse anaesthetic after consulting me decided to extubate her.However, on extubation, her breathing stopped.I was busy attending to another patient ,so the nurse anaesthetist intubated her and she was back on ambu bag.The whole village it seems were keeping a vigil in the vicinity of the hospital so there were no dearth of hands to bag her. We had given them some tips about watching the saturation et,al. At around ten–thirty at night I received a phone call from the nurse asking me to attend to the patient immediately as she was bloating everywhere.I rushed to the emergency care to see her struggling frantically and four big men holding her down as an enthusiaistic man was happily bagging her into a balloon. I asked the relatives to vacate,silently prayed that she had recovered spontaneuos respiration and extubated her.The tube was blocked with secretions completely.Her saturation dropped down to forty.I was worried but opted for oxygen mask and put her on a full flow oxygen and waited as her saturation picked up to above 95%.I got one of the nurses to get a suturing set and put small nicks in the subcutaneous tissue and milked out the air.It was half an hour before she was truly settled and I was confident enough to leave the emergency unit. Next morning when I went for rounds I saw that she was spiking a fever. She was already on antibiotics and if I had had to hike the antibiotic they would not have been able to cover the cost.I talked to the father who by now had been won over after the initial hostility they had showed the staff about the cost of the anti-snake venom.I shared my delimna with him but told him that we would wait and watch. He gratefully consented.In the evening when I went for my rounds there was no fever.The patient remained afebrile after that. Next morning she started talking to us and smiling at us but would not eat beyond a few spoons we coaxed her to during the rounds. It took another day before we could get the catheter out and get her to finish a whole bowl of porridge and with much joy in my heart I could bid farewell to what seemed like an entire village . She should be coming for her follow up in a week’s time. A few questions remained in my mind. 1)If we had had a ventilator it would have run an alarm and we would not have had the ordeal we had at that time. 2)In this day and age in a country like India should financial constraint be a reason for compromising on optimal quality care for a patient? The last forty thousand of our money went towards paying for forty vials of ASV on that day.The suppliers refused to send us the vials without the payment. 3)Did the patient have an option ,I am not sure considering the status of the patient at the time of presentation,I guess not. Malti survived by God’s grace,but what about other Maltis ?

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