Snakebite management: Key learnings from patient cases in Assam- Dr. Surajit Giri
M3 India Newsdesk Jan 08, 2020
Dr. Surajit Giri, a grassroots worker serving as an Anaesthesiologist and ICU physician in a small district of Assam, around 400 km East of Guwahati, shares his experience of treating 307 snakebite victims since 2010, and the key learnings he acquired from them.
India is the World's 'Snakebite Capital' with 2.8 million bites reported every year and 45,900 reported deaths (highest for a country). In this write-up, Dr. Surajit Giri reports on data from Demow Community Health Centre and Pragati Hospital and Research Centre, Sibsagar, Assam on the situation of snakebite management in Assam.
Dr. Surajit Giri writes...
Of 307 snakebite patients since 2010, 98% patients were socioeconomically, very poor. Literally, snakebite is a poor man’s 'occupational and environmental, acute emergency'. Almost all patients are from rural areas. They don’t have access to a multispecialty hospital, but only to the Primary Health Centre (PHC) and Community Health Centre (CHC).
Question is, can we treat these patients at PHC and CHC? If the PHC or CHC begin managing these patients, we are confident that we can drastically reduce morbidity and deaths. But to do this, we need aggressive campaigning in our society, particularly a must for the entire country.
We always discuss about the never-ending problems/difficulties in treating snakebite patients in PHC, CHC and at district hospitals. But we never discuss about the solutions. Here are some possible solutions for this neglected issue.
How to differentiate between venomous and non-venomous snakes
Sometimes, when a patient presents with a snakebite to the hospital, we are in dilemma whether the snake was venomous or not. If there are symptoms related to venomous bites with distinct bite marks, we label the bite as one delivered by a venomous snake. But, if we also interview the patient thoroughly, we can predict whether the snake was venomous or not.
- Venoumous snakes leave two distinct bite marks whereas nonvenomous may leave multiple bite marks.
- Non-venoumous snakes after attacking usually keep on biting on the area. Patients may have to struggle to get rid of the snake. Venomous snakes on the other hand usually bite and instantly let go of the bitten part.
- Because non-venomous snakes know they are very weak, they just want to create an environment of fear for the human. Venomous snakes know they have a bigger weapon, their venomous fangs.
- After biting, non-venomous snakes move very fast to save themselves, as they know they are weak. Venomous snakes after biting leave at normal speed, as they are aware that if humans attack them, they are ready to fight back with their venom.
- During a bite, non-venomous snakes usually coil aroud the limb tightly; venomous snakes don’t coil around the limb.
Note: These observations and suggestions are purely based on personal experience after interviewing 307 snakebite patients.This may not necessarily be the rule of thumb.
Snake species in Sibsagar, Assam
We have noticed that most bites that occur in our area are from the viper snake species. Fortunately, currently available anti-snake venom (ASV) injections are tremendously effective in treating venomous snakebites in our area. All patients who have previously been bitten by venomous snakes are doing fine.
Of the 307 patients we have had since 2010, only 29 bites were venomous and symptomatic. Most of the venomous bite cases presented to us with swelling and pain and were followed by no blood clot for infinite time with very high international normalised ratio (INR) within 12 hours. This condition is called Venom Induced Consumption Coagulopathy (VICC). The management for VICC is done by administration of coagulation factor. But, we have a totally different experience in our practice.
A case study and learnings acquired from it
In the year 2016, July 8th precisely, we treated a snakebite patient, injecting 55 vials of ASV until we noticed a blood clot over a period of 8 days. Until then, our thought process was to keep injecting ASV until the blood clots. But this patient gave us an important clue! We discussed in our WhatsApp group (more on that in the following paragraphs), whether these patients really require so much ASV, as the patient was absolutely fine without any symptoms, except for the non-coagulability of blood and high INR.
We decided to wait and observe closely after 20 to 25 vials in subsequent patients. We also decided that we will not interfere if the INR is static or in decreasing trend.
In other patients, when ASV injection is administered and pain and swelling subside, but blood fails to clot, we closely monitored with FFP (Fresh Frozen Plasma) and vitamin K. But, in this case everything failed to induce coagulation. However, we did witness a clot after 20 vials of ASV at 8 to 10 days even without further ASV injections on subsequent days in subsequent patients.
Later, we decided to administer a maximum 20 to 25 vials (according to the severity of symptoms) and started to observe these patients with conservative management only. We witnessed blood coagulation within 10 to12 days in all patients without FFP and Vitamin K. A similar pattern was noted among other patients being treated at Sibsagar District Hospital, Assam.
Now, our consensus is that we initially infuse 10 vials followed by another 10 after 12 to 18 hours if severity of local symptoms demands it and then stop. If there is no spontaneous bleeding and no blood clot within twenty minutes and the INR is high, we just closely observe the patient. We advice precautionary measures against injury and trauma to the patient and family members and also explain the significance of INR and non-coagulability of blood.
Today for any viper bite in Sibsagar, Assam, our protocol is; 10 to 20 vials (according to severity) of local symptoms like pain and swelling, followed by observation even if there is no blood clot. We have witnessed blood clotting at 12 to 15 minutes in 8 to 12 days. This was a remarkable observation in our district.
What we have done in Assam since
In the last few years, we are trying to educate the public about snakebite management in our district. We are frequently conducting awareness programmes with the help of the local youth groups of different areas. Thanks to our programmes, now patients are attempting to go to hospitals for snakebites.
We are taking the help of print media and various social organisations in our awareness campaigns too, thanks to our local media who have helped us with them. We are also using popular social media apps like Facebook and WhatsApp. To make it more effective we have formed a WhatsApp group with the general public. The name of our group is SNAKE: Public awareness group.
Right now, we have 100 such members starting from the youth and general public, politicians, press media persons, doctors, and lawyers who share the common interest of fighting against deaths caused by snake bites. Dr. Sanjib Baruah, Jorhat and Dr. Mrinmoy Baruah, Sibsagar and Dr. Arifur Rahman, a postgraduate student of Medicine (his thesis is on snakebite) from Assam Medical College, Dibrugarh are constantly making efforts to educate group members about snakebites. The members are keen on learning and playing active roles in increasing awareness in the society.
This is the beginning. We hope to work more extensively with the general public in the future and treat many patients successfully reaching our goal of zero deaths from snakebites in Sibsagar, Assam.
Sharing knowledge is the key
Doctors treating snakebite victims should communicate with each other and share their experiences of treating such victims. We need extensive studies to be conducted in the various districts of India.
We doctors are a part of the Snake Bite Interest WhatsApp group which also includes several reptile specialists from 17 states of India and other places abroad as well. The group is curated and managed by Priyanka Kadam, President & Founder, Snakebite Healing & Education Society and Dr. Dayal Bandhu Majumdar, a snakebite expert from West Bengal. In this group we discuss only about snakes and snakebite-related issues. There is tremendous learning from each other as complex cases of snakebite are discussed. In many instances, reptile experts help us identify various species of snakes based on information shared by a snakebite victims or their families.
On 4th December, 2019, through this WhatsApp group, two of our members (Mr. Duleswar Guwala and Mr Partha Nath from Athabari, Sibsagar) informed us about a 55-year-old gardener with a venomous snakebite with two distinct bite marks, just below the left medial malleolus. They not only informed us about this, but also took the lead and safely transferred the patient to our Demow CHC (covering around 8 lakh people), where we noticed decreased levels of consciousness and oxygen saturation (oxygen saturation, SpO2 in monitor 84% room air, normal value 95 to 100%), indicative of the venom affecting the nervous system causing weakness of respiratory muscles, pain in the bitten limb, with swelling extending up to the middle of the left leg.
We immediately started treatment with ASV injection, post which the SpO2 increased by 96 to 98%, 45 minutes after administration. We monitored coagulability of blood by the bedside 20-minute whole blood clotting test (20WBCT) and INR. After 12 hours, we had noticed no coagulation of blood for infinite time with INR rising to sky high levels (as we expected). Another 10 vials of ASV were injected on the following day as swelling extended further and he was observed closely and treated conservatively. After thorough monitoring, but no other intervention, on the 11th day, we noticed blood clot at 12 minutes, and now he is absolutely fine.
Thanks to our social network group, the patient was managed in the right way at the right time with the right connection- a systematic approach.
To read the next part in this series where Dr. Surajit Giri addresses common questions relating to snakebite management, click FAQs on snakebite management.
Declaration: Written consent taken from patients for publishing their names and photo for academic discussion only.
Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.
The author Dr. Surajit Giri is a Anaesthesiologist and ICU physician from Assam.
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