Snakebite Envenoming: A visit to the Western Ghats, India
The Western Ghats, Maharashtra, India: home several species of venomous snake
Health Project Director, Dr Michael Vaughan, recently travelled to the Western Ghats, India, earlier this year with Drs Sadanand and Pallavi Raut to learn more about a country which has more than 60,000 annual deaths from snakebite per year, with the great majority occurring in rural areas.
Here, he recounts the story of Renuka, who, at 28 weeks pregnant, was bitten by a venomous Saw Scaled Viper while collecting grass for her farm animals in remote rural India, almost losing her life and that of her child, is unfortunately commonplace.
Renuka was an ordinary yet extraordinary young housewife. She was 20 years old and 7 months pregnant with her first child; yet she was still working hard on the family farm at Sukalvedhe tribal village in the Junnar Taluka district Pune in the Western Ghats.
Renuka was cutting grass to feed the animals late in the day in December. This was part of the daily routine, but the stinging pain above her ankle from the bite of the snake which she had disturbed in the grass was not. She shouted to her father and brother-in-law who were working close by. They came quickly, pursuing and killing the snake for it to be taken to hospital in the hope that its identity would secure the appropriate treatment. It was identified as a venomous Saw Scaled Viper.
Renuka was more than a kilometre from home and a decision had to be made as to how to get the pregnant Renuka medical help as quickly as possible. Her father and brother-in-law were not capable of carrying her over the rough ground.
What would happen if she lost consciousness with the threat of harm to the precious unborn child? What could be done? It was decision time. Her uncle had come from his village by bicycle and the faithful and robust long-serving contraption had been left on the side of the road at the foot of a nearby steep and slippery escarpment. To descend this slippery incline meant a longer way home but at least the distraught, pregnant Renuka could be supported on the bicycle cross bar (not an uncommon means of transport and villagers were skilled in carrying loads on bicycle). The plan was agreed.
After Renuka reached home, she was taken 15 kilometres on a motorcycle to a Primary Health Centre. The snake venom was taking effect, and she was now becoming unwell and vomiting blood as a result. She was immediately transported by the Health Centre Jeep to the Rural Hospital at Junnar, 30 minutes away. Here, it was decided that Renuka's condition warranted being taken by ambulance to the Government Hospital in Poona, more than an hour away, where her condition was assessed as being so serious that she should be moved on to the Civil Hospital in Pune. The family were now becoming frustrated that Renuka had now been moved 4 times to receive treatment and was getting nowhere as it seemed that nobody had the experience or facilities to treat a deteriorating case of snakebite. Besides nobody wants the death of a young pregnant woman on their hands. The family were unhappy at the lack of activity and positive treatment to save the lives of bot Renuka and her unborn child.
The Saw-Scaled Viper snake, also known as Echis carinatus, is among the deadliest species of snake in the world, and is believed to be responsible for more human deaths than all other snake species combined in India
What was to be done? The family, now desperate, removed Renuka from the hospital against medical advice - to try their luck with a local Mantric traditional healer, some 120 kilometres away. The Mantric applied a tourniquet and recommended that everybody present should stamp their feet while reciting spiritual incantations. Renuka was now bleeding from her nose and gums, further evidence of the effects of the venom. The family now realised that the situation was becoming desperate and took her to a private doctor even though they might have to sell precious animals and possessions to pay. She now received antivenom from the private doctor, but luck was not on Renuka's side. She immediately developed a bad reaction to the antivenom (anaphylaxis), something which is not uncommon and associated with low blood pressure, difficulty with breathing, facial swelling and loss of consciousness.
After many miles searching out treatment and six different consultations, Renuka was moved to Dr Raut's Vighnahar Hospital in Narayangaon, Maharashtra, 80 kilometres from Pune and where doctors Sadanand and Pallavi Raut have developed a special interest in snakebite, treating more than 200 cases annually. Unfortunately, many die before getting to them. But there is a 100% survival rate once the patients are admitted, due to experienced staff, appropriate medicines and equipment for ventilation, cardiovascular monitoring and kidney failure.
After 54 hours of searching for active treatment, Renuka had now arrived at a hospital which had experience, expertise and the appropriate equipment to save her life. She had travelled more than 500 Kilometres in her ordeal.
The hospital had to get to work immediately as Renuka was dangerously ill. She was in shock with a very low Blood Pressure of 70-80 mm/Hg Systolic. She was treated vigorously and closely monitored. Her Hb was 6.0 gms/ml, less than half of what it should be for a pregnant woman. An Ultrasound Scan was carried out to determine the condition of her unborn child. It was possible that she might have bled from the placenta. This time, fortune was on Renuka's side. All seemed well with the child.
Health Project Director, Dr Michael Vaughan, pictured here with Renuka and her family
Renuka gradually recovered with the appropriate intensive treatment. She was discharged after 15 days and gave birth 8 weeks later, to a little girl at 36 weeks gestation. We visited the little girl, now aged 5, at her simple small home in her village where the family brought out their precious tea set in celebration of the visit. Many local people have concluded that the little girl is a miracle.
Without consulting anybody, Renuka named her daughter “Pranali”, which she says means a life which was plucked from the jaws of death.
What is to be concluded from this?
If there is one obvious conclusion, it is that in an area where snakebite envenoming is common, there would be enormous benefit in developing a system whereby those bitten by snakes are transferred immediately to a known regional centre of expertise e.g., Dr Raut at Narayangaon. This is a strategy which could easily be adopted and replicated in other areas of India. Education is important as there are still many who prefer traditional local healers to any alternative.
This strategy could be supported by capitalising on increasing mobile phone penetration. An App could be developed for local health workers to contain material e.g., short videos on lifesaving emergency treatment prior to getting to hospital in Narayangaon as well as other information to prevent snakebite, all geared to saving lives.
The Hamish Ogston Foundation is looking at how to get this up and running.
Dr Michael Vaughan, Health Project Director