This is the story of an unfortunate 10 year old boy, Imran S.K. Imran was the son of Moslem S.K., a poor farmer from Sikarpur village, under Bewa Gram Panchayat, Police Station & Block Farakka, District Murshidabad, West Bengal. He had 7 siblings and his father struggled to feed the family from the produce grown on the small tract of land he possessed. Imran was bitten by a venomous snake around 11 a.m. on 15th Oct 2015.
The family elders, being illiterate, resorted to faith healing by a local healer. When it became evident that the child’s condition was deteriorating, Imran’s father took him to the Beniyagram BPHC (Block Primary Health Centre). The staff there referred Imran (without treating him) to Dhuliyan Central Hospital (DCH) (a Central Govt Hospital for Bidi workers) at Tarapur, Shamsherganj, Dist Murshidabad. The child was brought to DCH 24 hours after the bite. His left foot had progressive swelling.
It was 10.30 a.m. 16th Oct 2015. Dr Saswati Naskar was the Medical Officer at DCH and attended to Imran in the OPD (Out Patient Department). She performed the 20WBCT (whole blood clotting time) test. The blood didn’t clot in 20 mins. This was a sign of a viper (hemotoxic) envenomation.
DCH is a hospital only for bidi workers. The general public is not treated there. The hospital also had no facility to treat snakebites. Dr Saswati further referred Imran to Jangipur sub-division hospital where Imran finally got his first dose of antivenom (10 vials) after almost 30 hours after the bite. Doctors at the Jangipur sub-division hospital further referred Imran to Murshidabad Medical College & Hospital at Berhampur, 40 KM from Jangipur. By this time Imran was heading towards renal failure. The hospital had a dialysis machine and conducts dialysis through the Public Private Partnership (PPP) with 10 beds kept for this purpose. Even though the facility was available at the hospital, the staff referred the patient to a Kolkatta hospital. The reason given was that the hospital didn’t have care facilities for children.
Moslem was asked to shift Imran at 10 p.m. in the night. Kolkata is approximately 200 kms away from the Murshidabad Medical College. Moslem SK did not have the finances to afford the trip and treatment. Heart broken, he decided to take his son back home.
Murshidabad is situated on the border of West Bengal and Jharkhand. There was a local faith healer in Talbehera village of Jharkhand. Frustrated at not getting treatment at the Govt hospitals, Moslem SK chose to take his son to this healer. It was evening of 17th Oct and Imran was by now very critical.
Meanwhile Dr Saswati Naskar from the DCH hospital was concerned about the boy not receiving proper treatment. She therefore brought this case to the notice of Dr Dayal Bandhu Majumdar who is the points person in West Bengal for Snakebite Management Training for doctors. Dr Dayal shared this information on the Snakebite Interest group on Whatsapp. This group has doctors, herpetologists and social workers working as a team to mitigate snakebite. Soumya Sengupta, a teacher from Bankura, West Bengal picked up the information and started following up with Imran’s family. Soumya collected the contact number of the BDO (Block Development Officer) of the Farakka Block and requested him to intervene. Dr Saswati called Imran’s family a couple of times as well. The stress of a child being critically ill and people repeatedly calling the family made the family provide wrong status of Imran’s health. In the meantime, the WhatsApp group made all arrangement at NRS Medical College, Kolkata for treatment of Imran.
Priyanka Kadam who runs Snakebite Healing and Education Society got involved at this point and Soumya and she started repeatedly calling Imran’s father to coax him to take the child back to the hospital. Imran was showing signs of renal failure with progressive swelling. By midnight, Imran breathed his last and he was buried as per Muslim custom in the early hours of 18th Oct 2015.
Priyanka called Moslem’s phone at 8 a.m. on 18th Oct and was informed by a relative about the boy’s death. It was a huge failure of the medical system to see a patient being taken out of hospital and back to a faith healer. A poor farmer had lost his child after running to 4 different hospitals in search of treatment.
The State of West Bengal gives Rs 1 lakh as ex gratia payment to the family of a dead snakebite victim (W B Govt Order No. 1561, Dated: 19.8.2009).
However, in this case, no death certificate was issued and no post mortem was conducted. Imran’s family had not even informed the local police of his death due to snakebite.
The Joint Secretary to the Government of West Bengal vide order number 1561 (19) F.R/4P-3/04 dated 19.08.2008, had waived off Post Mortem report for payment of ex-Gratia in case of death due to snakebite. Armed with this order, Priyanka approached the village Pradhan, Smt Munni and the BDO of Farraka to order a police investigation on the cause of death of Imran S.K. and use the report as supporting evidence to waive requirement of post mortem report to apply for an ex gratia payment to Imran’s impoverished family. Imran’s father was afraid the authorities would exhume his son’s body. He therefore avoided any official interference.
It took many calls to motivate the people on the ground to help with filing the request for ex-gratia payment. The application was filed in Nov 2015 and finally came through in June 2016. The collective efforts of Dr Saswati Naskar, Dr Dayal Bandhu Majumdar, Soumya Sengupta and Priyanka Kadam ensured the distraught family got some relief from their debt ridden existence.
This is a small victory against the challenges that the snakebite mitigation issues face regularly at multiple levels. Unless the Health & Welfare Ministry recognizes this as a tropical disease with a serious health care concern, many more Imrans will die of a condition that could be easily treated at a BPHC (Block Public Health Center) level where treatment is available free of cost for all in WB.
To sum up, a simple calculation may encourage Government officials to feel the importance of “Treating a Snakebite case at a BPHC level” – ten vials of ASV, which costs five thousand rupees at Govt rates, at Beniyagram BPHC could have saved the Govt Rs One Lakh which was given as ex-gratia payment. Most importantly, a precious life got snuffed leaving the victim’s family distraught.
The efforts of all concerned in this story is to ensure a timely treatment of all snakebite victims. We aspire for a stage when no one has to claim ex-gratia for a dead family member.
Written by Priyanka Kadam (with inputs from Dr Saswati, Dr Dayal Bandhu Majumdar and Soumya Sengupta).
On Sunday, 9th July 2015, my beloved junior Dr Sk Rajib called me over the phone from Dhoniyakhali Rural Hospital of Hoogly district of West Bengal at about 9.30 am. Dr Rajib wanted to draw my attention to a picture of a patient sent to me on WhatsApp (WA). Rajib informed me about a very interesting case of mysterious Common Krait (CK) bite admitted at his Rural Hospital. This incident triggered an idea to start a WA group for Snakebite case discussions.
Dr Rajib’s case deserves wide circulation among not only the medical community but also the regular public. The patient was a 40yrs old lady admitted with only complaints of pain in the abdomen on 7.7.2015 in the afternoon. Three doctors treated her in Dhoniyakhali RH in routine schedule of a common pain abdomen case. Third doctor had written the refer letter to send her to Burdwan Medical College for Ultra Sonographic examination. Dr Rajib was the 4th doctor to examine her. Dr Rajib had no doubt it was a case of CK bite. The only symptoms manifesting at that point was abdomen pain and bilateral Ptosis. He not just diagnosed the case accurately but confidently treated the snakebite victim at the Rural Hospital itself. He had started ASV infusion even before getting a response from me.
Like hundreds of my juniors who have my contact details after attending my workshop on Snakebite management in various institutions, Dr Rajib also had my number. He wanted my opinion as a confirmation to his diagnosis. So he made use of technology and got in touch via WA.
This incident prompted me to start the “Snakebite Interest Group”. Like any other initiative, this WA group also faced initial problems. Some people liked it, some others didn’t.
In the beginning, I had started this group with 60 people from my contact list. Though most of them were doctors, there were a few from other professions. We were all tied together by one common cause; “Snakebite”. There were junior doctors working in rural health centers and hospitals, a few senior doctors, some researchers and a few social activists who work for the cause of Snakebite mitigation. Two well-known reporters of Bengali daily Newspapers were also a part of the group right from its inception.
One of the reporters, Mr Biswajit Das of the Bartaman published an article on the WA group in his newspaper. This news article created much interest in the WA group and I started receiving requests from various people belonging to different professions to add them to the group. The maximum capacity that can be included in a WA group is 100. There were so many aspirants that I had to start a 2nd group due to popular demand.
Most of the junior doctors are very active in the group. They post Snakebite case details regularly, not only seeking advice from experienced seniors, but also to inform their field experience that comprised of success and failures. One important outcome of these discussions was that doctors at the referral centers were informed instantaneously, even before the referred patient reached the higher center. Such responses are crucial in a life death situation.
We were able to add legendary figures with snakebite treatment experience in our group. Dr Himmatrao Saluba Bawaskar and Dr Dilip Punde of Maharastra are in this group. Prof. Shyamal Kundu, HOD, Medicine Dept of B S Medical College is also an active member of this group.
We have doctors and Snakebite mitigation enthusiasts from six states in this group. Participants discuss not just Snakebite cases, but also Snake rescue, public awareness, mishandling of snakes, ASV quality and other matters pertaining to snakes and snakebites.
Many group members left us in the last 5-6 months, and many more have joined our initiative. I have gathered a lot of experience on human behavior and team management from this group. A few participants were initially very active and repeatedly requested me to retain them in the group; latter on these very people left the group abruptly.
Some advice from my experience of managing this WA group for those who may want to start a similar group; Never add any person on request from another person. Let each and every member join the group sending a request to the group admin.
Lastly, I would like to share a few pictures that were shared by our group members while discussing further line of treatment. The first two pictures were posted by Dr Sk Rajib. It depicts the CK patient having bilateral Ptosis. Second picture is of a Uro bag of a Krait bite patient treated at Basirhat Dist Hospital. Do note the dark colour of the urine. This condition is called hematuria. The third picture is of the Krait snake shared by Dr (Sr) Archana of Chhatrishgarh. The patient in this case suffered from coagulopathy after bite from this specimen.
Written by Dr Dayal Bandhu Majumdar