It was a humid June night in Bannu city in the southern Khyber Pakhtunkhwa area of Pakistan. Summer begins in this region from April and peaks in June. The family in this story lived in the suburban area of Bannu city. There were about 5-6 villages close by and an abundance of guava orchards which was a conducive habitat for snakes and other reptiles.
This family of around 10 adults and children lived in a cemented house with gardens around it. Baby Aaira (also called Mona), around 3 years of age was staying at her maternal grandparent’s house temporarily along with her parents and two elder siblings. Her father, Imran Khan, was a bank employee and had been transferred to Bannu recently. They were in the midst of setting up their residential quarters in the city.
On the fateful night of 11th June, 2019, Aaira was sleeping on the carpeted floor along with her mother, Nazia. Her father was sleeping close by. Around 2 a.m., Nazia felt something cold touching her feet multiple times. She woke up and looked down to find a snake on her feet. Nazia immediately brushed the snake away with her hands and shouted to the other family members alerting them of the snake being inside the house. Around 2.30 a.m., the snake was found and killed by the family members. Everyone in the family sat together feeling relieved that no one was bitten by the snake.
Aaira who had got up due to the commotion was jumping around playfully in between the chatter of the family members. It was around 3 a.m. when Aaira started complaining of stomach pain. She started showing distress in breathing. Her mamu (maternal uncle), Dr Sharukh Khan, checked her breathing and confirmed
respiratory distress due to airway compromise. In a few minutes, Aaira started losing consciousness and flopping her head which is a typical sign of neck weakness seen in patients of krait bite.
The family immediately put Aaira in their Toyota Corolla and drove to Khafila Gulnawaz Teaching Hospital (KGTH) where Aaira’s mamu Dr Sharukh works as a medical officer. The hospital is about 10 kms from their house but since it was night, the distance was covered in 10 minutes. On examination Baby Aaira was flaccid, unresponsive with non-reactive, dilated pupils with stable vital signs.
The pupillary dilation persisted in spite of direct light on the eye. Since doctors at KGTH were not able to ascertain the cause of distress, the family was referred to the Combined Military Hospital (CMH) which was inside the military cantonment area about 5 kms away. Baby Aaira was taken to the 2nd hospital supported by a hand held self-inflating bag to ensure assisted breathing. There was some delay at the gate of the cantonment area where the guard questioned the family to ascertain the reason to enter the restricted area in the middle of the night. Once the guard checked the identities of all the occupants and was satisfied about the genuineness of the case, he allowed the car to enter the cantonment area.
Baby Aaira was finally admitted to CMH, Bannu after almost 3 hours from the time she was bitten. At the time of admission, she was unconscious with high heart rate. The attending doctor asked for a picture of the culprit snake. On examining the image, he identified the same as a krait. Baby Aaira was administered 12 vials of Indian Polyvalent ASV and 6 vials of NIHS ASV (assembled in Pakistan). The arterial oxygen level was as low as 15-20 mm Hg.
On 13th June, 2019, Aaira who had been unconscious for two days finally moved her lips slightly and opened her eyes. She was not able to see anything. The only response was her increased heart rate when a family member called out to her.
In a few hours Aaira again slipped into a deep coma and didn’t respond to verbal commands and painful stimuli for the next few days. On the 6th day she opened her eyes and had symptoms like Nystagmus [a condition of involuntary (or voluntary, in some cases) eye movement]. Doctors in CMH Bannu discussed shifting the patient to a higher hospital as patient would need to undergo tracheostomy. (This is a medical procedure that involves creating an opening in the neck in order to place a tube into the person’s windpipe to assist regular breathing. The tube is inserted through a cut in the neck below the vocal cords. This allows air to enter the lungs). Prolonged tracheostomy has a risk of infection and related complications which would be challenging to manage at CMH Bannu considering the age of the child. Baby Aaira was therefore shifted to Rehman Medical Institute (RMI), a private hospital in Hyatabad, Peshawar via ventilator ambulance on the 7th day of the bite. It took approximately 4 hours to reach the Peshawar based hospital. Aaira was admitted in the children’s ICU.
It was around this time that the author, Priyanka Kadam, was referred this case by Dr Stephen Samuel, an Emergency Medicine doctor practicing in the UK. Dr Samuel shared a message posted by baby Aaira’s family on Facebook requesting expert doctors from other parts of the world to help the doctors on the ground to manage the complicated case of baby Aaira. Dr Samuel’s colleague, Dr Ayaz Mohammed, a Pakistani cardiologist had shared this information with him from social media. It was the 7th day since the bite. Ms Kadam who runs a national level snakebite awareness and management initiative called Snakebite Healing and Education Society (SHE-INDIA) immediately reached out to the family and got in touch with baby Aaira’s aunt Sidra Liaqat. Ms Liaqat shared the latest CT Scans and a few diagnosis papers which Ms Kadam shared with other doctors to seek their opinion based on their experience of treating snakebite patients.
Snakebite experts from India, who are also advisors of SHE-INDIA, Dr Dilip Punde, Dr Himmatrao Bawaskar, Dr Dayal Bandhu Majumdar, Dr Sadanand Raut and Dr Amit Agrawal were contacted copying Dr Samreen, the treating Paediatrician at RMI and Sidra Liaqat (patient’s aunt). Two neurosurgeons, Dr Amit Agrawal and Dr Bhede (Dr Punde’s colleague) confirmed that the patient didn’t need brain surgery. Dr Punde advised tracheostomy and shared his experience of successfully treating krait bite patients in his hospital.
Tracheostomy was done after 2 weeks from the bite. A few days later baby Aaira started showing very little response like opening of eyes, lip synching what her relatives were saying etc.
While baby Aaira was able to follow verbal commands, she could not see anything. The nystagmus like condition returned. While examining the patient, it was observed that her pupils showed no response to light. However, within a few days baby Aaira was able to assess the level of darkness. When the lights were on, she would tell her family members that it is “less dark” than when the lights were switched off. On the 19th day from the bite, the patient experienced slight vision. She was able to recognize her family members at a distance of 2 to 3 feet. Patient started improving and the tracheostomy tube was taken off. She was discharged from the hospital on the 21st day of the bite and asked to come for regular check-ups as an outpatient. The family stayed on in Peshawar for another week to monitor Aaira’s health and be in the same city in case there was a complication. They finally returned to Bannu after almost one month of the near fatal bite incident.
While at home, Baby Aaira’s vision was still blurred and she suffered severe weakness in her muscles, especially the left side of her body. She needed assistance to get up from bed and walk around. The physical challenges made her irritable and she would bite anyone who came close to her. A good palliative care by the family members ensured Baby Aaira’s condition improved over the next few days. Strength slowly returned to her limbs and she started walking around. On her visit to the RMI hospital in Peshawar for a check-up, her treating doctors were pleasantly surprised to see her full recovery.
Today, Baby Aaira is just like any other normal child, full of playfulness and mischief. The ordeals she and her family suffered due to the snakebite is behind them as the family prepares to send her to a beginners school.
The total cost of treatment in this case was close to PKR 10 Lakhs. This child could be saved as she is from an economically well to do family. , Hundreds of victims of snakebites in Pakistan die or suffer life changing disabilities due to non-availability of treatment. Many are referred to higher hospitals which results in serious condition of the patient and also pushes families into further poverty.
Written by Priyanka Kadam and Sidra Liaqat.