Madelina’s tragedy

Summoned back to heaven too soon?

by Umangi de Mel
[email protected]
 

Name: Manoharan Madelina
Birth: 30.01.2002
Death: 02.03.2008

Cause of Death: bitten by a Russell’s Viper

And so the band of angels in their sweet chariot came for little Madelina, to carry her home...to put her tiny body out of agonizing pain which she disclosed from her parents till the last breath.

Fourteen days after her untimely death, Madelina still haunts the minds of thousands of people who question her death with no satisfactory answer.

“She was her father’s joy and he called her his ‘queen’. He would cry at times about her having to leave home after marriage and said he would provide all the facilities needed for her and the husband to continue to stay at home. Now he sleeps on the floor, something he never did before, so that he could sleep near her photograph... Happiness has left us.

During the six years she lived, our ‘Rewathi’ did many things a little child doesn’t usually attempt to do. She was good in her studies and was into many extra curricular activities. She was very mature for her age and was a lot of things to us. She consoled and reassured us even at the last few minutes..

“But now life has come to a stand still and I’m still trying to convince myself that she’s no more which is very hard as I come across her belongings all over the house all the time!” says Jenita Ratnam, mother of Madelina who died on March 2.

Having lost their precious little girl, Jenita and her husband V. Manoharan are two helpless parents who pray to God that it won’t happen to another parent.

“We don’t want to sue the hospital, as it won’t bring her back. But I sincerely hope this doesn’t happen to any other parent. My child was coherent and lived for nine and a half hours, after she was bitten by the snake but nobody could save her.

They just let her go... True, fate may have had other plans for her and may be she was meant to die but had the doctors been a little vigilant and thoughtful while she fought for life, we could make up our minds. The doctor shouted at her just before she died asking her to shutup!

“There is no reason for us to lie as the authorities have said in the papers. We’ve lost our daughter and lies won’t bring her back. We told the papers what we witnessed at the hospital.

We may not know the medical jargon or their practise but we’re not fools either. They took things slow and easy till the minute her blood pressure and heart rate started dropping. I knew it the minute, the machine indicated it,” says a weeping Manoharan.

“Health Minister appointed a special committee that includes a member from the medical council and the National Poisons Centre, for further investigations at a press conference held on Tuesday as the hospital report was not satisfactory,” states D. Wanninayake, Media Secretary, Health Ministry.

“O positive blood was prepared, the minute, the child was admitted. Therefore, the allegations against the blood bank phone not being answered can’t be bought,” says Dr. Lalani Gurusinghe, Deputy Director, Ragama Hospital.

“We worked according to the management protocol which says the Anti Venom can’t be given unless there are signs of envenoming. I assure you there were no loopholes but the team that treated the child had done their best to try and save her life.

“Usually, if the snake’s available after a snake bite, they give the anti venom immediately but some wait for systemic manifestation (signs of envenoming).

1. Neuro toxin manifestation

2. Haemo toxin manifestation

3. Renal manifestation

“If it is a cobra or the common krait, symptoms of neuro toxin manifestation will show such as loss of consciousness, blurred vision, double vision and drooping of the eyelid.

“But for the Russell’s Viper, it’s mainly the signs of Haemo toxin manifestation (i.e.) Haemolysis of blood-Internal and external bleeding. After the child was put to ward two, she was treated by Dr. Mahanama, Registrar and three intern doctors.

They’d checked a blood sample and it was alright and the girl had been conscious throughout. Since we usually give the anti venom after signs of envenoming, they hadn’t started it till she passed blood with urine at 8.30 pm. The consultant of the Paediatric ward wasn’t available but the registrar had taken advice over the phone.”

When she was questioned as to why a doctor from the medical ward wasn’t brought for advice, Dr. Gurusinghe commented that it was not the ‘practise.’

Experts in the field of herpetology point out that paediatricians are less exposed to managing snake bites when compared to other doctors from the emergency wards though.

“And I can’t comment on Dr. Rajamanthri’s statement that was printed in another Sunday paper on what the child’s mother apparently has told him about the snake ‘hanging on’ to the child’s foot! All I can say is that this is not medical negligence,” states Dr. Gurusinghe.

In the mean time, Dr. Asha de Alwis, in charge blood bank of Ragama hospital says that the only extension available for the blood bank was busy due to another urgent need for ‘Bombay O blood’ which is extremely rare in Sri Lanka.

“But as soon as the line was free we did the needful. And Madelina’s blood was cross checked by two medical officers so the story about the child’s blood being another is not true.There’s nothing wrong in the blood bank set up.”

“The polyvalent is raised from the venom of Russell’s Viper, Cobra Common Krait, and the saw scaled viper. Thus it shouldn’t be given for all kinds of snake bites. We import it from India but since it’s made using these particular snakes in India, there may be side reactions as the venom, potency of the Sri Lanka snakes and the Indian snakes differ.

There may be allergic reactions and more. Even in Sri Lanka the venom potency of snakes varies according to the district. It’s a scientifically proven thing. So when our patients are given the Indian Polyvalent, more vials (more doses) are required,” says Anslem de Silva, Herpetologist.

“If you make a standard anti venom for Sri Lanka the venom samples should be collected from the entire geographic range in Sri Lanka and make a pool.

Most of the hospitals in Sri Lanka have the anti venom. Actually snake bite management is a very simple thing. During the undergraduate period the medical students are given lectures on snakes and snake bites during paracetology.

Irrespective of the size of the snake, unless it’s a dry bite, (that injects no venom) the toxin levels are the same.

But if it’s managed properly, there’s nothing to worry.

However, during the day time when it’s warmer, the spread of venom in the system could be accelerated. If bitten you should avoid making incisions as you could bleed to death. Also, tying a turnique is no longer practised as due to lack of circulation, the concentration of the venom will increase in the particular limb, below the turnique.

However, we can manufacture our own AVS here in Sri Lanka. It’s a simple thing that isn’t expensive as we have the resources and the expertise,” Anslem says.

“Any hospital will have the anti venom serum and if not, they transfer the patient to the nearest base hospital. The AVS (anti venom serum) is imported from India. Since it’s made out of the venom of the Indian Russell’s viper there may be allergic reactions depending on the sensitivity of each patient.

The AVS is anyway given after performing the clotting test,” says Shiromini, a research officer at the National Poisons Centre.

“Giving the AVS is also a little dicey as the patient could die if the dosage is too much. Also if the AVS triggers an allergic reaction we stop the AVS and manage the allergic reaction with other medication and start the AVS again. It’s a 10 ml. vial which has to be repeated six hourly.

Although there may be shortcomings of the Indian anti venom serum, we can’t make the AVS in Sri Lanka as it’s very costly. It takes a lot of research and the process is quite long. There is no infrastructure.”

However, experts in the field feel that according to evidence, the child’s death has occurred due to delayed administering of anti venom. They say that the clotting test which takes merely ten minutes should have been done at the time the child was admitted and that the blood urea shows severe systemic envenoming which undoubtedly should have shown in at least one of the clotting tests that the hospital staff claims to have carried out.

Dr.Sekar, Consultant of the Paediatric ward refused to comment `over the phone’ on the matter at the last minute although the Sunday Observer has been trying to contact them since Monday with no progress. Neither did he want Dr.Mahanama, Registrar, to comment on the issue without his consent.

The allegations

*Not identifying the snake till late even though it was produced alive in a jam bottle

*Preparation of the anti venom was done referring books and taking advice over the phone from the consultant who wasn’t available.

*Blood bank phone not being answered.

*If the blood given to her was the right group.

*Arguments over the monitoring unit brought from ICU.

*Not noticing the oxygen supply being stopped till the cylinder was empty - (due to which the child suffered breathing difficulties)

*Delayed treatment i.e. Anti venom serum wasn’t administered till the child passed blood with urine at 7.30 p.m.

(Madelina was bitten at about 3.10 p.m. outside her home and was admitted to the hospital at 3.20 p.m.)

The Russell’s viper

Is one of the most dangerous snakes in all of Asia, accounting for thousands of deaths each year. Once bitten, people experience a wide variety of symptoms including pain, swelling, vomiting, dizziness, blood incoagubility and kidney failure.

* Daboia russelii russelii is a highly venomous snake. It accounts for the highest death rate due to snakebite envenoming in Sri Lanka

First aid

First aid must be simple, effective and immediate

* Reassure the patient

* Remove rings, bangles, and anklets from the bitten limb immediately

* Immobilize the bitten limb to reduce movement

* Rush the victim to the nearest hospital

In case of snake bite:

* DO NOT incise, cauterize or apply Potassium permanganate

* DO NOT apply a tourniquet

* DO NOT give alcohol

* DO NOT let the victim, walk

* DO NOT give aspirin

- Anslem de Silva, Herpetologist.

According to a herpetological survey done by Mark O’Shea, the venom of the dangerous Russell’s Viper and the venom of Burmese vipers differ from that of Thai specimens and the venom of Sri Lankan Russell’s vipers being very different from that of the mainland Indian form.

Obviously this situation has series ramifications when it comes to treating snakebites because victims can only be treated with the available antivenom. Russell’s viper antivenom is manufactured in Thailand and in India but not in Sri Lanka, which uses Indian antivenom to treat snakebites.

Unfortunately the Indian antivenom does not address all the life-threatening aspects of the venom of the Sri Lankan race of Russell’s viper. Often Sri Lankan doctors are forced to administer large doses of Indian Russell’s viper antivenom, with all the inherent problems of hypersensitivity and allergic reactions which in themselves can be life-threatening, if the patient is to recover.

Sri Lankan Russell’s viper venom can cause kidney failure and internal haemorrhages, including brain haemorrhage. Such a snakebite, especially in a rural situation, is a major medical emergency.

(www.markoshea.tv)