Snake Bites - A Panel Discussion with Dr. Jorson, Dr. Wiseman and Dr. Silvano - Hosted by Jovito

Added: 2026-05-25

[00:00:26]My moans to each and every viewer of CCR TV a warm welcome.

[00:00:35]Welcome to a very special program breaking barriers through dialogue.

[00:00:42]Today's uh special program is on snake bites.

[00:00:49]Uh to share about the topic uh we have Dr. Johnson Fernandez uh our ENT specialist and the senior surgeon general of St. John's ambulance in Goa who is responsible for the entire first aid training in Goa and also in several other uh neighboring states all over India. I can say welcome uh Dr. Joseand.

[00:01:20]We have our moderator Dr. Wiseman Pinto, head of the ex head of the pathology department and exdean Goa University, ex head of the Goa blood bank. Welcome Dr. Wiseman Pinto.

[00:01:33]>> And we have a specialist former head of the forensic department in the Goa Medical College also professor ex- profofessor and head of the department of chipmare in Pondicherry karaka Dr. Silvano Sapiu. Welcome to Dr. Silwan.

[00:01:53]Uh we talked about uh the special topic that we are handling today is a snake bite. And snake bites are a medical emergency.

[00:02:03]Snake bite is an acute lifethreatening timelimiting medical emergency. In a worst case scenario, a person bitten by a snake could die in 30 minutes.

[00:02:20]We know that snakes have poison. Not all snakes have poison. About 300 snakes that we have in India. Only 52 carry poison in their poisonous glands which is injected through fangs. And the poison is not the same. When we talk of snake bite, we are talking about poisoning. Dr. Johnson could you elaborate on the different types of poison that is there in poisonous snakes?

[00:02:50]>> Okay. Uh basically we know about uh three types of poisonous snakes in our country India that we talk about. One is what is called as neurotoxic.

[00:02:59]Neuro means it is the nerve tissue that we are talking about. Toxic means we are talking about the poison. So the poison is affecting the nervous system of our body. The second one is heotoxic. Hemo means the blood. toxic means poison to the blood and the other one that is there is what is called the necrotising snake bites. Now it could be derm necrosis where dermal tamg so the skin start getting necros becoming dead tissue. We have got myiotoxic also where you find sometimes the muscle tissue is unable to function so it is toxic to the muscle tissue. So these are the different types of poisonous snakes that we have. Examples neurotoxic common example is a cobra.

[00:03:37]>> Naja naja or Indian cobra.

[00:03:40]>> Indian cobra.

[00:03:40]>> Even king cobra also would come under the >> under the Yes. Under the neurotoxic. But >> some of the snakes do have not only one type of poison, they have both the types that contains both hemotoxic as well as a little bit of dermosis.

[00:04:17]It is a hemotoxic snake bite. So there are different names culturally that people have given for different types of snakes that we have got. So basically these are the three types of snakes that we have got. Necrotising snake bites not very much. The most highly poisonous that we get is the mamba snake which is found in Africa but not found much in >> not much.

[00:04:34]>> Yeah. Not much in India. So these are the three poisonous snakes that we have in India that we come across whenever there are snake bite and first aid emergencies that we have to deal with.

[00:04:43]>> Yeah. So when you talk of necrotoxic you're talking about you said death of tissue.

[00:04:51]>> Yeah. And then you talk about king cobra. Cobra crate also is is also a part of that.

[00:05:00]>> Yes.

[00:05:00]>> And when you talk of hemattoxic >> wipers, >> viper, gonas, mandor, mandish, fch, different names that people have in different uh you know parts of the Goa region people wiper wiper.

[00:05:18]>> Pete wiper toy wiper.

[00:05:19]>> Toy wiper. So people give so they give different names.

[00:05:27]So these are the different names that people have culturally people have named them but people know that they are poisonous.

[00:05:35]So this is what people do along with when they see these type of things.

[00:05:41]Your cobra your feet wiper and sea snakes. Yes.

[00:05:50]>> Myiotoxic parameteriz they're also >> on the on the go shows. Yes. Sometimes you can see them.

[00:05:58]>> Yeah.

[00:05:58]>> Yeah. But very rarely not very common.

[00:06:00]Very very rarely.

[00:06:01]>> Yeah. Wiseman.

[00:06:08]>> We will start as Dr. Johnson has nicely described the types of snakes. This word snake comes from snakas or you know old English literature or it was called as shakan or it was called as a serpent in our Italian uh Latin. Why?

[00:06:27]>> You know ani sorup, serpent sorup and the Sanskrit it is called as naga you know nag >> now senor jovit snake bites is an emergency sari and but we have to see how common it is in the world there are 5 million cases in a year of snake bite Dr. Johnson will also sap is also Dr. And of which 3 million occur in India and in the world common is in Asia, South Asia, Southeast Asia, Africa subsahar in Africa and India Goya in Goa also snake bite is very common. Now one of our student Dr. um Chetan Karakar he's a lecturer in Dr. Sapico's department forensic medicine and his post-graduate Puri Mishal did a wonderful research study because you know you have to have evidence-based medicine to tackle snake bite only the administration understands this very well. So they did a study between 2020 and 2024 of number of snake bites which were there and deaths. So the snake bites were 1,663 for these five years and the deaths were less six in one year six in one year two 57 but still these deaths are could have been avoided and their study is very interesting because that during monsoon season it is very common s farmers is more common the occupation students bur age 21 to and lower part of the body face hand north goer south goer so it is a wonderful study it was carried by Navin times on the first page and uh he he seeks my advice now what they are doing there's another doctor from medicine now Dr. Ramnut he wants to do uh like you have registry for cancer registry for diabetes they he wants to do he is my student also wants to do a registry for snake bites in the whole of go but so they they are in the process they need approval so this is this case of uh uh so these are some of the studies that will help all of us to see various things that uh as Dr. Jordan has said the first aid is given at the site what they should do that we will discuss then we'll also discuss in your jovit when they come to the district hospital or when they come to go medical college kit kuran I think and then after that in case there is a death what we look at we will be discussing and then I'll also discuss with you some of the things that have taken place you know these cases are more common Dr. Johnson and Senior Jovitan in the more rural areas where there's forestation, forest, fields.

[00:09:43]So what advice we should give to the people so that the people do not get deforested like monkeys.

[00:09:58]Exactly.

[00:10:07]hills have been cut. Forest are being disturbed and their habitat is disturbed. They come and disturb all of us. This is what is happening.

[00:10:21]Neurotoxic they say that is the deadliest type of venom and little dose could kill somebody in 30 minutes.

[00:10:30]>> Yes.

[00:10:32]Neurotoxic cobra, crate, mamba, coral snake, sea snake also some of them come under this category toxic. Now normally they leave two puncher marks and all that. Is it correct to go by puncture mark? But there are some snakes who don't leave any puncture marks. Even pa you don't get those two prominent marks.

[00:10:57]>> Fang marks are not there. There are different types of species and they have different there are some of the snakes which have even got three fangs.

[00:11:04]The third one is the result.

[00:11:10]What type of a prey you catch when you're biting? If you catch a prey where exactly there's a bone your fang may break. Then you will get only two fang marks are there. But subsequent bite baby with only one fang mark.

[00:11:31]Now how do you describe it? There are not two fang mark. There's only one fang mark there. So these are the type of things that happen. So species differ in their presentation of the bite marks which may not be the same or universal in all cases. That's that's something very important.

[00:11:47]When you talk about this neurotoxic snake bite, what is the first paralysis that you see?

[00:11:52]>> The first Yeah. The first nerve to get paralyzed is the upper eyelid.

[00:12:18]after according to me what they saying is correct to see if that was their sign that was the symptom That was medical services.

[00:12:53]The faster you get to a center where there's an antis named is important because every case of a snake bite you must treat it like as if it is a poisonous snake. Unlessed you will not know whether it is important to rescue the patient. Correct.

[00:13:13]>> That is very important.

[00:13:16]There are all cultural beliefs.

[00:13:33]protocol. What is the protocol that we require is very important?

[00:13:41]One system is the lymphatic system.

[00:13:42]Another one is the vasculature system.

[00:13:44]Vascular blood vessels like the blood vessels. Blood vessels the blood is being pumped by the heart.

[00:13:58]blood circulation with that poison will go faster. That's number one. Point number two, poison because lymphatics the lymph is pumped by the muscles. As the muscles start moving, the lymph starts getting pumped. So immobilization that is more important for us than anything else. So rescue the patient looking after all the dangers you have to immobilize the part that is being bitten by no movement. No movement. No movement. No movement should be there. Third, now you have to make a move. Why?

[00:14:50]Ambulance.

[00:14:56]Ambulance especially during the night time in rural areas. 50,000 people die of snake bite in India which is absolutely abnormal. Exactly.

[00:15:09]The principle of golden hour that 10 minutes is a maximum time.

[00:15:23]They they are not waiting for that 10 minutes. That 10 minutes is the uppermost limit. Beyond that you cannot go otherwise you don't call an ambulance you call it a truck. Okay.

[00:15:40]driver and ambulance fit.

[00:15:43]>> These are the problems that we have to accept because ambulances need to be also test driver driven and said that okay baba this is fit now to be mobilized on the roads. Second thing, the driver should be trained as an ambulance driver. That is also not a motor vehicle. No heavy license driver.

[00:16:03]That is not ambulance driving. You must know how to hit the signal. You must know how to blow your siren. You must know how to negotiate. You must know how to have the GPS reading to be done. You must know which is the closest hospital that you are supposed to take. So there are so many parameters that ambulance driver needs to know which people are not even understanding.

[00:16:27]This is not the way. So there are situations. So ambulance driver is one part of it. Now the second part of it is >> we are now taking the patient from your hospital.

[00:16:36]>> I'll just interrupt only one minute jo also people get scared when there's a snake bite. So important to reassure that the victim to susagra all snake bites are not poisonous. Naza if he gets agitated you know then his heart rate increases heart rate increases then the the the venom also >> yeah but but uh the biggest positive thing is treat each and every snake bite as poisonous. It is poisonous and proceed accordingly but calm the man.

[00:17:16]That is the most important. So do there is first your first state part and second transportation and once you reach a good hospital correct where anti-nake venom is available and test can be conducted. So these are the two parts which are the most important question all private practitioners will not keep anti of essential medic list of essential medicines as anti-nake venom is one of those medicine which should be there into that list is it That is one question. Second thing where it is readily available north hospital, South Gu Hospital, Goa Medical College, maybe your community health centers, maybe your primary health centers, private doctors may not be keeping only if they find lot of cases are coming in, they may keep because it is costly.

[00:18:18]>> One, two, you have to also maintain the cold chain. So there are two important problems that you have to handle the vaccine.

[00:18:25]So, so it is costly. It has got a cold chain for its maintenance. It has got a short expiry. So, these are all the difficulties for the private setup or the private facility to store it because we were told that all district hospitals have anti-nake venom primary health center. We don't know.

[00:18:55]>> Yeah. So if district hospital we have got only two now subdist.

[00:19:12]So we have to find out it cannot be a strategy that I will make it available only here or I will make it available only there. The reason is simply because you have to find out where geographically there are more snake bites and in those concerned primary health centers you must see that antisake venom is made available to the doctors there should not be any restriction antake that means you are not authorized you may be a junior doctor so you wait for the senior doctor to come so senior doctor is he available is he coming is he going to delay what's going to happen because the treatment is awaited just because the senior doctor is not coming.

[00:19:50]So this type of restrictions also should be removed and the vaccine should be immediately given to the patient evidence based after doing your whole blood clotting time blood clotting test it's evidence based >> so we should as you rightly said Dr. Johnson in those areas where there are snake bites especially you know rural areas and especially near the forest or fields uh you know both north go south and patients come from Maharashtra and Karnataka also they also come to go there no other hospital that's okay >> so this is all a part of the whole so there also we should see the feasibility of keeping these you know antis all these our centers also whether it is district hospitals Subdist hospital J they have to maintain the stocks properly expire expiry days sometime two years sometimes five years because you cannot say how many will come and average in Goa there are 600 snake bites in a year that means two per day Dr. was telling me that during monsoon season August, September, October though in case this so it is it is a thing of concern we have to do you know by these evidence-based and showing the statistics the government and the high authorities should you know should be more proactive like diabetes what we did cancer what we did similarly segment continuing your discussion So again they say you should not tie the tourniquet I don't should not tie those are old razu ring ring or watch or jewelry or shoes so that you know the and immobilized hospital once they come to the hospital and they say take a photo of the snake if it's possible with your mobile Sai don't try to catch the snake you'll get more bite so that and show it to the doctors when you come z party snakes bite at night one of my relatives in Benoli they don't know who has beaten whether it's a snake whether it is so in the days when there were no mobiles so that's another issue which is there >> no I'll tell you about the turik now the old fun was >> fun >> that when the snake bites when you try pul on a single bone >> it traps the poison venom.

[00:22:27]>> This was the belief that they had there was no much research that was being done on that and then subsequently they realized that the venom is lymphophilic.

[00:22:36]It goes through the limb. So whether you tie or don't tie as the muscles move you will find through the lymph it will go ahead and with the blood circulation it will go ahead. So 60 to 90 beats per minute. That is a regular heartbeat. When a cobra bites you or a snake bites you, your heart rate will go to 120 beats per minute.

[00:23:16]All movies you will see that people are sucking the poison and throwing out.

[00:23:42]That's the reason I was saying that there are beliefs and cultural practices which should be changed which are bound because of the mass media information that people have right wrong whatever old new tested untested or whether it's the movies people embibbe normally when we get a clot when we get a cut are blood clots on that cut because the plate they are like the plumbers. So when the blood vessel is cut off the job of the plumbers is to seal that seal. So the blood clot is formed. Blood clot blood clotting mechanism fails when a wiper bites or wiper bite or bite.

[00:24:36]So you know treatment.

[00:24:44]If it is heotoxic you will bleed continuously. If it is necroizing then you will find the tissue will be all necros and you'll be left with deformities materials are being removed because the swelling develops onto the patient after the snake bite. So this is where they are removing all the constricting materials. Now Australian snake bite protocol they use what is called the pressure immobilization bandage PIB pressure but that is tied only for the neurotoxic snake bite.

[00:25:31]>> They have got their research. I don't have the papers with me and we don't have such a bandage also in India to tie it for a patient. Even if you know there is no research at all in India on snake virus and >> studies are being done now.

[00:25:46]>> Yes.

[00:25:47]>> We need to have these studies done because these are important for us >> important for go >> and and it will become more relevant based on our type and species of snakes that are available based on the type of emergency services that are available.

[00:26:01]Correct.

[00:26:01]>> Based on the way the anti-nake venom is available in the periphery or in the rural areas or maybe in the most communist geographical regions where the snake bites are possible because that will help us to redistribute our emergency services.

[00:26:28]Ambulance. No doubt. Ambulance has reached on the spot.

[00:26:47]it advanced. So how do you carry the person in a case of snake bite where you have already now immobilizing?

[00:26:59]So it is not only understanding about the snake but after rescue how do you transport right up to the ambulance is another one.

[00:27:08]The same methodology has to be used because there should not be any movement movement.

[00:27:12]the poison will start moving through the leaf and going ahead especially when you talk of neurotoxin the only way to find out whether there was poisoning or not Dr. Silvano you'll have to do the postmortm >> just to supplement what Dr. Json has said >> I want to tell that ideally the fang bites occur between the webs of the fingers and the webs of the toes. Ideal and when we have to immobilize we have to see that nobody massages the site very very important do not massage immobilize and then you say that apply that cor at single bone that was the old theory old >> but what is important is that the lymphatic drainage will take the blood into the system okay >> now coming back to your question >> you desire to know there there is a worst case there is a worst case 30 So the only way to find out is postmortm. Yes. Medical legally speaking any bite of any animal including human beings is a medical legal issue. It has to be investigated by the police investigating agency and a medical legal postmodm has to be done.

[00:28:32]In other words, an inquest punchanama has to be drawn and thereafter the body sent to a medical college or the rural health center or the dispensary wherever the approved centers and either a single doctor or a team of doctors will do the medical legal postmodm examination. Now when we do a medical legal postmodm examination we will check which are the sides. Remember that we always knew that bites were accidental. We have also come across in Kerala a case where homicidal poisoning has been done. So because of that a thorough medical legal investigation will be done the type of assessment bite whether the bites are simple bites or aggressive bites even that they come to know and that is how when we check that then we will take the tissue around the site at the time of medical legal examination we will collect that preserve that in saturated solution of common salt send it to the forensic science laboratory to determine the type of poison qualitative ative and quantitative analysis what has accelerated or precipitated the cause of death of that person.

[00:29:39]>> Yeah. But then uh the cause of death the type of snake poisoning can it be found through >> forensic evidence? Based on the findings whether it is a neurotoxic, hemotoxic or combination of factors we can determine subject to confirmation by the forensic science laboratory.

[00:30:03]>> Yeah. So, so test can be done and there is a possibility of pinpointing the exact poison of the snake >> and if the person has been admitted in the hospital they do bleeding time, clotting time and according to that they give the anti-nake venon serum. Remember that that uh injection anti-nake venom serum vial is a very expensive oil. Yes.

[00:30:24]>> Roughly it cost about 2,000 rupees per but human life is much more.

[00:30:29]>> Exactly. But what I'm saying there is expiry period. Uh Dr. Sgo and Senor Jovu as Dr. Sgo said I'll just elaborate further.

[00:30:39]>> Once a patient comes say comes to casualty immediately they do all the blood test especially clotting. If it doesn't clot, hetoxic doesn't clot. So they have to give the they evaluate the patient and see if there is any other problems the bite etc etc the wound and start giving the anti-nake venom by intravenous and they divided high-grade medium and low grade. They give about 10 vials in a drip slowly and over a period of one or two hours and then check the every 1 hour check the blood blood to see if there is any clotting or not clotting. So that's the second thing and if there is respiratory problem also has to be seen has to be put on ventilator has to be put in ICU and uh look after these things. So I I know of a patient who remained in ICU for a about a month and died after that. We also know of patients who come and die very fast also. Now at the autopsy as Dr. Sapi has said today now tests have become better and better. Now this toxicology this you take the fluid from that bite you can do with radioininoay eliza and fluoresence they can tell you exactly how much poison is there and how much is the the you know type. In addition, there are damage to the organs, liver, kidney, heart, lungs, there's pulmonary congestion, pulmonary edema and also the brain. So these are both notox. So these are some of the circumstantial also evidence. Now Dr. Sapeco and senior jovito when there is a postmortem it may be a snake bite but the patient may have other pathologies they also may have led to his death Dr. Johnson patient may have some cerosis patient may have you know so it has to so the real cause of death is usually given after you have done the postmortem you have done chemical analysis and Dr. and also hystopathology which is done and finally you can give an overall and today it has advanced as I told you as he said Dr. Sico said more modern tests have come so it gets more accurate like radiom may not be still available in >> hytochemistry definitely confirmed >> is confirmed Eliza and all this so so all these things have become important in today's world and scenario >> neurotoxic neurotoxic normally causes paralysis of the respiratory muscles how do you manage the respiration because breathing circulation.

[00:33:45]>> Now in this situation I'm not talking about hetoxic. I'm talking about only neurotoxicus.

[00:33:57]Second thing that we have to teach them is how do you immobilize? The third thing we have to teach them is how to transport. The fourth thing we have to see is that where it is readily available. Not that you go to one center.

[00:34:14]So there should be an universal system by which we operate and we say that's the standard level of our health sector where all antistakes venom will be available. Every primary health center or maybe every private hospital which has got five beds, 10 beds, 15 bed whatever. And the government supports these hospitals. If we want to save life, so this is how it should be done.

[00:34:37]Geographically, if you know there are more snakes bite coming from a particular region, then there should be a little bit of reinforcement of anti-nake venom that is going to be made available down there. Now resuscitation because if you do resuscitation patient life is going to be there till the patient comes to receive the anticum they do not know about ambush bag. They do not know about chest compression.

[00:35:03]They do not know about ventilations. But if we teach them, yes certainly they would prolong that life of the person till that the medical assessment is being done and the concerned ASV is being given for that particular patient and the life can be saved. So these are all intrusions of awareness and skill development of people which routinely every medical first responder should know as a citizen so that you can help people to live longer.

[00:35:29]>> Yeah. Dr. also we said that the deadliest type of venom is neurotoxic.

[00:35:35]Now depending where you have been bitten how fast it would travel depending also on the capacity or >> yes when the snake let us say there's a snake it has already beaten a frog or one prey already second before it could put pouch into a contraction and get everything inside through the fangs part of it is spilled out.

[00:36:12]So these are all situations where in that panic situation whether the snake has got enough time to inject is one important thing. Whether the fangs were totally full or they were empty or partly empty is another thing. Third thing is proximity to the heart.

[00:36:26]>> Yes, >> if you are bitten somewhere on a neck on your face or on a chest or an abdominal or the hands it is going to be much much faster traveling and causing the effect.

[00:36:35]If it is on the legs also because you are finally needing to walk and if you're walking then there will be mobilization and mobilization is something which is drastically going to affect a poisonous snake bite because the poison is going to travel faster. So these are the situations that people need to know and understand how they should be handling a case of a snake bite.

[00:36:54]>> Yeah. Again I'm talking about your neurotoxic we talked about neuropalytic paralytic patient neurop that means your breathing stops and sometimes you say tomo it's not correct to say that unless unless you do not eg that has to be established >> so so it looks normally even your ECG will not be able to tell tell you directly.

[00:37:26]So in that case ventilation is important. Airway stabilization is important. So your ambo's bag must be a part also of your of the ambulance the ambulance system of any medical emergency system or facility that you're providing it should be there. And it's not that only it should be there. People must also know to use it to use it. They should know to use it because that's the normal breathing pattern of a human being. We take four seconds to breathe out. All right.

[00:37:53]>> 1 2 3 4 1 and 2 and 3 and four. So tank ambush bag with 1 second to press. Wait for a count of up to four. One and a two and then again press again. That needs to be taught. Then you have to also teach them the technique how to open up the airway doing the head tilt chin lift. So all these are small manuals that anybody can learn.

[00:38:13]>> A common person can learn and you can save life. But >> this need to be going to down to the schools >> because a first responder could be anybody and you can save a worthy life of a human being. Having known these type of skills which are very much needed for a person I think we can certainly save lives but the program should percolate down to the level of medical in charge of the foreign would you get many cases?

[00:38:39]>> Yes. Yes, we did get when I was in the casualty department, we've handled plenty of uh snake bite cases.

[00:38:45]>> Snake bite cases.

[00:38:46]>> What used to happen at that time, we had what is called a school health officer.

[00:38:49]They were responsible to see that the hygiene and methodicity of all this was looked after. Today, they have abolished the post of school health officer. So, so I plead with the government authorities that the directorate of health services be empowered to see that all the district hospitals, subdistrict hospitals, CHC's, PHC's and the Goa Medical College is having this vaccine anti-nake venance serum available at a at in a jify.

[00:39:16]>> Yeah.

[00:39:16]>> And the expiry expire was talking about now this is this is being done being done. Wiseman >> in Australia is being done in United States because there monovent in India it is polyent any snake white shoe it is one all four but in America if it is neurotoxic then neurotoxic is very specific ours is poly and ours made by v some company >> that's What I'm saying for us there is no need of finding out which is next.

[00:40:03]>> So if you know it's a cobra and is neurotoxic ventilator can be kept ready.

[00:40:11]That is the issue. It is not that just anti-nake venoms symptoms that have so you will anticipate that you'll need a ventilator when it's a neurotoxic.

[00:40:22]Johnson will yes as when Dr. Sapo was there I was also professor of medical education we brought professor Vle from Amita in he has done lot of research on snakes >> and he has got poison information center that is the need of the medical chan Dr. Chetan has worked with him. He's he he he so that must have motivated him to do this study. It's a very good and when he came we also brought a snake catcher to explain us you know the snake catchers >> rescuers snake rescuers all over go and uh you know we had had seminars for our doctors >> plus when we organized this thing national academy of forensic medicine there also we have poison poisons You are authorized to give the report to say that he died of snake bite poisoning or not.

[00:41:24]>> Yes. Yes, we are authorized to give the report which is a confidential document which is a prerogative only of the police department to maintain and complete the investigations and the appropriate government authorities who are responsible to ensure that such >> but definitely the family will they get this report or not?

[00:41:42]>> Yes. Yes. Can I just add to Dr. Sapo?

[00:41:45]I'll only add this is a tentative report preliminary report. The final report you will actually give after you get the other reports the chemical analysis flores and hystopathology which takes time. So that is the final report. This is just a preision provision provisional report. So you have to >> final report comes with pending and that is done afterwards. It is given to the police afterwards. So a final report comes much later >> comes much later because esophage you can't do within a day >> you need you know certain processing times >> minimum 7 to 10 days minimum >> you can do in 5 days also I've done >> so Dr. Johnson what is most important is immobilization. So use splints and now they say that use the crap bandage from one end of the limb to the other end and immobilization use splints. Are there specific splints to be used? Wooden splints is the best thing because if we start talking about all the medical splints that are available for us people will get more confused. So just the wooden splints if available that can be used and then you can put a bandage for wrapping up. Yeah. So that the leg doesn't move or the affected limb or the bitten part of the limb doesn't move.

[00:43:00]And then the second one is transportation. You must not make the patient walk or hop or whatever it is.

[00:43:05]Just stop doing all that. In that itself situation, you can do what is called as a human stretcher with bed sheet without bed sheet. You can take that patient to the ambulance service from there to the appropriate center. So the most immediate thing is rescue after rescue.

[00:43:20]Immobilize after immobilization. See that the ambulance is ready for you.

[00:43:23]Transport them appropriately well. Don't move the patient unnecessarily uncalled for and take to a center where the ASV is surely available for you. Be ready for resuscitation. So every person in the periphery should be taught about these methodologies. At the same time they should be also taught about resuscitation that could save >> when they talk about uh neurotoxin they talk also about locked in syndrome.

[00:43:46]>> Okay, >> LIS that's basically with your breathing >> breathing. So your amu that we talked is important >> important very important for us >> because normally there have been cases where they said no to and without doing your EEG and they also talked about cerebral blood flow test and nerve conduction velocities. So all this uh has to be done >> that that is being done subsequently at a level in the medical for us to establish the death whether brain death has set in or not but for us at a local level what we need to do is till the doctor tells you you are going to continue your resuscitation because you are nobody as an ordinary person to certify anybody dead. So patient even if I am there as a first I may not be a doctor or I may be a doctor but I am going to resuscitate till we reach the center where the center will say okay fine baba now we are handling it and then we will decide whether the patient is dead or alive. So we leave it to the center but the moment I give up here in between and declare the person dead with what test am I going to declare? So my job is basically to resuscitate till he reaches the center. Once he reaches the center, the center will decide what needs to be done to establish >> doctor I will just discuss three more points.

[00:45:01]>> Yeah.

[00:45:02]>> Uh you know though I have retired I get calls from all patients from a patient came snake bite. So I have to phone I phoned her and uh the patient was saved.

[00:45:14]Only thing the patient they tied to young girl of 21 so that thing got you know infected ulcerated you know necrotic so they need debridement surgery so I found today she has gone home she has recovered and she has not yet walking but they are confident she will walk so this is one story second story is I' had gone to Sri Lanka Colomb PG student was doing a thesis on snake bites And I just read the this of Dr. Kar's Chetan's research. So she said sir I'm doing of Columbbo. I said see Columbbo you should not do you should do the periphery where there are the hills and you know hills and uh mountains jungles that is the area she agreed with me.

[00:46:03]Third thing I'll tell you one story which took place in Bihar. It's a true story. Elections were there in Bihar must be about 20 years back. And you know the is officers they are the election agents like commission you know election commission appointed by. So Patna is one and Bihar is very huge.

[00:46:22]There was a snake bite of another is officer in a place which is periphery.

[00:46:28]It was going to take 8 hours from Patna to that place. You know using their common sense and brains which I liked very much. They started from pata the the taking the anti-nake and told him to come and they met in the middle four hours four hours and saved it. So this is also something which all of us you know should think of. I know sometimes when there's an emergency the mind doesn't work but with experience all this helps in improving the the you know health care and as Dr. Johnson said besides teaching school children etc school we should also tell the people to take torches lights or now you have mobiles when they go you know in these areas and wear shoes or boots >> gum boots >> gum boots or you know that's important today where the because and they say sticks sticks because you know the uh since the snakes cannot see they they see the vibr they hear the vibrations or they sense the vibration So all these sort of pro protective measures >> yeah in this are tackled Dr. Johnson will share with us in wilderness first.

[00:47:47]>> Yes.

[00:47:48]>> First in wilderness is basically where you do not have facilities that we are talking about now in the civilian reach out. Yeah.

[00:47:55]>> And uh those are the type of things that we need to learn. There are many things that are there. If you look into the older uh books and maybe sometime people if you ask them to put it on the bun we were taught in school smoking is bad.

[00:48:47]So they used to sting them. So when they used to sting but they had the guts to do it so fast and so quick. So what happened?

[00:48:58]It gets burnt there.

[00:49:15]tradition.

[00:49:16]Yeah. But then that is not something suitable now.

[00:49:26]So because things are changing for they also say don't drink alcohol, don't drink coffee.

[00:49:37]This is some of the what I've read. No alcohol and coffee and coffee because interface with the manifestation of the poison kazum you are high now you are high because of poison high because of alcohol nobody knows that is one of clinician finds it difficult to assess >> difficult to assess okay that's one part of it coffee moment you drink coffee yeah it's a stimulant so you unnecessarily give a wrong feeling I think the clinician gets confused with the manifest as you said and senior in the forest there are a lot of I think resorts are like that thank you plus you know when I arranged this talk for Dr. Sapeo the you know department and the whole college it was of VB pill I met one of my student I said for the talk say yeah sir I go hiking we have to know about snakes so I'm going to attend last in Brazil there is an island of s pao where there are thousands of snakes man is not allowed to go there or poisonous snakes it's called as ilad kad grant of s pao followed all poisonous. It's they say that area got separated and these poisonous snakes live on the migratory birds which come there. Man goes there will be finished per square meter there is one snake. So there are thousands of snakes.

[00:51:17]>> Normally a lot of people they say wash the wound.

[00:51:20]>> Yeah.

[00:51:21]>> And first aid manual say do not wash the >> correct. Now when you wash the when you wash there are two ways of doing it. You can take a gosp and you can wash.

[00:51:32]When you wash what will happen you are moving the tissue you're rubbing the tissue that will cause if it is a necrotising or a dermac necrotic snake bite it is going to cause matters worse for us. So when you wash you can just pour water also and you can wash. Why are we washing? We are washing only simply because the snake is into an environment which is so very different and from that environment when the snake bites you will find little bit of debris from that environment which is going to come on top of that and if it is a necrotising snake it will become worse.

[00:51:59]So just pouring water is enough rather than rubbing it with a gauze on trying to clean it more thoroughly well like how we do it for a wound is going to be dangerous. So it's better not to wash also. People don't know >> just cover it with >> just cover with a loose loose >> and very often they say I told you that nonpoisonous and they say nonpoison no treatment nothing but antiers whether it is poisonous or not you have to be taken to the hospital >> and if it is non-poisonous >> TT is a must >> TT is a must for how long observation observation >> for how long a patient should be kept under observation to Blood test and symptom. Yeah.

[00:52:40]>> Blood test symptoms >> minimum minimum they say 24 hours at least at least >> because the poison can slowly start showing up afterwards. So that's the reason detonus like just the cluster day organisms are found almost everywhere >> mostly into the horse dung and the cow dung. So we do not know when they caught cows they go to the lake they are being washed there clean there their dung is also there into that same thing from there the snake comes. So you can have the cluster organism that are entering into your system. So for any cut any bruise that is there any opening into our skin it's always better to take a tetanus >> and anti snake venom calling any idea >> it's it's produced from the ecoin >> that means the horse's serum it has imunoglobilins but you need the snake venom.

[00:53:28]>> Yeah. Yeah. But it's from the snake.

[00:53:30]>> Yeah. What they do know they produce these imunoglobulins by injecting into the horses the venom they produce antibodies and so what it does >> when you inject it it this imunog globulins they act against the toxin neurotoxin it don't allow it to act >> it also acts against the other toxin which is heotoxin as Dr. Johnson said which will prevent coululation. So it destroys the toxin.

[00:53:56]>> So that means you you you need snakes to prepare the >> exactly you need to prepare the venom.

[00:54:04]>> Yeah. And if I'm not mistaken it was developed by Albert Katman. Kmet is the one >> who just the same fellow BCG and it was against the Indian Cobra. It was against Indianra. So you need you need >> Yeah. you you need >> and the big four snakes that they say in India is your cobra spectacle cobra common crate >> Russell's wiper and saw scaled wiper so >> first aid is very important you have been an expert you know you are the surgeon examiner and do people take it seriously unlearn and learn that's very important for very difficult.

[00:55:06]So you have to explain to them the whole pathophysiology so that they understand what is that poison, how does it travel into our system, how does it affect when it is neurotoxic, how does it affect heotoxic, how does it causes necrosis.

[00:55:18]So the poison is going to move into the body very fast. So yes dynamics.

[00:55:26]So that is the time they start learning.

[00:55:30]Finally they come to a conclusion that whatever they have been treating for snake bite it is all wrong and earlier in Australia still people are still talking even nonpoisonous snakes people have brought from Ambulance part of the body is dead. It is a nonpoisonous snake. Finally, people have got no option. They amputate him.

[00:56:27]Nonpoisonous snake.

[00:56:33]So there are there are a lot of instances like this type. So we have to be very careful of what we teach and what we should not do that is more important than what we should be doing.

[00:56:47]>> That government should be very very sensitive make availability of the ambulances in a jify. I myself have beta experiences where the ambulances have not reached even 4 hours and 2 hours later. So ambulances should be available prompt medical attention should be given by immobilization and in the hospital any private government hospitals availability of anti-nake venom serum is a must. So if this is available I think >> and finally Dr. >> this anti-nake venom acts against all and also acts against scorpion scorpion by now but there are small percentage of snakes against which it doesn't act. So it is these big four. So that is you know these are the outlines >> like for there is a spitting cobra spitting cobra does not bite you no fang marks at all.

[00:57:40]>> Exactly. So our authorities should take cognizance of the evidence-based and the studies which are done and do health education in those areas all all over go >> and second see that the ambulances are good and fast and third see that the hospitals are well equipped with anti-nake well not only few days back it was sunalo rabies vaccine was not there in one and they went to second. So such thing should not take good stock should be done of all these you know important things that >> that's why the who has come with this model list of essential medicines that are essential available in every every health facility >> you know health facility that these are common you see them daytoday dogs bite or snake bite are common so and then finally we should see that everything you know the the the health once the Health is good of the people, the people will be happy. But it all depends on all of us and the government of course and >> and also lot of people say mark but the bite marks today are of no use in identifying in a species is venomous or not. So there are a lot of misconceptions but I hope so we have sent a message. Thanks to Dr. Johnson, Dr. Silvano and Dr. Wiseman. Thank you very much. over here. Thank you.