LETTERS

DOI: https://doi.org/10.20529/IJME.2016.077


Should we share the management of acute life-threatening medical emergencies on the telephone?

Daily, I receive 3–4 social media messages regarding the diagnosis, management or clinical dilemmas of acute timelimiting medical emergencies due to snake bite and scorpion sting poisoning. I respond to the caller who has shared clinical signs and symptoms. I also follow up on the progress of the victim. I send pdf files of my publications on scorpion and snake bite.

On the morning of December 13, 2015, I received a phone call from a postgraduate medical student to whom I had already mailed all my publications and also delivered a three-hour lecture on scorpion and snake bite. The case was of a 35-yearold woman, a bakery worker, admitted with a snake bite on her right great toe. The blood clotted within 20 minutes. She had external opthalmoplegia but oculogyric crisis due to autonomic storm which was wrongly diagnosed as external opthalmoplegia and treated as neuroparalytic snake bite poisoning, but no ptosis; the blood pressure was 130/90 mmHg. For neuroparalytic snake bite poisoning, 80 ml (worth Rs 12,000) snake antivenom was given intravenously. But she was still sweating profusely, her extremities became cold, and she had marked tachycardia without any local oedema. She became breathless with SPO2<90% and pulmonary congestion. The electrocardiogram showed left anterior hemiblock with fascicular tachycardia. Clinically, it was a case of severe scorpion sting with autonomic storm. Within one hour, she developed massive pulmonary oedema with expectorated blood stained froth from nostrils and mouth. She had repeated cardiac arrest, she was resuscitated and intubated and put on a ventilator, with intravenous frusemide, prazosin by Ryle’s tube, and inotropic support. Scorpion antivenom of 40 ml was given intravenously in 100 ml of normal saline over 30 minutes. The patient gradually recovered with reduction in heart rate, improved haemodynamically, and was extubated on day 3 without neurological deficit.

In similar instances, I tell physicians in far-off places over the phone the difference between a scorpion sting and snake bite, or the difference between a krait bite and cobra bite (2, 3, 4, 5). Villagers, farmers and labourers are more prone to scorpion stings in wadis (small hamlets deep inside jungles) where only non-allopathic doctors are available. I have trained these nonallopathic doctors in managing severe scorpion sting, which has reduced mortality and morbidity (6).

When I discussed these details at a conference, a senior speaker and a high court advocate were totally against giving telephonic medical advice. I leave it to the readers to decide whether or not I am justified in offering medical guidance over the phone in such emergencies.

References

  1. Bawaskar HS, Bawaskar PH, Bawaskar PH. Premonitory signs and symptoms of envenoming by common krait (Bungarus caeruleus). Trop Doct. 2014;44(2):82-5. doi: 10.1177/0049475514521802
  2. Bawaskar HS, Bawaskar PH, Punde DP, Inamdar MK, Dongare RB, Bhoite RR. Profile of snakebite envenoming in rural Maharashtra, India. J Assoc Physicians India. 2008;56:88-95.
  3. Bawaskar HS. Diagnostic cardiac premonitory signs and symptoms of red scorpion sting. Lancet. 1982;1(8271):552-4.
  4. Isbister GK, Bawaskar HS. Scorpion envenomation. N Engl J Med. 2014;371(5):457-63. doi: 10.1056/NEJMra1401108.
  5. Bawaskar HS, Bawaskar PH. Efficacy and safety of scorpion antivenom plus prazosin compared with prazosin alone for venomous scorpion (mesobuthus tamulua) sting: randomized open label clinical trial. BMJ. 2011;342:c7136. doi: 10.1136/bmj.c7136.
  6. Bawaskar HS. Non-allopathic doctors form the backbone of rural health. Indian J Med Ethics. 1996; 4:112-14.