Poisoning in the Himalayas

We would get a few cases of poisoning every month, each one more bizarre than the other.

When we did Toxicology in College we studied about the antidotes for most of the poisonous and noxious substances. Or so I thought. However there were no chapters in the Toxicology Textbook for what met me in Bhutan and Nepal. There was certainly no chapter on antidotes for glass bangles.

One Sunday afternoon just before lunch, Krishna the ward boy came charging up the hill to tell me that a newly married bride had been brought to the hospital. He was so distressed, he could not get the words out properly. He gasped and spluttered that she had attempted to commit suicide after a fight with her mother-in-law. Apparently, these fights were the order of the day, in their home in the valley below. In a fit of rage, she had broken the new red glass bangles her husband had given her, ground them and swallowed them.

When I saw her, she was bleeding from the mouth and gums and crying profusely in her mother-in-law’s arms. Aiyee, look at what this foolish girl has done, Doctor Memsahib! wailed the old lady. Hernos-na Doctor Memsahib, ye ki gario …
She has swallowed her glass bangles
Stupid girl….…what am I going to do? Mo ki garu ?

A stomach wash was out of the question as it could do more damage than good. A practical option was to feed her masses of soft boiled sticky rice and wait. And pray. We cleaned her mouth and checked for any major cuts. Assured that they were merely superficial lacerations, we started the IV drip and force fed her with plain soft boiled rice made into  bite sizes boluses . We sat with her for 24 hours, examining every stool she passed into a bedpan, keeping a close watch on her pulse and blood pressure , checking for signs of tenderness or guarding of the abdomen.

I suspect it was a suicide gesture , where she was crying out for help and needed to draw attention to her circumstance. I do not think she had any intention of harming herself seriously. It worked and she got everyone’s attention and perhaps managed to put the fear of God in her. However I was not taking any chances and we relaxed only when she was discharged a couple of days later. She recovered, unscathed and returned later with her M-I-L to have her first baby with us.

Carbon monoxide poisoning was an occupational hazard with the migrant labour recruited to work on the construction sites in Bhutan. They were young men from the neighbouring states of Nepal and India brought in as a task force by a contractor or Baidhar to eke out a living. The youngsters would go to bed after a frugal dinner of rice and dhal , with the metal bukhari and chimney burning in the centre of the room.  All the windows were closed to keep warm.  As the wood burned out, the embers would release carbon monoxide which entered the bloodstream when inhaled. Carbon monoxide is a heavy gas that sank low and killed people fast asleep on their mats on the floor and the animals huddled around them.

Carbon monoxide binds to the haemoglobin in the blood 200 times more readily than oxygen. Inhaling high levels of the gas can quickly starve major organs like the heart, brain and nervous system of oxygen.In the morning they would be found dead. All of them showed cyanosis. Only a couple of them presented with the classic bright cherry red lips. Carbon Monoxide has tragically snuffed out many a dream of survival amongst the migrant workers.

On the first of the month the labour would line up to get their salaries. Far from home and lonely, they would head towards the local liquor brewed in homes and hit the bottle. For the extra kick they would pluck and eat a dark berry that grew wild in the Himalayas. The combination of liquor and berry would evoke a deadly neuro-toxic response and the patient would be brought to the hospital with opisthotonus , when the back arches like a bow due to severe muscle spasm, with the head and the heel touching the ground.  The staff had seen it so often they would snap into action quickly. A gastric lavage would remove the offending berry and they would recover completely and we never lost a patient to this peculiar toxin.

When I went to Bhutan I had no Hindi to write home about, as we did Malay as second language in schools in Singapore. My Hindi came off the screen with every Bollywood movie I watched. I knew choice curse words in Hindi, but I would hopelessly mix up words, tenses and gender with disastrous results. One night I  believe I stood there yelling Ithna peshap peekai aiya.  What I wanted to say in my agitation was Ithna sharab peekai aiya . I ended up mixing up sharab and peshap, alcohol and urine. I never lived that down.

A gastric lavage is a very unpleasant experience . It is effective only if the patient is conscious and brought within the hour of ingestion of the poison. The frightened patient lay on the bed, resisting violently and held down by strapping young ward boys. Ignoring all the confusion and the shouting in the room, we passed a well lubricated, flexible, rubber naso-gastric tube down one nostril, poured saline through a funnel into the NG tube to deliver saline into the stomach. This would induce vomiting and empty the stomach of its poisonous content.

Extremely gross. And extremely messy.

I have a comic memory of a particular patient running down the Anandaban hill with a naso-gastric tube dangling out of his left nostril, his hair in total disarray, tripping and falling over the single slipper on his right foot, clutching the loosened draw-string  of his pyjamas in his left hand,  desperately trying to pull out the rubber tube with his right hand.

He had fled in the middle of the procedure, throwing caution to the wind, never looking back. Mercifully, he had brought out most of the contents of his stomach eliminating the toxin from his body, so no one went chasing after him.

We just stood there and laughed.

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