From Duncan Hospital – Raxaul, Bihar, India

We got an amazing glimpse into some of the cases Dr. Christo Philip (Emergency Medicine) has taken care of in Duncan Hospital – a secondary referral center for > 11 million patients in Northern Bihar and Nepal.  Some highlights of the lecture:

18 y/o woman with sore throat, respiratory distress with bull-neck appearance- on intubation was noted to have pseudo membrane Untitled

  • Corynbacteria diphtheria: pseudo membrane can obstruct airway and bleed profusely. Toxin can spread in blood. Treat w/ penicillin or erythromycin, diphtheria antitoxin. High mortality (50%)

14 y/o boy with abnormal behavior at home, found to have rabies.

  • RNA Lyssavirus, spread via peripheral nerves to CNS (travels 1-2mm/day).  80% develop classic Furious Form, 20% develop Paralytic form.
  • Remember: hydrophobia based on involuntary pharyngeal muscle spasms during attempts to drink.
  • Palliative Care important: Haloperidol used in Philippines studies

45 y/o man with involuntary movements, found to have tetanus

  • Spatula test” : spasm of the masseters on touching the posterior pharyngeal wall. + test is the involuntary contraction of the jaw (biting down on the “spatula”) and a negative test result would normally be a gag reflex (high sensitivity + specificity)
  • Treatment: Metronidazole (for mild cases), early airway management with aggressive sedation (diazepam up to 400-800mg daily, magnesium, vecuronium), tetanus immunoglobulin,

4 y/o male with difficulty feeding, keeping head up after wedding celebration with various foods, found to have botulism

  • Clostridium botulism: begins w/ weakness, diplopia, dysarthria, then generalized weakness. No h/o fevers. Triad: bulbar palsy w/ descending paralysis, lack of fever and clear sensorium

5 y/o female with difficulty breathing and tachycardia to 150s, found to have been bitten by Indian Red scorpion (Mesobuthus tamales)scoprion

32 y/o woman with breathlessness, fatigue, ascites, Kussmaul’s sign and prominent “X” and rapid “Y” descent with constrictive pericarditis. pericardium2

  • Constrictive pericarditis: associated with exaggerated interventricular dependence, pericardial knock (sudden cessation of ventricular filling early in diastole, mistaken for S3) as well hepatomegaly, ascites, spider angiomata, palmar erythema and depedent edema.
  • Some say: if the heart is NOT palpable it is constrictive pericarditis.  If palpable, it is restrictive cardiomyopathy, if it is NOT palapable constrictive pericarditis. 🙂

2 y/o male with abdominal distension, respiratory distress, found to have congenital hypothyroidism.




Much more to learn: on additional topics such as Organophosphate poisoning (learn how to titrate atropine!), Intermediate Syndrome, status epileptics (learn when it’s necessary to skip to phenobarbital). Visit the Residency Website!


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