As a young intern in the early 1990s, working in a Base Hospital in Nuwara Eliya, we had to treat many patients who arrived in hospital after poisoning. They were mostly poor people working in the estates or who were in vegetable cultivation. Poisons, especially insecticides and weedicides were household items for many of them. Some died, especially those who came late to hospital, but many survived.
Relatives of those who died gradually accepted the fate of the deceased; they said it was the wish of the gods. They thanked us for our heroic efforts, often in the middle of the night to save their kith and kin.
For the families of those who survived, we were the gods who performed a miracle. It was the humble gratitude of these poor people who kept us going. Little would they have known that it was not us but science that saved their lives. The science on the principles of management of poisoning was put into pen by the renowned academic and the most senior Professor of Forensic Medicine of the University of Colombo, Prof. Ravindra Fernando who was also the pioneer who started the National Poisons Information Centre many years ago.
In Sri Lanka, more than 100,000 patients are admitted to state hospitals for poisoning annually. In 2008, 1311 patients died of poisoning and it is among the first ten leading causes of death in state hospitals. According to Police statistics, 2241 Sri Lankans committed suicide by poisoning (almost 56% of suicides) in 2009.
The new edition of the “Management of Poisoning” is out and is available now. This updated and revised new edition will help to reduce the morbidity and mortality from poisoning and improve the alarming statistics Prof. Ravindra Fernando has mentioned in the foreword of his book. It is one of those publications that give practical directions to doctors, nurses and para-medicals involved in the management of poisoning. Its reader friendliness, will save many lives as the preceding editions have done.
The majority of acute poisoning cases seen in clinical practice, as those I have explained at the outset, are deliberate or accidental ingestions. In Sri Lanka, due to its agrarian base, pesticides are the common culprit. Mild poisoning as a result of absorption through the skin or through inhalation is a common occupational hazard among people who spray pesticides. As Prof. Fernando explains in his book, acute poisoning is a medical emergency and especially in the case of chemicals such as organophosphates, cyanides and certain drugs, appropriate interventions in the first few minutes of management decide between life and death.
The book gives not just information, but attempts to make it a complete educational experience. Education means not only a change in knowledge but of knowledge, skills and attitudes. In addition to the knowledge that most books on poisoning give the reader, he attempts to change the attitudes of young doctors as well.
He states that the attitude of a few medical and paramedical staff to treat these patients with contempt, and to discharge them as soon as possible, must change. He criticises the fact that a heavy smoker who suffers from a myocardial infarct or an alcoholic with bleeding oesophageal varices gets sympathy and better care, than a poor young woman admitted with self-ingested poisoning.
Toxicology is the discipline that integrates relevant scientific information to help preserve and protect health from the hazards presented by chemical and physical agents. Prof. Fernando’s book is on medical toxicology, the science that deals with the management of patients poisoned with pesticides, drugs, natural toxins like snake venom and plants, and various other chemicals.
Professor Fernando, clearly explains the importance of maintaining adequate breathing and circulation as the first priority in acute poisoning. He details simple things such as ensuring a clear air way by removing secretions from the mouth and throat, removing dentures, if present, and supporting the lower jaw to be held forward and placing the patient on their side.
He then explains how antidotes can be given for certain poisons and the importance of supportive therapy. Techniques such gastric lavage are explained together with the pros and cons of doing it as well as the induction of emesis and Whole Bowel Irrigation.
Other techniques which any house officer in this emergency setting should be familiar with including, alkaline diuresis and acid diuresis as well as those reserved for more experienced doctors such as peritoneal dialysis and haemoperfusion are also dealt with in the book. The guidance he gives on the management of anaphylaxis would be useful to doctors not only in the case of poisoning but in other instances as well. Special instructions are given for cases of inhalation, eye irritation by poisons and for cases of skin contact. Much of the book deals with clinical features and management of some commonly encountered or easily accessible poisons.
The book has several chapters and sections. In the first chapter, the basic principles of management of poisoning are discussed. The chapter on “Medico-Legal Aspects of Poisoning” considers some of the issues physicians face in their practice. The “General Index” helps the reader to check poisons or groups of poisons discussed in this book. With the assistance of the Registrar of Pesticides and the members of his office the “Pesticide Generic Name Index” and a “Pesticide Trade Name Index” have been included which help to identify pesticides.
Prof. Ravindra Fernando does not stop at just treatment. He stresses on following up as well. He says that ‘once the patient is fit to be discharged, doctors should carefully assess his or her socio-economic and psychological status. The reason to consume poison must be determined. Doctors or nurses should counsel them adequately before discharge’.
I understand that a team of local and foreign experts in toxicology have also provided advice to Prof. Fernando on some sections of this useful book.
No review of a book is complete without a few words on the man whose pen was behind the writing. Professor Ravindra Fernando, my beloved teacher, qualified as a doctor with M.B.B.S. (Ceylon) from the University of Sri Lanka in 1975. He passed his Diploma in Medical Jurisprudence (Clinical and Pathology) London in 1980. He also has the degrees of FRCP from the Royal Colleges of Physicians, London, Edinburgh and Glasgow, FRCPath.(UK), MD (Sri Lanka), FCCP and FCCGP. He is the recipient of WHO Fellowships on ‘Medical Education’. He has over 80 academic publications and presentations to his credit and has written over 15 books, published in Sri Lanka and abroad.
He has held many prestigious positions including as the President of the Asia Pacific Association of Medical Toxicology, the founder Secretary General of the Indo-Pacific Association of Law, Medicine and Science, President of the Sri Lanka Medical Association, President of the Ceylon College of Physicians, President of the College of Forensic Pathologists of Sri Lanka and the Chairman of the Board of Studies in Forensic Medicine, Post Graduate Institute of Medicine, University of Colombo. Most of all he is the Father of the National Poisons Information Centre, which he established in the General Hospital, Colombo using funds mobilised from his own personal efforts through the International Development Research Centre (IDRC), Canada and other donors.
“Management of Poisoning” is available at the office of the Sri Lanka Medical Association (SLMA), Colombo 7, and the Department of Forensic Medicine and Toxicology, Faculty of Medicine, Colombo 8.