536 
THE CORAL TRIANGLE: HEARST BIODIVERSITY EXPEDITION 
amazed by the skill with which the most shockingly sick and apparently hopeless cases arrive in 
their ER and end up walking out of the hospital. During the two weeks I was there and the entire 
month that Stephen was there, there was not a single death or even complication resulting from 
treatment at the hospital. Amongst the many patients occupying the 100 beds of TCR Multispecial¬ 
ty Hospital were quite a few horrific snakebite cases. Virtually all the victims had sunilar stories 
and bite marks on an ankle or foot. Typically, the patient had gone to urinate in the pre-dawn hours 
or to a woodpile or some other innocuous activity and stepped on a snake. The snakes struck and 
very soon after, the victims were bleeding fi*om eveiy orifice, paralyzed or both bleeding and par¬ 
alyzed by the time they arrived in the care of Dr. Soundara Raj and his staff five to ten hours after 
the bite. All received antivenom and IV neostigmine if there was a neurologic deficit. Many ended 
up on dialysis. All survived. Stephen (all month) and I (just under two weeks) slept in two rooms 
we occupied in the hospital day and night waiting for snakebites and discussing the future of our 
project over dinner with Soundara Raj in the “Tank Room”. It wasn’t always work — we also 
entertained ourselves with imaginary Bollywood movie scripts such as, “Snakes and Saris: Venom 
for Venom,” a feature length film for which we are about 9 songs and 11 dance routines short. In 
one version, Angeline Saris, a bass player for Zepparella would play the theme song with a bass- 
sithar. Amala Paul would play the heroin and we hadn’t agreed about the hero, villainous nephew 
or the blind fortuneteller because most of our discussions deviated back to the topic of finding 
novel approaches to the treatment of snakebite. One thing we are all in agreement about is that 
EARLY treatments would allow more people to get to hospitals alive. The most telling statistic 
about how horrific the problem of snakebite is that of the patients who die from snakebite, only 
25% die in the hospital [16,29]. That means 75% of deaths occur without ever having made it to 
medical care. In the case of TCR Multi specialty Hospital, it is a good bet that if you arrive alive, 
you will live. Unfortunately, too many do not make it to the capable hands of physicians like Dr. 
Soundara Raj. 
I left Krishnagiri the third week of June and headed for Hyderabad to do the mouse studies to 
test the neostigmine against cobra venom. The results of this pilot study were astonishing — 10 of 
15 mice survived to be completely nonnal receiving nasal neostigmine while 0 control mice sur¬ 
vived the same dose of cobra venom. Needless to say, these results need to be replicated, but they 
are encouraging. What is most astonishing and a testament to Dr. Samuel and Dr. Soundara Raj’s 
vision for this project is that on June 27 ^^ — 2 months to the day — after I met Dr. Samuel in 
Chicago is that they actually treated a patient with a suspected krait bite using nasal neostigmine. 
I was working in the ER at Kaiser when I got a surprise e-mail headlined by “Complete reversal of 
ptosis!” that almost reduced me to tears. The patient, aged 50, had the horrifying experience of hav¬ 
ing woken up with a snake biting her arm. Her symptoms and signs all pointed toward a krait bite: 
Bitten while asleep, no fang marks, progressive paralysis. Briefly, she arrived at TCR Hospital 
about 9 hours after her bite, but still awake. While in the ER she became unresponsive as antiven¬ 
om was being infused. Dr. Soundai'a Raj put her on life support without any sedation and she was 
brought to the ICU. She received maximum doses of antivenom, but her facial paralysis pei'sisted 
and she could not lift her head or even open her eyes. Dr. Samuel and Dr. Soundara Raj report hav¬ 
ing treated her with a single dose of intranasal neostigmine and that she showed clinical improve¬ 
ment within 30 minutes — so much so that she insisted on leaving the hospital the next day. On his 
way home to Dublin, Ireland, two weeks after leaving Krishnagiri, Dr. Samuel stopped in San Fran¬ 
cisco. We called the patient’s brother in her village and he went to her residence. She had returned 
to her nonnal activities, remembered getting the nasal spray, how it felt and she asked quite 
adamantly, why she hadn’t been sent home with a supply. That made us smile, but there is a lot to 
do and scattered cases can serve as proof of principle, but they are not proof. 
