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I refer to the malaysiakini report Cobra kills 'Snake King' .

Ali Khan Samsuddin had initially sought treatment at the outpatient department of the KL Hospital for an injury deemed 'minor' but subsequently developed darkening of the affected hand and died rather quickly early Friday morning, three days later as a result reportedly of complications attributed to his underlying diabetes mellitus.

Snake bites can be serious but could the 'Snake King' been saved?

It is rather puzzling how in the first place, this diabetic with a snake bite was allowed home and treated as an outpatient. And even if he was in septicemia with diabetes the second time round, how is it that the KL Hospital (presumably one of the better-equipped ministry of health hospitals) couldn't save this Malaysian icon. Was Ali Khan really seriously ill or our health services lackadaisical? Perhaps a short tutorial on snake bites is in order.

Most snakebites are inflicted on body extremities. Bites on the hands and fingers are common. Local tissue damage is of primary concern. Cobra venom can affect patients variably. Although the venoms of these cobras contain neurotoxins, necrosis often is the chief or only manifestation.

Cobra venoms have been studied extensively and can cause either, neurological, cardiotoxic, coagulation problems and local necrosis. The Naja philippinensis (Philippine cobra) venom is the most toxic followed by the Naja naja (Indian cobra) and the Naja haje (Egyptian cobra).

Emergency care consists of prompt movement of the victim to a medical facility capable of rendering advanced care during the pre-hospital care including airway support, anti-venom administration, monitoring of vital signs and saline infusions. Other maneuvers include proximal compression and immobilisation.

All persons who have been bitten by a cobra should be treated as if a severe envenomation has occurred. Anti-venom is the only proven therapy for significant snake bites. About 20 laboratories in Africa, Asia, and Europe produce cobra anti-venoms. Some are monovalent, but most are polyvalent against venoms of all the important snakes of a nation or region. Once the anti-venom is located, the doctor may need assistance from the police or military to facilitate its rapid transport.

If possible, the anti-venom should have antibodies against venom of the cobra species that inflicted the bite. The definitive therapy for cobra venom poisoning is anti-venom administration, which should be started as soon as possible if evidence of systemic envenoming is present. The tetanus status is updated if necessary and antibiotic prophylaxis may be necessary if there is underlying infection.

People bitten by cobras should be cared for in a facility capable of intensive monitoring. Complications can include respiratory failure/arrest, cardiovascular collapse, prolonged neuromuscular weakness, tissue necrosis, antivenom-related complications, anaphylactoid reactions and delayed serum sickness.

Prognosis is good. Many patients recover with no specific treatment. The neurotoxic effects of cobra venom are completely reversible, though recovery may take up to six days. Reports of death within one hour of a cobra bite exist, but a time frame of 2-6 hours is more typical of fatal cases. With sound supportive care and appropriate, prompt anti-venom administration, recovery from cobra envenomation can be anticipated.

From media reports, Ali Khan sustained local necrosis which as a result of lack of monitoring could have worsened as a result of his diabetes. It is uncertain if he received any anti-venom administration. But extensive necrosis with his underlying diabetes may have caused his general condition to deteriorate causing him to present emergently at the KL Hospital.

By this stage, he would have developed septicemia and diabetic ketoacidosis, in which case a focused critical care team would have been his only hope that Friday night. Whether he had the services of this team or was the team up to the mark is uncertain. But Malaysia's 48-year-old 'Snake King' is no more.

It is rather appalling that the response times of our current emergency services are already mired with excuses such as lack of ambulances, etc, but to now have patients die when they have actually reached hospital does not augur well for our healthcare system.

The Private Healthcare Facilities and Services Regulations 2006 Act was instituted to 'regulate' private hospitals and clinics. Perhaps now the health minister and his director-general can enlighten the Malaysian public how they are now going to 'regulate' our atrocious emergency and outpatient services that actually kills patients during the in hospital phase.

Are they going to fine or jail government doctors or administrators or is there going to be one rule for the private sector and another for government hospitals?