Document Type: Original Article

Authors

1 Consultant Medicine, Anowara Upzila Health Complex, Chittagong, Bangladesh

2 Chittagong Medical College Hospital, Bangladesh

3 Professor, Head of the department Medicine and Principal, Marine City Medical College, Chittagong, Bangladesh

4 Professor and head of the Department, Medicine, Chittagong Medical College, Bangladesh

5 Department of Medicine, University of Science and Technology Chittagong, Bangladesh

Abstract

Background: Poisoning among commuters is becoming a major health hazards day by day in Bangladesh. Few studies were done in Bangladesh regarding this problem. To describe the clinico-epidemiological features of patients with suspected intentional poisoning during travel for robbery.
Method:This was a prospective observational study, conducted in medicine department of Chittagong Medical College Hospital, Bangladesh during March 2010 to September 2010.
40 patients were selected. Out of whom, 15 who had GCS < 8 at presentation were selected for urine analysis by detection kits for a few substances in the urine. Detailed demographic data were collected from the informant in a structured case report form. Clinical examination of the patient was done at presentation and urine was collected in selected patients. Routine patient follow-ups were carried out and the outcome was recorded.
Results: Victims being males of 31.23 ± 7.6 years of age, most of whom were married (80%), and businessmen (40%). Most of them were brought to hospital by their relatives (80%). Their financial loss by the incidence did not exceed 50,000 tk (i.e., 18937 Tk). They were mainly from middle class family, usually poisoned by beverage (55%), food (30%), and inhalation (5%). Most of them presented with unconsciousness (75%), having GCS 10 on average. Their pupils usually remained constricted bilaterally (75%) with intact light reflex in 35% of the cases. There was no papilledema, and cranial nerves were usually intact in those who could be examined (25%). Patients were usually depressed with absent planter reflex (70%) or flexor (30%). Within 2.5 days, most of them could walk without support and could be discharged. There was neither any case fatality reported or any long term disability recorded. Only 7.5% of the patients had substance examined by kit in their urine.
Conclusion: We can come to the conclusion that money bearing people were victimized by the miscreant and they usually used a substance which has short onset of action and which can sedate people for a short time with depressive neurological findings.
 

Keywords

Introduction

New insights in medicine and acceptable treatments necessitates an adjustment of the existing definition of clinical or forensic poisoning to: An individual’s medical or social unacceptable condition as a consequence of being under influence of an exogenous substance in a dose too high for the person concerned (1).

Acute poisoning is an emerging health problem in both developed and developing countries. In developed countries, drug poisoning is more common but in agriculture-based developing countries pesticide poisoning is commonest. In the United Kingdom, it accounts for 13-20% of all medical emergency admissions to hospital(2). Suicidal attempt in young population is the usual candidate for poisoning (3-5). Poisoning in the developing countries was with organophosphorus and other household substances in recent past (7).

Nowadays poisoning among the commuter is increasing and victims are getting admitted in hospital. Datura was initially used to stupefy for robbery; it was also used in India. But the pattern of poisoning is changed recently; culprits use benzodiazepine now (8).

In Bangladesh, acute poisoning related hospital admissions are not also less. Poisoning recorded with injury was the highest rate for admission in Upazila health complex (2,09,319, 19.49%), 2nd highest rate in district level hospital (93915,12.8%), and the highest in medical college hospital (96201, 18.75%) in 2015 (9). Separate poisoning data is not available.

In our country, poisoning causes around 300,000 episodes and around 2000 deaths per year.On average 1-2 patients of induced poisoning during journey got admitted in Bangladesh.A study conducted in Dhaka Medical College Hospital from Jan 2004 to July 2004 found that 172 patients were admitted due to induced poisoning which was 9.26% of total patients and 49.3% of poisoning patients (10). We do not get data about poisoning among the commuters from Chittagong Medical College Hospital as along with other poisonings it was labeled as an unknown poisoning. Total number of street poisoning at Unit I on 2008 was 240 (2.4% of total patients), unknown poisoning in Unit 2 & 3 was 752 (3.7% of total patients).The incidence of this type of induced poisoning in cities like Dhaka, Chittagong, Rajshahi, and Khulna is increasing during religious festival time like Eidulfitr, Eidulazha, and Durga Puja. Some people sell herbal medicine, chocolate at crowd, bus stand even in religious gathering like ijtema. They are part of the organized criminal core.Though mortality is not high due to such poisoning but relatives of the patients panic due to deep unconsciousness of the patient. Previous studies show that short acting benzodiazepine is widely practiced nowadays for making the patient sleepy during travel. They usually use lorazepam and nitrazepam, the metabolites of diazepam (11).

Being a border and port city, Chittagong serves as a transit of drug smuggling. Heroine, ganja (Marijuana), yaba, fensidylare are most abundant in Chittagong as a route of drug smuggling (12). Easy availability of drugs is the prime cause of the growing number of drug abusers in Bangladesh. Growing criminal activities, such as robbery, burglary, theft, mugging, extortion, forgery, family violence, sexual assault, and gang assault in Bangladesh are believed to be partly attributable to drug abuse(13). Some recent studies showed that drug facilitated crime is increasing and substances of abuse are being used as well as this type of drugs are easily available to that group of people(11, 14, 15). In this study, a rapid immunochromatographic test kit was used to detect the presence of some substances of abuse in urine. This is qualitative assay of substances like d-amphetamine, secobarbital, oxazepam, d-methamphetamine, methadone, buprenorphine, morphine, monoacetyl-morphine, phencyclidine, imipramine, and THC 57.

Methods

This was a prospective observational study conducted in Medicine Units of Chittagong Medical College Hospital, Bangladesh during March 2010 to September 2010. Patients admitted with a history of poisoning during travel with last 24 hours were enrolled in the study. Patients were selected after getting informed written consent from legal guardian when the patient was unconscious and from the patient when s/he became conscious. Patients unwilling to be part of the study were excluded. Detailed demographic and clinical data from the patient and their attendant were recorded in a case record form. Patients with GCS < 8 were selected for urine examination by the kit (MAHSAN Diagnostika BENZO) for a few substances like d-amphetamine secobarbital, oxazepam, benzoylecgonine, methamphetamine, methadone, buprenorphine, EDDP, morphine, monoacetyl-morphine, phencyclidine, imipramine, and THC 57. Case record form was used for documentation and SPSS 12 was used for statistical analysis.

 Results

Among 40 patients all were male (n = 40, 100%), with variable age mean of 31.23±7.6 years. Professional businessmen were predominating (n = 16, 40%). Most of the patients (60%, n = 24) came from middle income family. Public bus (n=22, 55%) and baby taxi (n=4, 10%) were the common vehicles used in these incidents. CNG fuelled baby taxi was used in case of inhalation mediated poisoning (Table 1).

Among the patients, 80% (n = 32) were married. Relatives (n = 32, 80%) brought the victim to hospital in most cases, monetary loss was usually by wallet, cell phone and mean loss was 8937 (SD ± 973) Tk. In most cases (n = 22, 55%), the miscreant offered a drink/beverage during journey or at bus stand in the form of cold water, green coconut, and juice. Food was offered in 30% cases like jalmuri, ‘chanachur’ (type of snacks). Inhalation was in 5% (n = 2) of the cases. This patient recalls that they smelt some odour before getting unconscious. 10% (n = 4) of the patients could not remember what had happened. 100% (n = 40) had no history of alcohol intake before the journey.

90% (n = 36) of the patients had a normal pulse, (mean 80 ± 11) bpm. 10% (n = 4) of the patients developed bradycardia, 70% (n = 28) had a normal blood pressure with systolic mean 112.25±14.97 mm of Hg, diastolic mean 72.63±9.7 mm of Hg, 30% (n = 12) had hypotension, 90% (n = 36) had normal respiratory rate with mean respiratory rate being 17(± 1) bpm, 10% (n = 4) had bradypnoea (respiratory rate < 8 /min). Breathing pattern was normal in 100% (n = 4) of the cases. Average GCS was 10 (SD ± 3).

There was no papilledema. Planter reflex was absent in 70% (n = 28) of the cases bilaterally. Sensory function was intact in 25% (n = 10) of the cases. Rest could not be examined due to unconsciousness. Gait was also normal in 25% (n = 10) of all the patients. Rest could not be examined. Cranial nerves in those who could be examined were normal. Muscle power was reduced in 90% (n = 36) of the cases in all 4 limbs, normal in 10% (n = 4) of the cases (Table 2). There was no abnormal voluntary movement, abnormal behavior and sign of meningeal irritation.

No patient was given gastric lavage at emergency or in ward. 65% (n = 26) of the patients were given antibiotic, all of whom who were catheterized. 15% (n = 6) of the patients were absconded before formal discharge remaining was discharged; no patient died. 2.5 days were the average hospital stay.

In 7.5% (n = 3) of the patients’ urine were kits positive that either of the substances was present in the patient’s urine. 

 Discussion

40 patients were enrolled in the study fulfilling the inclusion criteria. All (100%) were male, similar to the findings of Amin MR et al (100%), and Mojumdar MMA et al (98%)(8, 10).Males were predominant possibly because of the outdoor nature of their occupation. Males are financially an important group and they usually carry money. Traditionally females rarely go outside with money in public places. So, males are easy targets of miscreant for robbery. Moreover, religious background of Chittagong is highly conservative and Muslim females are not used to chat with unknown people during journey. Mean age at presentation was 31.23(SD ± 7.6) years; mostly within 16-45 years (85%) especially within 31-45 years (45%), slightly higher than Mojumder MMA et al(28.8 ± 2.5) and Howlader et al (40% of the patients in 36-49 years) (10, 16). Persons of young age group were targeted as they are economically productive. Most of them were married (80%).

Amin MR et al showed that the police were the initial rescuer in most of the cases (83.87%), but in this study we got a totally different picture (8). Patients’ relatives were informed before the patients arrived to hospital in most of the cases (80%). In most cases, someone (co-passenger, transport vehicle staff or passerby got identification note, e.g. phone book, card etc and contacted the family, relatives or a friend. They usually accompany while the patient is admitted in hospital. These sorts of awareness among the common people to keep an identity with him had changed the picture of the total scenario. Patients were more cared and more authentic history was taken with greater confidence. Loss was on an average 18937 (SD ± 9739) Tk ranging from no loss to 40,000 takas. In most cases, the victim lost his wallet, cell phone, only one patient in the study had large cash who was going to buy oxen from market. It was diverse in Mojumder MMA et al, varying from 0 to $500 (10). Most of the patients were businessmen (40%), the rest were farmers (10%), and students (15%). Howlader et al found 67.5% businessmen in his study while Mojumder MMA found 34.5% farmers/day laborer with 13.7% businessmen (10, 16). Chittagong is the port city of the country and business is the main profession in this region.

This finding differs from Mozumzdar et al (10).Bus (55%) was the commonest vehicle like other studies (76% in Mojumder MMA et al) (10). Bus service is still popular for common people. Those who are usually young use bus for longer routes of journey. In most cases (55%), the miscreant offers a drink/beverage during journey or at bus stand at the form of cold water, green coconut, and juice. Food was offered in 30% of the cases like jalmuri, ‘chanachur’, inhalation was in 5% of the cases. This patient recalls that they smelt some sweet odour before getting unconscious. 10% of the patients cannot remember what has happened. The result was similar to Mojumder MMA et al(71% drinks, 10% traditional drug during canvass), Amin et al, and Jain A et al, 2000(8, 10, 17). The offer was made after starting a chat. The thirsty victim was easily victimized with the offer of taking drinks or “dub water(green coconut water)”, juice, cold water, etc. Miscreants usually appeared in front of the victim from mobile venders like rickshaw van, howker and drink simultaneously with victims. There is usually an organized group to make this crime in public places.

Recently, one of the group leaders was arrested from ijtema (religious gathering of Muslims in Dhaka) who had experience of cheating at least 400 people in such way. 60% of the patients came from middle class family, 30% came from lower class family, and 10% from higher class family. Middle class family members usually use public transports like bus, train or baby taxi in regular traveling.

Most of the patients were haemodyamically stable at presentation. 90% of the patients had normal pulse, mean 80 (SD ± 11) bpm. 10% of the patients developed bradycardia, 70% had normal blood pressure with systolic mean 112.25 (SD ± 14.97) mm of Hg, diastolic mean 72.63 (SD ± 9.7 mm) of Hg, 30% had hypotension but no other feature of peripheral hypo perfusion or shock that urges the immediate resuscitation. 90% had normal respiratory rate with mean respiratory rate 17 (SD ± 1) bpm, 10% had bradypnoea (respiratory rate < 8 /min). Breathing pattern was normal in 100% of the cases. In study of Mojumder MMA et al 17% of the patients had bradycardia, 26% had hypotension (10).

Most of the patients were presented with unconsciousness (75%). Average GCS was 10 (SD ± 3.1). The duration of unconsciousness was short term and without any sequel. Mojumder MMA et al found patients with low GCS (GCS11-14 74% and GCS4-10 were 15%) (10). No specific management was required for gaining consciousness. This gives us the impression that miscreants use short acting substances which make the person temporarily sleepy or unconscious. Pupil was initially constricted in 75% of the cases with intact light reflex in 65% of the cases. There was no papilledema or cranial nerve involvement. Jerks were usually depressed.

All the neurological findings were consistent with depression of nervous system, all were transient and recovered. The findings were consistent with Mojumdar MMA et al, and Amin et al (8, 10).

Urine examination with rapid immunochromatographic test kits was to detect some substances of abuse in urine. 7.5% of the patients were kits positive. Any one of the substances might be present in patients’ urine. There were no chance to detect lorazepam which was the principal substance found by Mozumader et al in the kits (10). Within 2 days most of them could walk without support and were discharged, though 15% were absconded.

 Limitation

There was a variable difference between patients in duration between incidence and hospitalization. Clinical features may differ from patient to patient for this. The diagnostic kit was not specific. Either of the substances can be present in urine in patients who were ‘Kits Positive’. Study time and sample size was small. From this study we cannot get the whole picture. Larger study with large number of samples and multicenter involvement are required to conclude the situation.

 Conclusion

The study was to detect an epidemiological picture of the victims who lost their social security during travel and admitted helplessly to Chittagong Medical College Hospital and if possible to get an idea whether any substance of abuse is related with the poisoning. Huge number of patients were admitted in the hospital but only this group of people reflects the lack of our social security. They are not sick, their economic loss may not be too high, no significant mortality or physical morbidity is there except loss of working days but it is painful to confess that our state should give the assurance that one should not be hospitalized for such bad things. We hope and pray that we will not be among victims.

 

Conflict of interest: None to be declared.

Funding and support: None.

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