Two collapse cases at the Pushkar mela camp
During the Kartik Purnima fair at Pushkar in Ajmer district, your medical camp on the mela ground sees 260 patients in one afternoon. At 3 pm a 62-year-old male pilgrim from Nagaur is carried in. His temperature is 40.8°C, his skin is hot and dry, he is confused and does not know where he is, and his pulse is 132. Relatives say he walked barefoot in the sun since morning and stopped sweating an hour ago. A second patient, a 35-year-old woman, is fully conscious with heavy sweating, cool clammy skin, nausea and a pulse of 104. The camp has two ORS corners, 40 ORS packets left, four litres of bottled water and no IV fluids; the nearest ambulance is 25 minutes away. The mela water tank holds 5,000 litres and needs chlorination; you have bleaching powder labelled 30% available chlorine and a target free residual chlorine of 0.5 mg/L.
1. Distinguish the two patients, decide who is seen first, and set out the immediate management given that you have no IV fluids.
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The man has the picture of heat stroke: core temperature above 40°C, hot dry skin (sweating has failed), and altered mental state - confusion in a person who was oriented that morning. The woman has heat exhaustion: sweating intact, skin cool and clammy from vasodilatation and volume loss, conscious, pulse 104 rather than 132.
The distinction is the altered mental state with hyperthermia, and it is the whole triage decision: heat stroke is a medical emergency with a substantial mortality if cooling is delayed, heat exhaustion is corrected by rest, shade and oral fluids. He is seen first. While waiting 25 minutes for the ambulance: move him to deep shade, strip to minimum clothing, spray or sponge with the bottled water, fan continuously, place cool packs at neck, axillae and groin, and call ahead so the receiving facility prepares. Do not give oral fluids to a confused patient - aspiration risk. Recheck temperature every 10 minutes; cooling stops around 38.5°C to avoid overshoot. For the woman: shaded rest, legs elevated, ORS in small frequent sips, and observation - if she vomits persistently or becomes drowsy, she is referred too.
2. Calculate the bleaching powder needed for the 5,000-litre tank and describe how you would apply and verify it.
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Chlorine required = target concentration × volume = 0.5 mg/L × 5,000 L = 2,500 mg = 2.5 g of free chlorine.
Bleaching powder is only 30% available chlorine, so powder needed = 2.5 ÷ 0.30 = about 8.3 g. In the field, weigh approximately 8.5–9 g, since bleaching powder loses strength with exposure to air and moisture - a slightly generous dose is safer than an under-dose, provided residual is checked.
Method: make a paste with a little water in a bucket, then dilute to a thin slurry, add it to the tank and stir. Allow at least 30 minutes contact time before drawing water. Then verify, because the calculation is only a starting estimate: test free residual chlorine (comparator or pool tester) at the tank outlet; 0.5 mg/L after contact time is the target, with 0.2 mg/L the minimum acceptable at the tap. If residual is low, add more in small increments and retest; if it is high or the water smells strongly of chlorine, do not use it for drinking until it falls. Record the dose, time and residual, and repeat daily since chlorine decays.
3. Only 40 ORS packets remain and three hours of daylight are left. How do you allocate them?
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Forty packets cannot cover 260 patients, so the answer is to triage the queue rather than distribute evenly - that is the judgement being tested.
First, reserve a small buffer, perhaps 10 packets, for anyone who deteriorates on the ground. Second, give packets to those with actual fluid loss: diarrhoea, vomiting, and the heat-exhaustion woman. Third, for the many who are simply thirsty and hot, four litres of water plus shade will do; handing them ORS wastes a scarce resource that someone with cholera-like diarrhoea may need within the hour. Fourth, teach the mixing instruction aloud to each recipient and to the family, because a wrongly concentrated ORS is worse than none - one packet in one litre of safe water, not 'a pinch in a glass'.
In parallel, send a runner to the PHC or mela control room for resupply, and start an oral rehydration corner with a shaded seating area and clean water so that mild cases are managed without consuming packets. Record how many packets were issued and to whom, so you can justify the allocation at review.