Briefly, the Resolution of the Bite

One more quick update regarding Clint’s snake bite. Today, the plastic surgeon discussed with Clint and Amber the degree to which the tissue in the fingertip was dead, and they all agreed that amputating the tip was the best strategy. After a brief surgery to do this, Clint was discharged from the hospital and is now home.

Clint told me that he would like to write his own account of the past few days, and after getting a little more distance from the pain and worry of it, my guess is that it will be a witty and irreverent piece of gonzo journalism. Meanwhile, we’re all glad that this is over and Clint can recover. Hang in there, my friend!

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After surgery today

Then Comes the Debridement

This is the second update to “…And Then Stuff Happens,” documenting the snake bite Clint sustained Saturday afternoon. In the four days that have followed, he has been treated with Cro-Fab antivenom, given medicine to counteract an episode of serious low blood pressure and possible allergic reaction (to venom, antivenom, or both), and the hospital has carefully monitored some coagulopathies (problems with blood factors related to clotting). And yesterday there was what Clint described as the worst part of the whole experience, the debridement of apparently dead and necrotic tissue.

His fingertip had become progressively more discolored and swollen, although the overall swelling of his hand and arm had subsided. The plan yesterday was for a plastic surgeon to have a look at Clint’s finger. Once he had a look at it, the surgeon decided to remove tissue that he determined was “dead.” This would seem to be tricky business, since the region of a pit viper bite may have quite a bit of ecchymosis, or discoloration from pooling of blood under the skin or blood leaking from vessels. I would not pretend to know whether a dark, swollen, purple-black fingertip was necrotic (“dead”) or very discolored from ecchymosis. Initially the surgeon cut into the fingertip, producing quite a bit of pain, and so the area was deadened. Clint described the doctor taking scissors and pushing down into the finger and then spreading the scissors, and I’m not sure any amount of pain medicine would make that tolerable. In any case, Clint reported that as the medicine’s effects faded, the pain was the worst he had ever experienced. The surgeon removed the skin from the fingertip and advised that the area should be amputated.

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The debrided fingertip (ventral aspect)

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Debrided fingertip, dorsal aspect

We talked about this, made some calls, and Clint and Amber felt they did not have enough information to make an informed decision about this. The excruciating pain Clint felt from the debridement would make the average person wonder if there is not live, viable tissue there, and that the fingertip might be spared and might granulate in new tissue and recover. It certainly might not be like the original fingertip, but a damaged finger could be better than an amputated one. Clint’s and Amber’s decision was to ask for more information (including what the risks and benefits might be of attempting to save the finger) and ask for a second opinion.

As it turns out, Clint reports that the trauma physician who has been managing his care looked at it today and suggested that the finger might be spared and allowed a chance to heal. There is a consultation tomorrow with the plastic surgeon – we’ll see what is recommended and what Clint decides.

I am sharing this information about Clint’s experience at Clint’s request, to offer a detailed and first-hand account of what a venomous snake bite might be like. Our intention is certainly not to increase anyone’s fear of snake bite. For most people, even hikers and naturalists, these bites are unlikely to occur. They tend to be “wrong place at the wrong time” accidents, stepping or putting one’s hand in a place where the snake is present but not seen. For those of us who seek out these snakes to observe or photograph, or who move them or relocate them when needed, the risks are a little higher. Even then, the risk seems acceptably low, provided that we have the right training and experience.

Ten Units of Antivenom Later

This is a brief update on the article from yesterday regarding the bite Clint took from a small western diamond-backed rattlesnake. As of today, Clint is still in the ICU but was sitting in a chair, ready to have something to eat when I saw him. The swelling in his arm and hand are slightly reduced, but the damage to his fingertip is more pronounced, and there is a dusky color at the base of his fingers.

IMG_0907IMG_0906Pit viper venom not only kills prey but also begins to break down tissues, essentially beginning the digestive process before the animal is swallowed. And so, a bite from a western diamond-back does the same thing to a human victim, breaking down tissue and destroying red blood cells. Coagulopathies, which can create problems with bleeding, are common. Clint’s platelet count dropped Saturday night and then improved after he received antivenom. This significant drop in platelets (thrombocytopenia) has been shown to respond positively when the patient gets antivenom.  Today, his platelet count dropped again, and so he received an additional two units of Cro-Fab.

Clint reports that the docs are saying he should see improvement in the bitten finger, although it’s not clear if it will return to normal functioning. My bet is that he is keeping the rest of his fingers crossed, hoping that the “digestion” of his finger was limited enough that it will heal properly.

… And Then Stuff Happens

Yesterday was a bad day. Clint was bitten on the left ring finger by a young western diamond-backed rattlesnake. He is recovering, and with luck he will not have too much damage to that finger. He wanted to share his experience on the blog, to add to the reader’s information when out in the field where snake bite is possible. Venomous snake bite is a miserable experience in which the treatment itself can have serious side-effects.

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Two fang punctures, 3/18/17, 5:08pm (about 90 minutes post-bite)

Clint called just before 4:00pm to say that he had been bitten, and he was trying to decide which hospital to go to. The one in Decatur did not seem like the right choice, based on an experience over ten years ago. Not every hospital has the experience to do a great job with venomous snake bite. My suggestion was that they could get to Denton faster than Fort Worth, and so Amber drove him to Denton. On the way, they phoned the hospital and verified that they had antivenom on hand, and phoning ahead was a good thing to do. I met them there by 5:00pm.

At this point, well over an hour into the bite, Clint was in pretty good spirits, able to joke around a little, despite serious pain in the finger and up the arm. While the initial effects include burning pain, soon there is a different sort of pain, and he described the finger as feeling like someone had struck it with a hammer. He was also surprised, in a good way, that he had not experienced nausea so far.

After about 40 minutes at the hospital, the antivenom was ordered but still not started yet. At least in part, this can be attributed to the fact that it has to be mixed, and this has to be done gently or the antivenom will be ruined. We were anxious to see the treatment start, and he would be receiving Cro-Fab polyvalent antivenom, developed for use with any of the North American pit vipers (rattlesnakes, copperheads, and cottonmouths). There is no specific antivenom for individual species of snakes, and that is fortunate since the average person who is bitten may not be able to accurately identify the snake that bit them. There are new antivenoms hopefully coming soon, including Anavip, from the Mexican company Bioclon. Both Cro-Fab and Anavip work by binding to venom components and neutralizing them, but Anavip seems to remain in the bloodstream longer, where it can neutralize more toxins.

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At 5:21pm

At 6:06pm, about five minutes after he started receiving what would be 6 vials 0f Cro-Fab, Clint reported that the pain was somewhat worse and he was experiencing lots of itching. Patchy raised areas on his inner arm showed that he was experiencing some hives; however, he said that his ability to swallow and his breathing were fine. This is significant because the antivenom, as a foreign protein, can trigger severe allergic reactions including, at the worst, anaphylaxis, a life-threatening condition. We all watched him carefully, and shortly afterward his blood pressure dropped dangerously low. The Emergency Department staff tilted the bed so that his legs were elevated, upped the IV fluids, and gave him a steroid and Benadryl. And, with all of that, came the dreaded nausea that he thought he might avoid. Vomiting is a pretty predictable part of snake bite symptoms, and Clint had several episodes of this.

Before long, his blood pressure improved, but he was experiencing a little confusion, which is also not unexpected, both from the venom and from all the medicines. Even though his finger continued not to look horrible, his overall experience was quite horrible. Add to that, the ER doc was talking about the possibility of a fasciotomy or even amputation of the fingertip. This becomes a situation in which we needed to walk a delicate line between acknowledging that we are not physicians and this guy knew tons more about medicine than we did, and advocating for caution and additional medical opinions. A fasciotomy is the cutting and opening of an area in which pressure has built to the point of “compartment syndrome,” in which tissue can be damaged from lack of circulation. Untreated compartment syndrome can lead to necrosis and loss of a limb, but a fasciotomy should only be done if truly needed.

The physician said he wanted a consultation with a hand specialist, which was reassuring in terms of the fasciotomy question. But there was no hand specialist available at the time at that hospital, so the decision was made to transfer Clint to Harris hospital in Fort Worth. And because he had had a serious drop in blood pressure, they called for a helicopter to fly him there.

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Getting ready to fly from Denton to Fort Worth

As he was being placed aboard the helicopter, Amber followed me and we started the drive from Denton to Fort Worth, down the dreaded I-35 and all the road construction. We made it in pretty good time, and found Clint in exam room 220 at Harris, with staff taking various tubes of blood so that changes in things like fibrinogen, platelets, and other blood factors can be monitored. Pit viper venom attacks tissue in a number of ways, including destroying red blood cells and affecting clotting. Later in the night, his platelet count would drop severely, and then come back up to more normal levels.

He got an additional two vials of Cro-Fab, after another frustrating wait. He was transferred to the ICU, which did have some advantages in the event he had a serious reaction to the antivenom. The ER staff said that the surgeon on call who would look at his hand was very experienced, and it turned out that he said the degree of swelling was not alarming. Clint’s progress would be monitored carefully, but at the time there was no need for a fasciotomy.

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Morning of 3/19/17, with more discoloration

As of today, Clint is doing fairly well, and has been able to get out of bed a little. The pain continues to be significant, and the discoloration and bruising in the finger is worse, but the overall swelling is slightly reduced. I will post more as time goes by.

For those of us who love seeing venomous snakes in the field and are fascinated with their behaviors, their appearance, and their evolution, snake bite poses at least some risk. It is important to learn from others and gradually get the experience that will let us interact with them as safely as possible. It is also essential to have the respect for the animals and also the self-respect not to do “stupid stuff” with these snakes – there is no place for daredevil thrill-seeking. But even then, despite knowledge and experience, accidents are still possible. This one will not stop Clint’s interest in finding, observing, and photographing rattlesnakes. It is an interest that, pursued safely, is low risk, but the risk is never zero.

In the Woods, With No Thought of Tomorrow

Consider the lilies of the field, how they grow; they toil not, neither do they spin: And yet I say unto you, That even Solomon in all his glory was not arrayed like one of these. -Matthew 6:28-29

I grew up in a beautiful place, with oak woodlands and prairies with waist-high grasses whose pale blue-green leaves turned golden and rust-reddish in winter. Each spring turned patches of prairie blue with bluebonnets, crimson with Indian paintbrush, as well as yellow and pink from flowers like evening primrose. A big creek with clear water running over limestone traced its way through the prairie, a little shallow for swimming but perfect for wading and discovering the many animals there. I still live in that place, in the cross timbers of north central Texas, and consider it one of the miracles of creation.

Since I am now in my sixties, I have seen this region over a considerable span of time, and watched the highways and cities claim an ever-larger share of the land. I have watched as ever-fewer people know about those woodlands and prairies, and few would give a second thought to the wildlife in that creek. Some people do value nature, and I am very grateful for them. I am particularly grateful for those who want to get out and experience it, for no matter how beautiful the BBC series Planet Earth is on the screen, it is a representation on a screen, not an experience of being immersed in part of the actual planet Earth.

I am also grateful for those willing to slow down and experience the woods and fields by listening, really looking, and taking in the smells and the feel of the air, sun, and water. To borrow a term from health psychology and meditation, be “mindful” of it. What I mean by that is to let everything else go, and be there in the moment, with smart phone off and thoughts of yesterday or tomorrow dismissed. This is not just the curmudgeonly nagging of an old person who sees the world going too fast (though I am sure that applies a little). There is something to be said for mountain-biking through a place and experiencing the thrill of movement and physical mastery, and there is a place for animated conversations on a walk through the field. But stillness and peace and openness to each leaf and every bird are rewarding, too.

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Smith Spring, Guadalupe Mountains

I remember hiking up to Smith Spring in the Guadalupe Mountains, and sitting on a stone bench for some time, amazed at the little crystal clear pool edged with maidenhair fern, with a bough of bigtooth maple hanging over it. Several varieties of butterfly visited the scarlet penstemon at one end of the pool, and the buzzing of bees was audible in the stillness and quiet that was unbroken by the noise of highways and machinery. The dappled sunlight, the very slight smell of the mountain woodland, and the otherworldly quiet and calm made for an experience I can never forget. There are some times and places where talking and doing have to stop, in order to “lose” yourself in the experience.

I have walked through the oaks and elms that border the creek at that brief moment in the spring when all the new growth is a fresh, pale green and the tree canopy has not closed and the sun warms the earth. The whole world seems to welcome new life, and careful looking among the tree trunks and fallen branches reveals a little prickly patch of bark that is really a Texas spiny lizard, warily looking back at you with little golden eyes. Studying a protected spot of soil by an old stump might reveal two or three mushrooms poking up through the leaf litter, showing that even the soil participates in the irresistible growth of spring. These are small experiences, but I value them very highly.

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Riparian corridor along the creek

For those who want to lose themselves for a time, to step away from what happened yesterday or what will happen tomorrow and just be part of the exquisite beauty of life, the experience need not be far away. There are numerous little preserves near where I live, and bigger places throughout Texas and elsewhere. The U.S. Fish & Wildlife Service website lists 19 refuges in Texas, and Texas Parks & Wildlife Department maintains over 90 state parks and 47 wildlife management areas. And there is the Big Bend National Park, Big Thicket National Preserve, Padre Island National Seashore – a total of 14 treasures managed in Texas by the National Park Service. On top of that, organizations like the Nature Conservancy and Audubon Society own (or manage, in cooperation with landowners) places here and there, some of which are available to the public. For most of us, there is some place nearby where we can visit and either study nature or practice mindfulness while surrounded by it.

I cannot mention all these places without also noting that they are, to one extent or another, in considerable danger of being changed or poisoned. The land is not only a source of great inspiration and knowledge, it is where we plant food, grow cattle, and get minerals and petroleum from below the ground. It has often been our dumping ground, for the waste products of mining and drilling or even factory farms. When the human population was small and our technology not so advanced, we could use and even abuse the land and it seemed that the cost was small and acceptable. As we have grown in numbers and the reach of our technology has expanded, the cost – the damage to land and wildlife – has grown enormously. And the conflict between profiting from the land versus protecting it has become intense, with increasing calls to sell off federal land, allow extractive industries to degrade it, and roll back regulations that minimize the poisoning of the land, air, and water. The climate is becoming more unstable and hotter, and even our weak and tentative efforts to respond to that challenge may not be carried through. This is a time when all of us who care about nature should make our voices heard.

Those are part of a whole suite of worries that each of us carries. Can my elderly relative still live independently? Will I keep my job? How will we pay for this or that? Is this person really my friend? And the list goes on. If we can claim a few hours to get away, and if we can still our unquiet minds for a time, sitting at the edge of a pond listening to frog calls or watching birds may be powerful medicine. As can listening to music, or meditating, or looking at a painting. There are many ways to “take no thought for tomorrow,” in other words to let go of anxieties about the future, and nature is a particularly powerful way for some of us. To look at the birds in the sky and consider the lilies of the field; these are still powerful reminders of wonderful things happening of their own accord, just by living in the moment. In “The Peace of Wild Things,” Wendell Berry talks about seeking refuge in nature, and “For a time I rest in the grace of the world, and am free.”

To “come into the peace of wild things,” as Berry says, it is not necessary to be a field biologist or ecologist. I do not have to know how the Krebs cycle works to appreciate how its release of energy allows a hummingbird to hover around a flower. Many of us who spend a lot of time in the field know only a limited amount, often in only one or two areas. I am almost illiterate about the plant communities that support the network of wildlife of which my beloved reptiles and amphibians are a part, but I know just enough to recognize a few old friends among the trees and grasses and know roughly what neighborhood I am in. That is all that is needed to enrich the experience of being out in the field. Just know a few landmarks, recognize a few neighborhoods, and suddenly there seems to be more to see. For example, if you know that cedar waxwings like to eat juniper berries in winter, you might look for them around Ashe junipers or eastern red cedars. And, if you know that cottonmouths don’t really chase you, you may be much more comfortable stopping to take a photo if you see one. Male lizards may defend territory from others of their kind, and one of the displays they use to signal another lizard to stay away is a sort of “push-up,” sometimes done several times. On a walk in the woods, if you see a lizard bobbing up and down several times, it adds a little something to know what is going on. One more example: many people know that Texas horned lizards eat the big harvester ants, but they don’t often go right up to the central mound and start eating. Instead, they tend to station themselves along the little trails the ants use, and lap them up in ambush. When we are out in parts of south or west Texas in places where they can still be common, Clint and I will start from the harvester mound and walk outward, either in a spiral or along the trails, looking for horned lizards to see and photograph. This is more successful than wandering randomly and hoping to see one.

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Texas horned lizard, in coastal prairie near Rockport, Texas

But whether you know a little or a lot of the natural history of a place, the important thing, in my view, is to take your time and really be present when visiting a prairie or a pond or forest. The pretty picture you see in the first few seconds deepens as you let the details soak in, and you hear things or see or smell things that a quick glance did not reveal. Perhaps one of those greenbriar vines begins to move, and you recognize it as a rough green snake, a delicate and harmless creature that is a fierce predator of caterpillars and spiders in the branches of the possumhaw and other understory plants. Or maybe as you look out across a pond’s surface, a turtle emerges to get a breath, or a frog chorus begins, one species at first, followed by two or three others joining in. The thing is that you will be there, in that moment, not in traffic, not worrying about what you will do tomorrow, not with your brain miles away while your body is in the woods. The point is not the escape to the woods, just to get away from things. The benefit I am talking about is being content to be right where you are, putting your whole heart into the experience.

350.org. https://350.org (accessed 2/26/17)

Berry, W. 2012. New collected poems. Berkeley: Counterpoint.

Kabat-Zinn, J. 2013. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. NY: Bantam.

McKibben, B. 2011. Eaarth: Making a life on a tough new planet. NY: St. Martins.

National Park Service. https://www.nps.gov/state/tx/index.htm (accessed 2/26/17)

NOAA Climate. https://www.climate.gov (accessed 2/26/17)

Texas Parks & Wildlife Department. http://tpwd.texas.gov (accessed 2/26/17)

U.S. Fish & Wildlife Service. National Wildlife Refuge locator. https://www.fws.gov/refuges/refugelocatormaps/Texas.html (accessed 2/26/17)