… 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.

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