Snakes

I have never liked snakes. I dislike them more every day here.

Earlier this week I was walking past the nurses station and noticed a teenage boy in the ICU. The blood on the wall by his bed and on the gauze in and around his hands held up to his mouth caught my eye. “Did I miss a trauma patient?” I thought as I moved closer. I quickly asked what his problem was and was matter-of-factly told “snakebite.”  My role was to evaluate for compartment syndrome, excessive swelling in the arm or leg (as in this case) that can block blood flow to the foot or hand. This swelling can sometimes require fasciotomies (long incisions through skin, fat and muscle covering fascia) to relieve the pressure and restore blood flow. His foot and leg were swollen and painful but he had a good pulse in his foot. I was told he had received 5 vials of antivenom and hadn’t required transfusion. He seemed stable so I quickly moved on.

Yesterday, a similar scenario played out an older man bitten on the right hand. At first swelling was limited to his hand but as it ascended to the elbow over my lunch break and his tetanus shot injection site in the right shoulder started dripping blood - administration of our limited supply of antivenom became indicated.

First, I needed to verify that the snake he was bitten by was covered by our antivenom so I found a chapter on snakebite in the Principles of Medicine in Africa book in our library. I took it to his ER bed and began showing him snake pictures. He became quickly animated, pointing his extremely swollen hand to the picture of the saw-scaled viper. 

I had never even heard of such a snake before. Sure enough, it was covered by our antivenom and in fact, I read, that it is the species involved in most bites and deaths from envenoming in the semi-desert regions of Africa north of the equator. Bites from these snakes may case severe local swelling, blistering etc. but the “clinical picture is dominated by spontaneous systemic bleeding.” Early sites of of bleeding listed include the gums, nose and sites of trauma. More ominous outcomes were laid out in detail.

The maps in this section of the text were striking when you consider were Togo is on each of them.

I was called at midnight last night because a pulse oximeter reading could no longer be found on the fingers of the man’s right hand. While it was tempting to try to do something to relieve pressure in the swollen hand, I reasoned from my bed that his risk of unstoppable bleeding precluded this and I ordered another two vials of antivenom. At 5 AM I awoke. Nervous about the outcome, I walked to the hospital. Thankfully there was still some blood flow to the fingers and no other evidence of diffuse bleeding was seen. 

The final verdict on these two saw-scaled viper victims is still out, but they are hanging in there. We only have 4 more vials of antivenom left.