Snake Bite [HR][/HR] Whether most of us admit it or not, the majority of folks just don’t like snakes. They interest us all right, but much more so on TV than up close and personal. In all cultures in which the environment contains snakes, these belly crawlers are imbued with special powers. Despite the fact that snake bite is about as ancient a medical problem as you can find, even now there is some controversy as regards exactly what constitutes treatment for snakebite both in the field and in the emergency room. Nearly all North American snakebites occur in the months between April and October. However, snakes can’t wear a watch and don’t carry calendar and caution is always the best policy absent a blanket of snow or ice. This is because being “the other guy who gets hurt” seems to naturally trail all of us while in the field. Back into 1982, on a crisp, but not freezing, January morning Paul found a snake that did not have a calendar or a thermometer for that matter. While walking in cut fields Quail hunting, he relates that he felt something much softer under his foot then the hard ground. A quick look down revealed the head of a Copperhead striking his thick boot at lightening speed. After setting a new outdoor record for a 100 yard dash, (understandable but not medically appropriate) boot and socks were pulled off to reveal the venom on the third pair of socks. Luckily, the fangs never penetrated flesh. The cooler temperature had this snakes timing off and a lesson learned about the local serpent population was easier than it could have been! The most important thing to remember if you learn nothing else from this article is this: Almost all snakebites occur because we are “messing” with them. This is remarkable when one considers that all snakebites are medical emergencies and capable of causing at least serious infection and some bites can kill you quickly. We know this in our hearts, but our curious nature just gets the better of us sometimes. When we want to poke them, get close to look at them, try to catch them, or even try to kill them, we place ourselves in potentially mortal danger. JUST LEAVE THEM ALONE and keep moving on. You are not the TV Crocodile Hunter regardless of how many times you have seen either Steve Irwin (or for us older folks, Marlin Perkins) handle a snake. Even the “non-poisonous” snakes can deliver a bite that may lead to serious infection. Do not request a snakebite as you may very well receive one. The irony here is that we humans are too big to be prey animals for snakes and most snakes will do whatever they can to avoid contact with humans. Snakes will not poke at you nor try to get closer for a better look. They don’t want to be handled and unless provoked will certainly not chase you down and try to kill you…RETURN THE FAVOR! Accidental snake bite (truly accidental, not the invited type discussed earlier), generally occurs on the hands or lower legs as a result of routine field type activity. Picking up firewood, crawling around and over rocks, making your way thru thick vegetation and the like can bring you into contact with a serpent. Caution and awareness are essential as you are now invading their hiding places and dens. Use common sense and prod the wood pile with a LONG stick before you put your hands in there. Given the chance, the snake will leave. Snake bite treatment itself can present a very high risk of further illness or rarely even death. Several months ago in this column we discussed the concept of passive immunization. This is when a foreign substance (like small amounts of venom) is deliberately introduced into an animal to cause that animal to make antibodies to that substance, be it a virus, bacteria or snake venom. Then the antibodies are collected from the animal and made into a medicine. This process yields quantities of antibodies that can be given by shot to the unlucky person to thwart an attack by that same foreign substance (like venom) if the victim (you and I) have no natural immunity against it. Herein lies the problem. Some people have severe reactions to the animal antibodies (generally horse, occasionally sheep) which can lead to anaphylactic shock which is life threatening. A delayed serious reaction called serum sickness can also occur in patients treated with these “antiserums”. If the cure can be so risky, then the importance of prudent preventive behavior can not be over emphasized. Besides the risks associated with anti-venom, surgical treatments with and without anti-venom are not uncommon. Whenever you read the word debridement on your own medical chart you are in for a bad day. Fasciotomy, which most resembles what you do to clean a fish isn’t pleasant when applied to your leg. Though limb and life saving these are surgical interventions to be avoided! Serpents vary from region to region in many ways including; density of the population, toxicity of the venom, as well as their attitude toward us. Generally speaking the larger the snake, the more venom can be injected. Snake venoms are a very complex mixture of chemicals designed to short circuit the neurological system, breakdown tissues, prevent normal clotting, damage the heart, and assorted other tools needed for their routine task of killing and eating prey. Different snakes have different toxins in their venom. Also the same species of snake may have regional variations in the potency of their venom. Australian snakes are in general the most toxic and the most foul tempered and the management of their bites is a little different than North American, Asian, and African snake bites. Around 8000 snake bites occur in America in the average year. About 0.05% are fatal, but remember that treatment of a bite is no picnic and can be very debilitating. In Australia the average is about 3000 bites with about double the mortality at 0.1%. Medical advances have reduced snake bite mortality from around 50% to the current state of near total survival in Australia. Accurate data on African and Asian snake bite numbers isn’t readily available. Snakes that are not venomous can also inflict bites that can be dangerous. These bites can lead to local infection that can spread systemically. Also, venomous snakes can bite without injecting venom (20 to 30%), or they inject a small amount of venom, or they can inject a lethal dose of venom. Obviously knowing what snake just did what is critical. So how do you tell in the field? Catching the offending serpent sounds like the ideal way to tell what kind of snake did the biting, but think for a second. A snake that just bit you or a member of your party is in a foul mood. It bit not out of hunger, but out of fear. If you go chasing it down to get a better look, the odds favor another snakebite rather than retrieval of a snake corpse for identification. Many authors suggest that snakes are seldom more than a few yards away after they slither away from an attack. If the snake was seen, describe it to all in your party as this is critical information, but don’t go after the darn thing! By visiting our website thehuntdoctors.com, we can provide you with links to photos of the various kinds of snakes that you may encounter on your trip. It is a prudent idea to print the appropriate pictures for the area you are going to travel into and fold them up into a zip-lock type bag and just stuff into your day pack. Carrying these pictures around so a positive ID can be made of the offending reptile can result in better and safer post incident medical care. HOWEVER, UNLESS YOU ARE WILLING TO BET YOUR LIFE on your identification of the snake that bit you or your buddy, evacuate all snakebite victims quickly to formal medical care. There are some general rules that we need to follow if prevention has not worked and a bite has occurred as preparations are made to evacuate the victim to formal medical care. Field treatment of snake bites is often dangerously misunderstood. Myths about snakebite treatment abound and some of these “treatments” actually make things a whole lot worse. Because of the persistence of these myths we have decided to start with a list of THINGS NOT TO DO: DO NOT DO THE FOLLOWING 1) Do not cut X’s into the victims flesh so that the “poison” can be sucked out! You will only cause more tissue damage, enhance infection and you will not remove any of the venom. This is dangerous, ineffective and painful! 2) Do not use tourniquets. You will cause more damage and do little to no good. Pressure bandaging is recommended for some instances and will be discussed later. Pressure bandaging is a finesse procedure and the restricting tourniquet is a very bad idea indeed. 3) Do not apply ice or electrical shock to the victim around the bite area or elsewhere for that matter. This accomplishes only enhanced tissue damage and does nothing to reduce the impact of the venom. 4) Alcohol is not a medicine and has no place whatsoever in the treatment of this or any medical emergency. Pain killers need to be avoided until the victim is seen by medical personnel. Dulling the senses and altering the consciousness will not help you or your buddy if bitten by a snake, but may complicate the picture for the emergency medical folks. 5) Do not give the snakebite victim food or water by mouth until approved by medical personnel. 6) Do not waste valuable time searching for the offending snake or invite that second bite. If the beast is still right there, get a good look for identification and move along. 7) Do not allow the victim to exert themselves. Raising the heart rate only makes the problem worse. 8) Do not administer anti-venom in the field. The list of what actually constitutes rational modern field treatment does have some controversy. Different expert agencies from different parts of the world disagree on some aspects of field treatment. Let’s start with the universally agreed upon actions. DO THESE THINGS 1) Stay calm 2) Immobilize the area that has been bitten and keep it lower than the heart. No exertion by the victim (walking is exertion). 3) Evacuate and seek immediate medical attention. Look, we know no one wants to come out of the field unless they have to. The temptation to wait and see if venom was injected and then go for help is plain ol’ stupid. The risks are vastly greater than the benefit. Are you 100% sure that the marks on your flesh that penetrated your skin were inflicted by a non-poisonous snake? Some poisonous snakes (ie Coral snake) don’t leave fang marks at all due to small mouth size as they inject venom. 4) Remove constricting stuff like rings and jewelry from the afflicted area before the swelling starts. 5) You can apply a LIGHTLY constricting band near the wound on the heart side of the wound. Obviously head and neck bites are not candidates for this procedure. Venom is spread through the lymphatic system for the most part and a mild constriction (like the way socks fit) can slow the spread. This is not a tourniquet. Pulses below this mild constriction should be assured. A simple test is to be able to easily slip a finger under the constricting band. Experts disagree on a few things and we believe that when experts disagree, lay folks should be aware of options. In Australia, the authorities do not suggest either washing the wound or any form of suction. Their point is that there are now kits that will allow specific identification of the venom at the wound site and hence more specific and safer treatments. They believe this to be more important than the benefit of a Sawyer type suction device. The American Red Cross recommends washing the wound gently with soap and water during the evacuation. In North America, since there a limited variety of poisonous snakes we’ll go with “When in Rome do as the Roman Do” adage here. Gentle washing of the wound and mild suction are in order. Again everybody believes rapid evacuation to trained emergency medical settings need to occur ASAP! The technique of a pressure immobilizer bandage needs to be mentioned. This is an Australian idea that has proven itself effective. We suggest that PH’s and Guides in Australia and Africa become proficient in this technique. This is a procedure that is just a little too complicated to be able to safely accomplish simply by reading about it. Hands on instruction and an awareness of the complication require more training than we can provide here but we’ll have stuff on our web site if you want more information. Though less studied in Africa, this technique is likely helpful with the most poisonous of the African snakes. As always stay safe and enjoy the outdoors.