D e s e r t E x p o s u r e
December
2008
The Snake and I
When a snakebite transforms a doctor into a patient, he learns a lessonthat has nothing to do with venom.
By Michael Sergeant, MD
It was just a few rocks I was after. That's all. I wanted to make a beautiful arrangement for my wife, Diane, who was returning in the morning from taking care of her mom in the hospital in Atlanta.
 |
The author's snakebitten
foot, a few days after twin bites. |
I had the roses — delicately beautiful, magenta, magic. I had the lovely vase from Portugal. What I needed was a few desert rocks to complete the picture in my head and the feeling in my heart. It didn't quite work out that way.
The magic was different: I got to dance with the power of nature.
I was singly focused as I walked out the front door on a Tucson desert night with a dishpan (of all things) to gather those few rocks from the front garden. My vision was tunneled towards the creative endeavor.
I think the snake (or maybe snakes), for its part, would actually have been quite satisfied to be left alone. I expect it was not the least bit pleased to have the still of the evening disturbed by some human guy tromping around picking up the rocks near which it lay. It is even possible there was an even more egregious infraction: snake coitus interruptus. Whatever the case, indicting said snake or snakes for the subsequent events would be inappropriate.
So there I was, contentedly in my own front yard, dressed in my desert best (shorts, T-shirt and flip flops), in the pale and not very illuminating glow of the front porch light, gathering a few rocks I thought would lend beauty to my arrangement. Beneath the nearby garden wall, the ground was in shadow. I was oblivious. The night was quiet.
I was bending over to pick up the last couple of rocks when my peaceful world exploded in pain. My left foot had been crushed, it seemed, by an acid-coated sledge hammer wielded by no less than John Henry himself. Shock first. Then a knowing. And then, only after the truth had already permeated my consciousness, the slight and ever-so-ominous rattle. What I would not know until the next day is that I had actually, in that life-changing split second, been bitten twice.
The brief moments following the shock resulted in only a little disruption of the quiet desert night as a few choice words erupted from me — not so much a yell, more a series of almost disbelieving profane whispers. My mind, once convinced of the reality of being snake bit, switched almost immediately to a kind of analytic stillness. As I hobbled into the house I was telling myself that 20 to 30 percent of rattler bites are not envenomated, and though the ongoing pain was telling me otherwise, I was briefly hopeful that would be the case for me. By the time I reached the bathroom, the fact that this was not my fortune was evidenced by my foot having already ballooned to half again its normal size.
In the bathroom I found the top of my foot bloody. I had a syringe right there and actually attempted to aspirate some of the venom from the wounds. This was not one of my more brilliant moments, but the illusion that this would be effective fortunately lasted only a few seconds — ending with my recognition of the foolishness of this endeavor and an understanding of my need for immediate medical care. I needed anti-venom and I needed it as quickly as possible.
Back to clear thinking. I considered calling 911 for an ambulance and medics but reasoned that by the time they got to me, got me loaded and then again took off, much more time would be eaten up (and much more tissue with it) than if I just took off for a hospital. Further, and again perhaps foolishly, I didn't want to incur even more expense as I already knew this whole adventure would indeed be expensive.
So, with increasing discomfort (euphemism for pain) I got out to the garage, grabbed a tourniquet from my crash bag I keep in the car and opened the garage door. There was a brief moment of internal debate as I considered the tourniquet: Current evidence recommends against the use of a tourniquet in snakebite, as the amount of local damage is increased and there is a risk of bad things happening when the tourniquet is removed and a bunch of toxin is released quickly into the general circulation. Despite this, I decided to apply one very lightly, hoping to diminish systemic effects of the venom while I was driving myself to the hospital.
Once in the car, I realized I was unsure which hospital to head for, as I was pretty much right between at least two. Because of this I did then call 911 while driving to ask if there was a regional snakebite specialty place to head for. There wasn't. Assuring that whatever hospital I did arrive at had anti-venom sufficiently stocked also seemed of import. I did find that the 911 dispatcher was not pleased that I didn't want to wait for an ambulance. Of course, when I said jokingly that I knew I was fine because I knew it was October of 1947, her angst became significantly amplified and I had to repeatedly convince her that I was indeed joking and that I was OK to be driving. That said, it was a very surreal journey as I drove to the large private hospital, avoiding the regional trauma center on an urban Saturday night.
Upon arrival in front of the ER, the venom effects were getting markedly stronger. I was unable to bear weight at all on my left foot and was feeling progressively more ill. I left the car in front of the ER and I had to hop inside. Once I had announced the nature of my problem, I was quickly wheeled back to the triage area, two IVs were started and blood was drawn. Knowing I was now in the medical realm, I relaxed a bit — at least for a little while.
From there things seemed to move in a strange kind of slow motion. After the initial registration, lab draws, IVs and all that, I was moved into a treatment area. I was seen first by the ER nurse, then by an intern and a resident who really knew nothing about snakebite, so I treated my own anxieties by talking to them about the pathophysiology involved. The attending physician then showed up and the anti-venom could finally be ordered.
Herein lay the next problem: Anti-venom takes about an hour just to reconstitute. Tack onto that the time required to transcribe the order, send it to pharmacy and for pharmacy to get to work on it — there was an eternity yet to wait. By that time I had removed the tourniquet and had slipped briefly into a bit of denial, imagining that I might somehow get a few vials of anti-venom and then dance on home as if nothing had happened.
A brief digression regarding that dangerous Egyptian river, Denial: Its currents are powerful indeed, with all kinds of eddies and undertows. One should keep in mind here that I myself have treated quite a few rattlesnake bites and have seen how dangerous they can be. While none of my patients with this injury has died, they have universally required at least a couple days in the ICU and been quite sick. Thus my brief fantasy that I might just get a hit of anti-venom and slip on home was silly indeed. Not to mention that the anti-venom itself, though far safer than what we used some years ago (then we had a horse serum), still has a bit of inherent risk.
Well, my time floating on denial was short. I had managed to make two calls to my closest support, family in California: one to my daughter Caitlin and one to my sister Judy. (My wife was on the east coast where it was the middle of the night; she could get to me no sooner than the flight she already had and I felt she needed to sleep.) The one to Judy was answered by my brother-in-law Phil, who apparently did not understand what I was trying to communicate (he did, after all, have a cold) and didn't even tell Judy that I was hospitalized. Thus my thought at the time that my whole family would know what had happened was faulty. On a second try, or maybe it was a return call from her, I did talk to Caitlin briefly, which was very comforting.
Suddenly I felt worse, so I ended the call with Caitlin. "I feel really bad here, y'all," came from me and suddenly I was surrounded, my gurney was tipped head down (called Trendelenburg), someone was saying my pulse was in the 30s and my blood pressure was in the 50s, and those aren't good numbers. I don't remember how they knew my blood pressure so fast; I do remember feeling a way I've never felt before. It was something like the feeling one gets just before vomiting, but I wasn't really nauseated. It must be the feeling you gets as you faint, but I've never fainted so that's a guess. It was like being both here and there and not knowing which was what.
Someone else said, "Get the pacer pads," and a nurse was putting them on me. Then, in another moment of brilliance, I, the trained physician, said, "Don't do that, it will hurt." I laugh now as they did then. After all, what are some little shocks compared to the pain that was now not just in my foot, but climbing my leg, which had already swollen well above the knee? Further, if indeed I did need to be paced, it would be that very pacing keeping me alive and I really probably wouldn't file a protest. I guess my thinking was, perhaps, not at its best.
Good fortune followed. I never did require pacing, though I got close once or twice more. Lots of IV fluid running into both arms seemed to be adequate as a start. Then, maybe an hour and a half or two after arrival in the ER, the anti-venom was finally ready.
In these trying economic times, the anti-venom is its own adventure. Though much safer than what was used a few years ago, it still carries some risk for medical complications and a virtual guarantee of economic ones. It is about $1,750 a vial and I required a total of 12 vials (in retrospect, I perhaps should have been given more). Surprisingly, this is a moderate dosage, not extreme. I have seen as many as 22 vials given in extreme cases, particularly when there is a long time between snake bite and medical care.
Once the liquid money had started flowing into my veins, I was transferred from the ER to the medical ICU. Now, I have spent much of the last 25-plus years in hospitals because that is where I work, so some of this experience may have been a bit less traumatic for me than for some. Still, I got a completely different perspective from a hospital where I had never been before, nearly upside-down with feet up and head down. The primary view from this position is the ceiling.
I arrived in the ICU in one piece, still breathing and with my heart doing its own work unaided. My nurse was a rugby-playing Canadian man named Ron. He was great. He assisted me in finalizing the transition from regular human to patient by helping me from "civvies" to the highly stylish, if somewhat revealing, hospital gown. The movement required was surprisingly painful.
As I settled in and tried my best to answer yet again all the usual questions that one is asked myriad times by myriad people, how far into a haze I had descended became more apparent to me. The challenge of the evening was balancing pain control with the maintenance of blood pressure, which unfortunately are goals that can be at odds with one another. Despite liters of IV fluid, my blood pressure was only in the 80s to 90s (systolic, or the top number) and the nurse could not give me any narcotic for fear of further lowering it. I couldn't take any kind of aspirin or related pain meds because they interfere with platelet function and worsen the problem with blood clotting that already was significant from the snake's venom. During this time, the swelling was relentlessly progressing so that by the wee hours of the morning I could leave a dent knuckle-deep in my hip from the bites on my foot. It was a long night.
As morning approached, though I was still very sick and quite miserable, neither my survival nor my ultimate recovery seemed quite as uncertain to me as they had the night before. I wanted my wife. I thought I should call her before her flight, but after she had slept. It was a simple little call: "Hey, honey. Not to worry, everything's fine. I just happen to be in the ICU with multiple IVs, pacemaker pads and anti-venom dripping in. The weather's great." Well, that's not exactly what I said, but I was trying to communicate that really, I was OK. I don't think that part went so well. When she finally did arrive hours later, however, she was an angel manifest. From that point on the gifts amidst this horror emerged and began, ever so slowly, overcoming the costs.
Maybe, just maybe, that is really the point of all this. The gifts.
We are vulnerable beings on the physical plane. A creature that itself probably weighed less than five pounds changed my outlook and came treacherously close to extinguishing it in a mere moment. As the first drama receded, during times that the balance of pain control and narcosis allowed, I began to get glimpses of understanding about my own vulnerability.
The next couple of days were spent in the hospital with very good nursing care. My blood pressure came up and finally pain medicine was available. This time is a bit of a blur. I became quite anemic from the effects of the venom. On the last day I began to try to move around a bit, but the pain was searing any time my foot was not elevated. I was pretty weak. Just maneuvering to the bedside commode was both immodest and excruciating. Still, healing had commenced.
There were moments of frustration and moments of laughter. On day three, I was discharged from the hospital with a final touch of humor. My nurse on that last day looked to be about 11. She was asking me her nurse questions and when she got to "what is your work?" I answered that I was a doctor. She apparently was shocked. Why would I say that? I can only quote her: "Uhn-uh, a physician? Shuuut uuup!" I found this hilarious but also a reminder of the mythology that would suggest that those of us who happen to doctor for a living are somehow made of something different from the rest of "regular" folks. Lying in that bed, unable to really take care of myself, I was certainly reminded of just how regular I am.
I've now been home for quite a few weeks. I am just beginning to be able to bear a bit of weight and the swelling is now limited to the foot and ankle. A component of my blood-clotting system called platelets fell last week to very low and I had a little bleeding under the skin, but that has now resolved. I know I will be rehabilitating for some weeks to come. I am on the mend, but somehow I am not the same. I have been the recipient of not only a violent envenomation, but also of so much more.
Above I mentioned gifts. That is what I take from this experience more than anything else. I have been given a much deeper understanding of who I am, stripped of my titles, and even of the physical abilities by which it is so easy to define myself. Under all that I am just a man. I have worked at my job a few days and found it remarkably difficult physically, yet the support and care of those with whom I work has filled my heart. I have come to an even more powerful experience of love: that of my wife, my family and my community.
A couple of rattlesnake bites that landed me in the ICU and waved my mortality before me have left me less traumatized than thankful. Not to suggest that I would be interested in a repeat performance — no, once is enough. Yet, I would not wish for this not to have happened. The many costs of this event are repaid with interest by what I was given on a Tucson desert night.