snake attack

Probably the number one question that I get asked by people interested
in coming to visit is "what about the snakes". I've had some close
encounters with snakes since I've been here -- the time I went to the
pool to find a 6-7 foot spitting cobra swimming in the deep end; the
time I was riding my motor bike and a HUGE snake appeared out of the
grass about 10 yards in front of me -- its head had disappeared in the
grass on one side of the road before the tail appeared on the other
side; the four snakes I found on my doorstep in two weeks last
December. Remarkably, though, even if you get bitten, most people do
pretty well -- they get a big huge swollen leg that takes about a month
to go away, but there's not a lot of lasting damage.

Issues of expired drugs, unfamiliar diagnoses, and fatal diseases come
up routinely in the hospital and are part of what makes the medicine
here so challenging. This past week, we had the first severe case of
snake bite I've seen in the hospital -- a guy who was bitten 24 hours
previously and sent from one of our referring hospitals. Usually with
these severe cases of neuro toxins you expect them to die within just a
few minutes; why this man had such a delayed presentation I don't really
know (it was a 'green snake with a black head' -- more descriptive than
the usual at least, if someone wants to take a stab at identifying it).
But when he arrived at the hospital he was barely breathing and the
muscles all over his body were twitching uncontrollably. He was rapidly
accumulating fluid in his lungs because his muscles were so weak, and I
knew we didn't have much time.

Unfortunately, time was not the only thing in short supply; we have very
little snake anti-venom in the hospital, because it's expensive for us
to stock. Usually to treat a severe case of snakebite you need around
10-15 vials of anti-venom. I knew we had a hidden stash in the bottom
of the pharmacy refrigerator -- it was expired from 2004, but I had
resisted throwing it away in the hopes that it could still be useful.
Anti-venom is made from horses serum, and can be potentially dangerous
or even fatal to give if the horse serum reacts with your body. So I'm
contemplating giving a potentially dangerous drug which when it's good
can be trouble -- my batch, though, was 4 years out of date and slippery
from the mold from the bottom of the refrigerator. I've never given
this drug, or even seen anyone give it to a patient. And there's always
the chance that my diagnosis of neurotoxic snake bite could be wrong as
well, since I've never seen one of those, either.

I was surprised by our pharmacist, who reported that we had 18 of these
expired vials, about 10 more than I remembered having on hand. The man
was clearly dying, so I called in the other docs who agreed with me and
we started with 8 vials. They helped a little bit, but he was still
twitching like an electrocuted fish, so we ended up continuing to give
and give extra vials, nervously noting his wheezing with some of the
doses as he reacted to the medicine he was given. At vial #16, his
twitching finally stopped, and we ended up giving the full 18 vials to
him to make sure his symptoms didn't come back.

The next day, he's sitting up in bed, smiling, and saying he's feeling
much better! And he went home the next day after that with a slightly
swollen leg but not much the worse for wear. He also met with the
chaplains and decided to dedicate his life to God on the day he was
discharged. I can't help but think that it was unusual for him to take
24 hours to develop symptoms, to arrive at the hospital at just the
right time (an hour later he would likely have been dead), to need 18
vials to get better which just happened to be the amount that we had,
left over from some order back in 2002 or 2003, and that maybe there had
been a plan for him made a long time ago that was difficult to see until
he came.