The snake in the ER

The experienced emergency department nurse only added to the author's trepidation.

By Harold S. Jenkins, MD
Emergency Medicine Specialist/Madison, VA

There's a really bad snakebite coming in!"

As head nurse Marlene Hubbleworth hung up the EMS phone, her voice became even more imperious than usual. It was 1997, and I had recently sold my family practice and was getting back into the swing of my emergency medicine specialty. Although I was less than halfway through my first day in this particular hospital's ED, I had already concluded that Hubbleworth was a force to be reckoned with.

During my initial intrusion into her department, Hubbleworth (I've changed all names) had been helpful—to a point. She'd conducted the obligatory tour of the treatment rooms while maintaining a professional distance. After all, her demeanor seemed to say, emergency physicians come and go, but she'd been supervising this ED for decades.

"What did the paramedics tell you about the patient?" I asked, striving to mask my insecurity.

"It's some college kid," she replied. "He was picnicking with his friends in the national park, and he got bitten on the neck about 30 minutes ago."

"What kind of snake was it?"

"The ambulance crew didn't say, but it's poisonous—I'm sure of that. The boy's dizzy, and his blood pressure is on the low side—86/52. A diamondback would be my guess. There are lots of rattlesnakes in the park, and they're mean-tempered on these hot summer days."

The EMTs had started an IV infusion of normal saline, she added; they were administering oxygen to the patient and had placed an ice bag on the bite wound.

I quickly retreated to the doctors' office, where I grabbed the most up-to-date emergency medicine text and flipped to the snakebite section. Several years had passed since I'd seen a snakebite victim, but the recommended treatment hadn't changed much. Still, I was concerned that the patient had been bitten on his neck, where there's no way to slow the venom's absorption into the large central blood vessels leading directly to the heart.

"Dr. Jenkins, we need you in the trauma room," Hubbleworth's baritone voice boomed over the intercom. I dropped the book and raced into the hall, then screeched to a halt and reversed direction as I realized I was heading the wrong way.

"Dr. Jenkins," Hubbleworth said, "This is Alex Marshall." She nodded toward the pale young man on the stretcher. "He's had quite a snakebite," she said. "He's got a bad headache. He vomited twice in the ambulance. He's still dizzy, but his blood pressure's a little better now."

I surveyed my new patient. Alex was as limp and pale as cold pasta, his face and chest glistening with sweat. The heady aroma of beer hovered around him. He moaned about the excruciating pain in his neck. His lungs were clear, but his blood pressure was still worrisome at 95/60.

"Alex, what kind of snake attacked you?" I asked. Poisonous snakes often leave their trademark: two puncture wounds where their fangs tore through the skin. My patient's suntanned neck bore only a semicircle of abrasions.

"He doesn't know, of course," Hubbleworth said a bit too officiously. "He says he was eating lunch, leaning back against a stone wall out in the woods. The snake must have crawled up behind him through the rocks. His friends should be along in a few minutes; maybe they can tell you more."

"Alex," I said, "you certainly look sick, but I don't think your wound came from a venomous snake."

"I've already called the pharmacy for the antivenin," Hubbleworth interjected, focusing her self-assured gaze on me. "They're not very fast down there sometimes, and—you know—with these bad snakebites, every second counts." Clearly, she wasn't even going to pay lip service to my skepticism about the nature of the bite. "I've reserved a bed for Alex in the ICU," she continued. "And you'll have to call his parents in New York soon. I've got their phone number."

"I'm not going to die, am I, Doctor?" Alex sat up on the stretcher, his bloodshot eyes filled with tears. "When you get my mom on the phone, please let me talk to her. I want to tell her goodbye." I would probably have been angry at Hubbleworth for frightening him if I'd been more sure of my own diagnosis.

"I think you're going to be okay, Alex," I said. I checked his rapid but regular pulse and his improving blood pressure. The skin around his neck wound showed no swelling or purple discoloration. "I don't think the snake that bit you was poisonous. We'll do some lab tests and keep giving you fluids, and you should feel better soon."

Hubbleworth stiffened noticeably and rolled her eyes. I could sense that she had taken my evaluation as a personal affront. "Well, Doctor," she said, "the antivenin should be here anytime—just in case. I've seen a lot of snakebites in my day, and this one certainly doesn't look good to me."

Beneath my green scrub shirt, I felt a clammy sweat. I knew that 7,000 venomous snakebites occur annually in the US, but most of the ones I've treated have needed only an adhesive bandage and a tetanus shot. Only once, about five years into my medical career, had I witnessed a life-threatening reaction: A plumber who'd been working in a well had been bitten on the thumb by a copperhead. But when that man was brought in, his right arm had been swollen and purple. He'd been much sicker than the young man before me. Still, Hubbleworth had a lifetime of experience. What if she was right?

The trauma room door swung open, and a burly hospital guard carrying a wicker basket sauntered in. "Alex's friends just got here, Doctor," he told me. "And they've brought you a present." The guard slid the picnic container from his forearm to a nearby Mayo stand.

All around me, people stopped moving and awaited my inspection of a dead snake. Against the high-tech backdrop of portable X-ray equipment, surgical lights, and flashing cardiac monitors, every eye was fixed on the picnic basket.

I nervously fumbled with the clasp on the cover, which didn't immediately budge. Using all my strength, I tugged on the clasp. Suddenly, the lid flew open, and—only inches from my fingers—the head of a hissing snake struck out into the air.

I jumped back, colliding with the guard and an orderly. My coat sleeve caught the corner of the Mayo stand, which wobbled, swayed, and then crashed to the floor.

The nurses' screams were suitable for the climax of a horror movie. The orderly, with a single bound, leaped to safety on a countertop. Out of the wicker basket tumbled a few beer cans, followed by the slow, sinuous figure of a large black snake. Looking around the trauma room, the snake hissed at a circle of petrified people. Only Alex, safe on the stretcher and with a more-than-adequate blood alcohol level, was still breathing normally.

Hubbleworth recovered first. She tiptoed across the tile floor and seized the snake at the base of its neck. The snake fought and hissed, but the head nurse was once again in charge of all matters in her department.

"Oh, it's only a blacksnake!" she remarked, as she stroked her captive's shiny scales. "How awful that he's been locked in that stuffy basket all this time. I bet he's just scared to death!"

As the formidable nurse cooed to her new pet, I decided not to remind her that the snake wasn't the only one who'd suffered a traumatic morning. My own heart was racing, and I felt as limp as the intoxicated student on the stretcher.

"Isn't he beautiful, Doctor?" Hubbleworth whispered. For one terrifying moment, I thought she was going to hand the reptile to me. I stepped back, ready to bolt.

But she had a higher purpose. "Now, if you can just open the door for me, Doctor, I'll take him outside where he belongs. He'll be a lot happier in one of the flowerbeds."

After pushing through several doors, I watched from a safe distance as the head nurse knelt on the sidewalk and patted her charge for the last time. Our morning visitor slithered through the grass and disappeared into a bed of red and white geraniums.

Hubbleworth stood up, dusting her hands on a handkerchief. "Doctor," she said, "can you believe all the fuss over a harmless little blacksnake? I wonder what those college students did to irritate the poor thing."

I said I had no idea.

"Now we have to go inside and clean up that mess," she said, shaking her head. "For once, it's good the pharmacy was so slow. I'll call down there and cancel the antivenin."

"While you're doing that," I said, "I'll call Alex's parents and tell them everything will be all right."

I studied the solid figure in front of me. Could there be a faint twinkle in those authoritative gray eyes? I decided to take a chance. "And by the way, maybe you wouldn't mind canceling the ICU bed?"

Hubbleworth's pink face broke into a wreath of friendly wrinkles. Then she threw back her head and laughed so loudly that several visitors stopped to look us over.

Stepping to the front door, she squeezed my hand. "Doctor," she said, "I think you're going to work out just fine. You've done very well on your first day, and I hope you'll stay here with us for many years to come."

"Why, thank you," I said, thinking about the little surprises—like that wicker basket—that make our paths through life so interesting and unpredictable. "I appreciate the invitation."

 

Harold Jenkins. The snake in the ER. Medical Economics 2000;12:71.