a quandary....

The other day, i was watching some sort of television show on
medical emergencies. It was a montage, that didn't go into
nearly enough detail. Still, one of the vignettes left me
wondering...

Here are the basics: Somewhere in southern California, a
bunch of 20-something hicks decided to go off-roading in
the mountains. On their way there, they spotted some
sort of rattler on the side of the road. Anyways, being the
intellectual giants that they were, they stopped and decided
to tease it. As you can probably guess, one took what was
described as a 'massive envenomation' to his thumb.

This is where is gets interesting... He was rushed to a local
hospital (Loma Linda, I believe). The doc in charge was an
apparent venom expert that i have seen on other shows
before. He stated that the bite was so bad, that he needed
to use all of his 20 vials on Crofab. Then, he called around
for 40 + more.

This left me wondering... Does a zoo have to cough up it's
own precious antivenin in a situation like this?Should it
not be saved for their own staff? Or to help someone (a
child, perhaps) who was more deserving of it? In that, I
mean that they took a bite purely by accident: not as a
result of assinine behaviour. What are your opinions?

Also, the doc said that, in total, the guy received over
100 vials of Crofab. Is this accurate? What sort of crotalid
could have done this? Mojave green? A massive WDB?

One more thing: Tanith, I am really glad that you have
sponsored this forum. For a while now,I have been a fan
of you and your work.

Are you sure you didn't catch "Venom ER" on Animal Planet? Cause Sean Bush is the star of that show and he is in Loma Linda...On that particular series, the worst envenomation required some 54 vials or so, a record for sure...there was another guy who got over 40, and still died.

100 vials sounds a little unbelievable. The guy who got 54 vials was bitten by a southern pacific (C.o.helleri) rattlesnake and the snake held on for over 15 seconds, injecting a HUGE quantity of venom...I can't imagine a person being bitten severely enough to require twice the amount that guy did...BUT...it's not impossible.

Considering how Crofab can run about $700 a vial, that is one hefty hospital bill to be responsible for.

As for using up zoo supplies, Crofab is generally easily obtained by hospitals, especially in places where snake bite is fairly common. There was a shortage a few years ago that had everyone in a scare, but supplies are said to be good this year.

This left me wondering... Does a zoo have to cough up it's
own precious antivenin in a situation like this?Should it
not be saved for their own staff? Or to help someone (a
child, perhaps) who was more deserving of it? In that, I
mean that they took a bite purely by accident: not as a
result of assinine behaviour. What are your opinions?

In California we cater to the lowest common denominator. There is no need to worry about thinking for yourself (such as not messing with dangerous snakes) as long as you can pull media attention as they will make sure that you get what you require.

Thanks for the kind compliment. **blush**

CroFab is expensive but there is no current shortage of it. The problem it does have is recurrent coagulopathy, which in plain English means that your white blood cell count can do funny things (like plummet back down) shortly after it appears to stabilize in response to the initial treatment. So you have to keep giving more vials to keep the patient stable. The other problem it has is that it's on the weak side. People are guessing that the affinity purification column where a lot of the foreign and potentially allergenic ovine material gets filtered out is also pulling out the strongest antibodies and resulting in a weaker product.

I do not know whether 100 vials is the correct number but it would not surprise me too much considering the reports I have read on some of the problems with CroFab.

Smart zookeepers are now stocking the Bioclon product, a Mexican antivenom that is quite good against North American crotalids. Neither Wyeth nor the current formulation of CroFab would be my personal choices if I were bitten, and a lot of people in the field feel the same way right about now.

There is some hope for a veterinary formulation of CroFab that omits the affinity column step. If this ever emerges, I would personally choose this product to treat my own envenomation over the more highly purified and consequently much weaker formulation that is presently on the market as a human drug.

I think that Abishek is right about it being Dr Bush. I believe
that I have seen him on Venom ER before. He is the young
guy with the dark-rimmed glasses and blondish hair that
is pulled back in a ponytail?

However, this show was definitely not Venom ER. Like I
said, it was a compilation and was titled something to
the effect of 'Medical Emergencies.' I will have to look it
up in the TV Times.

Yes, I too was taken aback by the number of vials of Crofab.
I am, by no means, an expert on venom, but i do read about
the toopic often. And, the greatest number of vials that I
can ever remember being used was around 18 or so. That
is why I was so stunned by the 100+ number. I will try to
find more info on it.

Also, I am sure that they also performed a fasciotomy (sp?) on
the patient. Isn't this supposed to be an archaic procedure?
What is the latest beliefs on its use?

Originally posted by GinoInDaBronx
[b]I think that Abishek is right about it being Dr Bush. I believe
that I have seen him on Venom ER before. He is the young
guy with the dark-rimmed glasses and blondish hair that
is pulled back in a ponytail?

Dr. Bush is a major hottie. He's a smart guy too. If I was bitten I'd like him to be my attending physician. He could wear a cute little white outfit and stand by my bedside....er, well, never mind with the rest of that speculation. LOL

Also, I am sure that they also performed a fasciotomy (sp?) on the patient. Isn't this supposed to be an archaic procedure? What is the latest beliefs on its use?

Fasciotomy is appropriate in the presence of true compartment syndrome. Compartment syndrome is relatively rare in properly managed envenomation cases where sufficient antivenom is given. Dr. Bush is very competent to manage envenomation, but the only legally defensible antivenom choice (CroFab) for North American physicians right now is not a very good one. Dr. Bush cannot legally use either the Mexican Bioclon product or expired Wyeth when CroFab is available, even though either choice might potentially be a better one in some cases.

In the case of a truly massive envenomation to an extremity that was not responding well to CroFab, I could see compartment syndrome happening and consequently the legitimate medical need for a fasciotomy. Whether compartment syndrome could have been prevented in this case by the prompt administration of a better antivenom is hard to say. Most of the time the answer is yes, it could, but I don't know anything about this particular case.

Originally posted by GinoInDaBronx


Also, I am sure that they also performed a fasciotomy (sp?) on
the patient. Isn't this supposed to be an archaic procedure?
What is the latest beliefs on its use?

Fasciotomy isn't totally outdated, but most of the time in cases of snake envenomation, it is an un-needed technique that usually does more harm than good. Many times doctors will perform one when there are other options due to inexperience in dealing with snake bite.

Tanith elaborated much better than I did on fasciotomy...it IS a viable option with compartment syndrome (where ruptured muscle cells leak fluid into the extremities), but I've heard of some cases where it was done un-neccesarily. It leaves horrible scars, and as Tanith mentioned, if the envenomation is treated properly, true compartment syndrome is quite rare.



Theres a scar from a fasciotomy, I was going to post an actual picture of one, but decided against it because it is pretty damn graphic, and there might be little kiddos browsing this forum.

I know this is a very old discussion, (heck, no one may even see this!) but since I just saw the show in question the other night, I thought I would clear up a few things. The show was called Untold Stories from the ER, which shows several different emergencies during the hour episode. This show in question was one of them. Dr Sean Bush did state on the show, near the end of his segment, that this patient did indeed receive 140 vials of antivenom, and he believed that it was possibly a record number ever given. Many of you have stated, that 10 or so vials would be normal. But when working in a small rural hospital years ago here in Arizona, we had an elderly gentleman come in. He had been hoeing old growth in his garden, in August, when the live baby diamondback rattlers are born. One bit him on his toe. In fact, after killing it, he brought it in, for identification, and we in the lab had it in Formulin. He turned out to become quite ill. Being a rural hospital, we didn't have much antivenom. We ended up scrounging around many of the rural hospitals, which aren't many, this county borders Mexico and New Mexico, and the hospital I worked at is only about 20 miles from Mexico. He was so ill, he couldn't be transported up to Tucson, though the Dr's desperately wanted to do so. His coags were off the charts, (clotting factors) and we ended up giving him a total of 40 vials of antivenom. So though 140 vials sounds impossible, Dr Bush is quite the expert, especially with those Pacific Rattlers, which is what bit this young man, and I don't think he would have given that much unless he felt that was the only way to save his life. Just looking at how they had to open his arm up, to prevent the swelling from cutting off blood supply to the muscles and limb, (Fasciotomy) he really took quite a bite. When I worked up in Tucson, where man and snake meet frequently, conflicts occur alot, and giving many vials is not uncommon. We don't have too much of a problem with the Mojaves here, they are more in the upper mountain ranges, higher elevations, but we do have ALOT of diamondbacks in the lower ranges. Enough so that it's the fire department that responds to snake calls here, removing and relocating the snake a short distance away. I'm no expert on snakes by any means, but since moving to Arizona in 1989, I've done my best to educate myself about the unusual, and dangerous wildlife in my area. Working in hospitals helped me see the results of nature and man crossing paths. Just wanted to clear up the confusion, it's was just a coincidence that I happened to catch the rerun of this show the other night, and was doing some research on rattlers, and found this forum. For anyone that would like to see some of the unusual wildlife in my part of Arizona.......(Famous Town of Tombstone, AZ in my county, Gunfight at the OK Corral and all that) I have several pages with non-copywrited pictures and information about many animals and reptiles.
Arizona Wildlife http://www.angelfire.com/trek/miahkesha/Arizona.html
Alice