Martin Nowak
Martin's Snakes
This is a lengthy report about a new Alabama snake bite clinic and the basis for its founding. Apology for the length, the topic is complex, hope posted to the proper Forum.
On June 3, 2022, the University of Alabama at Birmingham (UAB) announced opening of a “Follow Up Snakebite Clinic”. The founding physicians are toxicologists and Dr. Rushton is also Medical Director of Alabama Poison Information Center.
https://www.uab.edu/news/health/ite...f-the-nation-s-first-offers-cutting-edge-care
On June 5, 2022, the state-wide newspaper Birmingham News carried the story.
https://www.al.com/news/2022/06/ala...ns-first-follow-up-clinic-for-snakebites.html
The physicians stated, “up to 50% bites are dry”. Readers will have their opinions about “dry bites”. My decades of experience with snakes, including venomous, is that if such exists, dry bites are uncommon. Certainly not at the 50% level. And I understand different bite mechanisms, for example Viperidae vs Elapidae which might result in differing rates of “dry bites”. I sent the lead physician a polite email inquiring about the source of the 50% assertion. He did not respond. Then I sent a polite note to the head of Media at UAB who responded the 50% claim was from the physicians. So, I wrote back asking for the source document, i.e., the source research publication for the statement. After some days I received this link as the basis for “50% dry bites”.
https://www.mdpi.com/2072-6651/12/11/668/htm
This is an interesting publication and worth reading. It indicates up to 50% bites by venomous snakes are “dry”. But it is important to note that Pucca et.al. gave the range of dry bites from prior worldwide publications, and not just the USA. Table 1 provides her data and sources. Separating the data assertions for only USA, there is a non-weighted range of 3-27% dry bites in the USA (according to the various authors). USA data is only relevant to the USA clinic. Other un-cited publications in the USA tend to assert about 25% dry bites. Some USA studies report only 3-5% dry bites. Most of such statements rely on prior publications, which in turn rely on yet earlier publications, and so forth. I think the whole notion of dry bites to be very difficult to research and obtain credible data.
A personal note is that I was bitten by a C. atrox on the Boy Scout Road, received Wyeth antivenin, and days later went into anaphylactic shock and admitted back into a hospital. A foolish mistake I made at the time. The physician at the Alpine hospital in my opinion treated my bite with expertise. He was a bit perturbed being awakened near midnight to treat me. He had treated many envenomation and wanted to know “did an atrox or scute get you?” I said, “atrox”. So, my buddy brought in the snake – he looked at it and declared “atrox”. Days later a local Birmingham physician very nearly let me die as I developed full blown reaction to the equine serum – but as is often the case, a competent nurse recognized my distress and called in another doctor who properly treated my declining condition. I’ve also seen about 65 pit viper bites within the day or two.
Over the years of feeding thousands of rodents to venomous snakes, I’ve never seen a dry bite under feeding circumstances. If a snake is disturbed enough to strike/bite, wouldn’t it result in envenomation? Can/does a snake really “decide” how much venom to inject? How could such be credibly researched? And so forth. I am aware that some authors hypothesize about the difference in an offensive bite, defensive bite, a “casual” irritated bite, and feeding bite; and theorize about the snake “choosing” delivery of venom or not. It is important to note my comments in this narrative are based on my experiences, observations, and I hope logical conclusions. Others may have differing experiences and conclusions. The referenced research paper is well written and addresses elements related to anatomy, biting, bites, dry bites, theories, and is intellectually stimulating. The terms “strike, bite, envenomation” are not always parsed with the precision of formal definitions.
Other statements in the press release will be of interest or question to experienced snake keepers. I just found the 50% dry bite assertion to be overstated, not relevant to the USA, not relevant to an Alabama clinic, and even sensational. And perhaps dangerous in treatment because such creates a biased view of venomous snake bite. I asked about why the 50% rate was stated versus only the U.S. rate and asked about other U.S. studies indicating much lower rates of dry bites. A response was not forthcoming.
Another example would be the statement, “Only about five people die per year from snakebite in America.” A 2021 research paper from Henry Ford Health using “Native snakebite cases from the American Association of Poison Control Centers (AAPCC) National Poison Data System from 1989 to 2018” indicates only 3.36 deaths per year. UAB indicated to me they used the CDC website for the “5 deaths per year”.
https://scholarlycommons.henryford....ticle=1231&context=emergencymedicine_articles
https://www.cdc.gov/niosh/topics/snakes/default.html
It is difficult to determine which source is more correct – the CDC or the National Poison Control Centers. Readers will have an opinion about credibility of each source. But it is of interest the founding physicians quoted CDC data versus data from their own national organization – the Poison Control Centers data.
Wikipedia provides a view of reported deaths in the U.S. over time and was used as a source by the AAPCC. https://en.wikipedia.org/wiki/List_of_fatal_snake_bites_in_the_United_States
A “scary” note is the clinic physicians stated receiving an “average one or two snakebite consults every day with providers throughout the state (Alabama).” Necessary inference here is that from 365-730 physician calls per year in Alabama are received asking how to treat snake bites. There are 120 +/- acute care hospitals in Alabama; about 40 of which are less than 100 beds, many less than 50 beds. Likely all envenomation’s would end up in a hospital ER under the care of a physician. I think most hospital ER physicians are adept at treating snake bite; or referring the patient to a larger hospital.
Of value and importance to reptile / snake keepers is that several literature sources distinguish between envenomation to snake keepers and envenomation to all other victims. Snake keeper envenomation is uncommon, even reasonable to class as rare. If venomous hobbyists minimize being envenomated, such will help the position that keeping venomous reptiles is not as dangerous as sensational opposition would have the public, Game & Fish, and politicians think.
A leading theory supporting “dry bites” is that of “metabolic cost for venomous reptiles to produce venom”. It is typically noted that venom production cost is high – therefore the snake doesn’t always expend venom. Pucca et.al. note this concept in their paper.
https://www.mdpi.com/2072-6651/12/11/668/htm
Accordingly, the snake “decides” if to expend venom and even how much to inject depending on circumstances. Are there any studies measuring the metabolic costs of venom production? By comparison, for prey capture, I suspect most experienced snake keepers would agree a little strike, a little venom, then wait a few minutes is far less metabolically costly than constricting or fighting a thrashing fish, frog, or lizard. Snake keepers often characterize strikes in terms of: “lazy strikes”, “angry strikes”, “reaction strikes”, all of which are accompanied by venom injection. Readers will have their own observations and opinions. Pucca and others also hypothesize about the volume of venom injected based on such conditions as: first bite vs. subsequent bites, bite shortly after consuming prey, bite during draught conditions, variations over time for production of venom, depth of fang penetration, and more. There are reports measuring “remaining volume of venom following strike / bite” by milking the snake to determine volume per bite. All fodder for considerations.
There are several take aways from the clinic opening, press release, its founder’s statements, and the data and literature. The medical and research experts are at odds on facts related to snakebite. The published research is ambiguous in data and conclusions. The academic experts may embellish and sensationalize the topic and perhaps do not understand enough about snake natural history. At least in Alabama, the implication is that community ER doctors may not be skilled at treating snakebite. The data recording and data collection, bite observations, severity of bite, offending snake identification, treatment, and so forth are without standards and quite varied. And again, readers will be able to arrive at yet additional conclusions.
Anyone wishing to inquire or make comments, here are the publicly available email addresses:
William Rushton, MD: [email protected]
Dag Shapshak, M.D: [email protected]
Bob Shepard: [email protected]
On June 3, 2022, the University of Alabama at Birmingham (UAB) announced opening of a “Follow Up Snakebite Clinic”. The founding physicians are toxicologists and Dr. Rushton is also Medical Director of Alabama Poison Information Center.
https://www.uab.edu/news/health/ite...f-the-nation-s-first-offers-cutting-edge-care
On June 5, 2022, the state-wide newspaper Birmingham News carried the story.
https://www.al.com/news/2022/06/ala...ns-first-follow-up-clinic-for-snakebites.html
The physicians stated, “up to 50% bites are dry”. Readers will have their opinions about “dry bites”. My decades of experience with snakes, including venomous, is that if such exists, dry bites are uncommon. Certainly not at the 50% level. And I understand different bite mechanisms, for example Viperidae vs Elapidae which might result in differing rates of “dry bites”. I sent the lead physician a polite email inquiring about the source of the 50% assertion. He did not respond. Then I sent a polite note to the head of Media at UAB who responded the 50% claim was from the physicians. So, I wrote back asking for the source document, i.e., the source research publication for the statement. After some days I received this link as the basis for “50% dry bites”.
https://www.mdpi.com/2072-6651/12/11/668/htm
This is an interesting publication and worth reading. It indicates up to 50% bites by venomous snakes are “dry”. But it is important to note that Pucca et.al. gave the range of dry bites from prior worldwide publications, and not just the USA. Table 1 provides her data and sources. Separating the data assertions for only USA, there is a non-weighted range of 3-27% dry bites in the USA (according to the various authors). USA data is only relevant to the USA clinic. Other un-cited publications in the USA tend to assert about 25% dry bites. Some USA studies report only 3-5% dry bites. Most of such statements rely on prior publications, which in turn rely on yet earlier publications, and so forth. I think the whole notion of dry bites to be very difficult to research and obtain credible data.
A personal note is that I was bitten by a C. atrox on the Boy Scout Road, received Wyeth antivenin, and days later went into anaphylactic shock and admitted back into a hospital. A foolish mistake I made at the time. The physician at the Alpine hospital in my opinion treated my bite with expertise. He was a bit perturbed being awakened near midnight to treat me. He had treated many envenomation and wanted to know “did an atrox or scute get you?” I said, “atrox”. So, my buddy brought in the snake – he looked at it and declared “atrox”. Days later a local Birmingham physician very nearly let me die as I developed full blown reaction to the equine serum – but as is often the case, a competent nurse recognized my distress and called in another doctor who properly treated my declining condition. I’ve also seen about 65 pit viper bites within the day or two.
Over the years of feeding thousands of rodents to venomous snakes, I’ve never seen a dry bite under feeding circumstances. If a snake is disturbed enough to strike/bite, wouldn’t it result in envenomation? Can/does a snake really “decide” how much venom to inject? How could such be credibly researched? And so forth. I am aware that some authors hypothesize about the difference in an offensive bite, defensive bite, a “casual” irritated bite, and feeding bite; and theorize about the snake “choosing” delivery of venom or not. It is important to note my comments in this narrative are based on my experiences, observations, and I hope logical conclusions. Others may have differing experiences and conclusions. The referenced research paper is well written and addresses elements related to anatomy, biting, bites, dry bites, theories, and is intellectually stimulating. The terms “strike, bite, envenomation” are not always parsed with the precision of formal definitions.
Other statements in the press release will be of interest or question to experienced snake keepers. I just found the 50% dry bite assertion to be overstated, not relevant to the USA, not relevant to an Alabama clinic, and even sensational. And perhaps dangerous in treatment because such creates a biased view of venomous snake bite. I asked about why the 50% rate was stated versus only the U.S. rate and asked about other U.S. studies indicating much lower rates of dry bites. A response was not forthcoming.
Another example would be the statement, “Only about five people die per year from snakebite in America.” A 2021 research paper from Henry Ford Health using “Native snakebite cases from the American Association of Poison Control Centers (AAPCC) National Poison Data System from 1989 to 2018” indicates only 3.36 deaths per year. UAB indicated to me they used the CDC website for the “5 deaths per year”.
https://scholarlycommons.henryford....ticle=1231&context=emergencymedicine_articles
https://www.cdc.gov/niosh/topics/snakes/default.html
It is difficult to determine which source is more correct – the CDC or the National Poison Control Centers. Readers will have an opinion about credibility of each source. But it is of interest the founding physicians quoted CDC data versus data from their own national organization – the Poison Control Centers data.
Wikipedia provides a view of reported deaths in the U.S. over time and was used as a source by the AAPCC. https://en.wikipedia.org/wiki/List_of_fatal_snake_bites_in_the_United_States
A “scary” note is the clinic physicians stated receiving an “average one or two snakebite consults every day with providers throughout the state (Alabama).” Necessary inference here is that from 365-730 physician calls per year in Alabama are received asking how to treat snake bites. There are 120 +/- acute care hospitals in Alabama; about 40 of which are less than 100 beds, many less than 50 beds. Likely all envenomation’s would end up in a hospital ER under the care of a physician. I think most hospital ER physicians are adept at treating snake bite; or referring the patient to a larger hospital.
Of value and importance to reptile / snake keepers is that several literature sources distinguish between envenomation to snake keepers and envenomation to all other victims. Snake keeper envenomation is uncommon, even reasonable to class as rare. If venomous hobbyists minimize being envenomated, such will help the position that keeping venomous reptiles is not as dangerous as sensational opposition would have the public, Game & Fish, and politicians think.
A leading theory supporting “dry bites” is that of “metabolic cost for venomous reptiles to produce venom”. It is typically noted that venom production cost is high – therefore the snake doesn’t always expend venom. Pucca et.al. note this concept in their paper.
https://www.mdpi.com/2072-6651/12/11/668/htm
Accordingly, the snake “decides” if to expend venom and even how much to inject depending on circumstances. Are there any studies measuring the metabolic costs of venom production? By comparison, for prey capture, I suspect most experienced snake keepers would agree a little strike, a little venom, then wait a few minutes is far less metabolically costly than constricting or fighting a thrashing fish, frog, or lizard. Snake keepers often characterize strikes in terms of: “lazy strikes”, “angry strikes”, “reaction strikes”, all of which are accompanied by venom injection. Readers will have their own observations and opinions. Pucca and others also hypothesize about the volume of venom injected based on such conditions as: first bite vs. subsequent bites, bite shortly after consuming prey, bite during draught conditions, variations over time for production of venom, depth of fang penetration, and more. There are reports measuring “remaining volume of venom following strike / bite” by milking the snake to determine volume per bite. All fodder for considerations.
There are several take aways from the clinic opening, press release, its founder’s statements, and the data and literature. The medical and research experts are at odds on facts related to snakebite. The published research is ambiguous in data and conclusions. The academic experts may embellish and sensationalize the topic and perhaps do not understand enough about snake natural history. At least in Alabama, the implication is that community ER doctors may not be skilled at treating snakebite. The data recording and data collection, bite observations, severity of bite, offending snake identification, treatment, and so forth are without standards and quite varied. And again, readers will be able to arrive at yet additional conclusions.
Anyone wishing to inquire or make comments, here are the publicly available email addresses:
William Rushton, MD: [email protected]
Dag Shapshak, M.D: [email protected]
Bob Shepard: [email protected]
