Emergency physician William Rushton, MD, used to lie awake at night, worrying about his snakebite patients. People rarely die from envenomations these days thanks to a new, safer generation of antivenins that came on the U.S. market in 2000.¹ An estimated 7,000–8,000 people are bitten per year by venomous snakes in the United States, though only about five of them die, according to CDC data. But somewhere between 10 and 44 percent of bite victims have lasting difficulties like loss of muscle control or part of a finger, and Dr. Rushton’s patients from the emergency department (ED) at the University of Alabama at Birmingham (UAB) Hospital often contacted him after release about such problems.¹

So many patients returned to UAB with swollen or discolored limbs that Rushton began to require all of them to send him pictures of their extremities three days out—the best system he could come up with even though, as he says, “It was incredibly inefficient.” Rushton—an associate professor of emergency medicine (EM) and pediatrics at UAB Hospital—was agonizing a few years ago over how to help a patient with a badly blistering wound when his colleague Dag Shapshak, MD, peered over his shoulder at the patient’s pictures. “Looks kinda like a leg I would see in my clinic,” said Dr. Shapshak, another associate professor of EM at UAB, who also helps lead UAB’s Comprehensive Wound Care Clinic. The encounter got the two physicians talking not only about that specific patient, but also about how they could better help all bite victims—a long conversation that culminated in 2021, when they launched UAB’s Comprehensive Snakebite Program, the first of its kind in the country. The new center not only provides initial resuscitation but something more difficult to find: comprehensive follow-up care for snakebites that, Dr. Rushton said, goes “beyond the brick and mortar of the ED.”

Alabama sees about 250 snakebites a year, and as medical director of the state’s Poison Information Center, Dr. Rushton consults on nearly every one of them—at least one or two a day through the poison center. In the past, patients often struggled to find any clinician willing to see them after they left the ED. Primary care physicians aren’t typically trained in treating snakebites and were therefore largely unwilling to take on any responsibility for them. Therefore, Dr. Rushton’s patients—suffering from swollen limbs, decreased range of motion, or persistent or rebound coagulopathy—sometimes drove as much as four or five hours back to UAB to see him for further help. That was hard on patients and on Dr. Rushton’s ED, which wasn’t set up for such treatment at the time—though, as Shapshak quickly saw, his wound clinic was. Bite victims needed post-discharge services that dovetailed neatly with those Dr. Shapshak was already providing—localized wound care, treatment for swelling, lab monitoring to ensure proper clotting, and referrals to physical therapy. Obvious as the overlap may seem now, it was obscured for a long time by the gap between the typical snakebite patient and the typical wound clinic patient: The former tend to be young, healthy, and active, between the ages of five and 30; the latter about 80 years old, suffering complications from diabetes or cancer. As Dr. Shapshak said, “The know-how was in our field. What’s novel is that we [were] able to connect the dots.”

Everyone at UAB seems to be connecting the dots lately when it comes to snake bites. Dr. Rushton recounted, “At our children’s hospital, pediatric burn dressings are used to reduce pain, and the burn nurses came to me and said, ‘Could we use these dressings to reduce snakebite pain?’ That’s worked amazing[ly] well and helped us reduce pediatric opiate use.” It’s not only the burn nurses who’ve gotten in on the game. “Our physical therapists have written order sets to get people up and moving around quickly,” Dr. Rushton noted. His team also includes ED pharmacists who help coordinate antivenin treatment. “This is very much a multidisciplinary project,” said Dr. Rushton.

These days, Alabamians with bites no longer struggle to find follow-up care. UAB’s center offers it not only to those they see bedside, but also to anyone who calls the state’s Poison Information Center. “It’s a resource for the entire state,” Dr. Rushton reported. “This year we took two people from Georgia too,” he said. Moreover, now that primary care doctors can rely on the UAB center to guide them through follow-up treatment, they’re more willing to take on snakebite patients—and Dr. Rushton and Dr. Shapshak are proud they have empowered their non-emergency medicine colleagues.

Emergency physician Sean Bush, MD, president of the North American Society of Toxinology, applauds UAB’s work. “Follow-up care is a challenge,” said Dr. Bush, an envenomation expert, “Snakebite is an uncommon emergency in most places, so it’s helpful to have people and places with a lot of knowledge and experience managing difficult cases.”

UAB’s new model may inspire colleagues in other states where venomous snakebites are common to start centers of their own—in the Southeast and Southwest especially. “The positive response to the center at UAB—people come to the clinic who are so appreciative of the care—shows that there is a need,” said Anne-Michelle Ruha, chair of the Department of Medical Toxicology at Banner-University Medical Center in Phoenix. “Alabama is setting a good example that others can follow.” Dr. Bush agreed: “Other states and academic medical centers where snakebites are common could definitely benefit from UAB’s approach.”

UAB is also contributing to the academic conversation. In 2021, they published an article looking at novel ways to screen for coagulopathy.² They’re collecting data on how patients heal, particularly with regard to persistent wounds. And in March, Drs. Rushton and Shapshak published a letter in The New England Journal of Medicine stating, “Our experience suggests that management [for snakebites] should embrace a multifaceted approach that includes post-hospitalization therapies targeted to the treatment of persistent venom effects.”

What’s in this for patients is obvious and Dr. Rushton benefits, too. “I sleep better,” he said. “I’m not waking up at 3 a.m. anymore, thinking: Is that blood blister on that six-year-old’s hand going to get so big that he’ll be the exception, the patient who will lose blood flow? I don’t worry about those things nearly as much anymore.”

Maura Kelly, a health writer, is a special contributor to ACEP Now.

References

1. The National Institute for Occupational Safety and Health. Venomous snakes. Centers for Disease Control and Prevention website. https://www.cdc.gov/niosh/topics/snakes/default.html. Updated June 28, 2021. Accessed October 9, 2022.
2. Rushton W, Rivera J, Brown J, Kurz M, Arnold J. Utilization of thromboelastograms in management of Crotalus adamanteus envenomation. Clin Toxicol (Phila). 2021;59(3):256-9.