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PostPosted: Wed Sep 24, 2014 10:48 am 
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Location: Pak Kok Village
Pascale has been bitten by a bright green Bamboo Pit Viper in the Yung Shue Long valley 4 days ago, Sep 20, 2014.
She's only just returned from Ruttonjee hospital and has agreed to share her story on Lamma.com.hk. On my request, Pascale's written a detailed account of her last 3 days. It's giving us Lammaites great advice on what to (and not to do) in case of a snake bite.
Many thanks to Kris who texted me about this serious incident and connected me to Pascale.

Pascale's Facebook Timeline: 20 September at 10:48:
"On my way to Ruttonjee Hospital. I was bitten by a bamboo snake an hour or so ago. Island police and health services have been admirably responsive."

Attachment:
File comment: Bamboo Pit Viper - by Tim Bonebeak
Tim-Bonebreak-Pitviper-wp.jpg
Tim-Bonebreak-Pitviper-wp.jpg [ 56.34 KiB | Viewed 3635 times ]

"9 am Saturday: I am within a 100 meters from home, returning from walking the dogs. I feel a horrendous burn on my foot and look down for what I think is a millipede. Instead I sight a green snake, realize I have been bitten and try hard to identify the features of the beastie before it disappears.

I immediately drop down to the ground, keep immobile, and start slowing my breathing down. I have read somewhere that venom rushes through the body at a very fast pace when people panic and have stress reactions. I do not know if the snake is venomous.

I start screaming for help, I don’t have my phone with me. A path cleaning lady appears and lends me her phone. I call the police. People start to appear, including two young representatives of a local environmental body. The police is called once more. Within 7 minutes two policemen appear, on their bicycles. They ask me to describe the snake: light green, pale underbelly, very thin, the size of a finger and no more than two feet long, very fast moving.

One policeman reassures me that this snake is not dangerous. This leads me to sit and start moving. Which is a big mistake. The first responders arrive, whisk me in the ambulance after carrying me along the Yung Shue long old village path to near the Beer Garden. A neighbor has ran to my home, and my helper brings me a few essentials in a bag.

I am seen immediately at the clinic, though the queue of outpatients is long. The doctor administers a tetanus shot, and pain killer shot, cleans the wound, and applies a light compression bandage. He tells me I am going to hospital for observation. He tells me that the snake I described is venomous. As I learn later, he has followed protocol to the letter.

I later learn that it is a bamboo snake, a pit viper.

The ambulance gets me to ferry. I find it hilarious that I am asked for the price of my fare to Hong Kong Island. They drop me on a seat and tell me that an ambulance will wait for me at the pier, and that I am to go to Ruttonjee hospital. I later learn that Ruttonjee specializes in orthopedics, which includes limb removal surgery. If all gets to the worst, at least the surgeon team is qualified!

9.30 am: The pain is unbearable. My foot starts swelling.

11 am: I am at the emergencies at Ruttonjee. The intern places a pen mark below my ankle and tells me this measures the progression of venom over time.

12 noon: First blood test and IV drip. The pain is beyond excruciating. Pen mark above the ankle

1pm: I scream for the anti-venom. I am told that the antivenin is as dangerous as the venom as it can create severe anaphylactic reactions, basically the heart stops beating and the lungs collapse. They want .to see how much venom I have in my system before deciding to give the jab and how much of it to give. The pen mark is 3 cm above the ankle.

3 pm: The progression of the venom is neatly marked along my leg. The mark reaches slightly above the middle of my lower leg. The progress of the venom is very apparent as the skin progressively swells. I have had 3 blood tests by now, a second intravenous pain killer after copiously arguing with the doctor who wants to give me a Panadol pill instead. I am told I’ll get the antivenin, too much of my body is ‘envenomed’. The vials are being sent from another hospital, require mixing and experts are communicating the protocols to the doctor attending to my case. He tells me that he is in contact with a specialist team from another hospital. He also adds that cell die off would occur if the venom is not stopped, leading to necrosis of tissues, blood clotting, kidney and liver failure. What is best, that, or lung collapse?

I feel I am between hot fire and frying pan. The pen mark now reaches just below my knee.

Taken to X-ray of chest and foot/leg. The radiologist refuses to accept that I cannot lower my foot down nor press it against the x-ray pad. She grabs it as I keep refusing to comply. I start screaming in pain and the people in the whole corridor come to see what is happening. The orderly gets it and brings in a high stool upon which she places the x-ray pad. As soon as my foot/leg is flat and raised just below heart, the pain immediately disappears. The radiologist mutters an apology.

5 pm: Pen mark just above knee. Two vials of anti-venom are administered with antihistamine and hydro cortisol intravenously applied. There’s adrenaline (epinephrine) available too just in case. The area of the jab starts swelling immediately in allergic reaction. The itching is intense. I am being told that I have a mild allergic reaction to the antivenin.

9 pm: The pen mark is static. More blood drawn for coagulation factor check, liver and kidney function. The pain remains unbearable. More pain killers.

4 am: Pen mark 4 cm above knee. I talk to the doctor on duty that perhaps an additional dose of antivenin would be good ‘now’ and that I don’t want to end up amputated. I am only half joking when I tell him that. He tells me that he has a vial ready for this eventuality. A third vial of antivenin is administered, together with the mix of antihistamines and hydrocortisone. I pass out in exhaustion.

8 am: I am told that there is no longer any venom in my system. Yet my left leg is now twice the size of my right leg. I am told that my body is processing the amount of dead cells, which explains the swelling as there is trauma in my tissues.

From there on: Blood test every 4 hours. Measurements of my leg to check the extent of the swelling. I am told the worst is over.

I am told that where I had to keep my foot below my heart (delay venom progression), now I must keep it well above the heart (reduce the swelling)

48 hours later: I am stabilized. More of the above, blood tests etc., save the anti-venom no longer required. I am kept in to verify if the swelling is going down. My arms left and right are swelling too because of the sheer amount of needle pricklings.

The nurses and orderlies are teasing me with light humor, one only approaches me playfully with snake likes motions, while others keep poking (or pretend poke) my leg to see how much I’ll jump this time! They are very nice and a few good laughs fly around.

During that time I scour the internet in search of information about what is happening. This is what I learn, and all has held to what I have experienced so far:

  • Identifying the snake leads to improved chances of survival.
  • Anti-venoms that are snake specific are extremely fast working and effective. Broad antivenins, as administered when the snake is not identified are slow working, and require more doses, potentially leading to more health complications.
  • The initial panic at being bitten is what kills people in 50% of the cases: people get a fight/flight response that increases heartbeat and cardiovascular functions leading to rapid spread of the venom.
  • Stillness, cleaning the wound and lose bandage compression is best as first intervention. Tourniquets, suction or incision are not recommended: the last two actually spread the venom further.
  • Anti-tetanus shot is first line of defense as even a dry bite can spread some nasties in the body.
  • Since 25% of bites are dry, anti-venom is administered only if the limb start swelling at a given rate. The rate of progression of swelling determines the amount of envenoming, and is verified through hourly blood test. This explains the delay of a few hours between bite and first antivenin injection, so to ensure safe yet effective dosage.
  • Keeping as still as possible, with affected limb below the heart until antivenin is administered is crucial.
  • Anti-venom can be as deadly as the venom, for other reasons. It creates anaphylactic shocks in many. A case of the cure killing as much as the illness. Hence the balancing of risks and waiting for a progression of the venom before administering it. The anaphylactic shock can occur as long as 2to 3 weeks after the initial injection: it is important to be monitored post hospital discharge.
  • The blood tests determine to some extent the probability of an anaphylactic shock.
  • The pain is beyond anything what one might experience ever. Well this is what happens with pit viper bites. Other snake bite may not cause any pain.
  • If antivenin is not effective or can’t be applied, and /or necrosis of tissues sets in, amputation is required.

The pain around the envenomed parts is exquisite and only disappears very slowly. The physical tiredness is immense but the brain is clear. Which is why it is important not to succumb to panic.

The discussions with staff and doctor reveal that even with antivenin, a snake bite is life threatening and is to be regarded seriously: prevention is the key.

The staff of Acute Medical Ward B7 at Ruttonjee was responsive, friendly, caring, helpful, and I am immensely grateful to them for the level of care they delivered and all they did to keep me informed, and reassured.

I am not happy with the policeman who pronounced that the snake I described was harmless: this lead me to move, not a good thing. I think though that he was trying to ease my concerns, but in so doing delivered wrong information.

The probability of a snake bite is low. However, it happened on a concrete/paved path. I believe that the cyclone of last week might have disturbed the snake out of its usual habitat, explaining its presence on a much frequented path. It was also bad luck that on the day my usual sports shoes were unusable and I was wearing open sandals.

As the island clinic nurse attempted to joke “good thing it wasn’t the dog who took the bite, he’d be dead”, it gave me an immediate taste of possible outcomes!

The cost of 3 days in an emergency/acute medical ward in Hong Kong: 300 HKD or 45 USD. Yes, 15 USD a day.

Includes: 2 x ambulance transfers, 24hr round the clock heart monitoring, 3x vials of pit viper antivenom, 7 x IV drips, 14 x blood samples and tests, 3 x hydrocortisol shots, 1 tetanus shot, 2 x IV pain killers, 3 x anti histamine shots, oxygen, standby epi-pen, orthopedic supplies and OT attendance, full nurse attendance and ancillaries. Well done, Hong Kong Hospital Authority. I took the donation form."



Facebook: "Dear all, thank you very much for your support during the past 4 days. I decided to write it all because I was scared out of my wits, understood how grave the situation could be, and felt compelled to be in touch with friends, 'just in case'. I also hope that the descriptive of my experience will spread some knowledge about what to expect/do in case of snake bite.

So far, I am recovering quickly. The issue remains some follow up, as delayed anaphylactic response is a possibility, so I'll take it easy for a wee while but this said....."I can walk again" !!!!
Cheers, and again, my gratitude to all of you."


Pascale's photo below from yesterday, Sep 23:
"The bite was half an inch away from the root of the pinkie on the side of the foot. Minute in size and difficult to see."
Attachment:
File comment: The foot and bite, 3 days later!
Pascale-photo-1.jpg
Pascale-photo-1.jpg [ 49.26 KiB | Viewed 3635 times ]

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PostPosted: Wed Sep 24, 2014 11:30 am 
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Wow - thanks for sharing! Hope the recovery is going well. I have 1 question regarding 'keeping the affected limb below the heart'. In this case, your foot. - Would it be best to then keep sort of a standing position, or to put it up on a stool or so?


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PostPosted: Wed Sep 24, 2014 11:48 am 
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Hi. Once bitten, it is impossible to apply any pressure on the limb/foot. The swelling being intense and rapid, gravity affects the weight of the limb. The tissues are being destroyed too. Standing upright is no longer possible. keeping the foot on a stool is good, below heart while envenomed is best. that's what I did during ferry transport in a modified way: kept the foot on the seat.

Once the foot was rested, the pain would subside. Then, if I had to bring it down to floor, I would scream my lungs off in pain. This lasted for 4 days. Today is day 5, the first seconds of standing upright are excruciating, still.
hope this helps!


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PostPosted: Wed Sep 24, 2014 1:14 pm 
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Quote:
a snake bite is life threatening and is to be regarded seriously: prevention is the key.

Sage advice.

I had a pit viper in our bathroom once, managed to kill it. Might not be so eager to engage after reading this.
After that I got a reference book so I'd know what bugs, snakes and other neighbours I might run into here.
Published by the HK govt, should still be available at their bookshops.
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PostPosted: Thu Sep 25, 2014 11:44 pm 
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Thank you for sharing, hope you get well soon. :thumb-up:


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PostPosted: Fri Sep 26, 2014 8:11 am 
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Yikes, scary. Thanks so much for the detailed account which will be very useful if such an event happens again. Also a timely warning for parents who see their small children running round in bush areas with bare feet.


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PostPosted: Wed Oct 22, 2014 11:41 am 
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Update from Pascale:

"Pit Viper bite - one month later.

This is what to expect:
Pain in the bitten region that still endures and abates very slowly. The venom contains neuro-toxins that damage the nerves in a specific way, creating hypersensitivity. A slight brush or touch on the affected area sends me screaming in pain. It is said to subside within 6 months.

Also, the immune system having been so heavily taxed, one's defenses are low. I have had cold and bronchitis, which I never do. Allergic responses, runny nose, eczema and much more cycle rapidly through any one day; as one symptom disappears, another one appears. Some day to the point of driving me insane, but then, I refuse to take anti-histamines. This fades over 3 weeks.

But the most bizarre has been my compulsive need to eat MEAT. My first seven days out of hospital was all I wanted, all I could eat. It is getting better now, I am kind of back to some veggies! I guess that the body screams to rebuild itself with proteins."

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PostPosted: Wed Oct 22, 2014 12:02 pm 
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In the meantime, another person on Lamma, a female visitor, has been bitten by a Bamboo Snake:


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PostPosted: Wed Oct 22, 2014 5:10 pm 
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Wow! You had a truly dreadful experience but sharing it with us might well help someone in the future. I've also passed it on to a friend who might not read Lammazine.

Thank you for taking the time, and good luck with your recovery. :D


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PostPosted: Wed Oct 22, 2014 6:50 pm 
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this is very useful. There have been one or two close encounters with bamboo snakes in the community garden in the last couple of weeks, so it is as well to be super-vigilant.


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PostPosted: Thu Nov 20, 2014 10:31 am 
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7 weeks later and Pascale still has foot pains and some neurological damage...

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PostPosted: Tue Nov 10, 2015 2:31 pm 
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It's happened once more! Pit Vipers cause by far the majority of snake bites in HK.
Update from Pascale:

"A person was bit by a mature bamboo viper Wednesday late afternoon and is now at Queen Mary still receiving vials of antivenin to this date.
Happened on main path in direction of sok kwu wan near a site storing construction materials and wid fence. Close to beach. Will post GPS coordinates when available. The animal was aggressive and did not move off path after biting. There could be a nest nearby.

First recommendation is "slow your vitals". See page 13, section 2-4. What is in is applied systematically as advice to anyone who might encounter poisonous snake and in first aid. https://fas.org/irp/doddir/army/fm90-5.pdf"


Some good advice from Ronan Keilthy:

"It is definitely not the best idea to kill the snake. It puts you in a lot more danger of another bite, and it is just cruel to kill an animal that just tried to defend itself. If you don't think you can ID a snake, that's what we have iPhones for.
Also, sucking out the venom is not effective in the least. The only thing it does is stop you from getting to hospital quicker. If you are bitten by a venomous snake, there is one simple rule: GET TO MEDICAL ATTENTION. If you do that as quickly as possible, there really is no reason to die from snakebite anywhere (especially Hong Kong).

That viper was not being aggressive. It isn't the warmest in Hong Kong at the moment, and that snake was probably trying to heat up on the path when someone stumbled across it. If the person was bitten anywhere else other than the foot/leg, they were obviously trying to kill or handle it, and the bite is 100% their fault.

Also, there is no such thing as a viper nest. Most vipers (including bamboo pit vipers) give birth to live young. When the babies are born, that's it, they go on their own way. They might hang around the same area for a few days, because any distance is large when you are about 15cm in length."

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PostPosted: Fri Dec 04, 2015 12:52 am 
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yes I was the lucky one that got bitten by the bamboo pit viper ! finally got the time to tell the story.
It was actually on my way home , just before Granny Chan's shop by the rubbish/ recycle bins , opposite the construction site .
I have no idea how it happened , was not looking at my feet while walking and talking with my husband, until I felt the sharp sting . Nothing much I must say, never thought it was a snake until and turn round to see what got me and saw the snake .

As per my husband's instructions , I sat down and stayed calm (surprisingly!) . I asked him to take a pic of the snake. he called the ambulance and they took me to the clinic . They were super efficient and very friendly !

There they checked my vitals and sent me off to the hospital by helicopter (fantastic ride !!). By then my foot was well swollen and the pain started to kick in . I was at the Eastern Hospital , A&E department . They were also very efficient . after registration etc ... they gave me some well needed pain killer through intravenous injection and also antibiotics .
By then the pain was really excruciating, could not touch my leg at all and every visit from the doctor felt like torture!

Anyways to keep a long story short , they kept me for 4 nights , gave me 3 doses of anti-venom (horrible experience), were going to give me a 4th dose but they run out , no more stock :-)!

Thanks to Pascale's great advice , which I follow to the letter , I actually recovered super fast . Visited the hospital one week later and even the doctor was surprised that I could walk without a walking stick!

As for the details , Pascale has already explained it better than I ever could . The pain, the swelling, IV drips, blood tests .... more pain ...

My heartfelt thanks to the paramedics, the Lamma clinic, the staff in A&E ward in Eastern Hospital , they were all very professional, friendly and helped me stay calm and informed !

HUGE thanks to Pascale for all her advice and support that were essential to my super quick recovery .

Crucial advice : try and get a pic of snake if you ever get bitten or at least a description...this will be a great help to the medical staff.


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PostPosted: Fri Dec 04, 2015 1:49 pm 
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Thank you so much for sharing!

Very helpful advice to all of us, especially hikers who might encounter snakes more frequently than on the concreted paths, even though I've seen several in person on the path since movig to Pak Kok two uears ago.

I've shared your advice in the Facebook group Snake Sightings on Lamma and it'll be a Lamma-zine story as well.
Thank you again!

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