Ocean breeze, 80’s and sunny, dogs playing in the surf, life doesn’t get any better. It’s all fun and games until someone steps on a Stingray. Or a rattlesnake.
In the few short months I’ve been working in California, I’ve seen three patients present to the Emergency Department (ED) with rattlesnake bites – two envenomations. That’s three more rattler injuries than I saw in 10 years in NYC and Philly. When it’s the real deal, a crotalid envonmation means ICU level care including expensive anti-venin and supportive management for extensive tissue damage and shock. My most recent patient experienced what’s called a “dry bite,” meaning there was fang-human skin contact without transfer of venom. The common risk factors for snake bites are the same as for submersion injuries (drowning): being male between the ages of 18-35 in the setting of alcohol. And the bite is usually on the guy’s hand, so you can demise how that might happen. (Sorry dudes – true story). What struck me about my most recent patient was that his bite was on the in-step of his foot; how’d that happen?
Parking Common Sense at the Door – Examples of What Not To Do
Pics and Videos I should not have
On one of my first backcountry trips in the Supersition Mountains of Arizona, I came across this slow creeping lizard whose jaw is so strong, it can break down human skin by clenching down forcefully with it’s toothless mouth and transfer venom directly into exposed tissue. This was exciting stuff, worthy of a picture, or even a video! While it’s helpful to have a photo of the offending creature, it’s more advisible to avoid the injury in the first place by putting down the camera, and moving right along. So here is the first and last time I filmed a venomous creature:
My Favorite Scar
A couple of summers ago, on what I hope was the first of many trips to Spain, I found myself driving a tiny Ford Fiesta, stick shift, up and down and around the steep and beautiful switchbacks that sculpt the fabulously gorgeous hills of Mallorca.
It was an exhilarating ride for sure, especially according to the front seat passenger, a deal old childhood friend, who probably still has some scary video footage of our journey around the island home of one of my favorite tennis players of all-time Rafa Nadal. Social media at its best, after checking out a friend’s facebook album, I got it in my head that I had to see Mallorca up close and personal, especially those perfectly secluded beaches that you can only get to from cliff trails. We landed in a town called Deia, parked the car, and started heading down the trail to the beach. I was in my favorite shoes: flip flops.
Well into the trail, on a pretty decent pitch, the tread on my flip flop gave out, and I slid a good fifteen feet, doing what I could to turn towards the uphill side and dig my hands and feet into the dirt as an emergency break. Finally my fall was halted by some Olive Tree roots; I had a foot hold for the time being, but no safe way up or down. Lucky for me, there were three spanish men hanging out on our almost deserted beach, just waiting to save the day.
Barefoot, the man in the organge suit met me at the Olive tree, offered me his hands to balance plank-style as he walked backwards and I walked forward down that steep trail. I offered the guy all I had – a nectarine and some hand sanitizer. And I came away with my favorite scar, sustained glacading down a cliff in Mallorca.
Any injury on the foot, even a bad blister, can be enough to ruin an active trip. That’s why in Wilderenss Medicine we spend a good deal of time talking about “hot spots” and prevention when it comes to Blister Care. But blisters aren’t the only pedal culprits. 48 hours before a trip to Kauai this year, we took our dog to the Del Mar Dog Beach. While running and playing with the pups, letting the sand flow through my bare feet near sunset, I thought I was in heaven, and we hadn’t even gotten to Hawaii yet.
Wading in the surf, I felt something sharp on my foot for a split second, but the sharp pain immediately resolved. I examined my foot on the beach and then carefully on the way home for a puncture wound or foreign body, but found nothing. 11 hours later I woke up to severe pruritis (itching) at the site where I’d felt the sharp pain. After almost scratching the entire sole of my foot off, I took some benedryl and went back to sleep. 24 hours later, upon arrival in Kauai, getting ready for our first big hike, I made this diagnosis:
These days, I travel prepared for all kinds of trip spoilers, and happen to have antibiotics with me. The culprit could have been the usual skin bugs (Staph and Strep) or something a little more exotic from the spine of a sea creature (Vibrio, aeramonas). I went for broad coverage with my cipro, stopped the cellulitis in its tracks, and wound up hiking some of the most beautiful trails in the world.
Back to My Patient with the Dry Bite on the sole of his foot
When I asked him where he was when he sustained the injury, I figured the answer would be the back garden or the sidewalk, but turns out he was hiking in a canyon – in flip flops. That’s actually what I’m often doing in the late afternoon or evenings with my dogs since I live on the edge of a canyon. The guy was fine – his injury occurred over 24 hours prior to coming to the ED, and he had no systemic symptoms (whole body symptoms). In fact, he barely had a localized reaction. The only interesting tidbit in his story, and sort of an aside but always humbling to me how patients in the ED quickly trust their docs enough to share this kind of information, was that he’d had a decreased appetite. But his lack of appetite preceded the snake bite, and in fact was related to situational depression from going through a divorce. My heart went out to this guy; I actually felt my own personal empathetic wave of nausea when he told me about his divorce. So I leveled with him – confessed my own lousy canyon-walking habits, and then made him a deal. If he agreed to stop walking barefoot or in flip flops through the hills, canyons and on the beach, I would stop as well. Six days into our arrangement, I’ve only broken the deal once. Doctors really are the worst patients.