On Aug. 22, 2021, I was bit by a copperhead in my backyard. During my treatment and recovery, I had a hard time finding documentation of what to expect during and after a bit, so I kept track of my experiences. Many thanks to Dr. Spencer Greene for collaborating with me on this. His advice and presence were invaluable during this time.
The Day-by-Day of My Bite, Treatment, and Recovery
TL;DR: Join the National Snakebite Support now. Nobody expects to be bitten by a venomous snake, but the attention and advice I received from the page admins, including medical toxicologist and emergency physician Dr. Spencer Greene were critical to my positive outcome. Skip down to the bottom of this blog if you want to get right to Dr. Greene’s tips!
TW: My snakebite pictures aren’t really that bad, but if you get at all queasy by some mildly gross swelling and injury, this may not be the document for you.
If you learned something useful from this, consider showing your appreciation here. It was a big hospital bill. 😉
Day 1: Aug. 22, 2021
I’ve always hated gardening. I’ve always loved the IDEA of gardening, but the actual execution of it left me flat. So when I looked at my garden following a swim one Saturday night, I wasn’t surprised. It was half weeds, half watermelon vines that I significantly underestimated. I figured that the temperature was cool enough that a little weed-pulling might not be so bad. Until it was.
It was 6:30 pm. The bite is quick and sharp, but I never guessed it’s a bite. Instead, I wonder what I’m growing that has such a sharp thorn. I certainly hadn’t intentionally grown something, but it definitely felt like a blackberry thorn. I look closer, and I see the unmistakable Hershey’s kisses pattern of a copperhead curled up under the rosemary. Shit!
I walk briskly into the house — but not too briskly. I know I’m supposed to keep my heart rate down. “Mia,” I yell. “I got bit by a copperhead.” She runs down, phone in hand. She dials 911 while I dial my husband Takes two sets of phone calls before he answers. “I’ve been bit. I’m sorry,” I say. “We’re on our way.” Meanwhile, Mia and I are answering questions with dispatch. “Lie down,” they tell me. So I do. The finger is throbbing and bleeding, but it’s not too bad. Yet.
My next obvious course of action is to tell Mia to post on the Facebook page National Snakebite Support. “Tell them I was bit by a copperhead — what should I know?” I’ve read it all before but can’t think of what to do. An admin responds nearly instantaneously with links to some of the information you’ll find at the bottom of this page and tags Dr. Greene. By now, my husband is home and starts reading off the responses. So far, so good. I take off my wedding rings and wait.
First responders arrive and assess the situation. Heart rate is 177, which I know can’t be. So many questions. Most of them are “Nos.” I’m not feeling dizzy or losing feeling in my hand or feeling nauseous. Then the ambulance arrives — apparently locking their keys in the ambulance in the process (so I heard from neighbors later on). “Why are you lying on the floor,” they ask. “Because dispatch told me to,” I answer. Seems logical enough. Mia asks to come with me. But of course, she can’t because we’re still in the midst of COVID protocols. UGH. COVID. The worst place to be for someone who has been sheltering at home is the ER! The family grabs me pajama pants, a charger, my computer, and my contact lens solution/case.
They put me on the gurney — still in a swimsuit (lovely) — and load me up into the ambulance. What hospital do I want to go to? We make a guess and pick a local one, not realizing there’s a website that will tell me who stocks CroFab (the antivenom. Note: at the time of my bite, CroFab was the only antivenom on the market. There is now also Anavip.). Only a small crowd is gathered on our street. I wave nonetheless. (I later learn that the predictions were that either my husband had a heart attack or that I fell down the stairs and had a concussion. Nobody had odds on a snake bite, but my predicament quickly makes the rounds of the community Facebook page.) My first responder starts an IV and gives me an ice pack. (I later learned prolonged ice isn’t the preferred course of treatment — it’s bad for the tissue – but it sure felt good at the time.) By now, the swelling was past the knuckle and extending into the back of my hand. It was throbbing.
Once I got to the hospital at around 7:40, I’d learned to elevate my arm over my head. (Elevation above the heart is important in a snake bite to distribute the venom and stop it from pooling near the bite and causing more damage.) So I did. We hung out in the hallway for a while. A LONG while. I learned that one of the ER doctors was familiar with National Snakebite Support and Dr. Greene (whom I’ll talk about soon). Eventually, the paramedics release me into the ER to wait further. In my swimsuit and the blue ambulance blanket that I begged them to let me keep. I look a sight, I’m sure, and I’m cold and horrified.
I take my seat in the busy ER, hand raised high above my head. More than one nurse came out to see if I had a question, but alas, I didn’t (other than “Can I have some socks?” and “How long will I be in the ER?”) The answer to the first was “Yes,” and the answer to the latter was “About three hours.”
Here’s where being a part of the National Snakebite Support page was critical — and how one of its leaders and Dr. Spencer Greene, a great toxicologist, went above and beyond for me.
I had posted that I was headed to the hospital on the National Snakebite Support page, and Dr. Greene messaged me around 8:45, asking where I was. He texted the hospital’s CMO to let him know that I was there and was following up with him, and then let me know the CMO was looking into things. But he also let me know that if I didn’t get seen relatively quickly, I should consider going to what he considered better choices. (Note for Houston-area residents: Dr. Greene is now at HCA Houston Healthcare — Kingwood, where he directs the busiest snakebite service in the United States. Go there if you’re bitten, even if you’re far away, unless you’re having life-threatening symptoms.)
I was panicking a little about losing the finger (while in the ER, someone from the snakebite group had messaged me — against group rules — about a similar bite they’d received a week before but didn’t receive antivenom and ended up with a partial amputation). But Dr. Greene assured me that that wasn’t likely to happen. Being given antivenom would accelerate my recovery and decrease the likelihood of permanent disability. Dr. Greene also warned me that the hospital might steer me away from getting antivenom — partly because there’s a risk for an adverse reaction (actually, CroFab has an excellent safety profile and the risk of adverse reactions is estimated to be around 1.4%-2.3%); partly because it’s really expensive; and partly because of an untrue misconception that once you get antivenom once, you can never get it again.
Dr. Greene was even kind enough to video chat with me when I accidentally video-called him, and he was a great, calming presence as I sat alone in the ER.
I let him know that the tenderness on my hand and forearm was increasing and that the swelling had now crossed my wrist. He said that the combination of swelling crossing a major joint within just two hours and tenderness is an indicator that treatment — antivenom — is needed.
He again reminded me that the hospital would tell me to consider risk-benefit and cost-benefit ratios, but he assured me it would be covered by insurance — and that it would help ensure I didn’t lose any functionality in the finger. Ideally, you want to start antivenom within 6 hours of a bite, but it could be beneficial even days later.
Eventually, I had bloodwork done (I learned that snake venom thins the blood) but not much more, and I was sent back to the ER waiting room.
My husband made the trip down to the hospital, bringing me some extra clothes, shoes, and a toothbrush — all that I gratefully accepted. Meanwhile, Dr. Greene let me know that my treating physician (whom I’d seen only briefly in the hallway) was supposed to be calling him.
Dr. Greene set his alarm for 10 p.m., and if nothing had happened yet, he was going to text the CMO again and would check in on me.
At 10:03, Dr. Greene let me know that the physician had allegedly ordered the CroFab for me. Whew.
Around 10:30 or so, they got an ER bed for me.
(Side note here: I had no idea at the time, because I associate ER visits with LONG waits, but Dr. Greene said someone should never be waiting in a waiting room after a snakebite. I firmly believe [and he concurs] that had he not been texting the CMO, things may not have gone as “smoothly” as they did. So if this happens to someone you know or to you: ADVOCATE FOR PROMPT TREATMENT.)
My hand was fine if I kept it up, but if it went below heart level at all, it started throbbing. Like, bad. A dose of morphine did nothing but make me nauseous. But two doses of anti-nausea meds and then an IV painkiller (though I forget what that was) helped. A little.
Soon after, my ER doctor came in and confirmed that he’d ordered the CroFab and to not worry about the cost (gulp). Thankfully, this doctor was familiar with Dr. Greene’s work and was fully supportive of the plan to administer the proper treatment. If one of his family members was bit, he said, this is the exact treatment he’d want them to have. I was relieved that I wasn’t going to have to argue for it or leave and go to a different hospital. They started a saline drip and added in the antivenom.
Dr. Greene let me know that prophylactic antibiotics weren’t warranted (infection is rare), so I should be watching for them trying to administer those (they didn’t).
By midnight, I was finally up in my room, getting vitals checked constantly, having my legs massaged with some contraption to avoid blood clots, and blood drawn every 4-6 hours. My nurses, Ashley and Jennifer, were the best. After eating some orange jello and crackers, building a ramp to keep my arm elevated well above the heart (I learned that even then, I should’ve had my arm up far more!), and FINALLY changing out of my swimsuit, it was time to sleep. Or, Facetime with Mia until about 1:30 (whom I apparently neglected to inform that copperhead bites aren’t fatal). Ashley woke me up overnight for pain meds, and we were both glad to see the swelling wasn’t worsening.
Day 2: Aug. 23
Dr. Greene messaged me in the morning to see how I was doing. The swelling seemed to have lessened, and I had better range of motion. They ran another set of bloodwork that morning, and one test came back slightly elevated (I believe it was one of the clotting tests) and I was waiting for the doctor’s eval.
I was released mid-afternoon with little fanfare and was actually experiencing very little pain. I was still pretty knocked out most of the day (unfortunate, given it was my son’s birthday).
Fun fact: The less than 24 hours I spent in the hospital ran up about a $75,000 insurance bill (the bulk of that was, of course, the antivenom). And yes, insurance covered all but the copay.
Day 3: Aug. 24
Surprisingly, the whole thing still really doesn’t hurt as much as you’d think. The pain meds didn’t seem to do anything, so I stopped taking them. It’s tender, but I feel good.
Day 4: Aug. 25
Day 5: Aug. 26
This was as far as I could bend the finger, in most part because of the swelling but also due to joint pain.
Day 6: Aug. 27
Day 7: Aug. 28
Still working on bending the finger all the way. The underside almost looks bruised — when you run your finger down it, the skin looks yellow, like an old bruise. The blister continues to diffuse, but it doesn’t get any flatter. Is it supposed to? I don’t know. The joints hurt a little, but not too bad.
Day 14: Sept. 4
I was starting to get a little freaked out because the main blister was still the same size, but the edges seemed to be expanding slowly (I diagnosed myself with a hemorrhagic bulla, which Dr. Greene later confirmed). It was impossible to find any information online about this, which is one reason I started to document my bite, treatment, and healing. The swelling and redness had been constant over the past week — not better, not worse. But I had no idea if a bite was supposed to look like this or not. All the pictures I found online were of black, necrotic-looking skin. Blech.
I was heading in for a follow-up appointment with my regular doctor, but I messaged Dr. Greene to see what I could expect.
He recommended leaving the blister intact. It wasn’t filled with venom, like I feared; instead, he said it was just leaky interstitial fluid.
Day 17: Sept. 7
Day 18: Sept. 8
Day 23: Sept. 13
Day 26: Sept. 16
Eventual Outcome
It took until Sept. 15 for the blister to dry up and fall off. Much longer — maybe 2-3 months — for all the swelling to go down and for complete range of motion to return. Four-ish months later, I still have a faint scar, a great story, lots of good knowledge, and a healthy fear/respect of weeds and gardens. (Two years later, and there’s hardly a scar and certainly no lasting effects.)
I strongly encourage everyone to join this Facebook group and be mindful of the great outdoors. What you don’t see (or know) could hurt you. I remain grateful to Dr. Greene and the National Snakebite Support page for guiding me through a scary time and helping advocate for me (and telling me how to better advocate for myself). I realize that he went above and beyond to make sure things were getting done, to speak with treating physicians, and to expedite my care. I feel fortunate that he was so vested in my case. He didn’t have to be — and neither did the page admins — but I’m thankful they were.
It’s my hope that this can help someone else from being in the same situation — or at least for knowing how to get properly treated in a similar situation.
Dr. Greene’s Top Tips
Snakebites are emergencies, and snakebite patients shouldn’t be left in the waiting room. Dr. Greene believes patients should be immediately assessed and have the affected extremity elevated. If it turns out nothing is going on, patients can be moved to a lower acuity area. But assume the worst until proven otherwise.
There’s an app — Snakebite911 — that tells you who stocks CroFab, but it doesn’t tell anything about the quality of care you might receive there. Just because the hospital has it doesn’t mean they know how and when to use it. It also does not list which hospitals have antivenom. One thing Dr. Greene emphasizes is that, although he prefers one antivenom more than the other, the most important factor is having a doctor with actual snakebite expertise managing your case. Most physicians have little experience with envenomations.
Pre-Hospital Care
The most important steps following a bite are:
- Arrange to get to the correct (not necessarily the closest) hospital as quickly as possible. That may mean calling a friend or 911. Definitely call 911 for any serious symptoms. Do not drive yourself.
- Remove any constrictive clothing and jewelry
- Elevate the affected extremity (please click here to learn why we elevate). Absolutely DO NOT place the affected extremity below heart level
- Take a picture of the snake IF YOU CAN DO IT QUICKLY AND SAFELY. It is helpful but not necessary. DO NOT bring the snake, whether dead or alive.
- DO NOT do any of the following: tourniquets, lymphatic bandage, pressure immobilization, cut and suck, extraction device, electrical stimulation, packing the extremity in ice.
Please see this pre-hospital management article for additional information.
Why You Shouldn’t Bring the Snake to the Hospital
Here’s why medical professionals ask you to not bring the snake — dead or alive — to the hospital if you have been bitten.
- Bringing a live snake is obviously potentially dangerous to humans as well as the snake.
- Bringing a dead snake is also dangerous to humans. People forget that dead snakes can envenomate, typically for about 30–45 minutes after the fatal injury, but the record is approximately 8.5 hours. Don’t believe it? Check these out:
Most importantly, and this may blow some people’s minds: Medical professionals don’t actually need to know what snake is responsible for the bite! All they have to do is determine whether or not it is a pit viper envenomation, and that’s a clinical diagnosis. A physician who is knowledgeable about snakebites can easily distinguish a bite from a crotalid from a bite from a non-venomous snake. And, in regions where this is relevant, it’s also easy to distinguish a coral snake bite from a pit viper bite and from a bite from a non-venomous snake.
Once doctors determine whether or not it’s a pit viper bite, they’re good. CroFab and Anavip are both FDA-approved for all North American pit vipers (copperheads, cottonmouths, rattlesnakes) so we do not need to know the species in order to treat patients appropriately.
If you can take a picture of the snake quickly and safely, that’s great. Almost everybody has a camera phone, and it’s nice to know the species for epidemiological purposes. However, Dr. Greene emphasizes that they definitely don’t want you to delay transport or treatment trying to ID the snake. Patients are treated based on the signs and symptoms.
In-Hospital Care
- Keep the affected extremity elevated.
- Make sure they check the following laboratory tests: CBC, BMP, PT/INR, Fibrinogen, CK.
- Ask them what their indications for antivenom are, and make sure they’re consistent with what we have mentioned here.
- If you do not feel you’re getting appropriate care, advocate for yourself. Request they involve an expert. If necessary, request a transfer to a more appropriate facility.
- Do not agree to prophylactic antibiotics or prophylactic surgical intervention.
Please see this in-hospital management article for additional information.
This is the unified treatment algorithm for in-hospital management of native crotalid bites.
We know that bites have the potential to cause serious local and/or systemic toxicity. We also know that antivenom can prevent and treat local, hematologic, and systemic toxicity. We know that CroFab has an excellent safety profile, with an incidence of acute adverse reactions ranging from 1.4%-8%. For Anavip, it’s ~ 5%-15%.
Antivenom isn’t cheap, but neither is a prolonged or permanent disability. Antivenom accelerates recovery in a clinically significant way. Furthermore, not all bites that go untreated will recover fully, and the incidence of permanent disability or disfigurement increases with the severity of the bite.
Administer antivenom for any of the following:
- Significant or progressive local tissue damage e.g., tenderness, swelling, hemorrhagic bleb
- Hematologic toxicity (e.g., PT > 15 s, fibrinogen < 150 mg/dL, platelets < 150K/µL)
- Systemic toxicity (e.g., hypotension, airway swelling, neurological toxicity)
Most physicians recognize the need to treat when there is systemic or hematologic toxicity. A common pitfall is to fail to treat the local findings. If the swelling and tenderness are more than minimal and have extended beyond a major joint (e.g. wrist, ankle), antivenom is warranted. If there’s significant local tissue injury (e.g., necrosis), antivenom is also indicated, even if the swelling hasn’t progressed across a joint. Antivenom is most effective when given early, and the previous approach of waiting for the damage to cross two joints should be abandoned.
Although every medication has the potential to cause an adverse reaction, CroFab has an excellent safety profile. In a large meta-analysis, the incidence of acute adverse reactions to CroFab was estimated at 8% (Schaeffer et al.). A study using data from the North American Snakebite Registry found the incidence of acute adverse reactions to be ~2.3% (Kleinschmidt et al.). Authors from the Arizona Poison and Drug Information Center calculated the incidence of acute adverse reactions to be approximately 1.4%, and nobody in this relatively large study required antivenom discontinuation (Khobrani et al).
There are certain conditions (e.g., latex allergy) that may predispose to an adverse reaction, but there’s no absolute contraindication to antivenom. If somebody’s envenomation warrants treatment, you treat with antivenom. You can always run an epinephrine infusion simultaneously, or at least have it readily available.
The cited articles can be found in the National Snakebite Support files section, and you can see the abstracts here:
It’s a misconception that, once you receive antivenom, you can never be treated with it again. That was kinda, sorta true with the antivenom used before 2000, because the incidence of side effects was so high. CroFab has a much better safety profile, and many snakebite physicians have treated dozens of patients multiple times with CroFab.
There’s a great case report by Dr. Eric Lavonas (author of the unified treatment algorithm) of someone who was treated with CroFab at least 19 times.
Four Birds 