Snakebite at a remote camp: first aid and the choice of hospital
At 19:20 on 12 August a 34-year-old daily-wage watcher is bitten on the right ankle while stacking firewood at the compartment camp, 26 km from the nearest Primary Health Centre and 46 km from the Community Health Centre where polyvalent anti-snake venom is stocked. He describes a dark, roughly one-metre snake that moved away fast; he did not see it clearly and nobody killed it. There are two puncture marks about 8 mm apart with oozing blood, the ankle is swelling and painful, and he is alert with normal breathing and no drooping eyelids. It is dark, the camp has one torch, a jeep with half a tank of diesel and no mobile signal. The 108 ambulance can be called only from a ridge 1.5 km away and would take about 55 minutes to reach the camp. The direct road to the CHC is open, while the road to the PHC has a culvert under repair that adds about 25 minutes. Another watcher can drive.
1. What do you do in the first ten minutes, and what must you specifically not do? Give the reason for each action.
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Do.
- Reassure him and keep him lying still. Exertion and panic speed up lymphatic circulation and venom spread.
- Remove the anklet, shoe, ring or any tight item from the limb now, before swelling makes removal impossible.
- Immobilise the leg with a splint - a stick and cloth will do - and keep the limb at about heart level, not raised above it.
- Wipe the wound gently, cover with a clean dry dressing, and note the exact bite time on his hand or in the diary.
- Allow small sips of water. Nothing else by mouth.
Do not.
- No tourniquet, no tight ligature. It causes gangrene and, when released, a sudden venom surge.
- No incision, no suction, no snake-stone, no kerosene or herbal application.
- No ice or cold packs.
- No aspirin or painkillers that thin blood; paracetamol is what a health worker would give.
- Do not raise the limb high and do not let him walk.
- Do not send anyone chasing or digging for the snake in the dark. A second bite is the classic way a rescue becomes two casualties.
On the pressure bandage. A firm pressure-immobilisation bandage is recommended for elapid (neurotoxic) bites but is not advised for viper bites. With local swelling, oozing puncture wounds and no ptosis, this looks more like a viper bite and the species is unconfirmed, so a tight bandage is withheld; splinting and stillness achieve most of the same benefit safely.
2. Which facility do you drive to, and do you send someone to the ridge for the ambulance? Reason it out.
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Go direct to the CHC.
The decisive question is not which hospital is nearer but which one has the definitive treatment. The PHC has no anti-snake venom; arriving there at about 1 hour 15 minutes, finding no ASV, and then driving on to the CHC wastes both time and the patient's remaining reserve. The direct CHC road is open and takes roughly 1 hour 40 minutes; that is where venom, a doctor and monitoring exist.
But set a decision point. If on the way he develops drooping eyelids, difficulty in swallowing, slurred speech, weakness or breathlessness, that is neurotoxicity and his airway is at risk. Then divert to the nearer PHC for oxygen, airway support and immediate referral - a dead patient on the road to the right hospital is no victory. Brief the driver on this rule before starting.
Yes, send one person to the ridge, but not the driver. The call does two things: it starts the 108 ambulance, which can be directed to meet the jeep at a named point on the main road, and it tells the CHC to keep ASV ready and to inform the duty doctor. Meanwhile the jeep does not wait for the ambulance - it moves.
Do not split the party to the point of risk. One person goes to the ridge, the rest travel with the patient; no one is left alone in the forest at night without a torch and a known route.
3. What do you monitor during the journey and what must you hand over at the hospital?
Read the worked answer
Monitor and record, with times.
- Breathing rate, pulse and level of consciousness every 10 to 15 minutes; note any change, not just the value.
- Eyelid droop, ability to swallow saliva, speech and limb power - the earliest signs of neurotoxicity.
- Swelling: mark the leading edge on the skin with a pen and write the time beside it. This single measure tells the doctor how fast the venom is acting.
- Bleeding from the gums, nose or wound, and any blood in urine - signs of a vasculotoxic bite.
- Urine output and colour.
Handover, in this order. Time of bite; time of arrival; what the snake looked like and that it was not killed; that no tourniquet, incision or suction was used; what was given by mouth; the splint and limb position; the swelling marks and times; and the drugs already taken, if any. Hand over the written slip, not just a spoken account, and keep a copy for the beat diary.
Afterwards. Record the incident in the camp register, report it to the Range Officer, and raise the two preventive points that this case exposes: a working torch and a mobile signal point at every camp, and boots and a stick for anyone stacking firewood after dark.