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Do you actually KNOW any nurses, or are you just talking out your ass?

I am not military at all (although... in another life) I only know what I have seen on documentaries, and discussions with soldiers. So my question is: Should'nt you get used too it?

For coral snakes native to the US it's "red on black, venom lack..." There are coral snake species from central and south America that do not follow this pattern. It's a misnomer that there is no available antivenom - the FDA extended the expiration date on the remaining stock until the fall of this year and there is available supply. Without antivenom, a severely envemomated patient might need prolonged ventilatory support. I caught this thread very late and am glad that the original poster did not have any problems, but I thought I'd comment about some of the practices some of the respondents seem to be supporting for bites by pit vipers (subfamily Crotalinae), which includes rattlesnakes, copperheads, and water moccasins. Tcripp, you asked about "what to expect" - it depends on the species, location of bite, patient comorbidities, and other factors. Many patients early on will have pain and local tissue swelling. Some develop signs and symptoms of systemic toxicity (e.g. nausea, parasthesias, etc) early on. Shock is usually from third spacing of platelets and plasma volume. Very rarely, someone who has been sensitized to proteins in the venom (e.g. someone who has handled snakes or venom or been previously bitten) may have a true anaphylactic reaction. We sometimes see anaphylactoid reactions with rapid onset shock and airway edema. Many patients develop coagulopathy, which can range from isolated thrombocytopenia or a syndrome of defibrination or a combination of the two that is DIC-like. Neurotropic findings, which can include neuromuscular blockade, can occur after bite by several species of rattlesnake, not just Mohave rattlesnakes. In terms of first aid, do not apply tourniquets or lympathic constricting bands, or ice packs. Maintain the bite in a neutral position (some medical toxicologists think elevation is reasonable - others thing neutral until antivenom is started and then elevate. Do not apply any kind of suction. If a tourniquet, pressure bandage, or constricting band has been applied, do not remove it in the field. In general, when this is done, we get big lines in the patient, give them volume, and start antivenom before releasing this. At least one IV should be started. Give fluids for hypoperfusion (obviously), but patients with intact perfusion and extremity swelling also need fluid boluses. Extremity swelling early after a bite is usually from the effect of polypeptides in the venom, and these cause tiny cracks in vessels that are large enough to allow platelets to leak out, but not large enough for red cells to leak out. This third spacing can be significant very early and cause significant hypovolemia and hemoconcentration. Very often, we see patients with rattlesnake bites who don't get enough IV fluid in the field. Give antiemetics for nausea, and treat pain (if you have fentanyl, I think it's preferred over morphine as the histamine release from the morphine can cloud close monitoring for development of allergic response to antivenom). The destination hospital may not necessarily be the closest hospital, or even the closest hospital with antivenom, but this would obviously be region-specific. I have seen horrible outcomes when patients are taken to hospitals where arrogant physicians refuse to consult a toxicologist - we've seen patients diagnosed with compartment syndrome who get unnecessary fasciotomy and even amputations that were likely totally unnecessary. Where I work most hospitals have antivenom but we have centers available to us that have onsite toxicologsist and very large supplies of antivenom and we fly our patients to these centers. The 2010 guidelines from AHA and ARC actually mention snakebite first aid, and they advocate using a pressure immobilization bandage for Crotalid envenomations. This recommendation is based on no evidence of any quality - in fact, one of the studies they cite as supporting the practice actually demonstrated worse limb outcomes when pressure bandages were applied (in a pig model). This practice turns what is very rarely a life threatening event into a limb-threatening one. This should be addressed locally, and hopefully administrators and medical directors will consult a medical toxicologist with snakebite expertise when establishing local or regional protocols. Pressure bandages seem reasonable for eastern and texas coral snake bites, and are standard for bites by neurotoxic snakes that cause rapid development of symptoms in Australia, but they will likely worsen injury when applied to victims of Crotalid snakebite. Finally, you can not diagnose a dry bite (fang puncture mark without envenomation) in the field. This requires observation for at least 8 hours (and labs). Especially after Mohave Rattlesnake bite, patient can have a life-threatening, potentially fatal envenomation event with minimal local tissue injury, sometimes without significant pain. Patients with probable Mohave bites are admitted and watched for 24 hours at the tertiary center we work with.

I'm sick of all these m f'n snakes on this m f'n forum!

I don't see a need for either medical control or my supervisor in this situation, as it truly is relatively straight forward if you've been taught critical thinking skills. I think that this thread is an awesome idea. As I've said many times in the past, I believe the vast majority of my most difficult decisions have been moral/ethical, not medical. And I don't think that I see a lot of this being taught, and very seldom see it practiced. I think we need a forum just for moral/ethical scenarios. When I state that the above scenario is relatively straight forward what I mean is that if I begin at the beginning, the fact that I am there not to cover my ass, but to be a patient advocate, then forcing this woman out of her house if she's mentating properly is going to be so far down on my list of possible options that it's unlikely that I will ever get there. She has a support system in place and is healthy enough to choose to rely on it instead of going to the hospital. Educate her and the neighbor to watch the bruises as they can become a significant health risk in a pt of this age, help her to the bathroom, get her comfy, make sure her telephone is within reach, remind her that I would like nothing more than to come over and help again if she needs it, and then document the shit out the call in case something goes sideways. Easy, right? I'm not sure at what point MC or a supervisor would have become useful unless I believed her to be significantly damaged and I couldn't change her mind about transport. Great thread. It would be fun if everyone posted their 'weird' calls, right? So we can flex our brains a little bit down this logic path. Dwayne

Read up on brain injury from ground level falls for the elderly before you leave another at home.

Lets all cry for the Nurses, I seriously doubt any of them are breaking a sweat at work, despite having more patients to care for, and I doubt they have substandard wages. Most nurses no longer have to draw up meds (the pharmacy does that), most charting is electronic, and they have aides to do the butt whiping. I agree that if you have a company that is abusing its employees, then unionize, but most of the bitching from people today is because they had a few perks removed, because the company is trying to stay profitable. If you have not realize how this economy has hurt collections for any healthcare provider, then I suggest you spend some time with someone in billing.