At Temple Health, we’re used to extraordinary cases, but a patient who’s been bitten by one of the world’s deadliest snakes is something even we don’t see every day. But that was exactly who arrived in the TUH-Main Campus Emergency Department this past November. The patient was the owner of a monocled cobra, who had been bitten while trying to help his snake shed its skin.
“He said, ‘I came here because I didn’t want to die,’” remembers Derek L. Isenberg, MD, Professor of Emergency Medicine at the Lewis Katz School of Medicine, who treated the patient when he arrived. “I called my toxicologist colleague, Dr. Murphy, who told me that the monocled cobra was one of the most dangerous venomous snakes on Earth, and that it’s been responsible for numerous deaths.”
Lauren T. Murphy, MD, Assistant Professor of Clinical Emergency Medicine and Medical Toxicology, wasn’t working that day, but she was more than happy to assist with the once-in-a-lifetime case. “My training means I’m able to treat exotic snake bites and know what resources to use, even if I’ve never worked with the snake before,” Dr. Murphy explains. “I remembered from my fellowship that the monocled cobra is incredibly rare, and that it’s one of the world’s deadliest cobras. I knew we had to get all the right resources in place, which meant ensuring our Poison Center was leading the case and searching the US for the antivenom.”
Finding the right antivenom—which would save the patient’s life—meant locating the nearest zoo with a snake whose venom is similar to the monocled cobra’s. All zoos with a venomous snake are required to keep that snake’s antivenom on hand; the snake’s location is then entered into a national database that providers treating snakebite victims can access.
Unfortunately, the Philadelphia Zoo no longer has venomous snakes. But the Bronx Zoo does—and the antivenom for their king cobra can also be used to treat monocled cobra bites. The TUH-Main Campus team made contact with the Bronx Zoo-affiliated Jacobi Medical Center, and physicians there agreed to provide us with the antivenom. Now, the only issue was figuring out how to get it from New York City to Philadelphia—and fast.
Getting Down to the Wire
Fortunately, the Temple Transport Team (T3) specializes in lifesaving missions done in the nick of time. “I called up T3, and they let us know that they could fly a helicopter to the Bronx, pick up the antivenom, and fly back to Main Campus in about two to two and a half hours,” Dr. Isenberg says.
That turned out to be necessary, because the patient’s condition—which had seemed stable when the helicopter took off—quickly began to deteriorate. “When I arrived, the helicopter had left the Bronx Zoo, and was about 45 minutes from Temple,” says Brendan Hart, MD, PhD, Assistant Professor of Clinical Emergency Medicine, who took over the patient’s care once Dr. Isenberg’s shift had ended. “The patient seemed a little sleepy, but we weren’t sure if that was due to the pain medicine he had just taken. We got a baseline reading of how he was doing, then continued to reassess him.
“If the pain medicine was making him tired, then he should’ve started improving, but it pretty quickly became clear that he was getting worse. He stopped being able to open either of his eyelids, and his speech became garbled. The snake specialist at Jacobi Medical Center let us know that this was almost certainly due to the neurotoxic venom, which affects the central nervous system and could lead to progressive paralysis that would eventually prevent him from being able to speak, and perhaps from being able to breathe on his own. If that happened, we should place him on a breathing tube to ensure he didn’t have a period when he wasn’t getting enough oxygen.
“The snake specialist had told us that, if we could hold off on intubating or placing a breathing tube, that would be ideal,” Hart continues. “We were telling the family that it looked like we were going to have to place a breathing tube in the next five minutes or so—but then, the antivenom arrived at Temple.
“T3 came down in their maroon jumpsuits with a big cooler,” Dr. Hart remembers. “At that point, we had decided that the patient was in the more severe range, so he needed all 10 vials of antivenom. Dr. Isenberg had already engaged Pharmacy, and they had done their research and were waiting at the bedside to reconstitute the antivenom and put in an IV infusion. We went slowly at first to ensure he didn’t have an allergic reaction, but within 15 minutes, there was a noticeable improvement in the patient’s speech, and within 30 minutes, he could open his eyes a bit. We decided that we could avoid intubating him and could complete the entire infusion, which took about two hours. By the end, he could open his eyes completely, and he was speaking fluently. His neurologic status had returned completely to baseline, which was really remarkable.”
A True Team Effort
While the case itself was exceptional (no one at Temple had ever seen a monocled cobra bite before), what’s even more remarkable is the level of collaboration required to save this patient’s life.
“There were so many moving parts in this case, and if any of them had been delayed or gone wrong, it all would have turned out differently,” Dr. Hart says. “We had to coordinate with T3, Nursing, Pharmacy, critical care physicians, the patient’s family, Poison Control, Jacobi Medical Center, and the Bronx Zoo. The two residents who worked on the case, Erika Tretner, MD and Zack Hintze, MD, were both instrumental in the patient’s care. Everyone came together to help the patient, and it was one of those moments that really makes you marvel at the power of modern medicine when it’s at its best.”
Dr. Murphy, the toxicologist, agrees. “I think everyone involved judged the case perfectly,” she says. “It really couldn’t have gone better. It was a confluence of experts that made it a success: everyone worked together seamlessly. That’s why it matters that this is an academic medical center: because in these extraordinary situations, we have these experts readily available to team up. And it really was teamwork that saved the patient.”
