I WAS talking to an emergency medicine colleague recently about whether antivenoms should be used in rural Australian hospitals and medical centres, or if it was better to transfer the patient by road or air to a regional or metropolitan hospital.
He said that since most small rural health facilities don’t have pathology services or intensive care wards where patients can be closely monitored and, if necessary, maintained on life support, wasn’t it better to move the patient to a larger centre that had all the bells and whistles? And, if that is the case, then surely there is no need to keep supplies of antivenom in rural areas?
His argument seems sound, and is certainly supported by a “Clinical focus” article published in the MJA, which said snakebite patients in Australia must all be treated in hospitals with onsite laboratories, antivenom and doctors who can treat anaphylaxis.
My friend makes another good point — snakebite is rare, and not all cases involve envenomation. So, most rural health professionals don’t have the experience needed to manage snakebites well.
But are these arguments really in the best interests of the patient?
Snakebite is a time-critical medical emergency and the earliest possible commencement of antivenom immunotherapy can be critically important when clinically significant envenomation is present. Surely delaying administration while a patient is transferred to another hospital must be counter-productive, especially if it places them at risk of haemorrhage or severe paralysis?
It can also be costly. With rotary-wing retrievals costing more than $5000/engine hour plus crewing costs, and fixed-wing retrievals costing $2400/engine hour plus crewing costs and land transport costs, transferring every snakebite patient to a major hospital for assessment and treatment comes at a price.
Shouldn’t we look outside our own experience to gain other perspectives on the management of rural snakebite?
Having managed a large ongoing study of snakebite in Papua New Guinea (PNG) for the past 15 years, I have first-hand experience of the challenges across the whole spectrum of health care facilities there. And some of them are enormous.
Crumbling infrastructure, ancient or broken equipment, dysfunctional drug supply lines, demoralised and desensitised health workers and a bureaucratic system with myriad flaws all present pitfalls and barriers to effective service delivery, and particularly so for the most critically ill and unstable patients. Snakebite is a key case in point.
Our neighbour has species of brown and black snakes, taipans and death adders, and uses Australian antivenoms, although shortages are commonplace.
Remarkably though, when antivenom is available at a rural health centre in PNG, it is routinely administered by non-doctor health professionals — typically nursing officers or health extension officers who rely on a simple bedside test to detect coagulopathy, basic protocols and fundamental hands-on clinical skills.
Patients with suspected snakebite who have abnormal bleeding, or a positive 20-minute whole blood clotting test (20WBCT) result and/or any signs of cranial nerve palsy or other paralysis are treated with a single vial of antivenom as soon as possible. If necessary, patients are then moved to a referral hospital by whatever means available.
My own observations are that early antivenom administration in rural health centres in PNG helps envenomed patients more than it harms, and ultimately saves lives.
Some will criticise the use of a simple bedside test using glass tubes and a wristwatch, but base their criticism on examples where no standard protocol is in place and the test was not first validated with blood from healthy volunteers, leading to common errors. In PNG, the test has been validated for the local population and uses a standard protocol with easily obtained sterilised soda-lime penicillin vials. This simple low-tech test reliably and accurately predicts abnormal haemostasis.
But there is more to treating snakebite than performing a simple test. In PNG, a national training course in snakebite management is heavily focused on teaching practical clinical skills including history-taking, patient examination and diagnosis, airway management, antivenom administration and the treatment of antivenom reactions. Rural health workers can now quickly evaluate cases of suspected snakebite and make informed decisions about whether antivenom is indicated or not, and know how to manage reactions.
An excellent Australian course, run through the University of Adelaide by Associate Professor Julian White, is currently struggling to enrol sufficient participants. This is unfortunate and disappointing, because rural health professionals could learn a great deal from this course that would benefit victims of envenoming in rural Australia.
Isn’t it better to train and educate our rural health workforce to improve their competencies, rather than pull services and skill sets away from the bush?
My colleague, having now seen how snakebite is managed in PNG, still says that even though some states, such as Queensland, have policies for antivenom administration by remote area nurse practitioners or paramedics, the concept that snakebite can be successfully treated outside a large hospital, let alone by a non-doctor health professional, will be rejected by many of his peers.
At least he agrees that as snakebite is time critical and lives can be at stake, perhaps Australia can learn some lessons from our PNG neighbours.
Dr David Williams heads both the Australian Venom Research Unit at the University of Melbourne, Parkville, and the Charles Campbell Toxinology Centre at the University of Papua New Guinea, Port Moresby. He is currently coordinating a Phase II antivenom trial at Port Moresby General Hospital and is a passionate advocate for the need to improve snakebite treatment in the developing world.