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Greetings to each of you from Kenya. I trust that you are all well and I could not resist the opportunity to tell you about just another case at Kijabe. For those of you who have not been to Kijabe this case may seem just too difficult to believe but those of you who know this situation, it is just another case to talk over at "Chai Time".

Three days ago a 25yo Masaii man from the Rift Valley arrived 8 hours after being bitten by a snake around 3am while he was checking on his goats. He returned to his boma(house) after killing the snake and waited until sunrise to visit the local herbalist. He then visited a dispensary (one-roomed dwelling where a nurse practices) and received a shot prior to being sent to Kijabe. He arrived 8 hours after the bite and we discovered that he was bitten by a puff adder. His arm was pulseless with compartment syndrome and normal vital signs, even though his hematocrit was 18. Upon induction then maintenance with halothane, he was hypotensive to 50 systolic with ventricular dysrhythmias. During the debridement, he was hypotensive and demonstrated signs of DIC. He stabilized. Upon further investigation, I discovered that the entire country has enough anti-venom to treat one patient and we would not be able to get this dose. We had an equally urgent problem because he was bleeding and we had no blood in the hospital for this man. Just as the surgeons do in the states, all of the physicians involved trotted to the blood bank for their free coke. We stabilized him with three units of fresh blood from the infectious disease guy, surgeon and anesthesiologist. The next day we returned for further surgery and we discovered that our one dose of propofol (recently donated) prompted SVT (resolved quickly) and then cardiac depression for about one hour. We are slowly learning about puff adder cardiac and heme toxicity. I decided to place a pulmonary artery catheter, but could not find the ICU nurse! We may amputate tomorrow. I would like to know which is the best block for puff adder bites.

Any suggestions? David (Brown), I did not find it in your book.

Have a great day.
Mark, for the family and the Masaii guy

Mark W. Newton, MD