Tips from a medical toxinologist, for U.S. venomous animal enthusiasts who are choosing a doctor

If you have just been bitten, call 911 and accept what is offered. It is too late to read this page. I hope you have the right antivenom with you.

Your best possible venom doctor is a physician who has admitting privileges at a hospital near you, has a passion for toxinology, has years of experience treating bites and stings, has participated in research, does not mind getting calls at all hours, and has a personality that works well with your own. This is hardly ever possible. Please don’t blame the docs who have only some of these characteristics for falling short –we are human, too.

If you need to compromise, look for a doctor near you who is willing to take some time to learn and prepare. Nearness and willingness are more important than experience, because a good doc will understand how to use long-distance consultants.

Here are ways to find a willing nearby doctor:

a. Attend meetings of your local reptile and arthropod groups. Check the membership roster for MDs and DOs. Talk with them. If there aren’t any, invite some to be speakers.

b. Level with your primary care doc about your situation. Ask who they think is good for this purpose.

c. Make an appointment with a doctor who does Medical Toxicology or Occupational Health. Yes, pay for the consultation, even if insurance does not cover it – you are asking for a lot of work from this person. (Beware: the word “toxicologist” means a lot of different things. You are looking for a MEDICAL toxicologist, preferably board certified. The American College of Medical Toxicologists has a list.)

d. Find out whether your local zoo or aquarium has an occupational health contract at a local clinic. Try them.

e. Get copies of peer-reviewed clinical trials publications related to antivenom in this country, and read the author lists. In the full version (not the abstract) you can see the authors’ affiliations. Scan for institutions in your city. Send an email message saying that you appreciated the publication and need advice choosing a doc.

Do not oversimplify. You are NOT looking for a gung-ho “snakes are cool” emergency contact who says he’d love a call if you are bitten but who will not do his homework. You are looking for someone who is unintimidated by the words “investigational drug” and “FDA” and “medical literature.” Someone who hopes never to get that emergency call, but who will work ANYWAY.

Have some humility. It is easy, after reading a bunch of tweets and Facebook posts, to claim that most doctors are stupid and that your buddy and you know more than we do. Okay, maybe you do, but maybe not – most medical school graduates know a lot of stuff. And you know what? Doctors are willing to resuscitate a bully who has an emergency, because it is the ethical thing to do. But we are NOT likely to go that extra mile researching something that requires committee routings and expert opinion, as a favor to someone whose opening line is “I hope you’re smarter than those guys that don’t know poison from venom.” Don’t tell the doc “this is the medical protocol” if you want them to sign off as a responsible consultant. Offer what you have as a draft, talk, let the doc take the time to call an expert, edit.

Make your doc’s job easier. This is YOUR special risk, so unless you are wealthy you should do some research yourself. Provide copies(paper and/or electronic) of selected papers that represent the very best you can find. If it is true, then admit that you do not know how to search the medical literature; but bring something good with you – a review paper, a clinical trial of the antivenom you plan to use, an authoritative summary of the species you are talking about, a sample protocol. Make a list of the top experts whose names are on the clinical trials that interest you, together with their institutional affiliation and contact information if you can find it. In a long author list,the most important ones for this purpose are the first one (“first author”),sometimes the last one (“senior author”), and sometimes one listed as“corresponding author.” These are experts that your doc can contact for advice.

(an aside: I am one of those experts. I’m always honored to receive calls from doctors in this situation as well as in emergencies. It is MUCH MUCH BETTER FOR YOU to have your doc contact me, rather than the other way around.)

Make your own job easier: team up with others.The herp society, the reptile park, the zoo, whoever. If you pool resources, it will be easier to pay for everything, plus you’ll have more credibility, plus you can maybe attract the doc with things like a family pass, a field trip, or a behind-the-scenes tour. We venom docs really love being invited to see what at-risk people do. Personally, I do a lot of “free” consultations in exchange for this kind of thing.

Once you know who your doctor is, follow-up. Between you, you’ll need to agree on protocols, and whether they need to be routed in advance to hospital committees. You’ll need to figure out who should keep how much of which antivenoms, and how to pay for them. If there is an IND involved, you need the doctor’s name officially listed as well as the sponsoring organization. The doc will need lists of every type of animal you’re dealing with, and you’ll need night and weekend contact information including for when the doc signs out to partners. In case you ever show up unconscious at the Emergency Room, you’ll want the people there to find that contact information on the TOP of whatever else they see.

Cheers, and be safe.

Leslie Boyer, MD