Expertise, caring cooperation and 17 vials of antivenom save plucky six-year-old
Few six-year-olds have had as eventful a start to 2018 as Mikayla Grove, who was bitten by one of Africa’s most dangerous snakes, a Mozambique spitting cobra, which found its way onto her bed while she was sleeping. However, within three weeks of being admitted to Netcare Alberlito Hospital in Ballito in a critical condition, the plucky young girl had recovered to the extent that she was discharged from hospital and was well enough to attend her first day of primary school.
“It was a warm Sunday evening in mid-January when my wife, Inge, and I had put the children to bed when suddenly, around 8pm, we heard a scream coming from the bedroom shared by our daughters,” says Mikayla’s father, Ludwig Grove.
Presuming that one of their daughters was having a nightmare, Inge went to investigate but did not switch on the light. As she bent over Mikayla’s bed, however, she heard a loud hissing noise before the Mozambique spitting cobra, which she could not see in the dark, sprayed a stream of venom into her eyes.
“My wife grabbed Mikayla and rushed to the bathroom next to the girls’ bedroom. Mikayla’s big sister Bella got out of bed and switched on the light just as I came to the room and saw the snake lying on Mikayla’s pillow. Thank goodness they all made it out of the room without more attacks by the snake.”
While Inge started washing the venom out of her eyes, Ludwig noticed two small spots of blood on Mikayla’s left cheek and realised that she had been bitten.
“We bundled the kids into the car and took a bottle of water with us so that my wife could continue washing her eyes, as the snake’s venom can cause blindness if it is not quickly and thoroughly rinsed out of the eyes.”
He immediately phoned one of the family’s close friends, a neonatal nurse at Netcare Alberlito Hospital, and asked that she alert the emergency department that they were en route and to explain the nature of the emergency.
When the family arrived at Netcare Alberlito Hospital, a team from the emergency department were ready and waiting for Mikayla. “We were extremely fortunate, as there was a highly experienced medical team ready to initiate treatment immediately. Anaesthetist, Dr Ian Lander, was outstanding, and he had already contacted Dr Bianca Visser, who has vast expertise in the treatment of snake bites.”
Dr Visser, who is the principal clinical manager of Netcare uMhlanga Hospital’s emergency department and a locum doctor for Netcare Alberlito Hospital’s emergency department, was off duty when she received the call and immediately rushed to join the team treating Mikayla.
”Treating a venomous snakebite is highly complex. On my way, I phoned ahead to instruct the treating doctor to start preparing everything we would need, as a Mozambique spitting cobra bite to the face is almost always critical. I have lots of experience administering antivenom, as I previously worked at Ngwelezane Hospital near Empangeni, where we sometimes treated up to 10 snakebites a day in peak season. In contrast, here we generally see only five to 10 snakebites over the whole season.”
“Mikayla’s condition was initially critical. She was agitated, vomiting, her face was swollen and there was imminent risk of her airway becoming obstructed. Mikayla was intubated and her airway was secured while the emergency department team started premedication with steroids and adrenaline to prepare her body to receive the antivenom. Mikayla received five vials of antivenom with no anaphylactic reaction, and then we administered another five vials,” Dr Visser explains.
“Thankfully, this stopped the swelling and Mikayla remained stable although she had to be monitored continuously. She was admitted to the intensive care unit [ICU], where she received seven more vials of antivenom overnight.”
The ICU medical team, comprising Dr Lander and paediatrician, Dr Kamendran Pather, made integral decisions that helped to stabilise Mikayla’s critical condition and manage the harmful consequences of the venom and infection that ensued. Dr Pather reiterated that the combined efforts of the diligent nursing staff and the allied disciplines, such as the dieticians and the physiotherapist, contributed greatly to steering Mikayla on the road to recovery.
According to Dr Visser, the effects of Mozambique spitting cobra venom are mostly cytotoxic, meaning that it causes damage to soft tissue including swelling and necrosis (causing cell death), however it can also result in some autonomic neurotoxic symptoms including vomiting, agitation, blurred vision and salivation.
“If someone is bitten by a snake it is imperative that they receive appropriate treatment as soon as possible. We do not need to identify the snake to be able to manage a patient appropriately therefore people do not need to chase the snake, trying to catch or kill it before seeking emergency care,” Dr Visser adds.
Four days later, Mikayla was transferred to the paediatric ward of the hospital under the care of paediatrician, Dr Kamendran Pather. Plastic and reconstructive surgeon, Dr Trishan Pillay, was consulted and found that there were still indications of infection in the soft tissue of her face and neck.
“We found that in addition to the loss of skin on her cheek where she was bitten, the venom had caused infection beneath the skin, extending under her chin, around her neck and onto one of her shoulders,” Dr Pillay explains.
“We had to take Mikayla to theatre four times in six days to clean out the infection, and by the sixth day the infection was under control. There had been significant loss of fatty tissue, however, and a hole remained in her cheek.
“We created a small tissue flap from under her chin to close the skin, and removed the surgical drain that had been put in place to help clear the affected area. A few days after Mikayla’s discharge from hospital I saw her for a follow-up appointment and she is doing extremely well and greeted me with a big smile. In a few months’ time we will need to transfer some fat to replace the lost fatty tissue, which gives structure and volume to the face.”
Mikayla’s parents paid tribute to all the doctors and nurses at Netcare Alberlito Hospital for their efforts in saving Mikayla’s life and securing her rapid recovery. The doctors and staff, in turn, expressed their appreciation for the support and trust the Groves placed in them, as well as for letting them know of her excellent progress since her discharge from hospital.
“Mikayla was very excited to attend her first day of primary school, or ‘big school’ as she calls it, the week after her discharge. We have spoken to her about her experience and I think she understands what she has been through. Mikayla was glad to hear that the snake that bit her was not killed but was released back into the wild. She even decided to name the snake, and called it ‘Pearl’,” Ludwig concluded.