In the February issue of Emergency Physicians Monthly the following reader case file was posed to the group and the question asked how would you respond? What would be your solution? The following is how the case was resolved at the time as well followed by the reader suggestions and comments.
Reader Case File originally printed in February 2011
It was a surprisingly quiet early May morning in a Midwest emergency department. I was partway through a coffee and enjoying the pace of the morning when the dreaded squad phone rang. We all got a quick chuckle as the nurse noted a local squad bringing in a 16-year-old male with a turtle bite; most of us thought a small pet turtle had snapped at him. Two minutes later, the squad called back and asked that med command approve Morphine for the patient. As it turned out, what was missed with the first call was that it was about a 25-30 pound snapping turtle, and the turtle was still on the patient’s face. The emergency department staff then became very busy as everyone tried to prepare for what we might see roll through the ambulance bay doors.
The staff and I had gathered several potentially useful instruments in preparation for the patient’s arrival including umbrella handles, tool box with pliers, a large cardboard box, orthopedic room cast spreaders and other potentially useful devices.
The doors opened and in rolled a-16-year old male holding a large local snapping turtle against his chest as the turtle clenched down with its jaws on the right side of the patient’s face. The turtle’s front claws were against, but not yet scratching, the patient’s anterior neck. Fortunate for the patient and the staff, the patient was surprisingly cooperative and unshaken by his situation. Staring at this scene amidst a slew of nurses and staff, the question was posed to me, “What do we do now?”
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My training was actually at the same facility, and by my accounts was very good training. I had been practicing several years and felt comfortable in most scenarios; however, this is one I can honestly say I had never seen before. While not life threatening by any means at this point, this turtle could potentially cause a lot of pain and trauma to a young man’s face. My training and practice, like most others in emergency medicine, has taught me to be able to think outside of the box. This training fit well in the case that faced me now as I tried to get a turtle off of my patient’s face without causing harm to the young man.
As the patient was calm and cooperative, the first thing we did was to put cardboard between the front claws and the patients neck as the claws were lying over his external jugular veins. Once the neck was protected, attention was turned to removing the turtles clench from the patients face. The turtle had part of the patients’ lower lip and cheek well inside its mouth. With any attempt to open the turtle’s mouth it bit down tighter and retracted further into its shell pulling the patients lip and face with it. While still calm, tears started to come down the patient’s face.
I decided to sedate the turtle, but had to figure out with what I would accomplish this task. The patient had an IV established, but not the turtle, and the nurses were not overly confident they could get one in the large reptile. The first order, Succinylcholine 100mg IM, to the turtle was injected in its left posterior thigh. I wasn’t sure on how to dose an IM injection on a turtle, so I did what most would do; I guessed and tried to miss on the high side. After a few minutes the turtle’s condition really hadn’t changed and it still bit down hard. I then ordered Versed 20mg IM. This was given by me into the turtle’s right lateral neck, hoping to hit a larger vessel. However as the turtle twitched and bit when the needle entered the skin, the injection turned into a deep IM injection.
A minute later, the turtle was visibly relaxed and I was able to insert cast spreaders into its mouth and spread the jaws apart and pulled the turtle off of the patient’s face. A nurse took the turtle and placed it in a large cardboard box. The box and turtle were then safely removed from the emergency department via the ambulance bay and away from other patients.
After all of this, the patient’s wounds consisted of superficial lacerations and abrasions that did not require closure. His Tetanus was updated, and he was started on Keflex and Bactrim. The patient was calm and understanding through the whole process which made our jobs easier. He was then referred for follow up to have his wounds re-evaluated.
An online review showed a scarcity of information related to turtle bites presenting to the emergency department this way. The review did show that common sedation techniques for turtles include IM injections of Ketamine 20-40 mg/kg, Midazolam 2 mg/kg and Medetomidine micrograms/kg. Also noted were IV medications including Ketamine 5 mg/kg, Medetomidine 50 micrograms/kg and Propofol 5-10 mg/kg.
While not the life-saving treatment of an MI or major trauma, this was an exciting case that brought the department together and put a smile on everyone’s faces for the remainder of the day. We had to think outside of the box as despite my several years of practice and an emergency department staffed with well experienced nurses, none of us had seen this before. I think that we will always remember this case, and can now claim the ability to take a large snapping turtle off of a patients face.
I would like to give a special thanks to the staff in the emergency department present that day as well as the crew of the ambulance service that brought the patient to us. Everyone worked hard to treat this patient appropriately.
Reference:
- Journal of the American Veterinary Medical Association. October 1, 2002, Vol. 221, No. 7, Pages 1019-1025 doi: 10.2460/javma.2002.221.1019
- Journal of Zoo and Wildlife Medicine 23(2): 201-204, 1992
- Merck Veterinary Manual
Reader Responses
>>Sever the turtles neck and I guarantee that you will be able to release it from the face! Then, irrigate the wounds and if cosmetically needed, repair them, update tetanus and cover for reptile related diseases with Doxycycline or Cipro and discharge the patient!
>>This would require some MacGuyvering, but I think that the corner of some cast spreaders would fit between the turtle’s jaws. Either that or slip one end of a Kelly clamp between the jaws and bend backward. Perhaps use a syringe to squirt something nasty tasting into the turtle’s mouth?
>>I would try to get as much as I could between the turtle and the patient to protect from further injury. At that point, with an adequate amount of padding, I’d consider injecting a massive dose of an IM paralytic into the turtle.
>>I would apply ice packs to the turtle . . . cool it down, then it should relax and let go. No need to harm it.
>>My first thought was to cover the turtle’s nostrils, but then I remembered that they can stay submerged under water for very long periods of time.
>>Well known in southern lore is the fact that snapping turtles don’t let go till it thunders!
>>Having caught several of these fishing, I agree with the tenacity and toughness of these critters, who can survive just about anything. Decapitation would be the fastest way to relieve the patient, but requires large instruments. Cutting its throat and allowing it to exsanguinate into a basin would work, eventually. Those who think they can open those jaws with a Kelly should think again!
2 Comments
I would ask the turtle what part of town he was from. Then I would give it some Dilaudid, because it’s allergic to Toradol and that’s probably what it came in for anyway
Not that this will necessarily happen again, but it would have been a much better idea to call a vet about sedating the turtle. They would have explained why your rear limb injection did not do much good: reptiles have a renal portal system. This means that anything injected into the caudal part of the body is run through the kidneys first for detoxification. This is not quite as important with things like are filtered through the liver, but still will be helpful.
The ketamine/midazolam combo has been my friend with reptiles in the past.