GERM
00:00:09.440 – 00:00:12.000
Oku ke fefe hake? My name is Germ.

WORM
00:00:12.080 – 00:00:12.880
I’m Worm.

GERM
00:00:13.040 – 00:00:29.760
Welcome to episode 115 of the Germ and Worm travel health podcast, Venom! A conversation with Dr. Richard Clark about things that bite and sting. It’s a big planet. See it in good health. I’m Dr. Paul Pottinger, also called Germ.

I’m a professor of infectious diseases at the University of Washington in Seattle.

WORM
00:00:29.980 – 00:00:35.340
I’m Dr. Chris Sanford, also known as Worm Family Medicine Doctor, also at the University of Washington.

GERM
00:00:35.580 – 00:02:00.800
You know every episode of Germ and Worm is special and well, this one is no exception because Chris was recently able to sit down with a world class expert in the topic of being bitten and stung, how to prevent this and what to do if it happens. That’s Dr. Richard Clark, and together they were faculty members at a wilderness medicine conference in Big Sky, Montana.

And so he got to ask Dr. Clark all kinds of questions about nightmare scenarios with being stung and bit. Ants, scorpions, spiders, snakes, bees, you name it, anything that can stick its venom into you.

If you have questions about this, well, you may in fact get an answer in this next half hour conversation. And by the way, it’s a great conference. It’s something that we’ve been fortunate to participate in before.

If you’re wilderness medicine, curious as a physician, or just someone who wants to be savvy about taking care of yourself when you’re outside, hey, check them out. They offer all kinds of great conferences in exciting places all around the world and you can learn more. Wilderness-medicine.com. We hope you’ll check them out. Meantime, let’s see what Chris has to say in his conversation with Dr. Clark. As always, we’ll start with our medical disclaimer.

This podcast is designed to inform, inspire and entertain, but it does not establish a doctor patient relationship and therefore it should not replace your conversation with a qualified healthcare professional. Please see one before your next adventure. Chris, it’s over to you.

WORM
00:02:00.880 – 00:02:23.520
I’m here today with Dr. Richard Clark, professor of Emergency Medicine at the University of California San Diego School of Medicine, where he directs the Division of Toxicology and serves as Medical Director of the San Diego Division of the California Poison Control System. He is an authority on all creatures venomous. Dr. Clark, thanks for joining us today.

Dr. Clark
00:02:23.680 – 00:02:24.560
Thank you for having me.

WORM
00:02:24.560 – 00:02:36.780
We’re going to talk about several topics today, including venomous snakes and scorpions and ants. Let’s start off with spiders. Where in the world and where in the US do we need to worry about Venomous spider bites.

Dr. Clark
00:02:37.180 – 00:04:32.530
All spiders are venomous. And really the only ones that have fangs that are big enough to pierce human skin are the ones we have to worry about in the United States.

That mainly falls into three big subtypes of spiders. The black widows, the brown recluse type spiders and tarantulas. Those are the only ones that really cause any damage at all.

Although other spiders can bite people as well. The black widow spiders, Latrodecta spiders, are mainly a neurotoxic type of spider.

And people who get bitten by those get the release of neurotransmitters at different sites in the body. That causes them to have really bad pain syndromes. They can get other things too, like hypertension and nausea and vomiting.

But it’s really the pain that sets that bite apart from other types of spiders. They’re found throughout the United States. They come in different colors.

The main one that we all know is the black widow, which is the largest female spider that bites us in that type of genus of spider. And they have the red hourglass on them. They, their bite is painful almost immediately, like a pin prick.

So most people who get bitten by a black widow see the spider and they come in if they have a really bad pain syndrome and they’ll say, this is the spider that bit me.

If not, they have pain that usually starts at the site of the bite and then spreads throughout their body to eventually give them pain in their back and their abdomen and their entire torso could be very debilitating. Come in and they’ll need lots of different types of pain medicine.

There is a, an antivenom antidote available for black widow spiders, but it’s not available in every emergency department in the United States. And it comes with a potential risk of allergic reactions, although that’s relatively rare.

But if there is an allergic reaction to it, it can be somewhat life threatening. And there is a skin test that you can use before you give it to somebody, but in the most severe bites, that’s probably the most effective therapy.

WORM
00:04:32.610 – 00:04:35.970
Where in the US is the risk highest for black widow bites?

Dr. Clark
00:04:36.050 – 00:04:43.210
Probably in the warmest parts, the southeast and the southwestern part of the United States. That’s where they’re most common, although they are found in every state.

WORM
00:04:43.210 – 00:04:47.050
What activities would put someone at elevated risk for a spider bite?

Dr. Clark
00:04:47.130 – 00:04:57.689
The black widows are mainly found outside, so it would be working with garages or woodsheds, things like that. The brown spiders, brown ray clay spiders, are mainly found indoor.

WORM
00:04:57.689 – 00:05:08.250
And let’s talk about scorpions. Scorpions, frankly, scare the hell out of me. I’m told that the stings are incredibly painful in the world and in the US where are these a threat?

Dr. Clark
00:05:08.760 – 00:06:00.080
The main threat to scorpions as far as life threatening stings are concerned are not in the United States. They’re mainly in South America and Africa and Asia. Those are the most venomous scorpions.

There’s some in Asia that can actually cause death even with an anti venom. Androctonus type scorpions. In the United States they mainly cause pain.

Most scorpions cause localized pain at the site where you’re stung, not a systemic type reaction. There is one in the United States called Centroides that’s found in the southwest, Arizona, New Mexico, eastern California.

And those can cause a systemic reaction with some neurotoxicity that can lead to some autonomic dysfunction. Not only just pain, but some disconjugate gaze and some really bizarre type neurologic findings.

There’s also an anti venom for those, but it’s only needed for the most severe bites.

WORM
00:06:00.160 – 00:06:07.550
So if a scorpion sting causes pain only but no allergic symptoms, no symptoms head to toe, you don’t need the antivenom.

Dr. Clark
00:06:07.630 – 00:06:08.190
That’s right.

WORM
00:06:08.270 – 00:06:12.110
And bees. Let’s talk about bees. Are bees a worldwide issue?

Dr. Clark
00:06:12.430 – 00:06:21.909
Sure. Bees are everywhere.

And bees and all Hymenoptera being what bees are, are responsible for more fatalities every year in the United States than any other type of arthropod.

WORM
00:06:21.909 – 00:06:24.350
More than spiders due to allergic reaction?

Dr. Clark
00:06:24.350 – 00:07:05.450
It is an envenomation syndrome and that is what causes the reaction itself. Bees are everywhere. Most bees are docile and don’t chase people.

There’s a new variety that’s a hybrid called an Africanized honeybee that you can now find in the warmer parts of the United States. Again, the Southeast and the Southwest, those are more vicious at defending their hive.

And you can be stung by a thousand of those at the same time because they will attack you as an entire hive. Fortunately, they don’t do that as much in the United States as perhaps more southern places like Mexico and South America.

But they are becoming more of a threat in the United States.

WORM
00:07:05.690 – 00:07:14.570
When I get stung by a bee, I just get a little pain and redness right at the sting site. How many folks will go on to symptoms affecting the entire body?

Dr. Clark
00:07:14.730 – 00:07:38.260
You need to be allergic to them first. So most people have been stung before, get sensitized and build up IGE antibodies and those are the people at risk for immediate anaphylaxis.

The the second time, most people who don’t have IGE sensitization will just get that localized wheel and flare at the site that looks all the world like maybe a mild infection, but is usually more of a reaction to the venom.

WORM
00:07:38.260 – 00:07:47.540
And for someone who has severe symptoms in response to a bee sting, such as swelling or trouble breathing, how should they prepare for potential future stings?

Dr. Clark
00:07:47.860 – 00:07:54.360
If you’ve had an anaphylactic reaction or a severe allergic reaction, you probably need to keep an EpiPen with you.

WORM
00:07:54.360 – 00:07:54.760
Okay.

Dr. Clark
00:07:54.760 – 00:07:59.520
Keep it at home. Take it where you travel just in case you get stung and start to develop symptoms.

WORM
00:07:59.520 – 00:08:19.920
Currently, Dr. Clark and I are at a wilderness medicine conference in Big Sky, Montana, and one of the speakers just showed a graphic video of Bear Grylls. That TV personality adventurer guy, he got a bee sting and he swelled up and he looks miserable.

How much time does someone have with a reaction like this that before they reach an emergency room?

Dr. Clark
00:08:20.080 – 00:08:40.480
Well, that’s why people keep EpiPens with them, because that can be a life threatening problem if you have true anaphylaxis, if it’s just a systemic reaction, sometimes it’s difficult to tell apart from anaphylaxis, but you probably have 30 to 60 minutes to get to an emergency room to get the treatment. If you don’t have it and you’re allergic to them.

WORM
00:08:40.480 – 00:08:43.920
In the U.S. do you need a doctor’s prescription for an EpiPen?

Dr. Clark
00:08:44.090 – 00:08:44.450
You do.

WORM
00:08:44.450 – 00:08:46.410
And how often should it be replaced?

Dr. Clark
00:08:46.570 – 00:08:53.530
They probably will last every couple years before you get them replaced, but if you have an older one, it’s probably effective.

WORM
00:08:53.530 – 00:08:57.770
How do beekeepers avoid getting bee stings and developing allergies to bees?

Dr. Clark
00:08:58.010 – 00:09:10.810
Well, many of them will be stung over and over again, and some of them claim to have developed antibodies against it that help them with some of the sting features. If they develop anaphylaxis, they can’t handle bees.

GERM
00:09:11.050 – 00:09:11.370
Got it.

Dr. Clark
00:09:11.370 – 00:09:25.050
But in order to handle bees appropriately, they use things like foggers that mask the pheromone that bees release that causes them to swarm. And they use beekeeping gear that’s usually of white clothing. Causes bees to be more docile.

WORM
00:09:25.050 – 00:09:35.770
When I visit Central and South America, I enjoy watching leafcutter ants, which carry things much bigger than their bodies. Where do people need to be concerned about venomous ants?

Dr. Clark
00:09:36.250 – 00:10:30.020
Most of the southern parts of the United States, fire ants have kind of taken over.

Solenopsis, or fire ants were introduced by accident from South America years and years ago, decades ago in the United States, and were found to have no natural predators in North America. So they’ve sort of taken over and they’re difficult to manage, but can be managed if people take proper precautions.

They’re impossible to tell until you see the way they react to being disturbed.

It’s impossible to tell them anatomically from a regular ant that we have in North America because the same they’re not too big, but they, they again defend their hive much more viciously than regular North American ants. And they will attack you in multiple varieties of hundreds of ants.

And they position themselves at the same time and then release a pheromone again that causes them to sting all at the same time.

WORM
00:10:30.100 – 00:10:30.620
Goodness.

Dr. Clark
00:10:30.620 – 00:10:33.300
And that causes like hundreds of different bee stings.

WORM
00:10:33.630 – 00:10:36.430
What can someone do to reduce the risk of ant stings?

Dr. Clark
00:10:36.750 – 00:10:58.510
Well, I would use some sort of repellent like deet that may keep them off of you. Use some tight fitting clothing, longer pants or boots that would cause them to have to climb up in order to get there.

And just stay away from anthills because if you stand on an anthill, they take that as a threat and they will attack.

WORM
00:10:58.670 – 00:11:02.830
Got it. And after an ant sting, what’s the best in the field treatment?

Dr. Clark
00:11:03.100 – 00:11:15.660
If you’re just bitten by several of them, there’s a potential for allergic reactions. But if no allergic reaction, use a topical antihistamine type product or a topical steroid if you have that, and something for pain.

WORM
00:11:15.740 – 00:11:20.140
And when you say topical antihistamine, do you mean something like Benadryl?

Dr. Clark
00:11:20.140 – 00:11:22.060
Yeah, you can use Benadryl or cortisone.

WORM
00:11:22.060 – 00:11:33.620
Let’s move on now to the exciting and frightening world of snakes. Should we all be like Indiana Jones and and avoid all snakes? Where in the world do we need to be concerned about poisonous snakes?

Dr. Clark
00:11:33.860 – 00:12:56.170
Venomous snakes are all over the United States. The warmer the climate, the more you will see them.

And the ones we have in the United States are really two main varieties of types of poisonous snakes. The vipers, Viperidae and the elapids. And the only elapids we have naturally in the United States are coral snakes.

And those are found mainly on the southeastern part of the United States. Georgia, Florida, that part of the United States. We do not have them on the west coast unless they’re in somebody’s collection.

So all of the elapids, which would be neurotoxic snakes, coral snakes would be found in the southeast. The vipers are found throughout the United States.

That would include rattlesnakes, copperheads, cottonmouths, all those are native vipers to North America. The worst snakes, the one that caused more fatalities every year in the world, are all elapids like cobras.

And mambas kraits found in places like Australia, Southeast Asia, different parts of the world, Africa. Those very lethal snakes are not generally found in the United States unless they’re in zoos or collections in the United States.

The ones we have, both coral snakes and crotalids or vipers all have an antivenom. There’s a different antivenom for the lapids, the coral snakes, and there’s one that we have. There’s actually two that we have for rattlesnakes.

WORM
00:12:56.170 – 00:13:09.210
There’s a little poem that purports to describe the risk of being bitten by a coral snake. And it goes something like red on yellow, kill a fellow. Red on black, friend of jack. Is that accurate or in any way helpful?

Dr. Clark
00:13:09.370 – 00:13:29.040
That’s relatively accurate. There’s a California kingsnake that looks very similar to a coral snake, but it’s red and yellow bands are not the same as the coral snake.

Red on black would be the California kingsnake. The coral snake has a yellow band in between the red and black bands. That’s how you can tell them apart.

WORM
00:13:29.040 – 00:13:36.200
Suppose someone is hiking in rattlesnake country and a rattlesnake bites them. What can they do prior to reaching an emergency room?

Dr. Clark
00:13:36.360 – 00:14:05.170
People always ask me what they should take. If they’re worried about rattlesnakes, they’re hiking into the Grand Canyon or something like that.

There are not a lot of things you can do before you get to a hospital to treat a rattlesnake bite. I usually recommend some pain medicine.

And if you’re struck, I usually will elevate the extremity myself because it helps with pain and splint it just because it feels better. There’s very little field management that works that’s not dangerous.

WORM
00:14:05.490 – 00:14:09.060
The cowboy strategy of bite and suck is no longer advised.

Dr. Clark
00:14:09.300 – 00:14:31.060
Cutting and sucking does not work. Tourniquets are not generally necessary in the United States, we don’t recommend those.

I would only use ice very sparingly because you don’t want to cause a cold injury to the place. I usually tell people what I would take is a cell phone and I dial 91 1.

And hopefully you’ll have cell service where you are and be able to get taken to a hospital that knows what they’re doing.

WORM
00:14:31.140 – 00:14:37.280
So essentially other than transporting the person to to emergency services, the less you do, the better.

Dr. Clark
00:14:37.360 – 00:14:37.840
Yes.

WORM
00:14:37.920 – 00:14:41.120
So your first intervention should be to dial 91 1.

Dr. Clark
00:14:41.200 – 00:14:41.680
Yes.

WORM
00:14:41.760 – 00:14:45.440
Is there benefit potential protection in wearing thick boots?

Dr. Clark
00:14:46.000 – 00:14:56.560
They need to get through whatever it is so that if you have thick leather Boots, I mean, that’s probably what cowboy boots mainly were meant for at the start. That will avoid snakes.

WORM
00:14:56.720 – 00:15:02.450
And with a hiking pole, what can I do with leaves or brush or other stuff on the trail if you, if anything?

Dr. Clark
00:15:02.690 – 00:15:33.660
Well, hike places where you can see what’s below your feet. Okay. Hiking where there’s a lot of leaves or brush or something that you can’t see could harbor snakes. Okay. So I would not do that. And the.

The other thing that I always tell people is even if you’re hiking on a hiking trail and you see some sort of a rattlesnake and you want to get it out of the way so the next hiker doesn’t get struck, that’s how we see a lot of people struck. Just trying to use their hiking pole to get the snake off the trail. Just leave.

WORM
00:15:33.740 – 00:15:35.740
How fast is the striking speed?

Dr. Clark
00:15:35.900 – 00:15:41.260
It’s very fast, and it can be. It can actually be farther than the length of the snake.

WORM
00:15:41.340 – 00:15:41.980
Oh, really?

Dr. Clark
00:15:41.980 – 00:15:49.580
Yeah, they can jump to a certain extent. So just judging how far they can strike based on their length is probably not that accurate.

WORM
00:15:49.660 – 00:15:54.920
I read in a text that they can only strike half their body length, but I guess that was in inaccurate.

Dr. Clark
00:15:55.000 – 00:15:58.440
Yeah, I wouldn’t bear that as fact.

WORM
00:15:58.600 – 00:16:03.480
Sometimes people ask me if they should carry anti venom with them. Is that realistic?

Dr. Clark
00:16:03.640 – 00:16:30.860
It didn’t used to be. The old antivenom that we had years ago had a higher instance of allergic reactions. The one we have these days does not.

But some of it has to be stored in a proper way and then mixed up in a way that usually is difficult in the field.

So I, in this day and age, do not think that it’s that much benefit to take a couple of vials with you, because a couple vials usually is not going to do anything.

WORM
00:16:30.860 – 00:16:33.900
Got it, Got it. And are you yourself a hiker?

Dr. Clark
00:16:33.900 – 00:16:34.380
I am.

WORM
00:16:34.620 – 00:16:38.380
And in the US how many people are killed by snakes each year?

Dr. Clark
00:16:38.540 – 00:16:41.260
It’s usually quoted about a dozen fatalities every year.

WORM
00:16:41.500 – 00:16:45.340
So deaths due to poisonous snakes. Frightening, but really rare.

Dr. Clark
00:16:45.420 – 00:16:49.900
It’s a small number, and I actually think it may be less than that, but that’s usually the quoted figure.

WORM
00:16:50.170 – 00:17:07.370
Dr. Richard Clark is a professor in the Department of Emergency Medicine at University of California, San Diego School of Medicine, where he directs the Division of Toxicology. Dr. Clark, thanks so much for talking with me today and sharing your expertise with the Germ and Worm travel health podcast.

Dr. Clark
00:17:07.530 – 00:17:08.250
You’re welcome.

GERM
00:17:15.940 – 00:17:40.660
Hey, everyone, thanks so much for joining us here on episode 115 of Germ and Worm. As always, we would welcome your questions on travel health. Send them along or tips for travel success.

Corrections Just let us know what is on your mind.

Germandworm@gail.com or visit our website Germandworm.com if you like what you hear on German Worm, help us out, subscribe, give us a favorable rating and spread the word with friends, family and on the socials. Those are free ways to support this podcast. I’m Germ.

WORM
00:17:40.660 – 00:17:44.870
I’m Worm. It’s a big planet. See it in good health.

GERM
00:17:44.870 – 00:18:05.710
We look forward to seeing you next time.

This podcast is designed to inform, inspire and entertain, but it does not establish a doctor patient relationship and so it should never replace your conversation with a qualified healthcare professional. Please see one before your next adventure.

The opinions in this podcast belong to Dr. Clark, Dr. Sanford, and Dr. Pottinger alone and do not necessarily represent the opinions of the University of Washington or UW Medicine.