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It's a Cobra!

Struck twice by a Mozambique spitting cobra, five-year-old Mikayla Robbertse was set to lose her arm – or her life.

Cobra

Charmaine Robbertse was tired but content.It was a week before Christmas, and the 46-year-old former insurance broker had finally settled her large family in the home they had always dreamt about – a rambling farmstead on 60 hectares of rugged bushveld near Lephalale (Ellisras), far north of Pretoria, in South Africa.

Charmaine was devoted to her family. Her husband, Bertus, was a supervisor at a nearby chemical company, and together the couple had seven children from previous marriages, three grandchildren, and a changing array of foster children – children the pair tried to put back together with patience and love.

But one foster child was particularly special. Mikayla, an elfin five year old with lively brown eyes, was the daughter of Bertus’s 25-year-old son, Lampie. The little girl’s mother separated from Lampie before she gave birth, but when Mikayla was born with foetal alcohol syndrome, the young mother struggled to cope. Lampie was often away for work, so Charmaine and Bertus became Mikayla’s full-time carers and officially fostered her soon after.

By nine o’clock that Monday night in 2011, Mikayla’s excited chatter about their new home “with the wild animals” had stopped, and she dozed happily on a sofa near Lampie and her pet Pekingese, Jimmy. Bertus scooped Mikayla into his arms, and Charmaine led the way to her bedroom. She lifted the cheerful, stripy cerise and lime duvet in a routine bush check for creepy crawlies, then Bertus slid ­Mikayla in. The couple smiled down at the child for a moment, then crept out.

Wake-up Call

It was 11.30pm when the bushveld stillness was broken by Mikayla’s piercing screams. “Snake! Kayla’s been bitten by a snake!” exclaimed Lampie, shocked into being fully awake when he discovered a puncture wound on his daughter’s left middle finger and another on her elbow.

Bertus left his son to find and identify the snake, and quickly bundled Mikayla into the cab of his Nissan van. Charmaine cradled the child on her lap while Bertus drove as fast as he dared down the dirt road to the Ellisras Hospital, about 40 minutes away.

As they pulled in, the call came from Lampie: he had found a metre-long Mozambique spitting cobra behind a bedroom cupboard. The snake – one of the most dangerous in Africa – is capable of spitting venom and blinding victims with deadly accuracy. Lampie would have returned most snakes to the wild, but he fiercely dispatched this one with a spade, his thoughts on his daughter.

At Ellisras, doctors placed a mask over Mikayla’s pale face and gave her oxygen before injecting two vials of polyvalent antivenom into her slender arm. “Is that enough?” asked Charmaine anxiously. She was assured it was for a child so small and that Mikayla should be fine by morning.

But by dawn Mikayla was struggling to breathe. Charmaine was told that the child needed to be transferred to nearby Marapong Private Hospital. After an examination at Marapong, the doctors advised that Mikayla needed more specialist care at the Steve Biko Academic Hospital in Pretoria. But that was 300 km away and there was no ambulance available.

Nightmare Ride

With Bertus called away for work, Lampie arranged to have a friend drive his stepmother and daughter. In readiness for the journey, the Marapong doctors taught Charmaine how to perform CPR and urged her, “Stay calm, the child’s life depends on it.” This became her mantra as she nursed Mikayla in the back seat of Lampie’s friend’s car.

Three times the child stopped breathing; three times a terrified Charmaine managed to revive her. But by the time they reached Warmbaths, Mikayla was unconscious, and they were still 100 km from Pretoria.

A rapid response vehicle had been alerted and raced to meet their car. Soon its flashing red lights were in view, bringing Charmaine unspeakable relief. The paramedics managed to stabilise Mikayla, but she was so weak they sped her not to the Steve Biko Academic Hospital but to the closer private Netcare Montana Hospital.

Although the Robbertses could not afford the fees, Mikayla spent three days in the clinic’s ICU. Her kidneys and lungs were failing, doctors informed them gravely. Mozambique spitting cobra venom is cytotoxic, with digestive enzymes that eat flesh as they spread, and as these reached her liver, they were affecting it, too.

At the same time, Mikayla’s small hand was swelling obscenely and slowly turning black. The doctors were terribly sorry, especially as she was left-handed, but her finger and probably her arm would need to be amputated to save her.

The Snake Man

With mounting private hospital expenses, it was decided to transfer Mikayla to the Steve Biko Academic Hospital, a government hospital, for the operation. On the way, a desperate Charmaine called a mobile number slipped to her by a paramedic at Montana. It was for Arno Naudé, an expert in snake identification and bite treatment, who lectures to medical students at the University of Pretoria.

When she told Arno that Mikayla would likely have her arm amputated, he had one word: “Whoa!” Doctors can be too quick to amputate, he said, and advised that they wait for the venom to run its course. In the end, however, the decision was made for them – Mikayla’s liver, underdeveloped from the foetal alcohol syndrome, was too seriously affected by the venom for her to undergo surgery.

Two days before Christmas, Mikayla’s little face and body had become distended and her skin had turned yellow. Doctors told Charmaine and Bertus she was unlikely to survive the night and advised them to summon the rest of the family.

Arno joined the family during their tearful bedside vigil. He told Charmaine that Mikayla should have been given at least eight vials of antivenom – four times the dose she received. He explained that smaller patients need just as much antivenom as adults. Now, he said, there was nothing to do but wait and pray.

Christmas Gift

Charmaine and Bertus did both, fervently, and by morning Mikayla had stabilised. By Christmas Day she was conscious, smiling through nausea at the gifts her family brought, and asking after Jimmy, her little Pekingese dog.

Mikayla continued to rally, and on December 28 was wheeled into theatre – not for an amputation but for doctors to open the massive blister that covered her hand and inspect the damage below. This was more extensive than imagined – the venom had tunnelled under the skin, eating away tissue to halfway up her forearm.

A plastic surgeon, Dr Anton Brewis, assessed the damage. He explained that the wound would need to be cleaned of every bit of infected tissue. Following that, he was confident that he could save Mikayla’s arm with a surgical procedure that temporarily attached her hand to a flap of skin on her groin.

On January 13 the wound was cleaned a final time, and exposed to the bone. Mikayla’s hand was stitched into place and remained there for the next two weeks while the flesh attached itself, slowly rebuilding her hand.

There was surprisingly little pain from the wound itself, but cleaning it was an ordeal, and Mikayla’s liver struggled to cope with the powerful medications she required. However, the feisty child never complained and on January 27 Mikayla’s hand was separated from her groin and the remaining wounds on her forearm were patched with skin harvested from her thigh.

On January 31, six weeks after she was bitten, Mikayla returned to Lephalale. Residents turned out to welcome her with banners and balloons tied to the trees, but all Mikayla wanted was to play with Jimmy and her toys, which included a large candy-striped knitted snake.

“Some snakes are naughty,” Mikayla observed simply, “but some snakes are nice.”

Work in Progress

In November 2012, Mikayla had the swelling on her hand reduced by liposuction to help her bitten finger grow straight. Her surgeon also transferred tendons from her left forearm to her hand to improve finger extension. Steel rods were inserted in her finger, but failed to work and had to be removed.

Focus shifted to helping Mikayla use her right hand for writing and drawing, overcoming her natural lefthandedness. She was moved to a special school, where she has surged ahead, coming top of her class last year.

Far from being self-conscious, Mikayla, now ten, proudly displays her ‘funny hand’ for educational talks about snakes with a local snake handler in primary schools, demonstrating that apart from writing, she can do most things with it, even holding a glass of juice.

And instead of being afraid of the snakes the handler uses, “she loves them!” says Charmaine.

In fact, Jimmy has had a rival for Mikayla’s affections: Fudge, a ball python, a gift from the snake catcher that he offered to care for at his home.

“We don’t feel comfortable with snakes in the house,” Charmaine confides. But, says Mikayla, happily, “Fudge is sweet, he doesn’t bite. People must just know which snakes do. And take care!”

 

The Spitting Cobra

The Mozambique spitting cobra (Naja mossambica) is most common in the northeastern parts of Southern Africa, parts of Mozambique and East Africa.

“This species appear to be very aware of what is going on around them,” comments Professor Graham Alexander, a herpetologist from the University of the Witwatersrand, Johannesburg. “They are likely to see you before you see them.”

Spitting cobras frequently enter dwellings at night and often bite victims while asleep. They release a cytotoxic venom, which destroys tissue cells around the bite, but there may be additional neurotoxic effects. They can also eject venom up to 2 metres away and often aim for the eyes. If left untreated, the venom can cause blindness. The head of a dead snake can still transfer venom, even if the snake has been decapitated. Ashleigh Austen

 

Surviving a Snake Bite

To keep safe

  • Snakes are not generally aggressive and will tend to attack only when they feel threatened or are disturbed. They are commonly found in warm places (near water heaters) and on or under surfaces where they can absorb solar heat (rocks, paving, corrugated iron).
  • Use mosquito nets tucked under mattresses when staying in the bush or camping. Always turn on lights or use a torch if you get up at night, and wear closed shoes. Check inside your shoes before putting them on.
  • Don’t have rubbish, compost heaps or long grass near your home or tent; they attract rats and other creatures that snakes prey on.

If someone is bitten

  • Don’t waste time or take risks catching or killing the snake, says South African snakebite expert Arno Naudé. Just try to note its size, colour and main characteristics, such as diamond markings or a hood.
  • Don’t cut, suck or tie a tourniquet around the bite; leave it alone or apply a firm bandage to the whole limb. Keep as still as possible – use a splint for limbs – to prevent the spread of venom into the circulatory system.
  • Rinse venom from eyes with clean water (milk will also work), keeping the eye open and rolling the eyeball under a stream of fluid.
  • Don’t administer antivenom yourself; the patient may have an allergic reaction that requires medical assistance.
  • Keep the patient calm but quickly get them to the nearest hospital with a trauma unit. Phone ahead to check they have polyvalent antivenom, which is effective against most lethal snake venom.
  • The hospital should treat the patient’s symptoms and administer antivenom only if necessary – in most cases it won’t be.

How likely is it?
Reporting of snakebite is not reliable. Nonetheless, the Global Snakebite Initiative estimates that, worldwide, snakebite claims some 125,000 lives a year – mainly in tropical developing countries where access to medical resources is poor. Developed countries have much lower injury and very low mortality rates.



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