John Pearn: Australia and the cities of Seattle and Chicago in the United States have the highest rates in the general community of being trained in first aid. One in 70 Australians each year undertakes a 16 hour examinable course in first aid. For example, every year Royal Life Saving Australia teaches 600,000 to 700,000 primary and secondary school children basic skills in extracting someone in trouble from the water and basic life support.

But in the specific area of first aid management of snake bite, we do very badly. I've been a paediatrician involved very much in clinical consulting in snake bite now for more than 35 years and I had never yet seen a proper arterial tourniquet applied prior to 1980 when that was the recommended treatment. About 80%-90% of victims who come in with known or suspected snake bite today have either no, or totally inadequate, first aid. So it's an area that is one of the great challenges for the future.

Once a patient gets to hospital, doctors go through certain drills and use certain skills. And when and if a doctor decides to use antivenom, a decision that has to be made is whether it's polyvalent or mono-specific antivenom. Struan had a major role in the philosophy of this decision. Polyvalent antivenom, made as a result of the wonderful research from our CSL team colleagues, is simply a cocktail of perhaps five different antivenoms all mixed together in the one vial. Or there are a whole range of mono-specific antivenoms, different sorts of vials that are specific for death adder, brown snake, tiger snake and so on.

Figure 17 Tiger snake copulation.
Photograph courtesy of Peter Mirtschin

It might seem that the decision is easy. Why not give polyvalent antivenom routinely. There are two reasons why that's not best practice. One is the cost. Currently one vial of polyvalent antivenom costs about A$1800 and in most cases, the victim who has received a decent dose of envenomation needs at least two or three and, in extreme cases, perhaps up to eight or ten vials. So we're looking at the cost of antivenom alone for any one person bitten by a snake of between $3,000 to $10,000 or $15,000 simply to have the antivenom infused intravenously. The second reason why monospecific antivenom is better in theory is that there's a lot less protein load of horse serum, as antivenom is made in horses. The sheer mass of horse serum that's given is related to the subsequent side effect of serum sickness downstream.

Still, today, there are disasters and near-disasters because someone says they know the identity of the snake and it hasn't been checked by a professional herpetologist and monospecific antivenom is given instead of polyvalent antivenom. One of Struan's great advocacies was that if there was any doubt about the identity of the snake, it was important to use polyvalent antivenom. I think it was a great practical legacy. And the need for his advocacy and legacy is needed just as much today in practice in hospital casualty departments and surgeries around Australia as it was when he was in his heyday.

Witness to the History of Australian Medicine