David Dammery[68]: I probably knew Struan longer than most because we were medical students together and we graduated together in 1960. But I too taught first aid in the early 1960s. And one of the points that was made in a slide but not commented on was washing the area. We still taught that if you didn't have any water, you urinated on it. And one of the things was that you lost the venom [from the skin surface] and of course the venom detection kits have made that one of the great no-nos of first aid. We taught the ligature, we taught the incision, but above all we taught this wash off the venom, not realising that if it wasn't under the skin it wasn't harmful to the patient and it was in fact beneficial to keep it. So that was just one more thing that Struan did.

Figure 18 Struan Sutherland on graduating DSc. Photograph courtesy of Sutherland family

And yes, he was available. I remember having a child about 18 months old who'd been envenomated by a white tipped spider and ringing Struan one morning and saying, 'What do you think I should do?' He said, 'Can you send her to see me', and she was duly there in half an hour or so for his opinion and further management. He was always available, but his knowledge and abilities were beyond belief. I remember him with great affection.

Ken Winkel: Thank you very much for that. Perhaps one of the final points I wanted to draw out was the challenges of the applications of the pressure-immobilisation technique outside Australia. It's certainly very well accepted within Australia for snake bite but, as we've already discussed briefly today, its relevance to other parts of the world - particularly where there are other manifestations of snake bite not seen in Australia - remains controversial. I was going to quote from an article which talks about a Malaysian pit viper and the effects of the application of a tourniquet and leading to amputation in many tropical developing countries where that is the first aid teaching, this is the consequence, amputation and permanent disability. The clinicians who present those kinds of effects of snake bite and first aid, such as David Warrell[69] who was a co-author of this paper, whilst criticising the effects, don't propose any alternative.

I was wondering what Forbes McGain, one of the Fellows from the Venom Research Unit, who spent time in Papua New Guinea studying snake bite, thought about the current state of the snake-bitten in a tropical developing country as opposed to the late 1960s. Forbes, if you could just tell us about how things are going today.

Forbes McGain: Well, certainly compared to the 1960s, a paper by Bart Currie about treatment of snake bite in Port Moresby General Hospital that was published in 1991 in the Medical Journal of Australia [provides useful information].[70] At those stages there was no shortage of antivenom and everyone was getting it.

Over the period 1992-2001, less than half [of those bitten] were actually getting antivenom. There are a number of reasons for that, money being the main one. But people were also getting antivenom quite late [in the course of a bite episode]. Unfortunately the practice was that patients would come in from the country or from the area around Port Moresby not having had any first aid or, in some cases, a tourniquet or an incision had been made or sometimes burning of the skin. But, even when the patient arrived with evidence of ptosis or early signs of neurotoxicity or bleeding from the mouth, the decision was made because of the lack of antivenom to not give it until several hours had elapsed and the patient was pooling secretions and lying in a moribund state. So the antivenom was then given too late.

In addition, there are a whole series of other issues, one of which is, who really cares about snake bite, because there is malaria and TB and HIV and much more important and common conditions? What I found most fascinating was that in the small intensive care unit where I worked more than half of the ventilated patients were there because of snake bite.[71] I found it extraordinary to think that the burden of this ventilation of patients was due mainly because of snake bite, not because of other more common conditions.

There were a number of other issues related to first aid and patient care generally. The nursing and medical staff had noticed over the years that there was an increase in deaths and a lack of antivenom. Also there was an unfortunate lack of knowledge. Warrell and others, as mentioned before, did some very interesting studies with the simple test of whole blood clotting where you place the patient's blood in a glass tube to see if it clots. They found a very strong correlation between clotting in a 20-minute period and envenomation by taipan. So you could then use the less expensive taipan antivenom alone rather than the more costly polyvalent antivenom (the former costs about $1700 and the latter $2000 per ampoule).[72] It's terribly sad in a way that such a useful and simple test hasn't really been taken hold of in Port Moresby General Hospital.

Witness to the History of Australian Medicine