532 
THE CORAL TRIANGLE: HEARST BIODIVERSITY EXPEDITION 
the worst imaginable, but there is little that can assist in answering question 3: If I blow the case, 
will the patient be harmed? Oftentimes, I am not onsite when these questions arise, so I am rely¬ 
ing on the reporting of the patient or bystanders on satellite phone, for example. Some people min¬ 
imize their symptoms and others can be very dramatic. Is the patient exhibiting anxiety because 
he’s anxious or is he anxious because he is dying? This might sound funny, but it is a very real con¬ 
cern and the two can be confused. It is dangerous to make the patient prove he or she is sick, but 
it is also dangerous and disruptive to evacuate unnecessarily. This is just a brief description of the 
mindset with which I approach expedition medical care. To be a field scientist is inherently risky, 
but that does not mean accepting risk unconditionally and diagnostic uncertainty is certainly not 
expected in every situation. 
Preparation for this expedition was different for me for the simple and odd reason that despite 
8 years of field experience I had never actually been confronted by the specter of dangerously ven¬ 
omous snakes. Within a few breaths of inviting me on the expedition. Dr. Ten*y Gosliner indicated 
that I would be on the “Terrestrial” team and before finishing the sentence handed me a copy of the 
World Health Organization’s (WHO) recommendations for the fteatment of snakebite for South¬ 
east Asia [10]. The recommendations are not massive or complicated. They are quite thorough, but 
they are not all that reassuring for a field scientist — remain calm (tell the victim to remain calm), 
seek medical attention and antivenom remains the cornerstone of treatment in the setting of ven¬ 
omous bites. 
In the WHO recommendations there is a note that in some types of envenomation, a dmg com¬ 
bination containing neostigmine and atropine or glycopyrrolate can be administered IV — and is 
thought to be useful in the setting of cobra bite. This caught my eye because neostigmine and gly¬ 
copyrrolate can be given simultaneously in a 1:1 ratio and would be easy to administer, relatively 
safe and inexpensive and heat stable. The best of what little reseai'ch is available on this type of 
drug combination came from the Philippines in a study of patients bitten by Philippine’s cobra — 
exactly the snake I was concerned about for the terrestrial group. So, with some relief I put togeth¬ 
er a kit with neostigmine, glycopyrrolate , some alcohol swabs, syringes and needles, with simple 
instmctions for use. 
Fortunately, we never had to use the snakebite kit. I left the Philippines about two weeks 
before the end of the expedition. It is customary to exchange photos and NataliyaPolydouri and 
I did this. She had taken several photographs of me explaining the kit to a herpetologist and it was 
on the plane home fi'om the Philippines that I saw these. My recollection of the conversation was 
that the scientist with whom I was speaking was enthusiastic about the kit and the concept. Never¬ 
theless, my perception of the same scientist in the photograph was that he was thinking, with some 
anxiety, about the possibility of having to administer such an antidote in a crisis. I have no idea 
what he was really thinking — likely just engaged — but it got me thinking: “There has to be a bet¬ 
ter way to do this. What if we just got rid of the needles?” I went to sleep and woke up in San 
Francisco thinking, “why not?”. 
The idea was lying fallow in my head for some time before I realized the implications of such 
an idea should it actually turn out to be a plausible approach. Months passed. The expedition had 
returned and there was no real practical pressure to think about it. In spring of 2012, there was a 
national shortage of midazolam and it was affecting the ambulance system. Midazolam and other 
drugs for seizures can be delivered through the nose and are safer to administer in a convulsing 
patient than those administered by IV or by any sort of injection. King-American’s chief para¬ 
medic, Josh Nultemeier and I were spending a lot of time ti'ying to find a source of these drugs and 
reviewing City protocols and our own to see how we could sti'etch out supplies much like every 
other ambulance service in the country. Time and again we came back to the nasal delivery as a 
