Animal Bite

A couple weeks ago I got a call from someone parked outside an ER who had suffered a dog bite… his dog. It was about 2 inches long on the inside of a finger. This kind of call is red flag city, but he was terrified to walk into the ER, because he got hit with a $2,700 bill after his last hospital visit with no insurance. I read him the red flag/happy words lists and he insisted we meet up for a bathroom repair.

Red Flags:

• Bite by any animal
• Exposed joint, bone, tendon
• Associated fracture
• Tendon laceration
• Weakness/numbness
• Hand, neck, eye or joint penetration
• Suspected foreign body (tooth?)
• Spurting blood
• Unknown or stray animal
• Strange acting animal and unprovoked
• Old (>24 hours) bite with signs of infection
• Chronic medical problems like diabetes, AIDS, cancer, transplants, taking steroids, etc.
• Patient or animal with no past immunizations

Happy Words

• Skin tear rather than puncture
• Easy to explore wound completely to its depths
• “It was my toothless cat and she gummed me when I reached for her toy.”
• “My dog still seems to have all his teeth after the bite.”
• “I can move and feel everything just fine.”

Human and dog bites are bad; cats, bats, raccoons maybe worse. Bears, alligators and sharks even worse, but for reasons beyond infection. No matter the animal though, it doesn’t really matter much in the end. We do all we can to irrigate these like crazy to limit the chance for infection.

The decision whether or not to repair with glue, suture or staple is very much weighted against. However, for wounds where every nook and cranny can be cleaned well, sometimes we will still repair these to limit scarring and speed healing. When in doubt or when there is suspicion for a foreign body, like a tooth, we leave these open. Sometimes we’ll consider closing these wounds 3-4 days later after swelling and infection risk go down, but that’s pretty rare.

X-rays can have some value if a foreign body or fracture is suspected. But frankly, these are often for medico-legal proof that we care. I usually give patients the option to X-ray or not with plenty of disclaimers. Frequently I’ll send patients home with antibiotic prescriptions, Augmentin being the most common.

However, I often say what I say for ear infections, sinusitis, and coughs… “Wait a couple days and skip the antibiotics entirely if every day is a little better than the last.” As long as no pain, redness, pus, fevers, red streaks, then healing is likely. Even if signs of infection develop after repair, it’s often helpful to just remove some sutures to allow drainage.

Invariably the question of rabies comes up. I have yet to see rabies or initiate the vaccine series, because it’s just so rare. Old Yeller has become hard to find these days. Like tetanus it’s making its way into the medical history books. That said, I do think if the rabies vaccine were a single shot instead of a long series, we’d probably be still be vigorously vaccinating for rabies as we do for tetanus today.

Whenever you get down in the mouth about US politics and policies, give thanks at least to our folks in public health. There’s a good chance you’ll spend your whole lives never seeing or experiencing rabies and tetanus. It’s still worth knowing the red flags though.

Here’s a great listen if you want a deep dive into rabies: Rodney Versus Death by RadioLab.

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