Bitten

When the fangs sank in through my pistachio-colored Pink Floyd T-shirt and sports bra, piercing my flesh somewhere outside my right peripheral view, I had been petting my elderly cat, seated on the ground in the center of the garden I grew up in amid the Klamath Mountains near the Humboldt-Siskiyou county line. It was about 5 p.m. on a crisp October afternoon, still broad daylight.

As I turned, to my total surprise, I found a fox staring back at me, jaws locked down on the fatty tissue of the underside of my breast. Yes, the site of the unprovoked bite raised some eyebrows and elicited some questions in the Arcata emergency room hours later. “How’d you get bit THERE?” the charge nurse asked dubiously. Don’t ask me, ask the fox! I’d like to have shot back. But my comebacks are always a tad too late, especially, it turns out, in the aftershock of a fox bite.

But back to the bite incident. It took a few seconds for my brain to register what my eyes took in — a fox that looked healthy but acted decidedly unhealthy, latched onto my body. I shrieked, a strange involuntary sound emitting from my mouth, and shook my upper body in an effort to jar the fox loose. It didn’t work, so I stood and shook some more. Finally, I was able to shake the animal loose, and was further alarmed to see that it just stood and stared brazenly back at me. It then ran a few feet and turned to stare at me again. It must have looked like some bizarre Northern California woods version of a Voodoo ceremony.

Still at close range, I threw a rock but missed.

I yelled, and my husband came outside from cooking dinner, a little annoyed at first at the interruption. “I was bit by a fox,” I cried out. He leapt into action, grabbed a gun and searched the center and the back of the garden, without any luck. He then noticed a pair of ears in the fauna nearby. The fox was stalking him, he realized. After two quick shots hit the fox, the critter crawled into a blackberry bramble where it took refuge, yelping and whimpering until its sad sounds died out and we could no longer hear it. We assumed the shots killed the fox, and briefly discussed the possibility of hacking in with a machete to retrieve the carcass and test the fox’s brain for rabies, but ruled it out because there was a sharp drop-off into deep berry bramble, which likely contained a fox den with possible other rabid and angered defensive animals. Also, it was getting dark, impairing visibility.

Now might be a good time to explain that my husband was subjected to rabies post-exposure treatment when he was a kid, after the family dog had an encounter with a rabid porcupine farther east in Siskiyou County. The rabies post-exposure prophylaxis protocol (aka PEP protocol) was different back then, and not in a good way. It involved 20 shots, with the vaccines delivered to the stomach, and left him with a lifelong needle phobia that has taken on a life of its own. “If I am bit by a rabid animal, I am not getting any shots,” he has declared repeatedly to me. More on rabies shots and the state of our health care system in a bit. (Pun not intended but not retracted, either.)

Back to the situation at hand. So, you’ve been bitten by a fox. Now what? Call the closest ER, which for me was at Mad River Community Hospital in Arcata. How soon do I need to get a vaccine? You should probably start heading this way, the charge nurse advised. Heeding advice from the internet, I washed the bite wound with soap and water. Brain reeling, I packed some pajamas in a red bag firefighters typically take on assignments, forced down a pork chop. Adrenaline was coursing through my body, shoving my appetite down to my toes, but I knew a trip to the ER could mean a long wait. It sucks, I thought. Not at all how I planned to spend my Sunday night, but I’ve never been afraid of needles, so let’s just get the dang thing over with and get on with life. Truly, I had no idea what I was in for.

I arrived at the hospital ER entrance, texted my mom and husband, and waded through the fog to the door around 8 p.m. The Mad River ER waiting room is a long, skinny, non-descript place with an inhospitable air. “Where do you check in?” I asked someone seated in a long line of chairs after surveying the horseshoe shaped hallway where the only visible sign warns occupants that the facility they’ve entered ranks 2 out of 5 in terms of structural integrity and might not withstand an earthquake. Someone motioned to a button — just ring the bell on the wall in that corner, they indicated. I did. A short man in a stocking cap stuck his head out an unlabeled door.

“What?” he demanded.

“I was bit by a fox, probably a rabid one,” I said.

“Have you been seen here before? Do you have your ID?” he responded?

I handed over the ID. The man in scrubs with the stocking cap vanished into the unlabeled room with my driver’s license and I seated myself in the line of people waiting for care.

Even with my fleece zipped up to cover my neck — brr! — between the chilly ambient temperature and the stress of the situation, sleep was impossible. By 8:30, I had been ushered into another unlabeled, small room for an intake assessment. “Where was your bite? I need to see the wound,” the nurse said. I pulled up my shirt, feeling thankful in that moment that I was raised by hippies not shy about removing clothes. The bite wound had a V-shaped laceration about a half inch long, ringed by a larger V-shaped bruise that showed striking resemblance to the shape of a fox’s jawline. It was enough to convince the nurse that I was not inventing the incident and she ordered me to lower my shirt. We established that the series of four (12, technically) rabies post exposure protocol vaccines was definitely called for. The shots will not be fun — they hurt, the nurse warned me.

Now, the thing to do was wait, and wait, and wait, while triage passed me over until 2 a.m. Two children with head injuries obviously took priority. A woman on drugs came in, complaining she couldn’t feel her legs. A nurse helped her into a wheelchair and left her there in the waiting room to pray for an easy death, sounding almost mantra like in her self-pity, until she wheeled herself out on her own recognizance, declining help along the way. A woman with excruciating stomach pain paced the hallway, moaning. A young couple checked in, anxious to receive ER care. However, after their intake assessment, they left in as big a hurry as they’d arrived. A doctor came out to welcome them back to the ER proper. The woman with the stomach pain explained they’d left. “That’s too bad,” the doctor said, shaking his head, and retreated back to his work. A couple in good spirits seated themselves next to me in the lineup. One had gauze wrapped around her hand.

“He stabbed me,” she teased her boyfriend. He grinned. “That’s a joke,” she followed up. “It was an accident. We were skinning a deer when his hand slipped with the knife and sliced my hand to the bone.”

We became waiting room friends and eventually shared a room with ancient ER equipment divided only by a curtain after being admitted back into the ER proper behind the original unlabeled door. We received treatment intermittently around the same time, so I overheard the whole stitching up process while I waited for the right immune globulin shots to be administered in and around my bite wound. Because of the fatty tissue padding the site of my wound, the shots didn’t actually hurt that bad. Nine shots later, eight around the bite wound and one in the opposite arm — six and a half hours after I was admitted — I was released, and collapsed into a hotel bed for about four hours of sleep.

When I woke, I ventured to the DMV at the mall in a second attempt (successful, this time) to beat the lines and change my driver’s license after getting married in July. I might look rabid in my new photo but at least I am smiling! Next, a stop at the drugstore to pick up a 10-day run of Augmentin. This cocktail of two powerful, broad-spectrum antibiotics has a reputation that precedes it and numerous friends told me that after bad Augmentin experiences, they refuse to take it again. Just before releasing me, the ER charge nurse made a strong recommendation to pair the Augmentin with a probiotic tailored for vaginal health to avoid a yeast infection. She wasn’t kidding!

After the two-hour drive home, I took a closer look over my discharge paperwork and noticed that the highly specific date regimen called for shots two, three and 4 on Days 3, 7 and 14 had been botched, listing the wrong dates for the follow-up injections. At 2:30 in the morning at the ER, what do you expect? (Well, an ER that would withstand an earthquake. Is that too much to ask?)

So, you’ve gotten the first in your series of rabies PEP vaccines. Now what? You need an appointment for your Day 3 shot in short order. My hope that I could have the shot done at the little local Karuk clinic in Orleans was quickly dashed. No answer either at the clinic in Willow Creek, so I tried Mad River Community Hospital to see if it would administer the other three shots to keep things simple. (Ha!) “Oh, we only administer the first in the series,” I was told. Next I called the Eureka Public Health Department, which informed me that it didn’t have the rabies PEP vaccines on hand and referred me to its communicable diseases unit. (Although rabies is communicable via saliva, it is not contagious in the usual sense of the word.) Via the communicable diseases unit, I learned that outside of Humboldt County’s two ERs, only one other facility keeps the rabies PEP vaccine on hand. Thus, highly motivated to avoid another 6.5-hour wait in the ER, I called the Providence (St. Joseph) Ambulatory Infusion Center (where cancer outpatients receive chemotherapy treatment) in search of an appointment two days later.

I would need a doctor’s order, someone at the infusion center said. No problem, I thought. I texted my primary care provider at the Karuk clinic in Yreka, who has earned my respect through various other medical adventures, and gave her the infusion center’s fax number to send the order. No problem, she thought. Near the end of that same day, I still had not heard anything from the infusion center, so I called again. Oh, we need a specific doctor’s order form that we just sent them, the voice on the other end of the phone explained. My primary care provider had already left the office for the day by 4 p.m. when the prescribed order form arrived at her office. No problem, I texted her back — it will all work out somehow. It’s only rabies, after all. We commiserated about how the medical system seemed ill set up to handle rabies post exposure cases, and tended to put the burden of seeking and receiving care on the patient who had experienced a traumatic bite already.

To their credit, Humboldt County public health representatives did make some efforts on my behalf to help find and get the needed appointments on specified days. During the limbo I was in, I came to understand the extent of the disarray that both Humboldt hospitals are in, as they contract services and struggle to retain providers. I also learned the slow rate at which rabies is thought to spread toward the brain (an inch or 2 per year), which was vaguely reassuring.

As I waited for the medical establishment to figure out what to do with me, I began to wonder what makes the rabies vaccine so scarce and absurdly expensive. It turns out that the rabies PEP protocol shots are sourced from human antibodies of the right blood types (now cultivated in labs in developed countries like ours), that have a short shelf life, so few medical facilities other than ERs can be counted on to keep the stuff on hand. If you’re wondering, as I was, the rabies PEP protocol — rabies immune globulin shots in and around the bite wound plus a shot in the arm as soon as possible (called RIG or HRIG for Human Rabies Immunoglobulin), followed up by three more shots in the arm — was first developed by Louis Pasteur in 1885, when he experimented with injecting rabbit spinal cord and rabbit brain tissue that contained progressively inactivated rabies virus and formaldehyde into a 9 year old who had been bit by a rabid dog. The risky but vital human immunization, based on years of Pasteur’s research in animals, was successful and marked the beginning of immunization.

“It is on much broader issues that Pasteur’s achievements must be judged,” says an article published in 1985 by the Centers for Disease Control. “He had demonstrated the possibility of investigating by rigorous techniques the infectious diseases caused by invisible, noncultivable viruses; he had shown that their pathogenic potentialities could be modified by various laboratory artifices; he had established beyond doubt that a solid immunity could be brought about without endangering the life or health of the vaccinated person. Thanks to the rabies epidemic … immunization (has) become recognized as a general law of nature. Its importance for the welfare of man and animals is today commonplace, but only the future will reveal its full significance in the realm of human economy.”

Just doing my part to validate the efficacy and life-saving nature of vaccines by being bit by a fox and surrendering to the requirements that follow. The rabies PEP protocol has proven highly effective when adhered to — there is no incidence of someone dying from rabies who has undergone the rigorous treatment regimen. But again, during the waiting that ensues, a patient like me also starts to wonder how a person would know if they had symptoms of rabies. A quick web search reveals: fever, headache, weakness, anti-social behavior, hydrophobia (fear and avoidance of water), hallucinations, disorientation, paralysis, hyperventilation, episodes of terror and excitement, hypersalivation and seizures.

Calm down — it’s only rabies. There’s a vaccine for that (or four or 12 when you count the RIG shots in the first hit). And it will only steal two weeks of your life and sanity, and it is only available and covered at ERs, and it only costs $1,500 to $2,500 a pop, or up to $10,000 for the whole course.

After several doctor’s orders and many phone calls, the Providence Ambulatory Infusion Center slid me into its schedule without a fuss, directing me to their non-descript little wing of the hospital. I was in and out of a chair in a room with multiple chairs where outpatients routinely hooked up to an IV drip for treatment in a flash. The place had a vaguely Buffy the Vampire feel, but the staff were friendly and helpful. I began to gather my discharge paperwork and even the boxes from my vaccines to create a paper trail for my treatment, readying to make the case that all my shots should be covered by MediCal.

A billing expert in the finance side of infusion center office informed me the shots will need to be coded correctly to invoke a law that states medical professionals cannot deny rabies treatment to patients. The Google trail here gets fuzzy on what law exactly that is, though in looking I did find that California requires that preventative rabies vaccines for dogs must be made available for free. (Not so free for humans, apparently, without knowing the right law and health insurance code.)

In hopes of visiting my mother on the Central Coast of California when my third vaccine needed to be scheduled, I established that the Public Health Department there could administer my vaccine, but it would cost $600 out of pocket since Partnership Health (Northern California’s MediCal administrator) didn’t have a negotiated contract with providers south of Marin. I could go to the Dominican Hospital ER to get the shot (and was assured over the phone that Partnership Health covers a visit to an ER anywhere in the U.S.), I learned, but was told its wait times rivaled Mad River Community Hospital. Dominican faces a similar crisis to Humboldt’s hospitals, plagued by overcrowding and inadequate staffing to keep things running smoothly. I pivoted and opted to get the shot at Redding’s Mercy Medical Center instead. As I marched past the helicopter landing pad into the ER there, I worried that I’d be in for long lines and a long wait here, too. But Mercy cycled me in and out in an efficient hum and sent me on my way within about an hour’s time.

Three shots down. One to go. I got my fourth and final rabies shot back at the Providence infusion center, almost an old pro by now. Predictably, each of the shots left me with three subsequent days of headaches, neck aches and eye aches. Meanwhile, the antibiotics treated me to intermittent nausea. And that yeast infection the Mad River charge nurse warned me about — it surfaced with a vengeance. Oh, joy!

I had gone into this adventure with a “How hard could it be?” attitude. I came out with a newfound appreciation for modern medicine, overworked charge nurses, public health officers, the Karuk Tribe’s clinics and medical professionals, and probiotics specifically for vaginal health.

I don’t recommend you get bit by a rabid fox, but if you do, I recommend you start at cdc.gov/rabies. And buckle up for the ride.

Erica Steinbring is a career conservation nonprofit worker, writer and editor from the North Coast’s Klamath Mountains.

This article appears in Bitten.