Nailed by a Stingray. Chapter Two: Serious Infection

[Puamana4me]

Wounds are good  to keep your immune system strong like what PB speaks of.

One thing I learned from reef cut/ MRSA is that wounds should be swabbed/cultured to acertain "what you got"  BEFORE blanket  antibiotics. Like Blue Crab said, maybe the wound is not infected.

Hope the Doc treating Wateronthebrain swabbed/ cultured the wound.

The world is turning into bunch of germaphobes, wipe your buggy at the market, wipe the gym equip.before you use it, when in doubt wipe it .

[covesurfer]

This is a great discussion. Overprescription of antibiotics really has hurt us all. I have a friend that has somehow gotten doctors to prescribe antibiotics for virally caused illnesses again and again. Antibiotics do nothing to kill off viruses. I was actually cursing her (privately) while I suffered through my second staph infection exactly one year ago.

Good to know that triple antibiotic ointment is not an effective antibacterial/anti biotic agent. I'd gladly replace it in my car kit with the silver stuff - what's it called exactly and can it be purchased over the counter?

My understanding is that puncture wounds have a higher risk of infection due to the lack of significant bleeding and difficulty of cleansing/flushing the wound thoroughly. I know that some surfers use a mildly bleach-charged solution for soaking an ocean based wound. The soaking allows penetration of germ-killing chlorine bleach. A capful of bleach in a gallon or 2 of water is what I've been told is effective. I'm always interested to learn more.

Nobody should underestimate how bad staph infections can be. Even without MRSA or other complications, 'cellulitis' is nasty and very scary when you get it. Even after successful treatment kills off the staph, the tissue damage and healing takes weeks. The pain is one of the worst things you can go through, where just lowering a limb can result in agony. I hope to never to through that again. It sucked.

[Blue crab]

Thanks for the responses.  Southwesterly: that is a beauty of a cellulitis…. could be in textbook.  A nice demonstration that soft tissue infections do indeed suck.  For what it is worth, it looks more like strep than staph. Staph / MRSA usually leads to a collection of pus (hence the need for drainage) surrounded by a red angry ring, whereas strep causes more diffuse redness akin to what I am seeing in the photo.  However, this is by no means an exact science.

This dovetails nicely into the Puamana4me's post about swabbing for culture.  As ID docs, we generally love this…. the more data the better. And we are pretty geeky about all of this as you might imagine. That being said, swabbing is a double edged sword at times.  Because strep & staph are also colonizers of skin, a superficial swab will often identify these bugs & this does not mean infection always.  We really only go for swabs if there is a deep wound or abscess that is not exposed to open air.  The presence of absence of infection is based on physical exam & labs mostly. With severe skin infections, blood cultures are sometimes positive for the culprit. 

The wound care folks use silver sulfadiazine.  However, my understanding is that this practice is informed by limited data and is most commonly used for full thickness ulcers and decubitus ulcers in bed ridden patients.  I have seen all sorts of practice by equally competent wound care nurses, and honestly have no idea how any of this would translate to abrasions related to surfing.  Silver is toxic to bacterial cell walls but there is an increasing appreciation that a diverse, and extraordinarily complex web of bacteria play vital roles in human physiology, so it might be deleterious to wipe these good guys out. Nobody knows.

From my perspective the lack of data is frustrating.  In medicine, when "expert opinion" / common practice is tested with rigorously designed studies, expert opinion is often found to be patently false.  In certain areas of practice (HIV, pneumonia, hep C etc….), we are blessed to have huge amounts of data to guide what we do. This is not the case for topical antimicrobials unfortunately. Therefore, when I get wounds, I just wash them as soon as I can, and watch them closely as they heal. 

The key with cellulitis is early identification & treatment. I wish there were better preventative strategies.  In patients with recurrent MRSA, there are decontamination protocols which are  only currently endorsed for crowded living situations with large MRSA outbreaks (prisons / military barracks / ICUs).  Decontamination at the individual level is more controversial as it appears that many people with MRSA rapidly recolonize their nasal passages after undergoing decontamination.  I am sure that I have been colonized with MRSA at one point or another given how often I am exposed, and I have never had an infection: just luck.  When relevant, control of glucose levels in diabetics & diagnosis / treatment of athlete's foot are also helpful.  Yet, none of these approaches are comprehensive.   

[juandoe]

The most important thing is to wash the wound copiously with soap and water.  Regular bar soap is fine.  In the warmer climates of the gulf coast, we see vibrio infections that rapidly become necrotizing fasciitis.  I saw one guy who scraped his leg and his brother poured alcohol over it.  Meanwhile, he is still covered in filth and is surprised to be in the ER with a pretty nasty infection. 

[Weasels wake]

This thread reminds me of a thread from not too long ago.
Fungus among us~
http://www.standupzone.com/forum/index.php?topic=14794.0

So would tea tree oil work as a good healing agent?

[Blue crab]

yeah.. I have seen a couple of necrotizing vibrio infections that went from 0 to 60 in a matter of hours.  Both were nearly fatal and resulted in amputations / prolonged ICU stays. One resulted from a woman with cirrhosis eating raw crabs: bad times.

[Zooport]

UPDATE: Just got back from the doctor and I'm in a very good mood.  She said that my foot had made an amazing turnaround and looked almost perfect now.  That makes me wonder if what Blue crab said about venom reaction applies to my circumstance.  Within about 48 hours my foot returned to normal.  Seems a little quick of a turnaround for a "serious infection"  maybe it was just an allergic reaction to the venom.  While she did a great job for me, she was an urgent care, McDoctor, so she may not be that well versed in stingray attacks.  Don't you think?

She then looked at my eardrum and said that it was healing really fast too.  She said I could SUS again in about 2 weeks.  Woo Hoo!  I thought I was out of commission until spring at least.  I plan to start flat water paddling in about a week.  That is, after I find some armored water shoes!

[excav8ter sup]

I took a poke from a stingray a few years ago, just above my heel, while helping my wife and kids into our boat while we were on vacation in Bradenton. Hurt like hell for 3 hours, then.... not so bad. I went to a foot specialist friend of mine.... 3 months later. There was still dead skin around the puncture area, but the pain was long gone. But it just didn't look right, turns out there was some of the barb or stinger still in there. So, a little  X with a scalpel,  some digging with a little tool and out came a piece of the stinger, about the size of a #2 pencil eraser.  Couple of stitches to close it up, and it was done. I guess my body was trying to reject it to some degree, because the skin never healed around the "hole".

[SuppaTime]

I was windsurfing down in La Ventana a few years back when another sailor got slapped on the top of his foot by a sting ray. He was in agony but we ran to the kitchen at the place we were staying, heated water on the stove to just short of the point of scalding, and plunged his foot in it. Instant relief. I believe the toxin is a protein that is temperature sensitive - the hot water just destroys it.

[PonoBill]

Yup. The toxin is a pretty delicate protein structure and the delivery mechanism is the surface of the barb instead of some injection mechanism, so hot water, directly applied, will break down the polypeptides. You could drip hot water on the entry point and have a similar effect--no point in parboiling the foot.

The sting is brittle and barbed. It's likely to be left in the wound, just like a wana (sea urchin) It can be adsorbed by your body or shoved out like a splinter. Not sure that carving it out is the right approach, but maybe. I figure a significant part of me is sea urchin spines, since I've adsorbed more than my share. That might explain my personality.

[northstoke]

damn man! who would have thought. know lots of people that have been tagged in the ankle by the small ones. stepped on a few in my day but luckily have been the bigger ones that usually just swim away. one session last year the water was super cold so all the rays were far inside soaking up the warmth and if you rode in within 100ft of the beach you were in waist deep water flying over dozens of giant sting rays on the sand right below you and you can see them there clear as day. just a bit unsettling!

[Zooport]

Where were you when this happened?  I used to windsurf off Seal Beach, CA, sometimes referred to as "Ray Bay" and I have seen this kind of thing too.  Almost every square foot of bottom had a ray on it.  Fortunately, you don't have to put your feet down much in windsurfing.  But that was where I got stung the first time.

[OC kbar]

I read this thread, went surfing, and got tagged in the toe at Bolsa Chica. 

It got me in the knuckle of the toe so it did not penetrate deep. It hurt but I was able to keep surfing. I must have been a baby.

Today it is a little read but already closed up and healing.

[stoneaxe]

in the absence of hot water meat tenderizer can be used to break down the protiens as well....if I lived where there are a lot of stingrays I'd have some in my car.

[starman]

I prefer A1 sauce. 

Anyway, if you are worried bring a thermos with your favorite hot beverage. If you survive the session you can enjoy a hot toddy.

A rule we had when windsurfing in a heavily infested area of rays was to shuffle your feet when walking in the water. Rays will usually only take a swing at you if they are surprised by the unexpected like a size 12 stepping on their head.