Tuesday, 7 April 2015

Stingray strike tests our medical emergency plans

April 7, 2015


Four days of planned relaxation on ‘Our Dreamtime’ over the Easter break presented us with an unexpected test of our preparedness to handle a medical emergency when Karen suffered a very painful and potentially dangerous strike from the poisoned barb of a stingray.

Minutes after we took this idyllic photograph Karen was wracked with pain after standing on a stingray
It all started well enough with a very enjoyable Sunday afternoon, downwind sail in 15-18 knots across thirteen and a half nautical miles of Moreton Bay from our marina berth in Manly Boat Harbour to Horseshoe Bay on Peel Island. Karen helmed most of the near three hour journey getting more acquainted with the how the Whitby 42 ketch behaves on a broad reach with modest following seas.

Karen hand steered most of the way getting to know our Whitby 42 ketch's quirks.

A beautiful day for a down wind sail in Moreton Bay
We were fully aware that the combination of the Easter weekend and perfect weather would make this beach lined safe haven a Mecca for boats of all sizes but two years cruising in the Mediterranean visiting many overcrowded anchorages has taught us not to avoid a beautiful spot just because others might be there. Besides, most of the boats would be gone the next day as the majority of the population prepared to head back to work. We, on the other hand, would be staying on until Wednesday or Thursday in comparative solitude.
Manly to Horseshoe Bay - 13.4 Nautical Miles - 3 Hours 03 Minutes - Average Speed 4.4 knots - Max 6.8 knots
 Although the bay was very well populated when we arrived mid afternoon, we had no trouble finding a good spot to anchor in just five metres of water. We soon had the boat secured, sunscreen applied, deck chairs out with snacks and cocktails in hand. We had full, four day agenda of doing very little firmly laid out and were determined not to deviate from the plan.

A relaxing afternoon on the stern
That evening, mother nature provided the entertainment double feature of a stunning sunset over the mainland with just a very brief intermission before the equally impressive sight of a near full moon appearing large and orange over the sand peaks of Stradbroke Island to the east. Tender steaks off the BBQ accompanied by a couple of fine reds enjoyed on the stern of our Whitby 2 ketch put the punctuation mark on a great day on the water.

Progressive stages of our Horseshoe Bay sunset



Next day dawned clear and calm with just a mild breeze blowing off the beach. After a relaxed morning aboard, we had a light lunch before lowering the dinghy off the davits. We then went for a ride through the bay checking out the huge range of boats at anchor before going ashore on the beach.

The warm, clear water and sandy shallows of Horseshoe Bay are particularly inviting and we had a lovely swim. With the tide running out, we began wading along in waist deep water parallel to the beach enjoying the sunshine, alternatively towing and pushing our dinghy along between us.


Suddenly Karen fell to the side and said she’d stood on something and been stung. We spotted a small stingray scurrying away across the bottom which we assumed to be the culprit. On examining Karen’s leg we found a small puncture wound bleeding on her ankle which she said was quite painful with a burning sensation akin to being poked with a soldering iron.

We made our way into shallower water so it was easier for Karen to get up into the dinghy but it was still very difficult for her to even manage this given the pain she was experiencing. Weheaded straight back to our boat. In the short time it took, Karen’s foot had begun to swell and the burning sensation was increasing and spreading up her leg. The normally simple climb from our drop down swim platform up to the stern proved a very painful challenge which she conquered with gritted teeth.

Once in the cockpit we washed the injured area with fresh water and administered two paracetamol painkillers and an antihistamine in case of allergic reaction. Then I went straight for our 450 page first aid manual only to find a totally inadequate, very brief three line section on the treatment of stingray stings.  Thank goodness for modern technology. We were well within service range for our mobile phones and 3G wifi so the next step was to ask that know it all Mr Google. A  search of ‘Stingray Sting Treatment’ revealed a long list of sites with detailed, multi-step guides to the appropriate first aid and subsequent treatment.  Rob quickly read through the first and then scanned another three to make sure they all basically agreed with each other. (Just because it’s on the internet doesn’t mean it’s always true. Look for more than one source)

Any barb strike to the torso must be treated as an extreme medical emergency and professional medical assistance should be sought immediately.  However most stingray injuries occur to the feet and all sites provided first aid information based around that premise. Here’s a step by step summary of the advice provided and how we implemented that advice. (Note: The same first aid treatment is also recommended for similar marine venomous stings such as stonefish.)

1 While still in the water irrigate the wound to remove fragments of spine and tissue.  A small amount of bleeding at this stage may assist the process of washing away toxins. Remove victim from the water.

We examined the wound immediately and could see no pieces of the barb and were then in the water for a minute or two moving to a shallower area before Karen was able to climb into the dinghy. This provided time for the salt water to wash through the wound.

2 Apply pressure above the wound if it is bleeding.

By the time Karen was out of the water bleeding was minimal so this was not an issue. Recommended treatment if bleeding is excessive is a pressure bandage ABOVE the wound.

3 Flush the wound in fresh water then soak in water as hot as the person can tolerate (approximately 43C - 110 F). As toxins may cause numbness of the effected limb, check the temperature with a non effected hand/foot to ensure it’s not so hot as to cause burns. When any bleeding has stopped use tweezers to gently remove any obvious pieces of spine.

Prior to reading this we had automatically flushed Karen’s wound with fresh water as a matter of course as soon as we reached the boat. However, I had also given Karen a bottle of cold water to take the antihistamine and painkillers which she had then momentarily used to put against the wound like an ice pack. This caused a seriously elevated level of pain so NEVER use an ice pack on this type of injury. Fortunately we had run our engine to charge batteries that morning and had  a plentiful supply of very hot water literally on tap. Karen was sceptical about plunging her burning foot into near scalding water but once accomplished she gained an immediate level of pain relief. The hot water is also said to deactivate remaining toxins to a degree. We found no obvious pieces of spine to remove.

4 Wash wound with soap and water. Apply tropical antibiotic ointment. Apply breathable, gauze dressing. Do not cover the wound with tape or close it with stitches.

By now any touching of the wound sent the pain meter to the maximum so this is something we didn’t do. The wound look very clean and Karen preferred to keep it down in the hot water for the pain relief it provided. The level of pain ebbed and flowed coming in waves reaching up as far as the thigh which was consistent with what was described on the internet. The websites all said that oral antibiotics are usually prescribed to limit infection and need to be continued  for at least 5 days after any signs of infection have cleared. Ever since we cruised in South East Asia we have carried a very extensive medical kit on board including just such a broad spectrum antibiotic so we administered one of those immediately to get ahead of any nasty bugs the aggrieved stingray may have left in Karen’s leg.

5 Go to hospital emergency department.

This is the stage when nurse and patient started to have divergent views. Karen did not want to go, saying we’d done all the treatment so everything would be fine soon. She’d been looking forward to four days of doing not much and no little stingray was going to spoil it. I on the other hand had just read about the, admittedly rare but still possible, negative outcomes which escalate through necrotising  infections where the surrounding flesh dies and can result in amputation in extreme cases up through allergic reactions to the toxins. The symptoms of which include •Difficulty breathing •Tightness in throat • Itching  • Nausea  •Fast pulse • Dizziness  •Loss of consciousness
The line that read “Perform cardiopulmonary resuscitation (CPR) if necessary” was enough to have me ready to weigh anchor on spot.  It was time to call in reinforcements to win this little impasse.


The Queensland Government Health provides an excellent telephone help line, 13 HEALTH (13 43 25 84) designed to lessen the load on hospital emergency departments by providing qualified staff to advise to people with medical issues on who to talk to and how quickly you should do it. Depending on the issue, many people are referred to more appropriate treatment providers other than hospital casualty departments. You can phone 24 hours a day 7 days a week for the cost of a local call.
I placed a call to them and was quickly connected to a registered nurse who immediately wanted to speak to Karen. She sought and was given a complete rundown on what happened, what treatment we’d administered on board and Karen’s basic medical history. The result was more a directive than advice. “Continue the hot water treatment and get into the harbour as quickly as possible. You will be going to the nearest emergency department which is at Redlands Hospital. Call me back when you are thirty minutes from the dock.”

Listening from the sidelines I knew the battle was won long before Karen was off the phone, by which time I had the dinghy up on the davits, swim platform stowed and was securing everything below. Karen mounted one last rear guard action with an unconvincing “I’m not sure about this.” When I asked if things were the other way around and it was me who’d been stung would she want to go or stay she meekly ran up the white flag with a quiet, “Go.”

Karen's swollen foot 'selfie' with the bucket of near scalding water below

Engine on, anchor up and away we went. In contrast to our meandering three hour, 13.5 mile sail to the island, our course back was a series of straight lines cutting close to each mark which abbreviated the distance to 12 miles while the engine turning at 2,000 rpm delivered 6.5 to 7 knots.  Regular changes of bucket saw the hot water treatment continue enroute. A flurry of phone calls began as we approached the channel into Manly Harbour less than ninety minutes after getting underway. Karen’s pain levels were still elevated and she was now quite nauseous. The 13 HEALTH advisor confirmed the need for hospitalisation and an ambulance was arranged to meet us at the dock. A call ahead had great marina neighbours standing by to meet the paramedics at the gates and guide them to the boat while others were ready to take lines to help Rob dock the boat solo.

Return trip was straight and as quick as possible. 12.0 Nautical Miles - 1 Hour 47 minutes - Average 6.8 kts - Max 7.4 kts

Within minutes Karen was examined on board which revealed elevated blood pressure. The paramedics asked for a complete rundown of the treatment we’d done and we also had a list ready for them of exact medication and dosages administered. We were relieved when they confirmed all were correct. Karen couldn’t help playing things down suggesting it was a lot of fuss over just a very small stingray. However, when it came time to leave the boat, the normally simple task of getting out of the cockpit and onto the dock revealed the truth. Her severely swollen foot could bear no weight at all and simply moving it shot waves of pain through her entire leg. It was another case of grit the teeth and punch through the pain barrier half crawling, half hopping before collapsing on the gurney on the pontoon light headed and struggling to keep the increasing nausea at bay.

Getting down from the boat to the gurney was no easy task
Once in the ambulance an ECG was done which showed some irregularities. With the marvels of modern technology again in play this was forwarded to the ER at the hospital in advance of transportation. They waited in the car park until a second ECG showed things were stable before hitting the road. 


'Big Foot' under observation later in the ER

On arrival at the hospital the staff reviewed the paramedic file notes, treatment we’d administered and again gave the nod of approval to our actions. Karen’s vitals were taken again and the puncture wound examined. It was now over four hours since the sting so the likelihood of allergic reaction was reducing by the minute. The nausea had passed, blood pressure settled back to near normal and the pain was slowly receding. The only real concern was whether any fragments of the barb remained in the wound which was much too painful to withstand anything in the way of prodding and poking. An x-ray showed no signs of anything but the radiologist suggested only an ultrasound scan would show up tiny fragments but that was not possible due to the painful swelling. Karen was also told that she was only the second stingray victim they had treated at the hospital.

Hard to believe that small puncture wound on the ankle could cause so much pain and swelling.

After monitoring for a couple of hours, Karen was discharged with course of antibiotics, the very one we’d administered shortly after the sting, and the instruction to come straight back in for an ultrasound if signs of any infection appeared at all.

Now a doctor saying you can go home is one thing but actually getting there is another. She’d arrived in an ambulance with two very qualified attendants. Now there was just us and our old Ford Explorer. Despite the improvement in her foot, Karen could barely manage the assisted hobble three metres from the emergency department door to our car. We live on our boat in the marina and although we are on the closest pontoon to the car park it’s still a distance of 100 metres or so including down a ramp the steepness of which depends on the tide.

Despite trying to put as much weight as possible on me, Karen only made it a few metres before coming to complete stop in far too much pain to continue on. If nothing else we sailors are a resourceful lot and before she knew it I was lowering her backside into one of the marina’s trolleys and wheeling her down the pontoon like a bag of groceries.  And so ended Our Dreamtime’s first and hopefully final medical emergency.

What we did wrong?

1 We both love stingrays and know they are timid, non-aggressive creatures of greater intelligence than most marine creatures. We also know that in their sandy shallows environment we should  both be on the lookout for them and shuffle our feet through the sand as a warning of our approach rather than bouncing along in big steps. On this occasion, Karen was unsighted walking at the back of the dinghy and we were both negligent in the way we were moving through the water.

2 While ensuring we had what appeared to be a comprehensive first aid manual on board we had never looked to see if it had adequate information regarding treatment of marine incidents we may experience. In fact we’d hardly examined it at all. It clearly didn’t provide the information we needed and if the sting had happened away from internet and phone access we would not have been able to respond anywhere near as well.

3 We did not head back to port and within easier reach of medical support immediately following our initial first aid treatment. Procrastination could have serious, even fatal consequences should a person have a more adverse reaction to the toxin. Neither the size of the stingray or the puncture wound is relevant.

What we did right.

1 We didn’t panic.

2 We did only very basic first aid until being sure of the appropriate further treatment steps to take. The first rule of medicine is ‘Do no harm’.

3 We had adequate first aid supplies and medications on board. Thanks to the assistance of our understanding GP we carry a range of medication which, in his words, are to “to stop you puking, make you poo, stop you pooing, antibiotics to beat the bugs and a range of different pain killers if you do something stupid to yourself.” Despite having much stronger pain relief on board Karen chose to limit herself to paracetamol to keep her wits about her and take an active part in her own treatment.
Our medical kit is extensive and well labeled so everything can be found quickly if needed.

4 We accessed assistance available to us including the internet, Government help line, friends, ambulance and emergency room. Although no actual treatment was deemed necessary in the ER, the situation could have been very different. As it was, despite immediate, appropriate first aid, Karen’s reaction to the toxins was enough to cause irregular heart beat shown on the ECG and elevated blood pressure quite apart from the pain inflicted. The peace of mind her time in the ER provided me is incalculable.

Stingrays

Unlike these small examples, stingrays are usually camouflaged in the sand.  (Image from internet)

Stingrays are non aggressive and remarkable intelligent creatures. But if frightened ,cornered or captured they can and will react purposefully and with great speed.
Stingrays are not capable of voluntarily raising and lowering their stings. It is reflex action. The wound comes from a powerful arching forward flick of the tale. During a sting the tip of the spine and the barbs pierce and lacerate the skin of the victim. Venom then simultaneously passes into the wound.
Stingray spines have many multiple barbs along both edges which often break off inside a puncture wound.
 (Image from internet)

Stingrays are known to frequently sting persons who capture them and then unwisely attempt to bring them into a boat, as well as when they are accidentally trod on by a person wading in the shallows. It is also dangerous to swim directly over a stingray as the spine may pierce the person's trunk with possible fatal consequences.

As of 1996, only 17 recorded  deaths had occurred worldwide from stingray barb injuries. The first reported Australian death in 1969 was contributed to a stingray barb directly to the heart of the patient, although there was no witness to the event. In 1989 a delayed fatality in a 12 year young boy stung after a freak accident in a small boat was reported. The sting of an air-borne stingray caused direct penetration of the left lung and the heart of the young victim.

The most famous victim was Steve Irwin who died in 2006 after being pierced in the chest by a stingray barb while filming an underwater documentary in Far North Queensland.

Avoidance of the most common injury (which is a sting from a stationary stingray to the lower leg in the shallows) can be avoided by inspecting the bottom of the area (eg boat ramp, shallow water, etc) and shuffling when wading in shallows. If a stingray is seen while snorkelling or diving, leave it alone! If a stingray is caught from a boat, cut the line or release the net and allow it to escape. Never pull it on board.

The stingray's intelligence far exceeds that of turtles and sharks. However their handling should not be attempted (except under expert supervision).

POSTSCRIPT: 

14 April 2015
Seven days after suffering the sting Karen is still suffering a burning sensation and discomfort in her foot but is at last now able to spend more than just very brief periods on her feet. The lingering power of the toxin injected by a single strike from a relatively small stingray is incredible but fortunately she is well on the way to a full recovery.



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11 comments:

  1. This is an excellent rundown which is not only free of panic but always exemplifies how much cruisers can act as their own medics in cases of emergency. Of course, there are limits to this, as well, as the trip to the hospital indicated, but I think you took all the right steps in terms of the first aid you were able to deliver, and the extensive preparation you made in terms of your medicine chest. There are books on the market that deal with specific cruiser-applicable medicine (lionfish and stonefish are also venom threats) and you may wish to have one of those aboard. I'm sharing this on Facebook...it's that good.

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  2. Thanks for your kind words Rhys. Three days after the event Karen is feeling much better but still walking with difficulty. We will be sourcing a cruiser-applicable medical book ASAP. If anyone has any suggestions, we'd love to hear them. Cheers!

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  3. Wow! What a drama and glad you are OK, KO! :) Thank goodness for 13 HEALTH and keeping calm. It's always good to test safety and security procedures! You've gained some excellent (but painful!!) experience! But hopefully this is the worst thing you'll experience! Looking forward to catching up soon. Much love. xx

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  4. they are nasty strikes ... One month on .... and I have been for further ultra sounds to see what this large grape sized lump is near the ankle. It's a fibrous calcium buildup around what was the main venom point ..... Can't take it out as to many tendons in the region .. Dr's advise wear soft shoes ... Lucky my ambition in life is only to wear flip flops from now on LOL.

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  5. Ten weeks on ..... I still have a scab where the barb entered just near the ankle, it just won't seem to heal.

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  6. Great post, a few years back I had almost an identical experience. The hot water was incredible! Without that I don’t know what I would have done. Unfortunately, mine got infected and I spent a night in the hospital. I feel for you, this was a terrible experience.

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    1. Karen took some convincing but as soon as she put her foot in the bucket of hot water she was sold. Did your infection take long to heal?

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  7. A fisherman's trick down here is to use the pee hole on an outboard motor to obtain hot water to help with the pain right away.

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    1. Good idea. We will keep that in the memory banks. Thanks.

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