Fishing is reputedly the most popular sport in Australia - indulged in an enjoyed by thousands country wide. It is not without its hazards. People get washed off rocks when fishing, some are even taken by crocodiles or sharks. Few escape some sort of injury as a direct consequence of their participation in their piscatorial adventures.
Last summer I saw two shark attack victims in a week - a couple of weeks after a man was killed by a shark only a few kilometres from us. The first was a teenage lad who was bitten on the thigh while surfing. By the grace of God the wounds were not life threatening. He attended us for management of the wounds after initial treatment by a surgeon. They healed nicely. The other was was also a teenage lad. He was working on his father’s professional fishing boat. He walked out of the boat’s cabin in bare feet and tripped over a small, freshly caught shark lying on the deck. The shark took exception and promptly bit the poor boy’s foot inflicting nasty wounds. He was well treated elsewhere initially and we only maintained the pristine state of the wounds.
Fishermen often become the victims of involuntary body piercing. In the holiday season we see one or two just about every day. Fish hooks embedded into fingers, hands, feet or sometimes even the face, eyes or ears. There are several different methods we can use to remove them. I prefer the “Advance and Withdraw” method - infiltrate the area with local anaesthetic, grasp the shaft of the hook firmly with artery forceps and push the barb through until it is clear of the skin. Then, cut off the barb with side cutters and pull the shaft back through the skin. A good clean up, a tetanus vaccination and a script for antibiotics and the job is done.
During recent school holidays a young man presented with a large tailor hook embedded in a finger. Attached to it were two other hooks of the same size – a typical gang of tailor hooks. I asked how he had managed to achieve this calamity. Abashed, he replied, “I was teaching my teenage son how to safely gang tailor hooks.” I asked where the son was. “Last time I saw him he was rolling on the ground laughing!” he replied in a matter-of-fact manner. I had to cut off the two free hooks before infiltrating the local anaesthetic and removing the embedded hook. The very next patient also had a fish hook embedded in a finger. However, it was a small herring hook and not ganged. It was much easier to deal with.
Hooks embedded in eyes are a very serious matter and require treatment by an ophthalmologist – (eye specialist). We don’t muck around with those injuries – eyesight is too precious. And it is not only the hooks from fishermen’s rigs that can cause damage. Sinkers can and do smash eyes - often causing permanent visual loss. This happens when an angler casts vigorously but the line is not free to run through the ferrules of the rod. The loose end will flick around causing the sinker to strike the eye with tremendous force. Similarly, when a line gets snagged on some underwater obstruction and the angler stretches the line attempting to free it. The line parts from the hook but the sinker stays with the line and hurtles out of the water to strike the hapless angler.
The tackle box always contains a knife. I had a salty old codger, literally, come in late one afternoon with a knife wound in his left bicep region. He smelled of Dettol and had a blood-stained, wet and rather dirty crepe bandage wound around his arm. His story was that he had been about twenty miles, (as he said), out to sea, with a mate in his boat, when he landed a small shark at about eight o’clock that morning. In attempting to sever the shark’s spinal cord it had lashed around and “somehow” the knife finished up sticking out of his arm. He pulled it out and continued in his endeavours to dispatch the shark, eventually succeeding before losing too much blood. He then poured some neat Dettol over the wound, bandaged it up and got on with his fishing. He didn’t consider it serious enough to abandon the fishing trip.
We took down the crude dressing to reveal a classic stab wound that had gone through the skin and into the biceps muscle. I said I felt we should get a surgeon to have a look at it with a view to taking him to the operating theatre and explore the wound properly. He refused point blank and asked me to do only what was necessary. He could not be persuaded otherwise.
Reluctantly, I perfused the wound with local anaesthetic, ( containing adrenaline to help prevent bleeding), and had as thorough a look around as possible. There was no foreign material in the wound but the muscle sheath had been incised. I could find no evidence of blood vessel, nerve or tendon damage. After thoroughly cleaning the wound I sutured the muscle sheath and then the skin. We gave a large dose of an antibiotic cocktail intravenously, a tetanus injection and dressed the wound. I wrote a prescription for follow up oral antibiotics and sent him on his way with strict instructions to get back to us if he had any trouble with it. He expressed his sincere appreciation for our efforts and left. He was rather anxious to get home to let his wife know he was OK before she called out the sea search and rescue people. He had not let her know what had happened or where he was. His boat was on its trailer in the hospital parking area.
Fish bones stuck in the throat are not an uncommon problem. Some are easy to treat while others are extremely difficult. The easy ones are those where a relatively large bone becomes embedded in the relatively large tonsils of a patient with a weak gag reflex. Often the bone can be readily seen with a light and a tongue depressor. It is then a simple matter to arrange the light to shine over the right shoulder, depress the tongue with a depressor in the left hand, reach down to and grasp the protruding bone with long forceps and gently withdraw it from the tonsil.
Small, fine bones such as those from garfish or whiting can be very difficult especially in someone with a strong gag reflex. These bones are difficult to see at the best of times. They are fine and they are short and can penetrate most of their length into the tonsil or other tissue in the throat. One such patient was here on holidays from Melbourne and got a garfish bone stuck in his throat. Trying to see down his throat was absolutely hopeless – he would gag violently as soon as I touched his tongue with the depressor. I suggested we arrange for him to see an ENT specialist in Fremantle but he declined stating he was returning to Melbourne next day and would sort it out over there. That was a shame but we cannot force patients to take our advice. The ENT people, nowadays, have fibre-optic endoscopes they can pass through the nose into the back of the throat and clearly see all of the tissues and any foreign bodies.
It is not uncommon for patients to present with the history of fish bone in the throat but nothing is found – even by the ENT people. We assume that a bone has scratched the throat and passed on or that it was only partly embedded and dislodged later. The sensation of a bone can last for even a couple of days after it has gone.
The flip side of this is the bone that is not removed from the throat. This may well cause infection with subsequent abscess which may be life threatening due to septicaemia (blood poisoning) or by causing enough swelling in the throat to block off the airway.
We often see people presenting with marine stings. Cobbler, flat head, cat fish and sting rays can inflict extremely painful wounds that are very difficult to treat. They cause excruciating pain which does not respond to injections of morphine and similar drugs. The commonly used method of relief is to immerse the wound into very hot water and keep it there and keep the water hot. It usually takes many hours before the pain eases. Theory has it that the heat slowly denturises the protein–based toxins that cause the pain.
I recently treated a sting ray wound to the ankle of a young adult male. The triage nurses had initiated the hot water treatment as soon as he presented. It was about two hours before I got to see him and the pain still returned with a vengeance as soon as he took it out of the water or the water cooled. He wanted to go home but he also wanted the pain to stop. The former was impractical until the latter was achieved.
I recalled a marine captain telling me that instant relief can be obtained from any marine sting by spraying the wound with CRC, WD40 or RP7. He had worked his way up in the industry by beginning as a deck hand on prawn trawlers. When the deckies got stung there was no stopping work – all they did was grab a can of strategically placed CRC or one of the others, spray the affected part, and get on with the job. I told my poor, suffering patient this and he promptly sent his wife off to get some. She returned with a can of CRC, we sprayed it on the wound and the relief was immediate and lasting. Don’t ask me how it works – I do not know. I do know it has worked a treat on wasp stings I have personally suffered when trimming the creeper on the back fence.
That same skipper told me that, on the prawn boats, they got stung by every marine creature capable of causing a sting and that the treatment worked with anything. I had occasion, recently, to use it on a woman in a bikini who swam into a swarm of common blue-bottle jelly fish. I warned her it would make her smell like a mechanic until she showered. It afforded immediate pain relief. I do not know how it would go on box jellyfish stings and certainly would not recommend it as the first line of treatment in preference to pouring vinegar over the stings. However, it is something that might well be worthy of academic investigation. It gets an occasional mention, in a Google search, as being useful in this context. During that search I came across the following pearl of wisdom.
A person needs only two tools: WD-40 and duct tape. If it doesn't move and it should, use WD-40. If it moves and it shouldn't, use the tape.
By the way; sting-rays inflict nasty wounds that require special attention. It is important to determine that the barb has not broken off under the skin and that there is no foreign matter in the wound such as beach sand. Stingrays do not have a venom sack. The toxin that causes the pain comes from the layer of slime covering its sting. Some of this enters the wound when the barb penetrates under the skin.
An old school acquaintance turned up in ED one day. He thought he had been stung by a cobbler while wading for crabs. He was in severe pain and there was a small laceration on top of his foot at the site of the pain. He told me he was wearing old, leather shoes at the time. I explained that a cobbler was unlikely to penetrate leather especially on the top of the foot. The wound and history were consistent with him having stood on a sting ray causing the tail to whip over into the top of his foot through the shoe. Anyway, I immediately tried the WD 40 - it did help some but not a lot. The hot water treatment did. He was keen to return home, about 150 ks away, but couldn’t keep his foot in a bucket of hot water all that way especially as he was driving. He left, still in pain, clutching a request form for an ultrasound of the foot to exclude embedded barb. A few days later he rang me to report he had purchased a can of WD40 and sprayed his foot frequently during the drive with some relief. He also reported the ultrasound showed no evidence of embedded barb.
The other day a middle aged chap presented with a dislocated toe. I put that back into place with the help of a few deep breaths of Entonox – a mixture of laughing gas (nitrous oxide) and oxygen and then had his foot x-rayed. That showed the toe in normal position and no fracture present. It also showed a large calcified foreign body between the long bones of the foot. He was at a loss to explain it for a while then remembered the sting ray attack he suffered quite a few years ago. He became a little indignant because a doctor had operated on his foot and told him he had removed the embedded barb. Obviously it had broken into two in the foot, the doctor found and removed what he thought was the complete object but didn’t x-ray the foot on completion of the job. Why it didn’t get infected I do not know.
The local estuary has some of the best crabs you are likely to find in Australia. They are easy to catch using drop nets from jetties or by scooping with a net while wading in the water. Youthful enthusiasm often leads to the crabs really coming to grips with children or teenagers. The crab’s nippers can exert a grip like the Boston strangler on the skin but rarely do any serious damage. The pointed ends of the nippers will puncture the skin and the shaft can cause considerable bruising to the skin – not to mention to the ego. It is uncommon for people to attend ED for crab bites but, now and then, a protective mother will bring in a child or reluctant teenager. All we do, as a rule, is clean the wound and give a tetanus injection and they rarely need anything else.
Marine species can effect a nasty revenge upon us even post-mortem (of the marine species). The angler cleaning his catch can finish up with a fish scale stuck on the cornea – much like a contact lens. The dorsal spines of fish often inflict puncture wounds into fingers and hands. People have been known to slip on fish bits and fall causing various injuries up to and including broken bones. I have witnessed the friendly banter of anglers, around fish cleaning bays, turn to violence.
Even after cooking and consumption the fish can be troublesome. Shell fish allergy is common and deadly serious. Even traces of , for example, prawn meat in a dish can trigger a life threatening reaction (anaphylaxis). Survivors of this insult will carry an Epipen injection with them at all times. At the first sign of a reaction they use it to inject themselves into the thigh with a life-saving dose of adrenaline.
And, of course, there is always the odd, crook prawn, in the kilo, that causes a nasty gastro-enteritis. The vomiting and diarrhoea can be severe enough to dehydrate the victim necessitating intravenous fluid replacement. The same can occur as a consequence of eating fish contaminated from poor cleaning, preparation or storage.
Bee sting allergy is another common, serious problem that necessitates the victims carry Epipen around with them. Immediate self-injection prevents anaphylaxis. Sensitivity is often treated with a course of desensitising injections which is usually very effective. It seems, too, that bee sting sensitive people get stung much more frequently than those who are not sensitive. However, that may simple mean that the sensitive patients present to doctor or hospital while the others just get the sting out and get on with it.
Removing a bee sting is simple but often done incorrectly. The sting protrudes from the skin – it is torn from the bee’s head immediately it punctures the skin – and has a venom sac on the end. (The poor old bee flutters away and promptly dies.) Common, reflex, practice, is to grasp the sting between thumb and forefinger and pull it out. This effectively squeezes all the venom from the sac into the victim under the skin. The safe way to do it is to scrape it out with a finger nail or a blunt knife edge or such like.
Strangely enough, the wives and children of bee keepers are often highly sensitive to bee stings. The mechanism behind this is frequent exposure to small amounts of bee proteins conveyed into the household on the clothing of the bee keeper. The family inhale and/or ingest tiny amounts repeatedly and this sets up an allergic response and sensitivity that can be catastrophic and fatal if they get stung by a bee.
One basic principle of allergy, little understood by the general population, is that allergic reactions rarely occur with the first exposure to an allergen such as bee sting, eggs, peanuts, prawns, penicillin or grevillia bush etc. It is only after the initial exposure that the human body begins to manufacture antibodies that precipitate the allergic reaction when the patient next comes into contact with the allergen. Any one suffering an allergic reaction to, for instance, penicillin must have previously had contact with penicillin in some form or other.
At the risk of wandering too far off my path, here, I might make mention of a strange phenomenon I regularly experience in the ED – people present to triage and state that they have been bitten by a spider. That is all very well and good – so to speak – but, after getting them into the department and settled on a couch, the first question I ask is, “What did this spider look like?” In the vast majority of cases the response is, “Oh, I didn’t actually see a spider but a bloke I know had the same sort of thing last year and he had been bitten by a spider.” – or words to that effect.
It is pointless to enquire if “the bloke” saw a spider. London to a brick he didn’t. So then I start from scratch the process of making a diagnosis. Rarely, there is sufficient evidence to support the self-diagnosis. Most times the diagnosis is something like a pimple, a scratch, an innocent insect bite or an allergic reaction.
It might be worthy of mention here that, in the words of a medical philosopher, the best that any doctor can achieve is to optimise conditions for nature to effect a cure. The doctor can achieve nothing more – and should achieve nothing less!