Stingray Envenomation Needs X-Rays

Stingray Envenomation Needs X-Rays |Poison Boy Takes a Stand

I teach all my residents that every stingray envenomation needs x-rays.

Giant, sedan-sized stingray!

I published a horrific case report a few years ago detailing the story of a patient that, while fishing off North Carolina, caught a stingray. While trying to work the stingray off his line, the ray whipped its tail around and nailed the guy in the wrist. It was really painful and he had a lot of trouble extending his middle finger, so he went to the local ER and they gave him some antibiotics (no x-rays or other imaging). The patient finished all his antibiotics (Cipro – not an unreasonable choice) but he continued to have pain and swelling. His middle finger was completely useless and his ring finger was getting difficult to extend, so he went to his primary care doctor, who decided that he needed another course of antibiotics (again – no imaging). The patient finished another 10 days of antibiotics but the pain and swelling continued and his middle and ring fingers were now completely useless and hung down like cow udders (see attached article and pictures):

Two-week old stingray barb injury in my patient. Notice the completely flaccid, useless middle and ring fingers, the continued swelling and the retained stingray barb on the x-ray.

He finally came in to the ER and saw me. After hearing that story I x-rayed his wrist and sure enough, the guy had multiple stingray parts stuck in his wrist (his dominant wrist, by the way). I called the hand surgeon, who took the patient to the operating room and cleaned out a disgusting slimy-gray mess out of his wrist. The hand surgeon left the wrist open for a week, treated the patient with more antibiotics and brought him back for another wash-out. He finally wound up with an interposition tendon graft and a substantially reduced functionality of his dominant hand. If he had x-ray on the day of the injury, I’m quite sure the poor guy would not have suffered such a severe, debilitating  injury. That’s why every stingray envenomation needs x-rays.

Why am I so worked up about this and banging the “stingray envenomation needs x-ray” drum at this moment? An article was published in the August issue of the Journal of Emergency Medicine looking at the natural progress of a few dozen stingray envenomations. This paper came out of San Diego and is the first prospective study of stingray injuries. The authors noted that all the stingray injuries were treated with hot water by lifeguards. None of them had any x-rays. I can’t understand how these very smart doctors allowed this to happen. Frankly, not only should these injuries all get x-rays, since the barb is covered in an integumentary sheath (which can’t be seen on x-ray) containing venom, all these injuries should, in my opinion, be locally explored for evidence of the retained sheath and aggressively and extensively irrigated with hot water.

There is always the question about what is the best way to reduce pain in these injuries. Take it from me – these injuries hurt like crazy! One of my colleagues, Mike Reihart, was recently stung by a ray and he told me that he was practically in tears and it was one of the worst things he has ever experienced. Mike practices emergency medicine in Lancaster County – Amish country – no place for a wimpy ER doc. Mike is a tough guy and I believe him when he says how much it hurt. Best way to reduce pain is with hot, hot, hot water – the hottest the patient can stand. It stabilizes the nematocysts and prevents them from releasing the venom. Everything else that has been tried – vinegar, meat tenderizer, local lidocaine, morphine – not of it works as well as hot water. Urine works – probably just because its hot. I told Mike “Dude – your stingray envenomation needs x-rays.” I don’t think he ever got any. Why should he listen to Poison Boy?

Dr. Reihart and His Recent Injury

Take it from Mike – hot water is the key to happiness

These injuries probably don’t all require antibiotics, but if that’s the worst thing a doctor ever does (treat a stingray injury unnecessarily with antibiotics) then that’s a pretty good doctor, in my opinion.

I’m heading down to Myrtle Beach, SC for a week at the beach. Hope to see some stingrays and maybe a copperhead or two and post a few more environmental blogs.

Myrtle Beach Bound – ETD 0400.