jamie-seymour_1_03-12-2026_103610: I walked in with a bandage
wrapped around the upper thigh.
And, my mate who runs the ED said, what are we putting this down as?
And I said can we not put it down as shark bite?
'cause that'll end up on the front page of the newspaper.
And he went, marine laceration.
Excellent.
Joe: Welcome to the Evidence-Based Urgentology podcast from EB Medicine,
where urgent care meets evidence.
I'm Joe Toscano, senior research editor for Emergency Medicine Practice,
and a member of the evidence-based Urgent Care editorial board.
Tracey: Hi there, and I'm Tracy Davidoff.
I'm editor in chief of Evidence-Based Urgent Care, and we're practicing
urgent care physicians with years of experience, probably too many years
of experience, on the front lines.
And for us, diagnosis is detective work and the clues are in the history,
the exam, and of course the evidence.
That thrill of solving the patient's puzzle is really
what keeps us coming back.
Joe: Each month we unpack the latest issue of evidence-based urgent care tackling
common chief complaints from presentation.
Through diagnosis to disposition, we highlight the best evidence, the key
takeaways, and the clinical pearls.
Tracey: And by the end of every episode, you'll have sharper skills, deeper
knowledge, and more sound strategies that you can use on your very next shift.
So let's dive in.
The evidence starts now.
And remember, you can always find more at www.ebmedicine.net.
Joe: Hello everyone.
We're excited to be able, again to include the authors of the issue.
We're gonna dive into this month, which is on the subject,
Tracey: Saw what you did there.
Joe: Which is on the subject of the urgent care Management of Common
Marine Life Injuries and Envenomation.
First, a quick announcement.
EB Medicine has rolled back subscription pricing for all its journals,
including evidence-based urgent care.
This pricing includes multi journal bundles.
Lower pricing means that learning and valuable CME opportunities
are accessible to clinicians who value clinical excellence.
Check it out on www.ebmedicine.net.
Tracey: That's awesome.
Always a good deal.
Gotta love it.
so this month our authors are Dr. Nicholas Byrd, who's the medical Director of the
Center for Hyperbaric Medicine at Virginia Mason, Franciscan Health in Seattle.
And Dr. Jamie Seymour, who is a research professor at the Australian
Institute of Tropical Health and Medicine at James Cook University.
And I hope I'm saying it right,
Cairns
jamie-seymour_1_03-12-2026_103610: Cairns.
Cairns.
just, bastardize the English language a little bit and you'll be right.
So Cairns.
Tracey: Us Americans we're always doing that sort of stuff, so in Australia.
So, welcome to Dr. Seymour, who is our first international guest on our podcast.
And we're very pleased to have him 14 hours ahead of us.
Joe: We also wanna give a shout out to our peer reviewers, Ivan Koay, who
practices urgent care in London, England.
Although I think he's changing now, he just sort of made an announcement
that he's changing his career.
But at the time he did the review, he was on the teaching
faculty of the Royal College of Surgeons in Edinborough, Scotland.
He hails from New Zealand though.
And our other peer reviewer was Lyndsie Watkins, who's a clinical
director and clinician with Northwell Go Health in Manorville, New York.
Tracey: Yeah, I actually spoke to Ivan this morning and he is still in London
and actively pursuing opportunities.
Joe: Cool.
Tracey: So this is one of the more exotic topics that we've had and some land lovers
or clinicians practicing hundreds or even thousands miles away from warm ocean.
Not me.
I'm in Florida and I guess not you 'cause you're in San Francisco, but
there's lots of people in Kansas, right?
They think they'll never have to take care of these conditions
discussed in this issue.
But you know what, I actually was gonna poo poo this when they suggested this
as an issue . And I emailed a few of my close friends across the country and
said, would you guys find value in this?
And everybody unanimously said, absolutely, we'd find value in this.
So we went ahead and, got the authors to go forward with it.
But can you tell us why any clinician might need to be conscious of
this no matter where you live?
nick-bird_1_03-11-2026_173609: I'll allow Jamie to chime in as well.
But my thoughts about this is that both the acute injuries as well as persistent
issues that can persist from stings and bites and all can have manifestations
that persist for days or weeks.
And so those can last after people have come back from their vacation.
So it is important to try to get a travel history from folks and
to figure out what's going on.
Most of those, if they're persistent symptoms may have the presentation
of infections or may have just persistent skin irritation.
And those are all important to be able to identify and, kind of work through.
If there is a progression of tissue necrosis or other damage, then
those also need to be evaluated.
So those are part one.
The other part is that there are a burgeoning number of aquarists
who would like to have stuff in their aquariums and lionfish are
a common one, just as an example.
And so lots of people get puncture wounds and envenomations from
lionfish just as an example.
And so just because they don't live natively in Kansas doesn't
mean that they might not be showing up in an aquarium near you.
Tracey: Yeah, the world's getting really much smaller and people are traveling more
and more and going to various different places, bucket list items, and even just
to see their favorite fish or whatever.
So yeah, so we're seeing a lot of people that are from all
over the place in Florida here.
We get tourists all the time that come from exotic environments on their trips.
And so, yeah, just because you live in Kansas or North Carolina or
Arizona, doesn't mean you're gonna not see something that, an injury
that occurred in the Caribbean or Australia or anywhere for that matter.
jamie-seymour_1_03-12-2026_103610: I think the other thing that, to in top
of that is a lot of, first of all, countries that go to, or tourists that
go to third world countries that get envenomed, their first port of call
is, they ring their GP back home.
And so you may have come from Kansas, you may be diving in Singapore
and get stung somewhere there.
And the local, medical paternity may not be up to speed with what's going on.
And the first port of call is you usually ring your gp and if you're a
GP sitting in Kansas and you have no idea what's going on from that point
of view, where do you go from there?
So I think, the number of calls I get from people in far away
continents going, what do I do now?
It's like, well, okay.
So I think it's important to do that.
And as Nick was saying, , the aquarists and the things of that
nature is becoming a real issue.
I mean, we've had just recently a person that was actually cleaning their fish
tank, and what happened is they had some zoanthids, which are like little
corals, and they upset them and they released this toxin into the water.
We ended up with, the family came down with poisoning from that.
And the local medical paternities, well, we have no idea what's going on.
We have these people that are coming in showing toxic effects, and we
have no idea where it's coming from.
So I, think you've got to keep in the back of your mind all the time
now that if you've got , these symptoms and things you can't explain
to be thinking of envenomations.
Joe: Awesome.
Jamie, it looks like you're a photographer, probably also a diver.
And this is a chance for you to plug some of the other folks who
helped you and Nick illustrate this issue with some fantastic photos.
You even got an up close and personal picture of a box
jellyfish and Irukandji jellyfish.
How far away were you
Tracey: No thanks.
Joe: To take those?
jamie-seymour_1_03-12-2026_103610: Yeah.
Joe: What kind of a Telephoto lens do you have
jamie-seymour_1_03-12-2026_103610: no, I wished it was there is, you can be pretty
much certain that most of the things that you've seen me take photos have,
tagged me at some stage along the line.
and it, it's interesting.
A lot of people say You must have been stung or bitten by
almost everything on the planet.
Which I have, but I actually don't wear it as a badge of honor.
Every time it's happened, it's because I've made a mistake
and those sorts of things that.
Yes, they're mistakes and they shouldn't happen, and you learn from them.
But the things that you do learn from them is, you then have some real hard
data of this is the animal that did the damage, this is what happened.
Rather than I think it was that, or I think it was something else.
But yeah, it just goes with the territory.
If you're gonna play with venomous animals somewhere on
the line, it's gonna go wrong.
And it's a matter of mitigating the fact that when it does go
wrong, it doesn't go wrong badly enough to end you up in hospital.
But then having said that, the local ED paternity here when I walked
through the door is the standard reply is, so what is it this time?
And it's oh, great.
Tracey: again,
jamie-seymour_1_03-12-2026_103610: Yeah.
Okay.
So, so I met the,, the last time we were playing with sharks and I got tagged in
the leg and I've got quite scars there.
And I, I walked in with a bandage wrapped around the upper thigh.
And, my mate who runs the ED said, what are we putting this down as?
And I said can we not put it down as shark bite?
'cause that'll end up on the front page of the newspaper.
And he went, marine laceration.
Excellent.
That sounds good.
Tracey: There you go.
Joe: Marine laceration.
Tracey: There you go.
Interesting.
All right, so, you emphasized both of you, I guess whoever wrote that
particular portion, but emphasizes the point that proteins are really the
composition for all known marine toxins.
So, by extension, hot water immersion is really first line
for treatment of these things.
And so obviously super low cost to reduce pain and to provide initial first aid.
What are some of the other unifying principles and best practices that
we should all keep in mind when we're treating in the field, but also treating
in the urgent care center as first aid and initial treatment when a patient
presents with this type of an injury.
nick-bird_1_03-11-2026_173609: I just, as a small aside, as a doc who has been
practicing hyperbaric medicine as well as urgent care medicine for most of my
20 plus years in practice the urgent care world is one of the areas about this
that really fascinated me, which was.
What do you do in that setting?
Because this is the sort of the, middle ground between primary medicine and
emergency care outside of a hospital.
And what can you treat locally?
What do you need to send?
And I think those disposition decisions are truly important.
with respect to, one of the things that I really loved about Jamie's research
is that for a long time the use of vinegar has been the mainstay of urgent
emergent care of all jellyfish stings.
And one of the fascinating aspects about his research was that while
that is probably reasonable or okay in non-lethal species, certainly in the
boxed jellyfish species, and, Jamie, please correct me if I'm misspeaking
or mischaracterizing your work.
Is that it can also create the release of additional up to 60%
more venom in those pneumatocysts that have already released venom.
It's one thing to stop other pneumatocysts from firing.
That's great.
That's a one box.
But the release of other additional amounts of venom that could be potentially
lethal at that point because it's a lethal toxin is really important.
So the approach is not just a one size fits all.
It is important to understand, in my mind, to appreciate both the timing of
where they are relative to their injury.
Is this a day, a week, a month out, or is this moments, are they still wet?
Are they in the water still?
And that all of those issues that timeline matter, and then the potential species.
So if you're in somewhere where Jamie lives in Queensland where
box jellyfish and Irukandji live.
These are important questions.
If you're in a place like where I am in Seattle, those
species are not here so much.
So, if you get stung it's likely a much less lethal concern.
Plus we're wearing dry suits and we're covered as thickly as we possibly can be.
So we're, it's cold out here.
I don't know if you've noticed, but the water's freezing, so we're
a lot lower risk of being injured.
So that's sort of the, foundation of this.
So the first part that I usually try to stress is getting
rid of the offending agents.
Most of the time if people are in the water and they're in salt water,
that's a great place to try to wipe off and remove these any kind
remaining tentacles or pneumatocysts that may be causing additional injury.
And then trying to neutralize some of that impact.
And this is where heat can help to destabilize some of these proteins and
minimize the risk of both the impact of venom and Jamie's research has
shown that we can with prolonged heat exposure of 20 plus minutes reduce the
impact and the lethality of that venom.
So that can be a huge impact.
Plus that heat can also reduce pain.
And so that's a big aspect of the first aid.
So lethality minimizing impact of symptoms, and also pain is
a big one that you can reduce.
By the time that, and Jamie, anything that I've misspoken about thus far,
jamie-seymour_1_03-12-2026_103610: No, I, I was gonna say that just to, to
reiterate that, I mean, one of the big things with Marine envenomations is
there is a variety of different things.
As Nick was saying, put vinegar on it, put heat on it, do this,
do that, do something else.
Debride the wound, don't debride the wound.
And the issue that we've found is the standard average run of the mill
punter on the beach when something happens is not sure what to do.
And as Nick was saying the timeline matters.
If you have somebody that has been envenomed on the beach,
they're not breathing, and their heart's not going, to us, what
you should be doing is so obvious.
It's CPR.
It is CPR.
It's not, do I put vinegar on it?
Do I move them over here?
Do I do something else?
And we see this routinely in Australia.
It's going, what do we do?
So as Nick was saying, the timeline's important.
But for us it's trying to make this simple so that, you know, what can we do?
Okay?
In the grand scheme of things, if the person's breathing
and they're screaming at you.
Yeah, they're in pain.
Do I really care what I do from then on in from the patient's wellbeing?
They're alive.
Yes.
Okay.
It's the patient that's not alive.
That we really need to panic about at that point in time.
Then later on, there's everything else, sort of falls on top of that.
But heat is the one that, we're trying to push.
But unfortunately it's not quite that simple because we know that, for
example, if you've been envenomed on the arm, and if the venom has been
sequestered in the arm, if I increase heat in that area, what do I do?
I increase blood flow to that area.
So if I've increased blood flow to the area, then I've possibly increased
the flow of the venom around the body.
So it's, not quite as cut and dry as we would like to it to be, but certainly
heat by and large seems to, you know, given that most proteins are heat liable.
If we heat them up, then we should deactivate them in some way.
Tracey: Yeah.
I found a lot of this information was really useful maybe not for me
to use in urgent care, but for me to use as a traveler, you know, I'm
on a beach somewhere on vacation and I see this happen to somebody,
what's the first thing people do?
Is there a doctor
jamie-seymour_1_03-12-2026_103610: Pee on them.
That's what you gotta do.
Pee on them.
Tracey: Well, I was gonna mention that too.
Because that's an old wives tale that many people, you know, that was the first
thing I was looking for, the first time I went through your manuscript is to see
if it said anything about peeing on it.
There's a famous show from the nineties around here called Friends.
I don't know if you've seen that in Australia, but that
was one of the famous episodes
jamie-seymour_1_03-12-2026_103610: Mm-hmm.
Tracey: was, somebody gets stung by something and, they all argue over
which one is gonna pee on the patient.
So yeah.
So let's just make it clear you are not recommending urine as a treatment
for any of these envenomations.
jamie-seymour_1_03-12-2026_103610: Definitely not.
and, And again, as Nick was saying, the timeline's important.
Stingrays a really good example.
So if you are a practitioner, you are not aware of what's happening
with Stingray envenomation, so you have a puncture wound.
The person comes in, it's a puncture wound, it looks
ugly, so what are we gonna do?
We're gonna suture it up so it doesn't bleed all over the place.
It's the worst thing you can do it, it's the sort of thing you would do for a,
if it was a knife injury or something, clean it, suture it up, away you go.
But the Venoms already there and, and it's not unusual for these patients to have
problems six to 12 months down the track.
So they're then no longer where they were.
They could be, in the middle of Siberia for the want of a better word.
And if you don't have an understanding of what's going on, and you've sutured
this wound up, the venoms doing its stuff underneath, and next thing you know,
you've got this necrotic lesion that, the person's liable to lose their leg from.
So, as, as Nick was saying, this timeline is really, really important.
nick-bird_1_03-11-2026_173609: So just to reiterate some of that for the listeners.
And I think that the physician traveler is actually probably a bigger concern
than the, urgent care practitioner.
Most of the time, by the, time someone presents to an urgent care
clinic, the acute window of where we're most worried about them has
passed for most of these stings
jamie-seymour_1_03-12-2026_103610: Yes.
nick-bird_1_03-11-2026_173609: If they get, even let's say they get
stung by a boxed jellyfish, if three hours later they walk into an urgent
care, they're not gonna die from it.
They may have pain, they may have a rash, they may be miserable,
but they're not gonna die from it.
And that's really important to know.
You can take a deep breath.
It's the person at the shore where they're stung and they're
immediately going into cardiac arrest.
That's the real problem.
So just as Jamie said those are folks that don't lose your mind and think, oh
shit, do I need to put, sorry uh, do I need to put uh, vinegar on this or do
jamie-seymour_1_03-12-2026_103610: Notice this was not the
Australian that swore like yes.
nick-bird_1_03-11-2026_173609: We're pirates from another planet, you
know, so it's important to recognize that we don't wanna lose our mind.
The issue is not vinegar versus CPR.
It's CPR, so let's just not miss the forest for the trees.
Let's really focus on life support then navigate some of the other issues.
They're a little bit more on some levels.
I, don't wanna say this flippantly, but they're a little bit more
cosmetic relative to that.
And it's, it's really important to just keep the forest for the trees on that.
and I think too Jamie's point about stingrays is such an important
one because these are persistent, nasty injuries that are often times
developed into something worse than what they are on initial presentation.
Even though the initial presentation is a lot of pain the wound itself may or may
not be as dramatic as you are thinking.
It's not like they're starting to rot away right now, but if you don't clean
it out really well, they may have persistent issues that move forward.
Tracey: Yeah, I mean, that's really good advice for any sort of animal injury.
You know, you're not gonna suture a dog bite.
You probably shouldn't suture a stingray laceration
nick-bird_1_03-11-2026_173609: Correct.
Tracey: For the same reason.
And, I have a, a good friend who always says that, decontamination is, the key.
The solution to pollution is dilution, is what he always says.
So, clean it out as good as you most possibly can, and don't suture
that baby up because you're gonna be in a world of hurt if you do.
Joe: Yeah.
In terms of applying heat, I love your, the improvisations you guys noted.
'cause I'd be thinking, where am I gonna get hot water or boil hot water?
But using the warm water outflow from a boat motor, or if you have a
thermos with some coffee or tea, it doesn't have to be water necessarily.
Or even hot sand.
I thought that was cool
jamie-seymour_1_03-12-2026_103610: Yep.
Joe: and you talked about the traveling physician.
I think that's another reason for us to know some of this stuff too.
'cause we can be more helpful when we are in some, some of these
locations, even if we live in Kansas.
So, I want to talk a little bit more about topicals because
there's more old wives tales.
I think you brought up the vinegar and that it's not a, one size
fits all solution and urine never.
But I can remember growing up in Florida people bringing adolphs meat tenderizer
with them just in case something, an ammonia alcohol or even that, oh, it's
a salt water thing, so use fresh water.
What about those kinds of things topically.
All bad.
jamie-seymour_1_03-12-2026_103610: No, not look, not, not bad, but not good.
I mean, if, if you take the meat tenderizer one for example, I mean if
you think about that theoretically, and if I had the venom and the
meat tenderizer and I put it together in a jar, it's gonna work.
There is zero chance now there's no problems there.
But the problem you have, you've gotta think, and this is where I think
people lose sight of the fact the venom is not on the surface of your skin.
The venom has now been, if it's a snake bite or if it's a jellyfish sting or
something, it's, I'm trying to convert this to imperial 'cause you guys haven't
come to the rest of the world yet.
But in millimeters it could be a quarter of a mil to a mil underneath the skin.
For the meat tenderizer to get there, it's first gotta chew up all the cells.
And then get to the venom.
So it's, it's, and this is what's happened.
You see this in a lot of first aid for a lot of venomous animals.
It's we'll do this because of, you know,, the old one of let's suck
the venom out of a snake bite.
It's seriously?
Or, what's the other beauty that we see is those electrical charges where
I'm gonna take an electrical, like a taser and you've been stung or bitten
by something, I'm gonna tase you at the spot and that's gonna denature the venom.
Tracey: Never heard of that
jamie-seymour_1_03-12-2026_103610: I've actually got, I, I should just
go and grab it outta my bookshop.
I've got a little machine that they sell and this is what they use it for.
So when you're bitten by a snake, you zap yourself with it.
And it's like, seriously, guys?
Just, just think it through.
And I think this is the, thing that, from a toxology point of view that
we've really tried to hammer out home in the last 15 or 20 years is,
let's go to evidenced based medicine.
There is so much out there.
Yes, I can understand there are times when you don't need to because
jumping out an airplane without a parachute, we don't need to run a
bloody randomized control trial on that.
But for a lot of the other stuff, we had zero evidence for why
we are using this yet we do it.
If it doesn't make the situation worse, great, then it doesn't really matter.
But sticking meat tenderizer on somebody's wound, zapping somebody with
electrical charge, urinating on somebody.
Guys, let's just think this through for a moment.
And I, think I said, that's where we are running nowadays
is evidence, evidence, evidence.
If we can come up with some evidence and if we go back to like the vinegar,
for example, when we originally started all this work vinegar.
I was singing the tune, you need to use vinegar.
You need to use vinegar.
'cause it deactivates these stinging organelles quite nicely.
But it wasn't until we did a study this end where there was a variety
of people not using vinegar.
I thought, oh, publish a paper showing that vinegar works and
this is why you should, we couldn't find any data to support that.
In fact, we found that when you used vinegar you ended up with more
opiates for that person and it's like, whoa, we've missed something here.
And it wasn't until we went back and looked at it and went, yes, it
causes, you know, certain, the ones that haven't discharged the stinging
organelles, from discharging, but nobody looked at what had already happened.
And so, you know, as Nick was saying, yeah, you can increase the venom
load in a victim by upwards of 60%.
So if you've got somebody that's sitting right on the edge
and you pour vinegar on them.
Bang, you've pushed him over into cardiac failure.
So, and it wasn't until we got, that evidence, but then having said
that, we still haven't been able to convince people to stop using vinegar.
It's, no, no, no.
We've been using vinegar for 20 years.
We're gonna continue.
Well, what's the evidence for its positive effect?
And there aren't any,
Tracey: Let's talk a little bit about foreign bodies.
Is there any use for x-ray or ultrasound , and how diligent do you have to be about
removing these and finding them all?
nick-bird_1_03-11-2026_173609: So I would say for , foreign objects it's important
to really always have this in mind with respect to puncture wounds, especially.
So, you know, if it's a jellyfish, you're not gonna have foreign
bodies there that are penetrating.
going back to that for just one moment, the application of heat is another one.
We talk about denaturing proteins.
The goal here is not to denature your proteins.
So if we cause a lot of burns and tissue injury, that doesn't help you.
So the goal is hot enough to help reduce your pain and maybe it helps
but recognize that surface heat can only penetrate again so far.
So you're not denaturing tissues that have been envenomated deeply into tissues.
So try not to also miss the application for what it can do
and what its limitations are.
So I just, small sidebar, but I want, let's go back to foreign bodies.
So the things that we talked about those can include certainly stingray
and urchins are a big one and they're just, the ocean's pin cushion.
That decides to leave these brittle barbs that are in you.
And there are not barbs so much, but they're all these spines that are in you.
And you can have people have multiples and oftentimes in the hands or in the feet.
And the biggest concern is places that are really of concern.
And if I asked a pool of doctors, if you had a puncture wound, what's the
biggest concern of a foreign body?
They say, well, a joint space.
Bam, you've already got it.
So if you've got a place that's really proximate or likely to be in
a joint space, that's a big concern.
And I would try to image those.
If you've got ones that are in a fleshy part of the body and there's really no
concern for a joint space, is there any neurological or neurovascular compromise?
And then do remember that you have these very brittle spines
that frequently stay in tissues.
May have a risk of infection because you've now just introduced external stuff
from the marine environment into there.
So infection risk is there but frequently the body does an amazing
job of spitting these things out and getting rid of them for most of these
injuries, at least most that I have seen.
These can get more complicated and punting to surgical expertise for
these is reasonable, but recognize too, this can be a fairly large
area, so , these are not like cactus thorns that are very easy to extract.
These are mushy annoying things that you try to extract and
they just dissolve on you.
Joe: Crumble.
Yeah.
nick-bird_1_03-11-2026_173609: They just crumble.
And so, on that level you may ask, so what are some tricks of the trade?
Well, you might as well, since they're gonna crumble, you might as well
contribute to their crumbling if you will, and try to get them maybe
washed out or more easy to remove.
And that's gonna be frequently my approach has been hot soapy, chlorhexidine Betadine
soap soaks where are helping to clean that area, helping to soften the skin.
And it may help to remove some of those urchin spines a little
bit, and they also may have some deposited pigment that persists
for months to even a year of time.
So sometimes that does not necessarily equate to retained foreign bodies, but
can be emblematic of retained pigment.
jamie-seymour_1_03-12-2026_103610: Sea urchin spines, just going from what Nick
was saying, can be an absolute nightmare.
We've had a couple of cases here where people have trodden on one and you end up
with 8, 9, 10 spines embedded in the heel and getting them out is almost impossible.
They're spines with recurved teeth on them.
So once they go in, they're not coming out.
As Nick's saying, they're brittle, they snap and they are a
monumental issue to try and treat
Joe: Was that managed by bringing 'em to the OR and
somebody pulling all of them out?
Or a wider debridement or just maybe leaving it in and seeing
if they came out on their own,
jamie-seymour_1_03-12-2026_103610: By and large with , the two or three patients
we'd worked with , it's a matter of, okay, you're looking at six to 12 months
down the track and with a bit of luck, they'll work themselves out but you can
start by, going , and we were reasonably aggressive to start with going, oh,
well, let's, slice it up and try and pull these things out, and you just end
up making the situation 10 times worse.
But if they're in a foot, then the person obviously can't walk and they
are horrific injuries to try and manage.
Joe: So with these kind of, deeper wounds, the chance of infections, you know,
deeper than it is long versus a wide open wound, chances of infection a lot higher.
And, and I got the feel from the article that antibiotic prophylaxis,
although it doesn't need to be for everybody, probably a higher proportion
of these marine injuries, we're gonna think about it versus wounds of other
characteristics or other settings, especially the wide open wounds.
Is there something, is it the salt water, is it the characteristics of the organisms
that are giving you the foreign body, or is it just the puncture wound that make
the antibiotic necessary in those cases?
And then the other question I had was you guys talked about a fairly broad spectrum,
triple antibiotic coverage with doxy and a first generation cephalosporin and levo.
Is that for prophylaxis or just for your truly infected wound and
something simpler if you just wanna do a kind of a preventative antibiotics?
nick-bird_1_03-11-2026_173609: This is great.
I, I'm, looking forward to what Jamie has to say.
It's just the sort of question where you ask three docs and you get four opinions.
And I, think that's at least been my experience.
And when in doubt, doxy is great for all the things that I can't
pronounce, and that are scary.
It's nice.
Doxy is a great sort of when in doubt but.
I wanna be thoughtful about antibiotic use.
So from gradations of injury, so minor scrapes that you can clean well and
watch oftentimes either no antibiotics or topical antibiotics would be sufficient,
just like you would with standard wound care, where you know that it's had some
contamination because although sea water is natural in quotes, it is not sterile.
So the marine world is filled with bacteria, it is
absolutely teeming with it.
So don't be naive to think that this is not a contaminated wound.
It is by its very nature.
And so it's important to be mindful and vibrio species are one that's important
especially for our doxycycline use.
Joe: Mm-hmm.
nick-bird_1_03-11-2026_173609: When you start having punctures and
lacerations, that risk increases in terms of the risk for infection.
And so even if you're seeing somebody, if you have the opportunity to see
them acutely, clean it out really well maybe debride tissue out and sort of
watch it and have close follow up, you may be able to continue to do good
wound care and cleaning and obviate the need for systemic antibiotics.
But at the first signs of infection, I would start them.
But if you've got somebody, let's say you're in Australia and that
person's gonna be leaving you.
And they're traveling back and you don't know when their next
follow up is actually going to be.
I would have a much lower threshold.
So these situations need to be thought through with respect to who they are
their comorbidities, their other risks.
I know we've talked about sort of extremes of age, the very young, the very old
comorbidities, people with diabetes the chronic smokers, people with microvascular
disease and peripheral vascular disease who have peripheral wounds that are
less likely to heal and respond well.
The immunocompromised those are all folks for which I would have a lower
threshold and be a little bit more aggressive and have much closer follow up.
jamie-seymour_1_03-12-2026_103610: and I think the other thing that often gets
lost on a lot of physicians is that the limited fuzzy data that we have,
it suggests that most of these marine venoms have a necrotic component to
them and for whatever reasons, and I've actually got a student here
at the moment that's come over from Brazil that's working with me on this.
It seems to increase the chances of getting infections in that area.
And having said that, it's so easy to ignore it.
And I wanna look at two particular cases.
One was a, a small child here where we had a stingray jump over the boat.
As it jumped through the boat, he got stung through the chest
and the child was all right.
They took him to hospital.
There was a puncture wound in the chest.
They checked it, it seemed all right.
No dramas.
Not a problem.
Child went home about five or six days later, I think the
child then collapsed and died.
And what had happened is the spine itself had gone through, punctured
through the chest and punctured the pericardium, the venom had stayed behind
and so the pericardium had closed over.
Not a problem.
The venom had stayed behind and what you ended up with is necrotic growth,
and you ended up with a hole in the pericardium bang, end of problem.
So that is a really good example of why it looked like a very minor wound.
But you didn't need to worry about it when in fact you did.
And then obviously the one the most famous one, which I was intimately
involved with was Steve Erwin's death.
Now, Steve, there, venom had nothing to do with that issue there you ended
up with a spine going between two ribs, and you ended up with a two and a half
centimeter puncture in the left ventricle.
Now Venom had no dramas there.
So you've got to look at this from all directions.
And I said in the first one, the injury itself was , not, small, nothing to worry
about, but it's the after effects of that.
Whereas in the second one, it was the injury to start with and not the venom.
But as I said, it's for some reason in the marine environment with toxins
involved, it seems to increase the chance of these secondary infections.
nick-bird_1_03-11-2026_173609: And, jamie has done a great job talking
to me about the stickiness, if you will, of especially stingray venom and
sticking to those tissues and causing more necrosis and tissue injury.
So debriding that out, cleaning that out surgically and
aggressively is really important.
So, don't be flippant about this.
This isn't your standard, sort of, I'm in the kitchen and I cut myself and
oh, I've washed it out kind of wound.
This is a very different flavor, even if the actual wound
itself is not that dramatic.
Tracey: So, just to be clear, we are saying that you do need
the three antibiotics for most of these that are infected?
nick-bird_1_03-11-2026_173609: Not necessarily.
But usually this is a one to two level of antibiotics.
So frequently this is doxy and cephalosporin or, doxy and, one of the
quinolones, depending on people's also be mindful of their allergy sensitivities.
But it's nice to have some, choices.
But oftentimes this is a, dual therapy, so you're trying to think
of what's likely to be there.
And also just think of your standard skin bugs that become opportunistic infections.
Joe: We've talked about a lot of, kind of detailed stuff, but
also just good general advice.
If you had to maybe give our listeners one overarching piece of advice
in dealing with envenomations and marine injuries what would it be?
jamie-seymour_1_03-12-2026_103610: I'm gonna go with the real simple
one, and then Nick can come in with the real complex one.
Treat what's in front of you.
If you treat what's in front of you, if the person's screaming
and yelling at you, great.
They're alive.
Let's look at pain management.
If the person's not, treat what's in front of you, if they need CPR, give it to 'em.
Forget everything else.
Breathe for 'em, thump up or down on their chest.
nick-bird_1_03-11-2026_173609: I couldn't say that any better.
As a family doc, when the kid is screaming, they're breathing, they're
angry as hell, but everything is working.
And so you can focus your attention towards the things that are not critical.
If they're a floppy, listless kid, that becomes a lot scarier.
And so that is very much like these.
So again, I agree entirely.
Focus on what's in front of you.
I would think in the urgent care setting on the whole these are not
life-threatening injuries that are presenting because they're usually
past the window of time where these things are the most concerning.
But do have your eyes open to issues of tissue necrosis and breakdown infection.
delayed surgical evaluation because things persist.
Tissue breakdown necrosis can suddenly, I mean that pericardial
example is very dramatic, but you can have other local tissue necrosis and
invasion that persists and continues that really just needs steel.
so this is the surgeon's desire.
It's like, right, we're gonna cut out bad tissue.
Perfect.
Get rid of it.
And so identifying those cases is excellent healthcare and knowing when
it needs to go on to that next level.
That's beautiful.
A lot of what the urgent care does, you are the highest level of triage.
You are figuring out what you can do yourself and what you need to send on,
and you can do people a tremendous amount of good service by recognizing that this
needs to go to a higher level and also helping those people at the higher level.
'cause just because you send it on to the surgeon does not mean that the surgeon
knows what the hell they're doing.
And you can really help to educate them with respect to, hey, this really
needs to be aggressively debrided and involve infectious disease.
'cause this was a marine life injury and these are possibly contaminated.
So setting the table for the specialist downstream from you
is also very integral to this.
Joe: All great points.
Tracey: Alright, well thank you so much.
We really enjoyed talking to you guys.
you know, It's kind of off the beaten path from our usual, but, definitely
incredibly useful information.
For anybody, like I said, whether you're a traveler or whether you're receiving
a traveler as a patient, things that we don't really know and hopefully, a
few of the things that we've discussed will stick in people's heads for that
future patient that walks in the door.
Because you know what?
It's urgent care.
You never know what's gonna walk in that door.
nick-bird_1_03-11-2026_173609: Thank you all so much.
jamie-seymour_1_03-12-2026_103610: Yeah.
Thank you guys.
Really appreciate your time.
Joe: Thank you guys
nick-bird_1_03-11-2026_173609: Cheers.
Tracey: I want to thank everybody to listening to this month's evidence based
urgentology podcast . Just a reminder that subscribers can go to ebmedicine.net
and read the full issue if you want more information, if you haven't already,
Joe: And if you're not a subscriber head to the site.
That's ebmedicine.net to check out what they have.
If you subscribe you'll get access to the article as well as future articles
and the whole archive of all past issues.
Tracey: Look forward to seeing you there.