1 00:00:00,000 --> 00:00:01,290 jamie-seymour_1_03-12-2026_103610: I walked in with a bandage 2 00:00:01,290 --> 00:00:02,460 wrapped around the upper thigh. 3 00:00:02,460 --> 00:00:05,769 And, my mate who runs the ED said, what are we putting this down as? 4 00:00:05,769 --> 00:00:07,855 And I said can we not put it down as shark bite? 5 00:00:07,885 --> 00:00:09,745 'cause that'll end up on the front page of the newspaper. 6 00:00:09,745 --> 00:00:11,815 And he went, marine laceration. 7 00:00:12,175 --> 00:00:12,625 Excellent. 8 00:00:20,338 --> 00:00:23,788 Joe: Welcome to the Evidence-Based Urgentology podcast from EB Medicine, 9 00:00:23,788 --> 00:00:26,068 where urgent care meets evidence. 10 00:00:26,178 --> 00:00:29,418 I'm Joe Toscano, senior research editor for Emergency Medicine Practice, 11 00:00:29,478 --> 00:00:32,208 and a member of the evidence-based Urgent Care editorial board. 12 00:00:33,513 --> 00:00:35,013 Tracey: Hi there, and I'm Tracy Davidoff. 13 00:00:35,013 --> 00:00:38,283 I'm editor in chief of Evidence-Based Urgent Care, and we're practicing 14 00:00:38,283 --> 00:00:41,163 urgent care physicians with years of experience, probably too many years 15 00:00:41,163 --> 00:00:42,903 of experience, on the front lines. 16 00:00:42,963 --> 00:00:46,833 And for us, diagnosis is detective work and the clues are in the history, 17 00:00:46,833 --> 00:00:48,543 the exam, and of course the evidence. 18 00:00:48,783 --> 00:00:50,943 That thrill of solving the patient's puzzle is really 19 00:00:50,943 --> 00:00:52,083 what keeps us coming back. 20 00:00:52,718 --> 00:00:57,158 Joe: Each month we unpack the latest issue of evidence-based urgent care tackling 21 00:00:57,158 --> 00:00:58,958 common chief complaints from presentation. 22 00:00:58,958 --> 00:01:02,828 Through diagnosis to disposition, we highlight the best evidence, the key 23 00:01:02,828 --> 00:01:04,058 takeaways, and the clinical pearls. 24 00:01:04,928 --> 00:01:08,048 Tracey: And by the end of every episode, you'll have sharper skills, deeper 25 00:01:08,048 --> 00:01:11,768 knowledge, and more sound strategies that you can use on your very next shift. 26 00:01:12,158 --> 00:01:13,118 So let's dive in. 27 00:01:13,118 --> 00:01:14,258 The evidence starts now. 28 00:01:14,408 --> 00:01:19,688 And remember, you can always find more at www.ebmedicine.net. 29 00:01:20,352 --> 00:01:21,042 Joe: Hello everyone. 30 00:01:21,072 --> 00:01:24,012 We're excited to be able, again to include the authors of the issue. 31 00:01:24,012 --> 00:01:27,882 We're gonna dive into this month, which is on the subject, 32 00:01:27,912 --> 00:01:28,422 Tracey: Saw what you did there. 33 00:01:29,682 --> 00:01:32,802 Joe: Which is on the subject of the urgent care Management of Common 34 00:01:32,802 --> 00:01:33,962 Marine Life Injuries and Envenomation. 35 00:01:34,962 --> 00:01:35,952 First, a quick announcement. 36 00:01:35,977 --> 00:01:39,637 EB Medicine has rolled back subscription pricing for all its journals, 37 00:01:39,637 --> 00:01:41,377 including evidence-based urgent care. 38 00:01:41,797 --> 00:01:44,077 This pricing includes multi journal bundles. 39 00:01:44,167 --> 00:01:47,317 Lower pricing means that learning and valuable CME opportunities 40 00:01:47,317 --> 00:01:50,257 are accessible to clinicians who value clinical excellence. 41 00:01:50,647 --> 00:01:54,607 Check it out on www.ebmedicine.net. 42 00:01:55,407 --> 00:01:56,217 Tracey: That's awesome. 43 00:01:56,307 --> 00:01:57,267 Always a good deal. 44 00:01:57,267 --> 00:01:57,897 Gotta love it. 45 00:01:58,407 --> 00:02:01,887 so this month our authors are Dr. Nicholas Byrd, who's the medical Director of the 46 00:02:01,887 --> 00:02:06,077 Center for Hyperbaric Medicine at Virginia Mason, Franciscan Health in Seattle. 47 00:02:06,317 --> 00:02:10,577 And Dr. Jamie Seymour, who is a research professor at the Australian 48 00:02:10,577 --> 00:02:14,027 Institute of Tropical Health and Medicine at James Cook University. 49 00:02:14,027 --> 00:02:15,677 And I hope I'm saying it right, 50 00:02:15,887 --> 00:02:16,137 Cairns 51 00:02:16,682 --> 00:02:17,162 jamie-seymour_1_03-12-2026_103610: Cairns. 52 00:02:17,162 --> 00:02:17,772 Cairns. 53 00:02:19,182 --> 00:02:21,792 just, bastardize the English language a little bit and you'll be right. 54 00:02:21,797 --> 00:02:22,767 So Cairns. 55 00:02:23,107 --> 00:02:27,157 Tracey: Us Americans we're always doing that sort of stuff, so in Australia. 56 00:02:27,157 --> 00:02:31,857 So, welcome to Dr. Seymour, who is our first international guest on our podcast. 57 00:02:31,947 --> 00:02:35,494 And we're very pleased to have him 14 hours ahead of us. 58 00:02:35,894 --> 00:02:39,404 Joe: We also wanna give a shout out to our peer reviewers, Ivan Koay, who 59 00:02:39,824 --> 00:02:41,774 practices urgent care in London, England. 60 00:02:41,834 --> 00:02:44,654 Although I think he's changing now, he just sort of made an announcement 61 00:02:44,654 --> 00:02:45,644 that he's changing his career. 62 00:02:45,644 --> 00:02:48,884 But at the time he did the review, he was on the teaching 63 00:02:48,884 --> 00:02:52,864 faculty of the Royal College of Surgeons in Edinborough, Scotland. 64 00:02:53,264 --> 00:02:54,824 He hails from New Zealand though. 65 00:02:55,214 --> 00:02:57,974 And our other peer reviewer was Lyndsie Watkins, who's a clinical 66 00:02:57,974 --> 00:03:01,874 director and clinician with Northwell Go Health in Manorville, New York. 67 00:03:02,674 --> 00:03:06,054 Tracey: Yeah, I actually spoke to Ivan this morning and he is still in London 68 00:03:06,054 --> 00:03:08,584 and actively pursuing opportunities. 69 00:03:09,069 --> 00:03:09,359 Joe: Cool. 70 00:03:09,464 --> 00:03:13,604 Tracey: So this is one of the more exotic topics that we've had and some land lovers 71 00:03:13,604 --> 00:03:17,204 or clinicians practicing hundreds or even thousands miles away from warm ocean. 72 00:03:17,979 --> 00:03:18,369 Not me. 73 00:03:18,369 --> 00:03:21,549 I'm in Florida and I guess not you 'cause you're in San Francisco, but 74 00:03:21,549 --> 00:03:23,229 there's lots of people in Kansas, right? 75 00:03:23,539 --> 00:03:25,639 They think they'll never have to take care of these conditions 76 00:03:25,639 --> 00:03:26,569 discussed in this issue. 77 00:03:26,569 --> 00:03:29,545 But you know what, I actually was gonna poo poo this when they suggested this 78 00:03:29,545 --> 00:03:33,659 as an issue . And I emailed a few of my close friends across the country and 79 00:03:33,659 --> 00:03:35,369 said, would you guys find value in this? 80 00:03:35,369 --> 00:03:39,089 And everybody unanimously said, absolutely, we'd find value in this. 81 00:03:39,309 --> 00:03:42,279 So we went ahead and, got the authors to go forward with it. 82 00:03:42,629 --> 00:03:46,479 But can you tell us why any clinician might need to be conscious of 83 00:03:46,479 --> 00:03:47,769 this no matter where you live? 84 00:03:48,234 --> 00:03:50,308 nick-bird_1_03-11-2026_173609: I'll allow Jamie to chime in as well. 85 00:03:50,308 --> 00:03:56,571 But my thoughts about this is that both the acute injuries as well as persistent 86 00:03:56,571 --> 00:04:01,711 issues that can persist from stings and bites and all can have manifestations 87 00:04:01,711 --> 00:04:03,631 that persist for days or weeks. 88 00:04:03,691 --> 00:04:07,131 And so those can last after people have come back from their vacation. 89 00:04:07,311 --> 00:04:11,091 So it is important to try to get a travel history from folks and 90 00:04:11,091 --> 00:04:12,171 to figure out what's going on. 91 00:04:12,171 --> 00:04:16,821 Most of those, if they're persistent symptoms may have the presentation 92 00:04:16,821 --> 00:04:19,731 of infections or may have just persistent skin irritation. 93 00:04:20,061 --> 00:04:23,741 And those are all important to be able to identify and, kind of work through. 94 00:04:24,331 --> 00:04:28,351 If there is a progression of tissue necrosis or other damage, then 95 00:04:28,351 --> 00:04:30,301 those also need to be evaluated. 96 00:04:30,301 --> 00:04:32,401 So those are part one. 97 00:04:32,641 --> 00:04:36,251 The other part is that there are a burgeoning number of aquarists 98 00:04:36,301 --> 00:04:39,661 who would like to have stuff in their aquariums and lionfish are 99 00:04:39,661 --> 00:04:41,521 a common one, just as an example. 100 00:04:42,151 --> 00:04:46,391 And so lots of people get puncture wounds and envenomations from 101 00:04:46,391 --> 00:04:48,391 lionfish just as an example. 102 00:04:48,391 --> 00:04:52,141 And so just because they don't live natively in Kansas doesn't 103 00:04:52,141 --> 00:04:55,261 mean that they might not be showing up in an aquarium near you. 104 00:04:56,061 --> 00:04:59,481 Tracey: Yeah, the world's getting really much smaller and people are traveling more 105 00:04:59,481 --> 00:05:03,926 and more and going to various different places, bucket list items, and even just 106 00:05:03,926 --> 00:05:06,176 to see their favorite fish or whatever. 107 00:05:06,426 --> 00:05:09,276 So yeah, so we're seeing a lot of people that are from all 108 00:05:09,276 --> 00:05:10,446 over the place in Florida here. 109 00:05:10,446 --> 00:05:14,636 We get tourists all the time that come from exotic environments on their trips. 110 00:05:14,636 --> 00:05:18,966 And so, yeah, just because you live in Kansas or North Carolina or 111 00:05:18,966 --> 00:05:22,239 Arizona, doesn't mean you're gonna not see something that, an injury 112 00:05:22,239 --> 00:05:26,129 that occurred in the Caribbean or Australia or anywhere for that matter. 113 00:05:26,129 --> 00:05:28,349 jamie-seymour_1_03-12-2026_103610: I think the other thing that, to in top 114 00:05:28,349 --> 00:05:32,459 of that is a lot of, first of all, countries that go to, or tourists that 115 00:05:32,459 --> 00:05:36,849 go to third world countries that get envenomed, their first port of call 116 00:05:36,879 --> 00:05:39,249 is, they ring their GP back home. 117 00:05:39,904 --> 00:05:43,454 And so you may have come from Kansas, you may be diving in Singapore 118 00:05:43,634 --> 00:05:45,734 and get stung somewhere there. 119 00:05:45,764 --> 00:05:50,894 And the local, medical paternity may not be up to speed with what's going on. 120 00:05:50,924 --> 00:05:53,834 And the first port of call is you usually ring your gp and if you're a 121 00:05:53,834 --> 00:05:57,644 GP sitting in Kansas and you have no idea what's going on from that point 122 00:05:57,644 --> 00:05:59,624 of view, where do you go from there? 123 00:05:59,624 --> 00:06:03,624 So I think, the number of calls I get from people in far away 124 00:06:03,624 --> 00:06:05,694 continents going, what do I do now? 125 00:06:05,694 --> 00:06:07,134 It's like, well, okay. 126 00:06:07,934 --> 00:06:09,339 So I think it's important to do that. 127 00:06:09,339 --> 00:06:12,209 And as Nick was saying, , the aquarists and the things of that 128 00:06:12,209 --> 00:06:14,039 nature is becoming a real issue. 129 00:06:14,039 --> 00:06:19,059 I mean, we've had just recently a person that was actually cleaning their fish 130 00:06:19,059 --> 00:06:22,149 tank, and what happened is they had some zoanthids, which are like little 131 00:06:22,149 --> 00:06:26,239 corals, and they upset them and they released this toxin into the water. 132 00:06:26,569 --> 00:06:29,749 We ended up with, the family came down with poisoning from that. 133 00:06:30,109 --> 00:06:33,769 And the local medical paternities, well, we have no idea what's going on. 134 00:06:33,769 --> 00:06:37,339 We have these people that are coming in showing toxic effects, and we 135 00:06:37,339 --> 00:06:38,959 have no idea where it's coming from. 136 00:06:38,959 --> 00:06:42,046 So I, think you've got to keep in the back of your mind all the time 137 00:06:42,046 --> 00:06:45,016 now that if you've got , these symptoms and things you can't explain 138 00:06:45,016 --> 00:06:47,246 to be thinking of envenomations. 139 00:06:47,811 --> 00:06:48,261 Joe: Awesome. 140 00:06:49,061 --> 00:06:51,971 Jamie, it looks like you're a photographer, probably also a diver. 141 00:06:51,971 --> 00:06:54,401 And this is a chance for you to plug some of the other folks who 142 00:06:54,401 --> 00:06:57,731 helped you and Nick illustrate this issue with some fantastic photos. 143 00:06:58,121 --> 00:07:00,521 You even got an up close and personal picture of a box 144 00:07:00,521 --> 00:07:03,801 jellyfish and Irukandji jellyfish. 145 00:07:04,071 --> 00:07:04,911 How far away were you 146 00:07:05,141 --> 00:07:05,211 Tracey: No thanks. 147 00:07:05,411 --> 00:07:06,101 Joe: To take those? 148 00:07:06,531 --> 00:07:06,831 jamie-seymour_1_03-12-2026_103610: Yeah. 149 00:07:06,901 --> 00:07:08,271 Joe: What kind of a Telephoto lens do you have 150 00:07:08,471 --> 00:07:11,051 jamie-seymour_1_03-12-2026_103610: no, I wished it was there is, you can be pretty 151 00:07:11,051 --> 00:07:14,021 much certain that most of the things that you've seen me take photos have, 152 00:07:14,071 --> 00:07:16,441 tagged me at some stage along the line. 153 00:07:16,461 --> 00:07:17,361 and it, it's interesting. 154 00:07:17,361 --> 00:07:19,371 A lot of people say You must have been stung or bitten by 155 00:07:19,451 --> 00:07:20,331 almost everything on the planet. 156 00:07:20,691 --> 00:07:23,061 Which I have, but I actually don't wear it as a badge of honor. 157 00:07:23,541 --> 00:07:26,391 Every time it's happened, it's because I've made a mistake 158 00:07:26,891 --> 00:07:29,006 and those sorts of things that. 159 00:07:29,696 --> 00:07:32,876 Yes, they're mistakes and they shouldn't happen, and you learn from them. 160 00:07:32,876 --> 00:07:37,241 But the things that you do learn from them is, you then have some real hard 161 00:07:37,241 --> 00:07:40,811 data of this is the animal that did the damage, this is what happened. 162 00:07:40,811 --> 00:07:43,361 Rather than I think it was that, or I think it was something else. 163 00:07:43,361 --> 00:07:45,604 But yeah, it just goes with the territory. 164 00:07:45,604 --> 00:07:47,374 If you're gonna play with venomous animals somewhere on 165 00:07:47,374 --> 00:07:49,084 the line, it's gonna go wrong. 166 00:07:49,264 --> 00:07:52,684 And it's a matter of mitigating the fact that when it does go 167 00:07:52,684 --> 00:07:55,524 wrong, it doesn't go wrong badly enough to end you up in hospital. 168 00:07:55,524 --> 00:07:58,734 But then having said that, the local ED paternity here when I walked 169 00:07:58,734 --> 00:08:02,004 through the door is the standard reply is, so what is it this time? 170 00:08:02,004 --> 00:08:02,694 And it's oh, great. 171 00:08:03,389 --> 00:08:03,504 Tracey: again, 172 00:08:03,534 --> 00:08:04,104 jamie-seymour_1_03-12-2026_103610: Yeah. 173 00:08:04,104 --> 00:08:04,524 Okay. 174 00:08:05,324 --> 00:08:08,879 So, so I met the,, the last time we were playing with sharks and I got tagged in 175 00:08:08,879 --> 00:08:10,409 the leg and I've got quite scars there. 176 00:08:10,409 --> 00:08:13,529 And I, I walked in with a bandage wrapped around the upper thigh. 177 00:08:13,529 --> 00:08:16,839 And, my mate who runs the ED said, what are we putting this down as? 178 00:08:16,839 --> 00:08:18,924 And I said can we not put it down as shark bite? 179 00:08:18,954 --> 00:08:20,814 'cause that'll end up on the front page of the newspaper. 180 00:08:20,814 --> 00:08:22,884 And he went, marine laceration. 181 00:08:23,244 --> 00:08:23,694 Excellent. 182 00:08:23,754 --> 00:08:24,354 That sounds good. 183 00:08:24,409 --> 00:08:24,709 Tracey: There you go. 184 00:08:24,774 --> 00:08:25,794 Joe: Marine laceration. 185 00:08:26,169 --> 00:08:27,039 Tracey: There you go. 186 00:08:27,109 --> 00:08:27,739 Interesting. 187 00:08:28,539 --> 00:08:31,686 All right, so, you emphasized both of you, I guess whoever wrote that 188 00:08:31,686 --> 00:08:35,383 particular portion, but emphasizes the point that proteins are really the 189 00:08:35,383 --> 00:08:37,293 composition for all known marine toxins. 190 00:08:37,683 --> 00:08:41,089 So, by extension, hot water immersion is really first line 191 00:08:41,089 --> 00:08:42,139 for treatment of these things. 192 00:08:42,139 --> 00:08:47,569 And so obviously super low cost to reduce pain and to provide initial first aid. 193 00:08:47,899 --> 00:08:51,109 What are some of the other unifying principles and best practices that 194 00:08:51,139 --> 00:08:54,489 we should all keep in mind when we're treating in the field, but also treating 195 00:08:54,489 --> 00:08:58,179 in the urgent care center as first aid and initial treatment when a patient 196 00:08:58,179 --> 00:08:59,703 presents with this type of an injury. 197 00:09:00,103 --> 00:09:03,313 nick-bird_1_03-11-2026_173609: I just, as a small aside, as a doc who has been 198 00:09:03,413 --> 00:09:08,123 practicing hyperbaric medicine as well as urgent care medicine for most of my 199 00:09:08,423 --> 00:09:12,813 20 plus years in practice the urgent care world is one of the areas about this 200 00:09:12,813 --> 00:09:14,433 that really fascinated me, which was. 201 00:09:14,928 --> 00:09:16,308 What do you do in that setting? 202 00:09:16,368 --> 00:09:19,991 Because this is the sort of the, middle ground between primary medicine and 203 00:09:19,991 --> 00:09:22,361 emergency care outside of a hospital. 204 00:09:22,631 --> 00:09:24,401 And what can you treat locally? 205 00:09:24,451 --> 00:09:25,451 What do you need to send? 206 00:09:25,981 --> 00:09:29,131 And I think those disposition decisions are truly important. 207 00:09:29,504 --> 00:09:34,134 with respect to, one of the things that I really loved about Jamie's research 208 00:09:34,164 --> 00:09:39,234 is that for a long time the use of vinegar has been the mainstay of urgent 209 00:09:39,294 --> 00:09:42,144 emergent care of all jellyfish stings. 210 00:09:42,564 --> 00:09:46,454 And one of the fascinating aspects about his research was that while 211 00:09:46,514 --> 00:09:51,294 that is probably reasonable or okay in non-lethal species, certainly in the 212 00:09:51,294 --> 00:09:54,594 boxed jellyfish species, and, Jamie, please correct me if I'm misspeaking 213 00:09:54,594 --> 00:09:55,944 or mischaracterizing your work. 214 00:09:56,259 --> 00:10:00,889 Is that it can also create the release of additional up to 60% 215 00:10:00,889 --> 00:10:04,839 more venom in those pneumatocysts that have already released venom. 216 00:10:05,799 --> 00:10:08,379 It's one thing to stop other pneumatocysts from firing. 217 00:10:08,379 --> 00:10:08,949 That's great. 218 00:10:08,949 --> 00:10:09,909 That's a one box. 219 00:10:10,269 --> 00:10:14,889 But the release of other additional amounts of venom that could be potentially 220 00:10:14,889 --> 00:10:19,029 lethal at that point because it's a lethal toxin is really important. 221 00:10:19,809 --> 00:10:24,599 So the approach is not just a one size fits all. 222 00:10:24,599 --> 00:10:29,489 It is important to understand, in my mind, to appreciate both the timing of 223 00:10:29,579 --> 00:10:31,829 where they are relative to their injury. 224 00:10:32,159 --> 00:10:36,659 Is this a day, a week, a month out, or is this moments, are they still wet? 225 00:10:36,659 --> 00:10:37,859 Are they in the water still? 226 00:10:38,309 --> 00:10:42,899 And that all of those issues that timeline matter, and then the potential species. 227 00:10:42,899 --> 00:10:46,409 So if you're in somewhere where Jamie lives in Queensland where 228 00:10:46,499 --> 00:10:48,479 box jellyfish and Irukandji live. 229 00:10:48,824 --> 00:10:50,504 These are important questions. 230 00:10:50,564 --> 00:10:53,864 If you're in a place like where I am in Seattle, those 231 00:10:53,864 --> 00:10:56,054 species are not here so much. 232 00:10:56,084 --> 00:11:01,024 So, if you get stung it's likely a much less lethal concern. 233 00:11:01,294 --> 00:11:06,124 Plus we're wearing dry suits and we're covered as thickly as we possibly can be. 234 00:11:06,124 --> 00:11:07,894 So we're, it's cold out here. 235 00:11:07,894 --> 00:11:11,194 I don't know if you've noticed, but the water's freezing, so we're 236 00:11:11,194 --> 00:11:13,274 a lot lower risk of being injured. 237 00:11:13,649 --> 00:11:16,509 So that's sort of the, foundation of this. 238 00:11:16,799 --> 00:11:19,909 So the first part that I usually try to stress is getting 239 00:11:19,909 --> 00:11:21,379 rid of the offending agents. 240 00:11:21,409 --> 00:11:24,529 Most of the time if people are in the water and they're in salt water, 241 00:11:24,709 --> 00:11:28,769 that's a great place to try to wipe off and remove these any kind 242 00:11:28,769 --> 00:11:32,049 remaining tentacles or pneumatocysts that may be causing additional injury. 243 00:11:32,569 --> 00:11:35,749 And then trying to neutralize some of that impact. 244 00:11:35,799 --> 00:11:40,149 And this is where heat can help to destabilize some of these proteins and 245 00:11:40,149 --> 00:11:44,149 minimize the risk of both the impact of venom and Jamie's research has 246 00:11:44,149 --> 00:11:49,579 shown that we can with prolonged heat exposure of 20 plus minutes reduce the 247 00:11:49,579 --> 00:11:52,309 impact and the lethality of that venom. 248 00:11:52,669 --> 00:11:54,469 So that can be a huge impact. 249 00:11:54,799 --> 00:11:57,159 Plus that heat can also reduce pain. 250 00:11:57,159 --> 00:11:59,489 And so that's a big aspect of the first aid. 251 00:11:59,839 --> 00:12:03,819 So lethality minimizing impact of symptoms, and also pain is 252 00:12:03,819 --> 00:12:05,769 a big one that you can reduce. 253 00:12:06,449 --> 00:12:10,869 By the time that, and Jamie, anything that I've misspoken about thus far, 254 00:12:11,114 --> 00:12:13,066 jamie-seymour_1_03-12-2026_103610: No, I, I was gonna say that just to, to 255 00:12:13,071 --> 00:12:16,791 reiterate that, I mean, one of the big things with Marine envenomations is 256 00:12:17,241 --> 00:12:19,581 there is a variety of different things. 257 00:12:19,631 --> 00:12:23,311 As Nick was saying, put vinegar on it, put heat on it, do this, 258 00:12:23,311 --> 00:12:24,751 do that, do something else. 259 00:12:24,901 --> 00:12:26,551 Debride the wound, don't debride the wound. 260 00:12:26,941 --> 00:12:31,201 And the issue that we've found is the standard average run of the mill 261 00:12:31,201 --> 00:12:35,071 punter on the beach when something happens is not sure what to do. 262 00:12:35,601 --> 00:12:37,638 And as Nick was saying the timeline matters. 263 00:12:37,858 --> 00:12:41,038 If you have somebody that has been envenomed on the beach, 264 00:12:41,428 --> 00:12:46,428 they're not breathing, and their heart's not going, to us, what 265 00:12:46,428 --> 00:12:49,128 you should be doing is so obvious. 266 00:12:49,428 --> 00:12:50,418 It's CPR. 267 00:12:50,808 --> 00:12:51,498 It is CPR. 268 00:12:51,528 --> 00:12:53,118 It's not, do I put vinegar on it? 269 00:12:53,328 --> 00:12:54,258 Do I move them over here? 270 00:12:54,258 --> 00:12:55,098 Do I do something else? 271 00:12:55,098 --> 00:12:57,308 And we see this routinely in Australia. 272 00:12:57,308 --> 00:12:59,078 It's going, what do we do? 273 00:12:59,408 --> 00:13:01,798 So as Nick was saying, the timeline's important. 274 00:13:02,168 --> 00:13:07,358 But for us it's trying to make this simple so that, you know, what can we do? 275 00:13:07,568 --> 00:13:07,898 Okay? 276 00:13:07,898 --> 00:13:10,088 In the grand scheme of things, if the person's breathing 277 00:13:10,088 --> 00:13:11,198 and they're screaming at you. 278 00:13:11,573 --> 00:13:12,593 Yeah, they're in pain. 279 00:13:12,833 --> 00:13:17,033 Do I really care what I do from then on in from the patient's wellbeing? 280 00:13:17,183 --> 00:13:17,933 They're alive. 281 00:13:18,173 --> 00:13:18,683 Yes. 282 00:13:18,713 --> 00:13:19,133 Okay. 283 00:13:19,583 --> 00:13:21,413 It's the patient that's not alive. 284 00:13:21,938 --> 00:13:24,698 That we really need to panic about at that point in time. 285 00:13:25,148 --> 00:13:28,608 Then later on, there's everything else, sort of falls on top of that. 286 00:13:28,608 --> 00:13:30,771 But heat is the one that, we're trying to push. 287 00:13:31,041 --> 00:13:35,031 But unfortunately it's not quite that simple because we know that, for 288 00:13:35,031 --> 00:13:38,571 example, if you've been envenomed on the arm, and if the venom has been 289 00:13:38,781 --> 00:13:43,251 sequestered in the arm, if I increase heat in that area, what do I do? 290 00:13:43,251 --> 00:13:44,551 I increase blood flow to that area. 291 00:13:45,201 --> 00:13:48,351 So if I've increased blood flow to the area, then I've possibly increased 292 00:13:48,631 --> 00:13:50,431 the flow of the venom around the body. 293 00:13:50,431 --> 00:13:55,431 So it's, not quite as cut and dry as we would like to it to be, but certainly 294 00:13:55,431 --> 00:14:00,011 heat by and large seems to, you know, given that most proteins are heat liable. 295 00:14:00,291 --> 00:14:03,191 If we heat them up, then we should deactivate them in some way. 296 00:14:03,381 --> 00:14:03,681 Tracey: Yeah. 297 00:14:04,051 --> 00:14:07,576 I found a lot of this information was really useful maybe not for me 298 00:14:07,576 --> 00:14:11,506 to use in urgent care, but for me to use as a traveler, you know, I'm 299 00:14:11,506 --> 00:14:14,506 on a beach somewhere on vacation and I see this happen to somebody, 300 00:14:14,756 --> 00:14:15,866 what's the first thing people do? 301 00:14:15,866 --> 00:14:16,406 Is there a doctor 302 00:14:16,601 --> 00:14:17,261 jamie-seymour_1_03-12-2026_103610: Pee on them. 303 00:14:17,441 --> 00:14:18,281 That's what you gotta do. 304 00:14:18,281 --> 00:14:18,941 Pee on them. 305 00:14:19,646 --> 00:14:21,626 Tracey: Well, I was gonna mention that too. 306 00:14:21,649 --> 00:14:24,769 Because that's an old wives tale that many people, you know, that was the first 307 00:14:24,769 --> 00:14:27,899 thing I was looking for, the first time I went through your manuscript is to see 308 00:14:27,899 --> 00:14:29,579 if it said anything about peeing on it. 309 00:14:29,629 --> 00:14:32,859 There's a famous show from the nineties around here called Friends. 310 00:14:32,859 --> 00:14:34,826 I don't know if you've seen that in Australia, but that 311 00:14:34,826 --> 00:14:35,556 was one of the famous episodes 312 00:14:35,696 --> 00:14:35,906 jamie-seymour_1_03-12-2026_103610: Mm-hmm. 313 00:14:36,396 --> 00:14:39,526 Tracey: was, somebody gets stung by something and, they all argue over 314 00:14:39,526 --> 00:14:41,476 which one is gonna pee on the patient. 315 00:14:41,846 --> 00:14:42,476 So yeah. 316 00:14:42,476 --> 00:14:46,646 So let's just make it clear you are not recommending urine as a treatment 317 00:14:46,646 --> 00:14:48,393 for any of these envenomations. 318 00:14:48,878 --> 00:14:49,018 jamie-seymour_1_03-12-2026_103610: Definitely not. 319 00:14:49,048 --> 00:14:51,236 and, And again, as Nick was saying, the timeline's important. 320 00:14:51,516 --> 00:14:53,166 Stingrays a really good example. 321 00:14:53,436 --> 00:14:56,496 So if you are a practitioner, you are not aware of what's happening 322 00:14:56,496 --> 00:14:58,806 with Stingray envenomation, so you have a puncture wound. 323 00:14:59,376 --> 00:15:01,326 The person comes in, it's a puncture wound, it looks 324 00:15:01,326 --> 00:15:02,196 ugly, so what are we gonna do? 325 00:15:02,376 --> 00:15:04,356 We're gonna suture it up so it doesn't bleed all over the place. 326 00:15:04,356 --> 00:15:08,496 It's the worst thing you can do it, it's the sort of thing you would do for a, 327 00:15:08,546 --> 00:15:11,696 if it was a knife injury or something, clean it, suture it up, away you go. 328 00:15:11,726 --> 00:15:15,896 But the Venoms already there and, and it's not unusual for these patients to have 329 00:15:15,896 --> 00:15:18,686 problems six to 12 months down the track. 330 00:15:19,091 --> 00:15:21,581 So they're then no longer where they were. 331 00:15:21,701 --> 00:15:24,521 They could be, in the middle of Siberia for the want of a better word. 332 00:15:24,881 --> 00:15:28,147 And if you don't have an understanding of what's going on, and you've sutured 333 00:15:28,147 --> 00:15:31,727 this wound up, the venoms doing its stuff underneath, and next thing you know, 334 00:15:31,727 --> 00:15:35,587 you've got this necrotic lesion that, the person's liable to lose their leg from. 335 00:15:35,587 --> 00:15:38,832 So, as, as Nick was saying, this timeline is really, really important. 336 00:15:39,632 --> 00:15:42,602 nick-bird_1_03-11-2026_173609: So just to reiterate some of that for the listeners. 337 00:15:42,662 --> 00:15:46,622 And I think that the physician traveler is actually probably a bigger concern 338 00:15:46,622 --> 00:15:48,232 than the, urgent care practitioner. 339 00:15:48,712 --> 00:15:51,946 Most of the time, by the, time someone presents to an urgent care 340 00:15:51,946 --> 00:15:56,917 clinic, the acute window of where we're most worried about them has 341 00:15:56,917 --> 00:15:58,377 passed for most of these stings 342 00:15:58,492 --> 00:15:58,762 jamie-seymour_1_03-12-2026_103610: Yes. 343 00:15:58,827 --> 00:16:00,342 nick-bird_1_03-11-2026_173609: If they get, even let's say they get 344 00:16:00,342 --> 00:16:03,857 stung by a boxed jellyfish, if three hours later they walk into an urgent 345 00:16:03,857 --> 00:16:05,837 care, they're not gonna die from it. 346 00:16:06,287 --> 00:16:09,407 They may have pain, they may have a rash, they may be miserable, 347 00:16:09,527 --> 00:16:10,847 but they're not gonna die from it. 348 00:16:10,937 --> 00:16:12,527 And that's really important to know. 349 00:16:12,527 --> 00:16:13,667 You can take a deep breath. 350 00:16:14,207 --> 00:16:18,017 It's the person at the shore where they're stung and they're 351 00:16:18,017 --> 00:16:20,147 immediately going into cardiac arrest. 352 00:16:20,147 --> 00:16:21,077 That's the real problem. 353 00:16:21,077 --> 00:16:26,334 So just as Jamie said those are folks that don't lose your mind and think, oh 354 00:16:26,357 --> 00:16:30,617 shit, do I need to put, sorry uh, do I need to put uh, vinegar on this or do 355 00:16:30,617 --> 00:16:31,847 jamie-seymour_1_03-12-2026_103610: Notice this was not the 356 00:16:31,847 --> 00:16:33,862 Australian that swore like yes. 357 00:16:37,366 --> 00:16:40,776 nick-bird_1_03-11-2026_173609: We're pirates from another planet, you 358 00:16:41,426 --> 00:16:46,266 know, so it's important to recognize that we don't wanna lose our mind. 359 00:16:46,266 --> 00:16:48,486 The issue is not vinegar versus CPR. 360 00:16:48,486 --> 00:16:51,636 It's CPR, so let's just not miss the forest for the trees. 361 00:16:51,636 --> 00:16:56,076 Let's really focus on life support then navigate some of the other issues. 362 00:16:56,076 --> 00:16:57,696 They're a little bit more on some levels. 363 00:16:58,401 --> 00:17:00,651 I, don't wanna say this flippantly, but they're a little bit more 364 00:17:00,651 --> 00:17:02,031 cosmetic relative to that. 365 00:17:02,351 --> 00:17:05,561 And it's, it's really important to just keep the forest for the trees on that. 366 00:17:05,841 --> 00:17:09,138 and I think too Jamie's point about stingrays is such an important 367 00:17:09,138 --> 00:17:13,698 one because these are persistent, nasty injuries that are often times 368 00:17:13,788 --> 00:17:17,598 developed into something worse than what they are on initial presentation. 369 00:17:17,598 --> 00:17:21,668 Even though the initial presentation is a lot of pain the wound itself may or may 370 00:17:21,668 --> 00:17:24,738 not be as dramatic as you are thinking. 371 00:17:25,143 --> 00:17:28,533 It's not like they're starting to rot away right now, but if you don't clean 372 00:17:28,533 --> 00:17:31,818 it out really well, they may have persistent issues that move forward. 373 00:17:32,618 --> 00:17:35,978 Tracey: Yeah, I mean, that's really good advice for any sort of animal injury. 374 00:17:35,978 --> 00:17:37,628 You know, you're not gonna suture a dog bite. 375 00:17:37,628 --> 00:17:39,998 You probably shouldn't suture a stingray laceration 376 00:17:40,073 --> 00:17:40,563 nick-bird_1_03-11-2026_173609: Correct. 377 00:17:40,788 --> 00:17:41,778 Tracey: For the same reason. 378 00:17:41,778 --> 00:17:46,089 And, I have a, a good friend who always says that, decontamination is, the key. 379 00:17:46,089 --> 00:17:49,529 The solution to pollution is dilution, is what he always says. 380 00:17:49,829 --> 00:17:53,009 So, clean it out as good as you most possibly can, and don't suture 381 00:17:53,009 --> 00:17:55,629 that baby up because you're gonna be in a world of hurt if you do. 382 00:17:55,964 --> 00:17:56,414 Joe: Yeah. 383 00:17:56,814 --> 00:17:59,844 In terms of applying heat, I love your, the improvisations you guys noted. 384 00:17:59,844 --> 00:18:03,554 'cause I'd be thinking, where am I gonna get hot water or boil hot water? 385 00:18:03,554 --> 00:18:07,238 But using the warm water outflow from a boat motor, or if you have a 386 00:18:07,238 --> 00:18:10,448 thermos with some coffee or tea, it doesn't have to be water necessarily. 387 00:18:10,738 --> 00:18:11,638 Or even hot sand. 388 00:18:11,638 --> 00:18:12,598 I thought that was cool 389 00:18:12,998 --> 00:18:13,198 jamie-seymour_1_03-12-2026_103610: Yep. 390 00:18:13,408 --> 00:18:15,478 Joe: and you talked about the traveling physician. 391 00:18:15,478 --> 00:18:18,238 I think that's another reason for us to know some of this stuff too. 392 00:18:18,268 --> 00:18:21,378 'cause we can be more helpful when we are in some, some of these 393 00:18:21,378 --> 00:18:22,998 locations, even if we live in Kansas. 394 00:18:22,998 --> 00:18:25,478 So, I want to talk a little bit more about topicals because 395 00:18:25,478 --> 00:18:27,128 there's more old wives tales. 396 00:18:27,128 --> 00:18:30,133 I think you brought up the vinegar and that it's not a, one size 397 00:18:30,133 --> 00:18:31,933 fits all solution and urine never. 398 00:18:32,293 --> 00:18:36,499 But I can remember growing up in Florida people bringing adolphs meat tenderizer 399 00:18:36,499 --> 00:18:42,049 with them just in case something, an ammonia alcohol or even that, oh, it's 400 00:18:42,049 --> 00:18:43,699 a salt water thing, so use fresh water. 401 00:18:43,709 --> 00:18:45,539 What about those kinds of things topically. 402 00:18:46,339 --> 00:18:47,059 All bad. 403 00:18:47,314 --> 00:18:50,314 jamie-seymour_1_03-12-2026_103610: No, not look, not, not bad, but not good. 404 00:18:50,314 --> 00:18:53,944 I mean, if, if you take the meat tenderizer one for example, I mean if 405 00:18:53,944 --> 00:18:58,114 you think about that theoretically, and if I had the venom and the 406 00:18:58,114 --> 00:19:01,534 meat tenderizer and I put it together in a jar, it's gonna work. 407 00:19:01,804 --> 00:19:04,054 There is zero chance now there's no problems there. 408 00:19:04,324 --> 00:19:06,634 But the problem you have, you've gotta think, and this is where I think 409 00:19:06,634 --> 00:19:11,074 people lose sight of the fact the venom is not on the surface of your skin. 410 00:19:11,779 --> 00:19:15,739 The venom has now been, if it's a snake bite or if it's a jellyfish sting or 411 00:19:15,739 --> 00:19:20,046 something, it's, I'm trying to convert this to imperial 'cause you guys haven't 412 00:19:20,256 --> 00:19:21,426 come to the rest of the world yet. 413 00:19:21,636 --> 00:19:25,786 But in millimeters it could be a quarter of a mil to a mil underneath the skin. 414 00:19:26,566 --> 00:19:30,081 For the meat tenderizer to get there, it's first gotta chew up all the cells. 415 00:19:30,691 --> 00:19:31,681 And then get to the venom. 416 00:19:31,681 --> 00:19:33,661 So it's, it's, and this is what's happened. 417 00:19:33,661 --> 00:19:37,231 You see this in a lot of first aid for a lot of venomous animals. 418 00:19:37,231 --> 00:19:40,271 It's we'll do this because of, you know,, the old one of let's suck 419 00:19:40,271 --> 00:19:41,591 the venom out of a snake bite. 420 00:19:42,071 --> 00:19:43,111 It's seriously? 421 00:19:43,141 --> 00:19:47,054 Or, what's the other beauty that we see is those electrical charges where 422 00:19:47,054 --> 00:19:50,174 I'm gonna take an electrical, like a taser and you've been stung or bitten 423 00:19:50,174 --> 00:19:53,264 by something, I'm gonna tase you at the spot and that's gonna denature the venom. 424 00:19:53,344 --> 00:19:54,134 Tracey: Never heard of that 425 00:19:54,464 --> 00:19:55,964 jamie-seymour_1_03-12-2026_103610: I've actually got, I, I should just 426 00:19:55,964 --> 00:19:57,194 go and grab it outta my bookshop. 427 00:19:57,494 --> 00:20:00,908 I've got a little machine that they sell and this is what they use it for. 428 00:20:00,908 --> 00:20:03,338 So when you're bitten by a snake, you zap yourself with it. 429 00:20:03,338 --> 00:20:04,491 And it's like, seriously, guys? 430 00:20:04,491 --> 00:20:05,751 Just, just think it through. 431 00:20:05,751 --> 00:20:09,201 And I think this is the, thing that, from a toxology point of view that 432 00:20:09,251 --> 00:20:12,701 we've really tried to hammer out home in the last 15 or 20 years is, 433 00:20:13,091 --> 00:20:16,631 let's go to evidenced based medicine. 434 00:20:17,021 --> 00:20:18,641 There is so much out there. 435 00:20:19,221 --> 00:20:22,041 Yes, I can understand there are times when you don't need to because 436 00:20:22,091 --> 00:20:24,731 jumping out an airplane without a parachute, we don't need to run a 437 00:20:24,851 --> 00:20:26,681 bloody randomized control trial on that. 438 00:20:26,961 --> 00:20:31,763 But for a lot of the other stuff, we had zero evidence for why 439 00:20:31,763 --> 00:20:34,223 we are using this yet we do it. 440 00:20:34,323 --> 00:20:37,383 If it doesn't make the situation worse, great, then it doesn't really matter. 441 00:20:37,743 --> 00:20:42,093 But sticking meat tenderizer on somebody's wound, zapping somebody with 442 00:20:42,093 --> 00:20:44,673 electrical charge, urinating on somebody. 443 00:20:45,473 --> 00:20:48,203 Guys, let's just think this through for a moment. 444 00:20:48,203 --> 00:20:50,549 And I, think I said, that's where we are running nowadays 445 00:20:50,549 --> 00:20:52,019 is evidence, evidence, evidence. 446 00:20:52,019 --> 00:20:55,179 If we can come up with some evidence and if we go back to like the vinegar, 447 00:20:55,179 --> 00:20:58,226 for example, when we originally started all this work vinegar. 448 00:20:58,256 --> 00:21:00,446 I was singing the tune, you need to use vinegar. 449 00:21:00,446 --> 00:21:01,406 You need to use vinegar. 450 00:21:01,406 --> 00:21:02,336 You need to use vinegar. 451 00:21:02,636 --> 00:21:05,486 'cause it deactivates these stinging organelles quite nicely. 452 00:21:05,876 --> 00:21:10,386 But it wasn't until we did a study this end where there was a variety 453 00:21:10,386 --> 00:21:11,436 of people not using vinegar. 454 00:21:11,436 --> 00:21:14,406 I thought, oh, publish a paper showing that vinegar works and 455 00:21:14,406 --> 00:21:17,736 this is why you should, we couldn't find any data to support that. 456 00:21:17,736 --> 00:21:21,921 In fact, we found that when you used vinegar you ended up with more 457 00:21:21,921 --> 00:21:25,581 opiates for that person and it's like, whoa, we've missed something here. 458 00:21:25,851 --> 00:21:28,251 And it wasn't until we went back and looked at it and went, yes, it 459 00:21:28,251 --> 00:21:31,526 causes, you know, certain, the ones that haven't discharged the stinging 460 00:21:31,676 --> 00:21:35,116 organelles, from discharging, but nobody looked at what had already happened. 461 00:21:35,536 --> 00:21:38,326 And so, you know, as Nick was saying, yeah, you can increase the venom 462 00:21:38,326 --> 00:21:41,176 load in a victim by upwards of 60%. 463 00:21:41,716 --> 00:21:44,326 So if you've got somebody that's sitting right on the edge 464 00:21:44,656 --> 00:21:45,856 and you pour vinegar on them. 465 00:21:46,276 --> 00:21:48,496 Bang, you've pushed him over into cardiac failure. 466 00:21:48,556 --> 00:21:52,326 So, and it wasn't until we got, that evidence, but then having said 467 00:21:52,326 --> 00:21:56,906 that, we still haven't been able to convince people to stop using vinegar. 468 00:21:56,936 --> 00:21:57,866 It's, no, no, no. 469 00:21:57,866 --> 00:21:59,786 We've been using vinegar for 20 years. 470 00:21:59,786 --> 00:22:00,476 We're gonna continue. 471 00:22:00,476 --> 00:22:03,123 Well, what's the evidence for its positive effect? 472 00:22:03,243 --> 00:22:03,873 And there aren't any, 473 00:22:04,273 --> 00:22:06,533 Tracey: Let's talk a little bit about foreign bodies. 474 00:22:06,583 --> 00:22:12,643 Is there any use for x-ray or ultrasound , and how diligent do you have to be about 475 00:22:12,643 --> 00:22:14,173 removing these and finding them all? 476 00:22:14,793 --> 00:22:18,173 nick-bird_1_03-11-2026_173609: So I would say for , foreign objects it's important 477 00:22:18,263 --> 00:22:22,043 to really always have this in mind with respect to puncture wounds, especially. 478 00:22:22,073 --> 00:22:24,813 So, you know, if it's a jellyfish, you're not gonna have foreign 479 00:22:24,813 --> 00:22:26,553 bodies there that are penetrating. 480 00:22:27,353 --> 00:22:31,103 going back to that for just one moment, the application of heat is another one. 481 00:22:31,103 --> 00:22:32,813 We talk about denaturing proteins. 482 00:22:33,023 --> 00:22:35,903 The goal here is not to denature your proteins. 483 00:22:35,903 --> 00:22:40,743 So if we cause a lot of burns and tissue injury, that doesn't help you. 484 00:22:41,163 --> 00:22:45,646 So the goal is hot enough to help reduce your pain and maybe it helps 485 00:22:45,646 --> 00:22:49,486 but recognize that surface heat can only penetrate again so far. 486 00:22:49,486 --> 00:22:54,513 So you're not denaturing tissues that have been envenomated deeply into tissues. 487 00:22:54,523 --> 00:22:59,283 So try not to also miss the application for what it can do 488 00:22:59,283 --> 00:23:00,633 and what its limitations are. 489 00:23:01,083 --> 00:23:04,533 So I just, small sidebar, but I want, let's go back to foreign bodies. 490 00:23:04,773 --> 00:23:08,213 So the things that we talked about those can include certainly stingray 491 00:23:08,676 --> 00:23:11,626 and urchins are a big one and they're just, the ocean's pin cushion. 492 00:23:12,276 --> 00:23:15,426 That decides to leave these brittle barbs that are in you. 493 00:23:15,426 --> 00:23:18,276 And there are not barbs so much, but they're all these spines that are in you. 494 00:23:18,276 --> 00:23:22,080 And you can have people have multiples and oftentimes in the hands or in the feet. 495 00:23:22,800 --> 00:23:26,789 And the biggest concern is places that are really of concern. 496 00:23:26,839 --> 00:23:30,259 And if I asked a pool of doctors, if you had a puncture wound, what's the 497 00:23:30,259 --> 00:23:31,759 biggest concern of a foreign body? 498 00:23:31,759 --> 00:23:32,704 They say, well, a joint space. 499 00:23:33,349 --> 00:23:34,639 Bam, you've already got it. 500 00:23:34,639 --> 00:23:37,459 So if you've got a place that's really proximate or likely to be in 501 00:23:37,459 --> 00:23:39,199 a joint space, that's a big concern. 502 00:23:39,779 --> 00:23:41,039 And I would try to image those. 503 00:23:41,039 --> 00:23:44,519 If you've got ones that are in a fleshy part of the body and there's really no 504 00:23:44,519 --> 00:23:49,429 concern for a joint space, is there any neurological or neurovascular compromise? 505 00:23:49,849 --> 00:23:54,109 And then do remember that you have these very brittle spines 506 00:23:54,109 --> 00:23:55,785 that frequently stay in tissues. 507 00:23:56,135 --> 00:24:00,855 May have a risk of infection because you've now just introduced external stuff 508 00:24:00,855 --> 00:24:02,385 from the marine environment into there. 509 00:24:02,835 --> 00:24:07,175 So infection risk is there but frequently the body does an amazing 510 00:24:07,175 --> 00:24:11,555 job of spitting these things out and getting rid of them for most of these 511 00:24:11,555 --> 00:24:13,145 injuries, at least most that I have seen. 512 00:24:13,665 --> 00:24:18,495 These can get more complicated and punting to surgical expertise for 513 00:24:18,495 --> 00:24:22,710 these is reasonable, but recognize too, this can be a fairly large 514 00:24:22,710 --> 00:24:27,290 area, so , these are not like cactus thorns that are very easy to extract. 515 00:24:27,650 --> 00:24:32,120 These are mushy annoying things that you try to extract and 516 00:24:32,120 --> 00:24:33,484 they just dissolve on you. 517 00:24:33,669 --> 00:24:33,939 Joe: Crumble. 518 00:24:34,114 --> 00:24:34,474 Yeah. 519 00:24:34,589 --> 00:24:34,899 nick-bird_1_03-11-2026_173609: They just crumble. 520 00:24:35,129 --> 00:24:39,522 And so, on that level you may ask, so what are some tricks of the trade? 521 00:24:39,552 --> 00:24:42,072 Well, you might as well, since they're gonna crumble, you might as well 522 00:24:42,072 --> 00:24:45,622 contribute to their crumbling if you will, and try to get them maybe 523 00:24:45,622 --> 00:24:47,812 washed out or more easy to remove. 524 00:24:47,862 --> 00:24:53,612 And that's gonna be frequently my approach has been hot soapy, chlorhexidine Betadine 525 00:24:53,612 --> 00:24:58,392 soap soaks where are helping to clean that area, helping to soften the skin. 526 00:24:58,602 --> 00:25:02,522 And it may help to remove some of those urchin spines a little 527 00:25:02,522 --> 00:25:06,242 bit, and they also may have some deposited pigment that persists 528 00:25:06,452 --> 00:25:08,762 for months to even a year of time. 529 00:25:08,762 --> 00:25:12,572 So sometimes that does not necessarily equate to retained foreign bodies, but 530 00:25:12,842 --> 00:25:14,792 can be emblematic of retained pigment. 531 00:25:15,237 --> 00:25:17,127 jamie-seymour_1_03-12-2026_103610: Sea urchin spines, just going from what Nick 532 00:25:17,127 --> 00:25:20,337 was saying, can be an absolute nightmare. 533 00:25:20,587 --> 00:25:24,337 We've had a couple of cases here where people have trodden on one and you end up 534 00:25:24,337 --> 00:25:30,367 with 8, 9, 10 spines embedded in the heel and getting them out is almost impossible. 535 00:25:30,827 --> 00:25:32,867 They're spines with recurved teeth on them. 536 00:25:32,867 --> 00:25:35,207 So once they go in, they're not coming out. 537 00:25:35,217 --> 00:25:38,307 As Nick's saying, they're brittle, they snap and they are a 538 00:25:38,567 --> 00:25:39,997 monumental issue to try and treat 539 00:25:40,784 --> 00:25:43,474 Joe: Was that managed by bringing 'em to the OR and 540 00:25:43,534 --> 00:25:44,944 somebody pulling all of them out? 541 00:25:44,944 --> 00:25:48,544 Or a wider debridement or just maybe leaving it in and seeing 542 00:25:48,544 --> 00:25:49,564 if they came out on their own, 543 00:25:49,639 --> 00:25:51,859 jamie-seymour_1_03-12-2026_103610: By and large with , the two or three patients 544 00:25:51,859 --> 00:25:55,369 we'd worked with , it's a matter of, okay, you're looking at six to 12 months 545 00:25:55,369 --> 00:25:57,949 down the track and with a bit of luck, they'll work themselves out but you can 546 00:25:57,949 --> 00:26:01,239 start by, going , and we were reasonably aggressive to start with going, oh, 547 00:26:01,239 --> 00:26:04,169 well, let's, slice it up and try and pull these things out, and you just end 548 00:26:04,169 --> 00:26:07,139 up making the situation 10 times worse. 549 00:26:07,229 --> 00:26:10,575 But if they're in a foot, then the person obviously can't walk and they 550 00:26:10,575 --> 00:26:12,460 are horrific injuries to try and manage. 551 00:26:13,667 --> 00:26:17,207 Joe: So with these kind of, deeper wounds, the chance of infections, you know, 552 00:26:17,237 --> 00:26:21,617 deeper than it is long versus a wide open wound, chances of infection a lot higher. 553 00:26:21,617 --> 00:26:27,017 And, and I got the feel from the article that antibiotic prophylaxis, 554 00:26:27,017 --> 00:26:30,857 although it doesn't need to be for everybody, probably a higher proportion 555 00:26:30,857 --> 00:26:34,640 of these marine injuries, we're gonna think about it versus wounds of other 556 00:26:34,640 --> 00:26:37,790 characteristics or other settings, especially the wide open wounds. 557 00:26:38,190 --> 00:26:42,210 Is there something, is it the salt water, is it the characteristics of the organisms 558 00:26:42,630 --> 00:26:46,410 that are giving you the foreign body, or is it just the puncture wound that make 559 00:26:46,410 --> 00:26:49,000 the antibiotic necessary in those cases? 560 00:26:49,000 --> 00:26:53,120 And then the other question I had was you guys talked about a fairly broad spectrum, 561 00:26:53,120 --> 00:26:57,860 triple antibiotic coverage with doxy and a first generation cephalosporin and levo. 562 00:26:58,280 --> 00:27:01,730 Is that for prophylaxis or just for your truly infected wound and 563 00:27:01,730 --> 00:27:05,720 something simpler if you just wanna do a kind of a preventative antibiotics? 564 00:27:06,025 --> 00:27:06,625 nick-bird_1_03-11-2026_173609: This is great. 565 00:27:06,625 --> 00:27:08,875 I, I'm, looking forward to what Jamie has to say. 566 00:27:08,925 --> 00:27:12,315 It's just the sort of question where you ask three docs and you get four opinions. 567 00:27:12,675 --> 00:27:15,245 And I, think that's at least been my experience. 568 00:27:15,405 --> 00:27:18,015 And when in doubt, doxy is great for all the things that I can't 569 00:27:18,015 --> 00:27:19,515 pronounce, and that are scary. 570 00:27:19,915 --> 00:27:20,635 It's nice. 571 00:27:20,755 --> 00:27:22,725 Doxy is a great sort of when in doubt but. 572 00:27:23,525 --> 00:27:25,445 I wanna be thoughtful about antibiotic use. 573 00:27:25,445 --> 00:27:30,195 So from gradations of injury, so minor scrapes that you can clean well and 574 00:27:30,195 --> 00:27:34,405 watch oftentimes either no antibiotics or topical antibiotics would be sufficient, 575 00:27:34,405 --> 00:27:37,621 just like you would with standard wound care, where you know that it's had some 576 00:27:37,621 --> 00:27:43,961 contamination because although sea water is natural in quotes, it is not sterile. 577 00:27:44,681 --> 00:27:47,771 So the marine world is filled with bacteria, it is 578 00:27:47,771 --> 00:27:49,551 absolutely teeming with it. 579 00:27:49,551 --> 00:27:53,643 So don't be naive to think that this is not a contaminated wound. 580 00:27:53,643 --> 00:27:55,593 It is by its very nature. 581 00:27:55,593 --> 00:28:00,303 And so it's important to be mindful and vibrio species are one that's important 582 00:28:00,553 --> 00:28:02,419 especially for our doxycycline use. 583 00:28:02,699 --> 00:28:03,119 Joe: Mm-hmm. 584 00:28:03,219 --> 00:28:04,749 nick-bird_1_03-11-2026_173609: When you start having punctures and 585 00:28:04,749 --> 00:28:08,929 lacerations, that risk increases in terms of the risk for infection. 586 00:28:09,729 --> 00:28:12,819 And so even if you're seeing somebody, if you have the opportunity to see 587 00:28:12,819 --> 00:28:17,429 them acutely, clean it out really well maybe debride tissue out and sort of 588 00:28:17,429 --> 00:28:22,049 watch it and have close follow up, you may be able to continue to do good 589 00:28:22,049 --> 00:28:26,429 wound care and cleaning and obviate the need for systemic antibiotics. 590 00:28:26,429 --> 00:28:29,309 But at the first signs of infection, I would start them. 591 00:28:29,759 --> 00:28:32,279 But if you've got somebody, let's say you're in Australia and that 592 00:28:32,279 --> 00:28:33,539 person's gonna be leaving you. 593 00:28:33,879 --> 00:28:36,289 And they're traveling back and you don't know when their next 594 00:28:36,289 --> 00:28:37,759 follow up is actually going to be. 595 00:28:37,999 --> 00:28:39,409 I would have a much lower threshold. 596 00:28:39,469 --> 00:28:44,089 So these situations need to be thought through with respect to who they are 597 00:28:44,339 --> 00:28:46,439 their comorbidities, their other risks. 598 00:28:46,529 --> 00:28:50,459 I know we've talked about sort of extremes of age, the very young, the very old 599 00:28:50,489 --> 00:28:54,849 comorbidities, people with diabetes the chronic smokers, people with microvascular 600 00:28:54,849 --> 00:28:58,629 disease and peripheral vascular disease who have peripheral wounds that are 601 00:28:58,749 --> 00:29:00,759 less likely to heal and respond well. 602 00:29:01,384 --> 00:29:05,694 The immunocompromised those are all folks for which I would have a lower 603 00:29:05,694 --> 00:29:08,784 threshold and be a little bit more aggressive and have much closer follow up. 604 00:29:09,424 --> 00:29:12,044 jamie-seymour_1_03-12-2026_103610: and I think the other thing that often gets 605 00:29:12,044 --> 00:29:15,514 lost on a lot of physicians is that the limited fuzzy data that we have, 606 00:29:15,574 --> 00:29:20,944 it suggests that most of these marine venoms have a necrotic component to 607 00:29:20,944 --> 00:29:24,798 them and for whatever reasons, and I've actually got a student here 608 00:29:24,798 --> 00:29:27,108 at the moment that's come over from Brazil that's working with me on this. 609 00:29:27,408 --> 00:29:32,628 It seems to increase the chances of getting infections in that area. 610 00:29:32,988 --> 00:29:35,652 And having said that, it's so easy to ignore it. 611 00:29:35,652 --> 00:29:37,632 And I wanna look at two particular cases. 612 00:29:37,732 --> 00:29:41,092 One was a, a small child here where we had a stingray jump over the boat. 613 00:29:41,512 --> 00:29:44,692 As it jumped through the boat, he got stung through the chest 614 00:29:45,332 --> 00:29:46,877 and the child was all right. 615 00:29:46,877 --> 00:29:47,717 They took him to hospital. 616 00:29:47,717 --> 00:29:49,037 There was a puncture wound in the chest. 617 00:29:49,377 --> 00:29:50,607 They checked it, it seemed all right. 618 00:29:50,637 --> 00:29:51,297 No dramas. 619 00:29:51,297 --> 00:29:51,897 Not a problem. 620 00:29:52,272 --> 00:29:55,692 Child went home about five or six days later, I think the 621 00:29:55,692 --> 00:29:57,882 child then collapsed and died. 622 00:29:58,212 --> 00:30:01,272 And what had happened is the spine itself had gone through, punctured 623 00:30:01,342 --> 00:30:05,352 through the chest and punctured the pericardium, the venom had stayed behind 624 00:30:05,412 --> 00:30:06,955 and so the pericardium had closed over. 625 00:30:06,955 --> 00:30:07,495 Not a problem. 626 00:30:07,675 --> 00:30:10,795 The venom had stayed behind and what you ended up with is necrotic growth, 627 00:30:10,945 --> 00:30:13,955 and you ended up with a hole in the pericardium bang, end of problem. 628 00:30:13,955 --> 00:30:18,455 So that is a really good example of why it looked like a very minor wound. 629 00:30:19,055 --> 00:30:21,305 But you didn't need to worry about it when in fact you did. 630 00:30:21,305 --> 00:30:25,345 And then obviously the one the most famous one, which I was intimately 631 00:30:25,345 --> 00:30:27,025 involved with was Steve Erwin's death. 632 00:30:27,325 --> 00:30:31,525 Now, Steve, there, venom had nothing to do with that issue there you ended 633 00:30:31,525 --> 00:30:35,975 up with a spine going between two ribs, and you ended up with a two and a half 634 00:30:35,975 --> 00:30:38,495 centimeter puncture in the left ventricle. 635 00:30:39,230 --> 00:30:40,910 Now Venom had no dramas there. 636 00:30:41,120 --> 00:30:44,110 So you've got to look at this from all directions. 637 00:30:44,110 --> 00:30:48,410 And I said in the first one, the injury itself was , not, small, nothing to worry 638 00:30:48,410 --> 00:30:50,990 about, but it's the after effects of that. 639 00:30:50,990 --> 00:30:54,140 Whereas in the second one, it was the injury to start with and not the venom. 640 00:30:54,190 --> 00:30:59,050 But as I said, it's for some reason in the marine environment with toxins 641 00:30:59,050 --> 00:31:03,070 involved, it seems to increase the chance of these secondary infections. 642 00:31:03,870 --> 00:31:05,735 nick-bird_1_03-11-2026_173609: And, jamie has done a great job talking 643 00:31:05,735 --> 00:31:10,115 to me about the stickiness, if you will, of especially stingray venom and 644 00:31:10,115 --> 00:31:13,595 sticking to those tissues and causing more necrosis and tissue injury. 645 00:31:13,965 --> 00:31:16,745 So debriding that out, cleaning that out surgically and 646 00:31:16,745 --> 00:31:18,305 aggressively is really important. 647 00:31:18,305 --> 00:31:20,405 So, don't be flippant about this. 648 00:31:20,405 --> 00:31:24,215 This isn't your standard, sort of, I'm in the kitchen and I cut myself and 649 00:31:24,425 --> 00:31:25,985 oh, I've washed it out kind of wound. 650 00:31:26,045 --> 00:31:29,193 This is a very different flavor, even if the actual wound 651 00:31:29,193 --> 00:31:30,813 itself is not that dramatic. 652 00:31:31,568 --> 00:31:34,148 Tracey: So, just to be clear, we are saying that you do need 653 00:31:34,148 --> 00:31:37,113 the three antibiotics for most of these that are infected? 654 00:31:37,163 --> 00:31:38,213 nick-bird_1_03-11-2026_173609: Not necessarily. 655 00:31:38,213 --> 00:31:42,050 But usually this is a one to two level of antibiotics. 656 00:31:42,080 --> 00:31:45,940 So frequently this is doxy and cephalosporin or, doxy and, one of the 657 00:31:45,940 --> 00:31:50,227 quinolones, depending on people's also be mindful of their allergy sensitivities. 658 00:31:50,497 --> 00:31:52,457 But it's nice to have some, choices. 659 00:31:52,757 --> 00:31:55,937 But oftentimes this is a, dual therapy, so you're trying to think 660 00:31:55,937 --> 00:31:58,007 of what's likely to be there. 661 00:31:58,337 --> 00:32:02,727 And also just think of your standard skin bugs that become opportunistic infections. 662 00:32:03,127 --> 00:32:05,997 Joe: We've talked about a lot of, kind of detailed stuff, but 663 00:32:05,997 --> 00:32:07,937 also just good general advice. 664 00:32:07,987 --> 00:32:11,727 If you had to maybe give our listeners one overarching piece of advice 665 00:32:11,777 --> 00:32:15,082 in dealing with envenomations and marine injuries what would it be? 666 00:32:15,482 --> 00:32:16,802 jamie-seymour_1_03-12-2026_103610: I'm gonna go with the real simple 667 00:32:16,802 --> 00:32:18,692 one, and then Nick can come in with the real complex one. 668 00:32:18,992 --> 00:32:20,012 Treat what's in front of you. 669 00:32:20,782 --> 00:32:23,755 If you treat what's in front of you, if the person's screaming 670 00:32:23,755 --> 00:32:25,045 and yelling at you, great. 671 00:32:25,045 --> 00:32:25,645 They're alive. 672 00:32:25,645 --> 00:32:27,055 Let's look at pain management. 673 00:32:27,565 --> 00:32:32,185 If the person's not, treat what's in front of you, if they need CPR, give it to 'em. 674 00:32:32,215 --> 00:32:33,295 Forget everything else. 675 00:32:33,685 --> 00:32:35,245 Breathe for 'em, thump up or down on their chest. 676 00:32:36,168 --> 00:32:37,965 nick-bird_1_03-11-2026_173609: I couldn't say that any better. 677 00:32:37,965 --> 00:32:41,185 As a family doc, when the kid is screaming, they're breathing, they're 678 00:32:41,185 --> 00:32:43,085 angry as hell, but everything is working. 679 00:32:43,275 --> 00:32:48,015 And so you can focus your attention towards the things that are not critical. 680 00:32:48,345 --> 00:32:52,305 If they're a floppy, listless kid, that becomes a lot scarier. 681 00:32:52,545 --> 00:32:55,115 And so that is very much like these. 682 00:32:55,115 --> 00:32:56,945 So again, I agree entirely. 683 00:32:57,155 --> 00:32:58,495 Focus on what's in front of you. 684 00:32:58,795 --> 00:33:02,255 I would think in the urgent care setting on the whole these are not 685 00:33:02,255 --> 00:33:04,835 life-threatening injuries that are presenting because they're usually 686 00:33:04,835 --> 00:33:08,155 past the window of time where these things are the most concerning. 687 00:33:08,165 --> 00:33:14,665 But do have your eyes open to issues of tissue necrosis and breakdown infection. 688 00:33:14,675 --> 00:33:18,255 delayed surgical evaluation because things persist. 689 00:33:18,355 --> 00:33:22,465 Tissue breakdown necrosis can suddenly, I mean that pericardial 690 00:33:22,495 --> 00:33:27,175 example is very dramatic, but you can have other local tissue necrosis and 691 00:33:27,175 --> 00:33:32,215 invasion that persists and continues that really just needs steel. 692 00:33:32,525 --> 00:33:34,115 so this is the surgeon's desire. 693 00:33:34,115 --> 00:33:36,275 It's like, right, we're gonna cut out bad tissue. 694 00:33:36,725 --> 00:33:37,175 Perfect. 695 00:33:37,325 --> 00:33:38,045 Get rid of it. 696 00:33:38,355 --> 00:33:44,595 And so identifying those cases is excellent healthcare and knowing when 697 00:33:44,685 --> 00:33:46,695 it needs to go on to that next level. 698 00:33:46,875 --> 00:33:47,685 That's beautiful. 699 00:33:47,745 --> 00:33:51,315 A lot of what the urgent care does, you are the highest level of triage. 700 00:33:51,345 --> 00:33:55,365 You are figuring out what you can do yourself and what you need to send on, 701 00:33:55,365 --> 00:33:59,595 and you can do people a tremendous amount of good service by recognizing that this 702 00:33:59,595 --> 00:34:03,315 needs to go to a higher level and also helping those people at the higher level. 703 00:34:03,345 --> 00:34:06,135 'cause just because you send it on to the surgeon does not mean that the surgeon 704 00:34:06,135 --> 00:34:06,895 knows what the hell they're doing. 705 00:34:07,295 --> 00:34:11,285 And you can really help to educate them with respect to, hey, this really 706 00:34:11,285 --> 00:34:15,095 needs to be aggressively debrided and involve infectious disease. 707 00:34:15,125 --> 00:34:18,935 'cause this was a marine life injury and these are possibly contaminated. 708 00:34:18,935 --> 00:34:23,195 So setting the table for the specialist downstream from you 709 00:34:23,375 --> 00:34:25,085 is also very integral to this. 710 00:34:25,885 --> 00:34:26,845 Joe: All great points. 711 00:34:27,353 --> 00:34:29,347 Tracey: Alright, well thank you so much. 712 00:34:29,407 --> 00:34:31,180 We really enjoyed talking to you guys. 713 00:34:31,180 --> 00:34:34,225 you know, It's kind of off the beaten path from our usual, but, definitely 714 00:34:34,225 --> 00:34:35,935 incredibly useful information. 715 00:34:36,275 --> 00:34:39,365 For anybody, like I said, whether you're a traveler or whether you're receiving 716 00:34:39,365 --> 00:34:42,795 a traveler as a patient, things that we don't really know and hopefully, a 717 00:34:42,795 --> 00:34:45,525 few of the things that we've discussed will stick in people's heads for that 718 00:34:45,525 --> 00:34:46,935 future patient that walks in the door. 719 00:34:46,935 --> 00:34:47,595 Because you know what? 720 00:34:47,595 --> 00:34:48,225 It's urgent care. 721 00:34:48,225 --> 00:34:49,965 You never know what's gonna walk in that door. 722 00:34:50,535 --> 00:34:51,615 nick-bird_1_03-11-2026_173609: Thank you all so much. 723 00:34:51,975 --> 00:34:52,185 jamie-seymour_1_03-12-2026_103610: Yeah. 724 00:34:52,185 --> 00:34:52,785 Thank you guys. 725 00:34:52,785 --> 00:34:53,985 Really appreciate your time. 726 00:34:54,035 --> 00:34:54,285 Joe: Thank you guys 727 00:34:54,418 --> 00:34:54,868 nick-bird_1_03-11-2026_173609: Cheers. 728 00:34:55,697 --> 00:34:58,857 Tracey: I want to thank everybody to listening to this month's evidence based 729 00:34:58,857 --> 00:35:03,258 urgentology podcast . Just a reminder that subscribers can go to ebmedicine.net 730 00:35:03,448 --> 00:35:06,998 and read the full issue if you want more information, if you haven't already, 731 00:35:07,896 --> 00:35:09,786 Joe: And if you're not a subscriber head to the site. 732 00:35:09,956 --> 00:35:12,726 That's ebmedicine.net to check out what they have. 733 00:35:13,050 --> 00:35:16,660 If you subscribe you'll get access to the article as well as future articles 734 00:35:16,680 --> 00:35:19,280 and the whole archive of all past issues. 735 00:35:19,733 --> 00:35:20,883 Tracey: Look forward to seeing you there.