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Hot Water for Jellyfish Stings

There are multiple therapies recommended for field therapy (first aid) for jellyfish stings. These include topical decontaminants, such as vinegar (acetic acid), rubbing alcohol, papain, citrus juice, ammonia, and others; rapid decontamination combined with removal of nematocysts (by scraping, shaving, or abrasion); application of ice or cold packs; and application of heat. In addition, there is the consideration of therapy for an allergic reaction to jellyfish venom(s).

Application of heat, in the form of hot water “to tolerance” (non-scalding) is a relatively new therapy, in comparison to others that have been recommended for years in one form or another. The major proponents for this therapy are Australians, who have observed and evaluated this therapy clinically, predominately in victims of the Australian species of man-of-war jellyfishes. Their observations have been that this therapy is very helpful, as the victims improve clinically, particularly in showing relief from pain.

I am encouraged by this finding, and hope that it proves to be true over the long haul, and not just until it falls out of favor based upon some new recommendation. So, until further notice, here is general advice about how to manage a jellyfish sting:

The following is recommended for all unidentified jellyfish and other creatures with stinging cells, including the box jellyfish, Portuguese man-of-war (“bluebottle”), Irukandji, fire coral, stinging hydroid, sea nettle, and sea anemone:

1. If the sting is felt to be from the box jellyfish (Chironex fleckeri), immediately flood the wound with vinegar (5% acetic acid). Keep the victim as still as possible. Continually apply the vinegar until the victim can be brought to medical attention. If you are out at sea or on an isolated beach, allow the vinegar to soak the tentacles or stung skin for 10 minutes before you attempt to remove adherent tentacles or further treat the wound. In Australia, surf lifesavers (lifeguards) may carry antivenom, which is given as an intramuscular injection at the first-aid scene. There is recent discussion in the medical literature about whether or not antivenom against box jellyfish as currently administered to humans is beneficial. Until further notice, it is likely to be used by clinicians. Notably, the pressure immobilization technique is no longer recommended as a therapy for jellyfish stings.

2. For all other stings, if a topical decontaminant (vinegar or isopropyl [rubbing] alcohol) is available, pour it liberally over the skin or apply a soaked compress. Some authorities advise against the use of rubbing alcohol on the theoretical grounds that it has not been proven beyond a doubt to help. However, many clinical observations support its use. Since not all jellyfish are identical, it is extremely helpful to know ahead of time what works against the stinging creatures in your specific geographic location. For instance, vinegar may not work as well to treat sea bather’s eruption, which is commonly seen in certain Mexican coastal waters; a better agent (also subject to some differing opinions) may be a solution of papain (such as unseasoned meat tenderizer). For a fire coral sting, citrus (e.g., fresh lime) juice that contains citric, malic, or tartaric acid may be effective, with emphasis on the word “may.”

Until the decontaminant is available, you can rinse the skin with seawater. Do not rinse the skin gently with fresh water or apply ice directly to the skin, as these may worsen the envenomation. A brisk freshwater stream (forceful shower) may have sufficient force to physically remove the microscopic stinging cells, but nonforceful application is more likely to cause the stinging cells to discharge, increasing the envenomation. A nonmoist ice or cold pack may be useful to diminish pain, but take care to wipe away any surface moisture (condensation) prior to its application.

As I mentioned above, observations from Australia suggest that hot (nonscalding) water application or immersion may diminish the sting of the Portuguese man-of-war from that part of the world. The generalization of this observation to treatment of other jellyfishes, particularly in North America, should not automatically be assumed, because of the fact that application of fresh water worsens certain envenomations. However, the concept is intriguing, and I intend to try it the next time I am stung if hot water is available. (How hot is hot? The upper limit of temperature should be 113 degrees Fahrenheit or 45 degrees Centigrade.) Otherwise, I will continue to use vinegar (e.g., StingMate) or another of the useful topicals.

3. Apply soaks of vinegar or rubbing alcohol for 30 minutes or until pain is relieved. Baking soda powder or paste is recommended to detoxify the sting of certain sea nettles, such as the Chesapeake Bay sea nettle. If these decontaminants are not available, apply soaks of dilute (quarter-strength) household ammonia. A paste made from unseasoned meat tenderizer (do not exceed 15 minutes of application time, particularly not upon the sensitive skin of small children) or papaya fruit may be helpful. These contain papain, which may also be quite useful to alleviate the sting from the thimble jellyfish that cause sea bather’s eruption. Do not apply any organic solvent, such as kerosene, turpentine, or gasoline. While likely not harmful, urinating on a jellyfish, or any other marine, sting has never been proven to be effective.

4. After decontamination, apply a lather of shaving cream or soap and shave the affected area with a razor. In a pinch, you can use a paste of sand or mud in seawater and a clamshell.

5. Reapply the vinegar or rubbing alcohol soak for 15 minutes.

6. Apply a thin coating of hydrocortisone lotion (0.5 to 1%) twice a day. Anesthetic ointment (such as lidocaine hydrochloride 2.5% or a benzocaine-containing spray) may provide short-term pain relief.

7. If the victim has a large area involved (an entire arm or leg, face, or genitals), is very young or very old, or shows signs of generalized illness (nausea, vomiting, weakness, shortness of breath, chest pain, and the like), seek help from a doctor. If a child has placed tentacle fragments in his mouth, have him swish and spit whatever potable liquid is available. If there is already swelling in the mouth (muffled voice, difficulty swallowing, enlarged tongue and lips), do not give anything by mouth, protect the airway, and rapidly transport the victim to a hospital.

To prevent jellyfish stings, an ocean bather or diver should wear, at a minimum, a synthetic nylon-rubber (Lycra [DuPont]) dive skin. Safe Sea® Sunblock with Jellyfish Sting Protective Lotion, which is both a sunscreen and jellyfish sting inhibitor, has been shown to be effective in preventing stings from many jellyfish species.

This post, Hot Water for Jellyfish Stings, was originally published on Healthine.com by Paul Auerbach, M.D..

Political Meddling Forces Approval Of Dangerous Clinical Trial (TACT)

In one of the most unethical clinical trial debacles of our time, the NIH approved a research study (called the TACT Trial – Trial to Assess Chelation Therapy – a supposed treatment for arteriosclerosis) in which the treatment had no evidence for potential benefit, and clear evidence of potential harm – and even the risk of death. Amazingly, the researchers neglected to mention this risk in their informed consent document. The NIH awarded $30 million of our tax dollars to ~100 researchers to enroll 2000 patients in this risky study (ongoing from 2003-present). Even more astounding is the fact that several of the researchers have been disciplined for substandard practices by state medical boards; several have been involved in insurance fraud; at least 3 are convicted felons.

But wait, there’s more.

The treatment under investigation, IV injection of Na2EDTA, is specifically contraindicated for “generalized arteriosclerosis” by the FDA. There have been over 30 reported cases of accidental death caused by the administration of this drug – and prior to the TACT, 4 RCTs and several substudies of chelation for either CAD or PVD, involving 285 subjects, had been reported. None found chelation superior to placebo.

So, Why Was This Study Approved?

The NIH and the TACT principal investigator (PI) argued that there was a substantial demand for chelation, creating a “public health imperative” to perform a large trial as soon as possible. In reality, the number of people using the therapy was only a small fraction of what the PI reported.

It’s hard to know exactly what happened “behind the scenes” to pressure NIH to go forward with the study – however a few things are clear: 1) the National Heart, Lung, and Blood Institute (NHLBI) initially declined to approve the study based on lack of scientific merit 2) congressman Dan Burton and at least one of his staffers (Beth Clay) and a lobbyist (Bill Chatfield) worked tirelessly to get the study approved through a different institute – NCCAM 3) some of the evidence used to support the trial was falsified (The RFA cited several articles by Edward McDonagh, the chelationist who had previously admitted in a court of law to having falsified his data.) 4) The NIH Special Emphasis Panel that approved the TACT protocol included L. Terry Chappell, whom the protocol had named as a participant in the TACT.

All evidence seems to suggest that political meddling managed to trump science in this case – putting the lives of 2000 study subjects at risk, without any likely benefit to them or medicine.

A formal analysis of the sordid history and ethical violations of the TACT trial was published by the Medscape Journal of Medicine on May 13, 2008. Atwood et al. provide a rigorous, 9-part commentary with 326 references in review of the case. Congressman Burton’s staffer, Beth Clay, published what is essentially a character assassination of Dr. Atwood in response.

The NIH Writes TACT Investigators a Strongly Worded Letter

On May 27, 2009 the Office for Human Research Protections Committee sent a letter to the investigators of TACT, stating that they found, “multiple instances of substandard practices, insurance fraud, and felony activity on the part of the investigators.” The letter describes a list of irregularities and recommends various changes to the research protocol.

It is almost unheard of for a letter from the NIH to state that research study investigators are guilty of fraud and felony activity – but what I don’t understand is why they haven’t shut down the study. Perhaps this is their first step towards that goal? Let’s hope so.

Conclusion

The TACT trial has subjected 2000 unwary subjects and $30 million of public money to an unethical trial of a dubious treatment that, had it been accurately represented and judged by the usual criteria, would certainly have been disqualified. Political meddling in health and medical affairs is dangerous business, and must be opposed as strongly as possible. Congressmen like Tom Harkin and Dan Burton should not be allowed to push their political agendas and requests for publicly funded pseudoscience on the NIH. I can only hope that the new NIH director will have the courage to fend off demands for unethical trials from political appointees.

Alcoholism, Burns And Emergency Procedures

In my line of work there is sometimes a fine line between cruelty and kindness. Sometimes the line can seem to blur. Hang around me long enough and you will probably be shocked at some stage.

The guy had apparently fallen asleep next to his fire. When he rolled over into it his alcohol levels ensured that he only woke up once his legs were well done. Someone found him and brought him in late that night.

When I walked into casualties I could smell him. You can almost always smell the burn patients. I took a look. The one leg actually wasn’t too bad. It had an area of third degree wounds but they weren’t circumferential. I could deal with that later. The other leg, however, had the appearance of old parchment from about mid thigh to ankle right the way around. This could not wait for later.

In third degree circumferential burns, the damaged skin becomes very tight. Constricting is actually a better description because unless it is released the taught skin will so constrict the leg’s bloodflow that if left untreated the patient’s leg will die. It is like a compartment syndrome only the entire leg is the compartment. Interestingly enough in third degree wounds all the nerves have been destroyed so in these areas the patient has no feeling whatsoever. That means when we do the release (an escharotomy which is cutting the dead skin along the length of the leg in order to release the pressure and thereby return the bloodflow) no anaesthetic is needed. You just cut the skin and as soon as you hit an area that the patient feels you’ve gone too far. If you do it right they will feel nothing. The longer you wait the higher the chance that he will lose his leg. I knew what I needed to do. I also knew my students might never get to see this again before they might have to do it themselves in some outback hospital in their community service year.

I asked for a blade and gathered my students around me. I sunk the knife through the dead skin and ran it down the length of the leg. The wound burst open as the pressure was released. The patient didn’t flinch. Quite a number of the students did. One excused herself and ran out. I think she might have been crying. Despite me telling them that it wasn’t painful and it was in the best interests of the patient to actually see it was more than most normal people could take.

When I wrote my last post and expressed a form of traumatic stress I found the contrast within myself compared to this incident quite interesting. everything seems to be relative and during the job there will be things that leave scars and many things that traumatise/desensitise us. I was ok doing what that one student obviously thought was gruesome and bizarre because I was convinced it was in the best interests of the patient. When I did this procedure which, on the face of it, is so much more brutal than taking someone to shower, I was ok, but the shower incident was terrible for me. I ended up hoping the student didn’t see me as quite that monsterous. I also hoped she would get over the trauma I had inadvertently caused her.

Ten Tips For Overcoming your Headaches

One of our most revered faculty members, Lee Archer, MD, a neurologist, provided a copy of the handout he gives to his headache patients. With his permission, I adapted it for use with my own patients. I thought it was so good that I asked him if I could publish it on my blog so that others could benefit from his advice.

Headaches are incredibly common and usually frustrating for providers. It has become increasingly evident that chronic or frequently occurring headaches are often virtually impossible to identify as either “migraine” or “tension” headaches and often simply are called “chronic headaches”. Treatment often becomes a revolving door of trying new medications that sometimes work, but more commonly don’t. And, even worse, many headache patients gradually simply become dependent on addictive pain medications just to try to cope with their often daily discomfort.

But, there are some really basic things about dealing with chronic headaches that we should never forget to try. So, without further ado, here is his advice:

Ten Steps to Overcoming Your Headaches

There are some things that everyone can do to help their headaches. There are a number of things you can besides just take medication to help their headaches. If someone follows all of these directions, the need for prescription medication is often dramatically reduced if not eliminated.

1. First and foremost, taking pain medication everyday is definitely not a good idea. Daily pain medication tends to perpetuate headaches. This is true for over-the-counter medications like Excedrin and BC powders, as well as prescription medications like Fiorinal, Midrin, and “triptans” like Imitrex, Zomig, Relpax, Frova, etc. Exactly why this occurs is unclear, but it is a well established clinical finding. Anyone who takes pain medications more than twice a week is in danger of perpetuating their headaches. Occasional usage of pain medications several times in one week is permissible, as long as it is not a regular pattern. For instance, using pain medication several days in a row during the perimenstrual period is certainly permissible.

2. Regular exercise helps reduce headaches. Exercise stimulates the release of endorphins in the brain. These are chemicals that actually suppress pain. I encourage people to aim for at least 20 minutes of aerobic exercise (like walking or swimming) five days a week if not daily. In addition to helping reduce headaches, this also will prolong your life because of the beneficial effects on your heart.

3. Stress reduction is a definite benefit in reducing headache frequency and severity. Headaches are not caused by stress alone, but can make most headaches worse. There are no easy answers for how to reduce stress. If it is severe, we can consider referral to a therapist for help.

4. Too much or too little sleep can trigger headaches. Pay attention to this, and note whether or not you are tending to trigger headaches from sleeping too little or too much. People differ as to how much sleep is “right” for them.

5. Caffeine can precipitate headaches. I encourage patients to try stopping caffeine altogether for a few weeks, and we can decide together whether or not caffeine might be contributing. Abruptly stopping all caffeine can trigger headaches, too, so try to taper off over a week.

6. NutraSweet (aspartame) can cause headaches in some people. If you are drinking multiple servings/day of beverages containing NutraSweet you might consider trying to stop that, and see if your headaches respond.

7. There are some other foods they may trigger headaches in some people. Usually people learn this very quickly. For instance, red wine will precipitate migraines in many people, and chocolate, nuts, hot dogs and Chinese food triggers headaches in certain cases. I generally don’t advise omitting all of these foods, unless you notice a pattern where these foods are causing headaches.

8. If I give you a prophylactic medication for headaches, you should take it daily, as prescribed. If you have trouble tolerating it, please let me know and we can consider using something else. No prophylactic medication works in every patient with headaches. Generally, each of the medications works in only about 60% of people. Therefore, it is not uncommon to need to try more than one medication in any given patient. We must give any of these medications at least four to six weeks to work before giving up on them. It generally takes that long to be sure whether or not a medication is going to work.

9. Keep a calendar of your headaches. Use a standard calendar and mark the days
that you have a headache, how severe it is on a scale of one to ten, what you took
for it and how long it lasted. Also note anything that you think could have
precipitated it. By keeping this over time we can tell if our efforts
are helping.

10. Riboflavin (vitamin B2) 400mg daily helps prevent migraines in many people. It
comes in 100mg size tablets, so you will need to take four of them each day. You
can add it to anything else we try. You do not need a prescription for it.

Do you have chronic headaches? If so, I challenge you to apply these ten principles, then come back and provide a comment on this blog post!

Thanks and good luck!

*This blog post was originally published at eDocAmerica*

Tips For Treating Dermatitis, Eczema, And Chronic Wounds

Being a plastic surgeon, I have a great interest in the skin and no I don’t see or treat much dermatitis as the primary physician.  Patients do occasionally ask me about patches/rashes they have.  It’s always nice to be up on the topic and to know when it’s important to make sure they see a dermatologist.

The article listed below is a nice, simple  review of conditions that fall into the eczema /dermatitis categories.  The article discusses atopic dermatitis (AD), nummular (coin-shaped) eczema, contact dermatitis, and stasis dermatitis.  It is not a deep article on the subject, but did include some nice reminders and tips.

Allergic dermatitis is not uncommon in patients with chronic wounds.  One study documented more than 51% of leg ulcer patients acquire contact allergic dermatitis to local dressings and other topical treatment.  This is important to any of us who treat wounds, acute or chronic.  Sometimes the wound fails to heal due to this.

There is a nice table which lists the common allergens in patients with chronic wounds.  If your chronic wound patient has a contact allergy to these products, it can certainly complicate their wound healing.

  • lanolin (common in moisturizing creams and ointments)
  • perfumes/fragrances
  • cetylsterol alcohol (used as an emulsifier, stabilizer, and preservative in creams, ointments, and paste bandages)
  • preservatives:  quaternium 15, parabens, chlorocresol  (all are used to prevent bacterial contamination in creams, but are not in ointments)
  • rosin (colophony)  — a component of some adhesive tapes, bandages, or dressings
  • rubber / latex

The key to treatment and prevention of future exacerbations is identification of any provocative factors so that they may be avoided as there is no absolute cure for dermatitis.   Here is a summary of tips the article gives:

Laundry and Clothing Suggestions

  • Avoid wearing wool or nylon next to their skin as they may exacerbate itch.  Choose materials made of cotton or corduroy which are softer.
  • Rather than use fabric softeners and bleach, which may be irritating to the skin, add a white vinegar rinse in the washing machine rinse cycle cup/dispenser to remove excess alkaline detergent.

Moisturizers

  • Keep water exposure to a minimum.
  • Use humectants or lubricants regularly to replenish skin moisture.  Apply these agents immediately after bathing while the skin is damp.
  • For severe hand eczema, cotton gloves may be worn at night to augment the moisturizing effect of humectants and other topical treatments.

Topical Steroids

  • Topical steroids continue to be the mainstay therapy for treating dermatitis.
  • Topical steroid creams can be kept in the refrigerator or combined with 0.5% to 1% of menthol (camphor and phenol are alternatives) to give a cooling effect.   This often helps.
  • Treat the dermatitis with a topical steroid when the skin is red and inflamed.  Tapering the topical steroid use by alternating  with moisturizers as the dermatitis resolves.
  • Remember that  percutaneous absorption of topical steroids is greatest on the face and in body folds.  They suggest only weak or moderate preparations be used in these areas.
  • Moderate to potent topical steroids should be used on the trunk and the extremities.
  • The palms and soles are low-absorption areas, so may require very potent topical steroids

REFERENCE

The ABCs of Skin Care for Wound Care Clinicians: Dermatitis and Eczema; Advances in Skin & Wound Care: May 2009, Vol 22, Issue 5, pp 230-236;  Woo, Kevin Y. RN, MSc, PhD, ACNP, GNC(C), FAPWCA; Sibbald, R. Gary BSc, MD, MEd, FRCPC (Med, Derm), ABIM DABD, FAPWCA (doi:10.1097/01.ASW.0000350837.17691.7f)

*This blog post was originally published at Suture for a Living*

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