Mystery sting - you can't be too careful!

[salimbag]

Just a word of caution - you can't be too careful!

We were working on a coral gardening project off the west coast of Palawan in the Philippines. We'd just wrapped up a day of shooting and had climbed into a local banka (small double outrigger) to take us back to our boat. We'd left the coral fields when I decided we needed one last topside shot of the area. I don't like to shoot much anymore, but I was in the most convenient position regards the camera and the rail so I slid into the knee deep water and our assistant handed me the camera.

I braced myself on the sandy bottom like I do before any shot, and twisted my body in preparation for a long pan. The day was calm, but the tiniest swell knocked me ever so slightly off balance (the camera on my shoulder and the "twist" didn't help) and I did a little stutter-step backwards and hit something with the outside of my left lower calf. I felt just the tiniest scrape, and looked down to see a large rock. I ignored it, reset, got the shot, and we were off.

We were in a hurry, of course. I gave my leg a cursory look and then was distracted by a radio call from the boat and just forgot about it.

Two days later large suppurating sores grew in an area about 6 inches square on my lower calf and the leg, from just above the knee to the toes, swelled. The wounded area was as hard as if a quarter-inch steel plate were just beneath the skin. The wounds took about two months to heal - they alternately bled quite freely and then dripped orange sticky goo for weeks - and now it's been about three months and the lower leg is still swollen, although it's subsided considerably.

Of course, I knew better than to ignore it. Since there was no pain at the time and no marks on the skin and I was in a hurry I didn't make the easy and basic kind of first aid application I know in hindsight I should have. Since I was busy I realized now that my subconscious made several quick and stupid mental rationalizations for taking no action: we were away from the coral fields when it happened so there's less chance it's a toxic marine organism (huh?), we have a marine biologist in staff and if it were a problem he would have said something (but since I didn't complain how was he to know?), I've never encountered any problems before in these waters (so?), I saw it, it was just a rock.... thoughts that if I'd been paying attention to the real world my rational self would have realized were ridiculous. I was just tired, concerned about other issues and anxious to move on. Don't let things like this get in the way of your routines!

I did go to local medical facilities - I was pretty sure little could be done at this point, but if nothing else I thought I should get a tetanus shot. (Everyone on the island, as it turns out, was out of tetanus vaccine.) The doctors said nothing could be done (other than antibiotics, antihistamines, just kind of basic stuff), and that recovery could be a year, an opinion echoed by doctors in the States. Much of this depends on one's personal allergic reaction, and I tend to have very benign reactions to bee stings, spider bites (a solid bite by a black widow once barely fazed me), most jellyfish, etc. compared with my companions. So again, I felt I had reason to be incautious.

There has been virtually no pain associated with this, even though large chunks of necrotic skin peeled off the side of my lower leg. A high grossness factor that my five-year old liked, anyway. And the swelling contributes to considerable stiffness. But by and large it's just a minor irritation. About the only thing that's a problem, ironically, is swimming with fins.

So beware! Don't let yourself get distracted and don't let yourself get cavalier because you "think" you have plenty of "experience!"

Of course, we have no real idea what it was that got me. In hindsight, I probably have ignored other similar injuries with no negative consequences - so you never know!

 

[fisherdvm]

There are rapid growning mycobacterium that could have caused the necrosis. At minimum, you should have been started on an antibiotic that covered for aquatic infection. Frequently, it would be prescribed for 1 to 2 months duration while waiting for a culture result for both regular culture and for mycobacterium culture.

Unless this was not done, I think the doctors treating you might not be meeting the standard of care.

 

[fisherdvm]

A second comment is, even without seeing your leg, you would likely benefit from a moderate compression support stocking. Below the knee type, rated from 20 to 30 mm mercury.

You would be surprised to see how much faster your leg would improve with the support stocking.

You would be wise to get a second, perhaps third opinion from some good dermatologist or doctors specializing in leg ulcer and wound care. We would have to make sure you do not have underlying venous diseases, or to miss difficult to diagnose condition like pyoderma gangrenosum.

 

[salimbag]

Oh yes, thanks for the thoughtful reply. I did get that treatment, and apologize that I kind of glossed over it in the above description, since I was hoping the doctors would have some treatment specific to the injury rather than just the more predictable broad-spectrum preventative medicines like you mentioned and that they did give. But my limited experience with this kind of injury, which I've run into before with myself and some crew members over the years but with much less severe conseqences, was that if not treated on the spot there's little that can be done.

The details of the treatment were that we were recommended by the local adventist hospital to a dermatologist who started me on two powerful anti-biotics (one was cypro) as well as a megadose of prednazone, but only for about 10 days. I later went to another filipino doctor with a more holistic approach who was horrified by this treatment, but said that I certainly should not have any infection! He really thought it was dangerous overkill. He said just debride it and keep it clean and dressed and perhaps some anti-histamines.

I have to admit that I was also not particularly careful - it took us a couple of days to get access to medical care and then I still didn't go to the doctor for a couple more days. I washed the wound a couple of times a day but did not cover it, running around the capital city and allowing all kinds of infectious agents access to it. Through any of it I really never did have any classic signs of infection/inflammation. No puss, no redness, etc. Just the sticky orange drip. No real pain either, even as I forceably removed large chunks of flesh. The only real problem is the stiffness that is a result of the continued swelling.

I also later made the mistake of telling doctors in America it was "fire coral" and they all started researching and developing treatments for real coral - they were concernd about little hard abrasive chunks of coral skeleton wedged beneath the skin - when it was most certainly a soft organism.

Thanks again.

 

[harleyxx]

Do you have any pictures you can post? I would love to see some shots of the coral gardening project.
Hey you can even post some pices of the injury if you have any. They might be helpful for some of us newer divers to see what can happen if were not careful.

 

[Spongebobscubasteve]

I second pics of the orange superating sore are way in order! That has some serious war wound factor to it! Super cool!

But thanks for the word of caution, I will remember your story!

 

[salimbag]

For the record, what I should have done at the time was immediately rinse the area with vinegar. (Vinegar is everywhere in the Philippines, it's its own food group, so there was plenty around.) Don't use fresh water on it initially - I made that mistake years ago on a similar but less severe injury - and it just irritates it. (That one cleared up in a week or so, but was more painful.)

Pictures would have been a great idea! But I have none. This is the continuing irony of my life working in TV and film - I never take pictures of anything.... The wound is not dramatic enough now to bother photographing, sadly (sadly?). All right, I have to admit, I did think it was kind of cool.... Still, don't lose the moral to the story! This one initially seemed to be the most inconsequential injury you could imagine, and in the end turned out to have the WORST consequences.

No pix around of the gardening project either, I'm afraid. This was not part of the work we were doing at the time, but a day of freelance shooting for another producer who contacted me since we were already there, and the tape was immediately shipped out to him. (I never even looked at it. This is pretty typical.) I'll check with the rest of our group to see if any of them snapped any stills.

In brief, corals in the area were devastated by cyanide and percussion fishing. Staghorn coral is preferred since it grows the fastest. Chunks of staghorn coral about 6 inches long are tied to a metal rod with copper wire and transported (all underwater) to a new site where the rods are driven into the ground. The plots were small, about 10 feet square each. Each plot had a dozen or so "seedlings" in it. This was in about 10 feet of water. They grow about 6 inches a year, so in a few centuries the corals will be back!

The cool thing about Palawan is they have a very pro-environmental government, and most of the local politicians and leaders are on board, it seems, with environmental monitoring so such destructive fishing techniques are, seemingly, on the decline. This is a hard sell where people are poor, but Palawan seems to be pulling it off. Of course, mining companies, foreign governments, logging interests, local and national politicians, etc. are all trying to sabotage them.

 

[salimbag]

Yes, I have done the compression sock. It has been invaluable - DVM's advice has been spot on.

 

[Tagerisatroll]

You know what your wound reminds me of a venomus reaction, the damage and symtoms are similar to what you might see with a Brown recluse spider bite. With someone who had venom senitivity other than your not having any pain. I would bet the proper treatment would be the same as they use to treat that type of bite.

 

[fisherdvm]

Pyoderma gangrenosum is frequently misdiagnosed as brown recluse spider bites. Unfortunatedly, debridement stimulates its growth - so the well meaning doctors who keeps on debriding the dead tissue only make it grows larger.

The logic behind the dermatologist to put you on a brief course of steroid is backed up only if he did a good biopsy while trying to rule out pyoderma gangrenosum. It would be really cool if you can get a copy of the biopsy report and post it for us to see.

Google pictures of pyoderma gangrenosum and brown recluse bites and you would see nearly identical presentation.