Editors Note: Scott Bolhack MD, MBA, CMD, CWS, FACP, FAAP, shares the insights he gained from the uncommon wound he encountered.¹ The 7th Day Stingray itch syndrome, although well known on the west coast, is not familiar to providers who practice inland. Learn how Dr. Bolhack and his co-author discovered the best course of action for this delayed histamine reaction to a stingray injury and how it can be applied to the problem solving of treating other uncommon wounds.¹

Transcript:

What was unique about this case that it inspired you to present?

Scott Bolhack, MD, MBA, CMD, CWS, FACP, FAAP: So this is one of those cases that develops when you have a family member, in this case, my daughter, Jessica, who's also one of the authors of the poster. We were out in California and she wound up with a stingray laceration. Thank God it wasn't severe. It didn't require any immediate wound care except for the normal things that you would do for any kind of laceration. We made sure it was clean. She did have the immediate pain syndrome associated with that, and that was resolved, again, by going online and put your foot in as hot water as you can without burning yourself, and the pain dissipated. And we just monitored it, and around day 7 for her, she developed this incredible amount of itching and the area became indurated. And so she calls the father, me, the wound care expert, and says, "What should I do?" And I say, "Well, you probably should have some antibiotics. I think that would be a good idea." But my daughter being as she is, she went online and started researching and she wound up with this blog where there were dozens of people over about a decade, and that's referenced in the poster, that expressed their opinions and posted pictures of their stingray experience. And it turns out that between day 6 and day 10, that this post itch syndrome, which is not documented in any textbook that I could find or online in any article that I can find, is actually a common occurrence. And so people would post exactly their experiences and it was really remarkable. It was anywhere from being admitted, having a surgical debridement and IV antibiotics, all the way to, "Just leave it alone. This is a known occurrence. You don't need to panic," and everything in between. Oral antibiotics, some IV antibiotics, monitoring, local debridements, the whole full spectrum. And my daughter, because she was secure, because she knew she had access to health care, she decided to just sit back on it, no antibiotics, and eventually, the syndrome went away. So here's this event that no one else describes in any of the literature that was available on this particular online health community, and from my experience from wound care, just in our wound care industry by itself, we're perfectly aware that we have so much variability in what treatments we deliver, especially for uncommon syndromes associated with common ulcerations. Let's just say venous ulcerations are the most common thing that we see. But if you have an unusual presentation, how to treat that is very variable. And also the other variability comes in wounds that we don't get to see too often, like pyoderma gangrenosum, for example. And when people go to treat that, if you ask 10 wound care experts from around the country on how they treat that, you're probably going to get probably 5 to 10 different kinds of answers in response to that. And so the thought is that these online health communities can be very effective and very helpful if used appropriately in helping guide the individual in what they should ask for if they go see a clinician or by self-care. And this was particularly true with the stingray community, because obviously you developed the stingray injury either being on the East Coast, but mostly on the West Coast, the California coast. And more than half of those people, it sounds like they were travelers, so then they go back to the interior. Now, the chances of an ER doctor or a nurse practitioner or a PA in an Oklahoma emergency room to know anything about stingrays is just about 0, and so you're going to get all kinds of answers. And so one of the responses among these dozens of people that talked about this syndrome was the person who got a stingray laceration in Hawaii, went to go see the emergency room doctor, and she quoted essentially the doctor - I think it was a woman - she quoted the doctor. She said, "I see this all the time. You have nothing to worry about. This is a known thing. Just leave it alone. You don't need any antibiotic, nothing else needs to be done." And there was the package that we needed, but that's a doctor who sees these things fairly frequently and is comfortable saying that, whereas everybody else wasn't. So the point is these online communities probably can be very helpful and can help guide not only clinicians, but more importantly the patient in asking the right questions and understanding the parameters around their condition and helping them make the best decision for themselves.

What key point do you feel clinicians can take away from this poster’s findings, regardless of their location of practice?

There needs to be some promotion actually from the wound care community to promote these online communities. It would be very helpful and I think ultimately helpful for the clinicians involved in wound care, and certainly it'd be very helpful for the patient who's seeking care and can understand something when they're going to a highly specialized clinic, wound clinic, and being offered a whole bunch of opinions. In wound care, we have such variability, we have doctors and nurse practitioners and physician assistants practicing, each with their own bias in their training. And then within each of those specialties, we have multiple kinds of doctors that can be delivering health care. For myself, I'm an internist. We have emergency room doctors, general surgeons, plastic surgeons, family practice doctors, podiatrists - each one of them brings their own bias into treating patients with all kinds of wounds. We also suffer a little bit in the wound care world from Hobson's choice. You know the famous story about Hobson? He was a horse trader in England and people would come and purchase a horse from him and he realized all his best horses were being sold and so he could never replicate, reproduced the horses fast enough. So it became known as Hobson's choice. You can choose any horse you want out of all my stables, as long as you just choose the horse that's in the first stable. We do this in health care all the time, right? A patient comes in and we say, "This is the treatment," but we don't offer any alternatives. We don't give them options. And so our paradigm for our choices become just what we are comfortable doing, just what we know, just what's within our knowledge base without extending other options to the patient. So I think these online communities essentially democratize decision making in health care. Reference

1. Bolhack S, Bolhack J. Advancing Wound Care Knowledge through Online Health Communities (OHC): The 7th Day Stingray Wound Itch Syndrome. Poster presented at: SAWC Spring 2023; April 26-30 2023; National Harbor, MD

About the Presenter Scott Bolhack, MD, MBA, CMD, CWS, FACP, FAAP, is an internist in Tucson, Arizona and works in hospice and palliative care. He has worked in the wound care space for upwards of 25 years and started in skilled nursing facilities. He’s practiced across the entire transition of care, including assisted living facilities, home health, and wound care in hospice. Over a period of 12 years, he was the medical director and practicing physician at hospital outpatient department of wound care, along with 2 nurse practitioners. Now, he is a regional medical director for a nursing home chain and still practices wound care at a local nursing home. The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies