Abdullah and the Stonefish foot By Dr. Terry Bennett

Terry Bennett is the last remaining solo GP in Strafford county, New Hampshire. He attained national celebrity two years ago after a patient complained to the state medical board when he lectured her about her weight. After fighting off the ensuing attempt to censure him, Dr. Bennett went on to become an outspoken advocate for reform in the medical education system. In the final analysis, he believes that medicine has been put in a box. And that it needs to be taken back out again. Today he shares a story about a long ago encounter that helped shape his views on the practice of medicine and his understanding of what it means to be a doctor. — John Irvine

It is Summer of 1988, and I am in Los Angeles, attending the Saudi Arabian National Cultural Exhibition. To the rhythm of drums, an old friend and patient is dancing with a line of other Saudi men. Nothing too unusual about that, it is part of Saudi folkloric behavior, the not-so-obvious-to-everyone-else-there exception, is that Abdullah A.R. is dancing on two flesh and blood feet, which appear completely normal, just like anyone else’s..

Now let me tell you why this is noteworthy.

It is the year 1978, and I am in Jeddah Saudi Arabia. It is ten years prior to my seeing Abdullah in Los Angeles.

Late on a Saturday afternoon, the phone rings. It is Abdullah, the cousin of my sponsor, Feisal A.R.. [The A.R. family is large and part of the inner circle of Saudi Society. My sponsor’s father is the Ambassador to the US]. Abdullah says he was wading around looking for shells and must have stepped on something .

His foot is hurting him a lot. Would I come and look at it?

This is a familiar, oft told, and thoroughly alarming story. Very early in my sojourn in Saudi Arabia I was asked to come see an airline wife who had also “stepped on something while looking for shells on the reef.”

The patient was described as having an “infected foot and leg”, and a fever…

“Would I be so kind??”….

As a newcomer physician, you have no idea what to expect, with a request like this,

I am brand new to the country, and the Red Sea, and have only a vague idea of the flora and fauna.

I go to see the patient, unsuspecting.

Jesus!! This woman is nearly dead as I arrive at her home. Her leg is swollen, dark purple, splitting at the calf, leaking purplish liquid from deep fissures, and the discoloration extends to her groin.

Her leg is so stupefyingly infected/deformed that foreverafter, I will remember nothing else about the woman, not how she looked or spoke, nothing..

This is a gangrenous leg, a putrefying leg, something much more complicated than a simple infected wound.

Worse, it is going to kill her if it is not amputated immediately. She is fevered, demented, uncooperative, moaning, tossing in her bed.I examine further and find that she has a line of punctures on the bottom of her foot. She has stepped on something with a series of spines on it…

Suddenly I remember the story I was told of a poisonous fish, called a “Stonefish”, that inhabits the Red Sea.

The fish is ugly as can be, related to the sculpins that we see in the coastal waters of the USA, which are also poisonous, but only mildly so.

Quickly I put together the knowledge and the presenting story of this woman’s injury. This patient must have stepped on a Stonefish, and a week of inadequate treatment has produced a nearly dead woman, who will need major surgery, amputation/disarticulation at the hip.

Her leg is so deteriorated, so far gone, that she may not survive, even so.

Over her objections, I tell her husband that if he does not get her out of the Kingdom, to a surgeon by the next day, she will die. The airline airlifts her out to London and she loses her leg, but survives.

The couple never returns to Jeddah. I learn a truly awful, indelible, lesson. A Stonefish wound is horrible beyond imagination, unbelievably toxic. Left untreated, the toxin extruded into such a wound rots the flesh, corrodes the blood and lymph circulation, quickly damages all of the circulation, also directly damages all the surrounding tissue producing very rapid gangrene.

The patient will die an agonizingly awful death as the toxins from putrefying flesh are absorbed into the general circulation.

Stonefish are lethal, and quite common.

The reef is practically covered with these camouflaged predatory fish, who lie in wait, stalking the small fish that they ambush and ingest at a single gulp. They are camouflaged, very difficult to spot, and thus very successful at stalking small fish. They have few natural enemies.

They are very ugly, and their coloration quickly and easily changes to meet their surroundings.

The camouflage/altered coloration to match the surroundings makes them nearly invisible, even if you are snorkeling with a mask and fins and specifically looking for them.

Their hugely successful defense against larger predators is a line of spines on their backs, connected to sacs full of toxin so potent that even a small quantity will produce a fatal injury.

These spines are erected by the fish if anything disturbs it, such as a shuffling foot in the nearby reef top sand and coral.

A line of injected punctures is the result of treading on one of these fish.

These punctures, left untreated in a very timely fashion, will produce destruction of the entire injured area, rapid gangrene, and will require amputation, or cause an agonizing death, as with the airline wife

Timing is everything.

The only treatment that is effective is no picnic itself. There is an antivenin, produced in Australia by injecting Stonefish venom into horses and then harvesting serum which now contains antibody to the venom.

The stuff is expensive as hell, however, and has a relatively short shelf life..

You can kill a patient who happens to be allergic to horse serum, by injecting what you thought was a livesaving antivenin. The near dead airline wife at the beginning of my sojourn has made clear what happens to the untreated. I will never willingly allow such a disastrous outcome to happen again..

I will have to take my chances with the antivenin treatment, the risks in employing it and treat anyone so afflicted. There really is not a viable alternative choice

On the very next day I went to my employer, Raytheon, and insisted that they order a supply of this antivenin.

The Raytheon housing compound is inside the seaside Saudi Military Camp, perched on the side of the reef.

Dozens of Raytheon wives and children are wading the reef, looking for shells and other treasures on a daily basis.

It is only a matter of time until a new tragedy is at hand.

The management agrees, and for the next seven years, from Raytheon and other large Construction/Contractor companies I will have several Stonefish antivenin doses in my freezer, having learned an indelible lesson from the suffering woman.

Once separated from Raytheon, I insist that any major company who is planning to use our medical services, has ordered and had shipped to me a dose of Stonefish Antivenin, on a to be used as needed by all comers basis. I tell them all that it is a public service, to have this antivenin available, so that anyone afflicted can be treated in a timely manner.

It is a public service, which may never be needed by their own employees, but the cheapest kind of insurance, if ever needed, and great P.R. even if never needed.

In the ensuing time frame, I have treated locals and foreigners alike, using 6 or 7 Corporation provided doses over time. Nobody ever suffered again like the airline wife, whose rotting leg and desperation will haunt me forever.

Nobody will ever lose a leg and agonize in front of me, ever again. I have lengthened my list of unacceptable outcomes, once more.

Even so, advance planning/timing is everything in life.

Genuinely “defying death” is done with exquisitely and carefully timed interventions, the later the intervention, the less optimistic the outcome.

Abdullah is only a few words into his description of his day and his injury before it is clear to me what has happened to him. Damn!!

I am on the move, first to the refrigerator, then to collect my bag, then to my car, and a helter skelter drive across Jeddah, no simple task, ever. Half an hour later, I am looking at a small line of punctures down the bottom of Abdullah’s foot.

The wounds are pathognomonic, diagnostic of a stonefish wound, and the telltale severe pain, which happens early and progresses rapidly to agony, is increasing as we speak..

The manufacturer’s recommended course of treatment is to inject the antivenin intramuscularly, allow it to be picked up by the bloodstream and delivered to the wound site indirectly, in a much diluted concentration, where it will neutralize the toxin. Built into this treatment plan is an unavoidable delay in arriving at total neutralization, due to the delay in absorption of, and delivery of, the antitoxin to the wound site.

On all previous injuries I have treated, I have followed this treatment plan.

In every previous case a certain amount of tissue necrosis/gangrene occurred, and the patients were never the same, never as good as pre injury.

All of them complained of altered sensation, chronic pain, wasting of the foot and sometimes the calf as well. On balance, I have achieved good results, but far from perfect outcomes, following standard procedure as recommended on the package..

While I am looking at Abdullah’s foot, it strikes me that if I were to use a very fine, very long needle, I could inject some of the antivenin directly into the flesh surrounding the individual punctures, thereby arriving at a very high, very immediate, very local concentration, conceivably averting the damage that has occurred in all previous cases.

I can always give what is left intramuscularly as originally directed.

The only downside is that the high concentration might do damage locally.. I dither..

It is always somewhat risky to go outside recommended treatment advice…I may get a much better than usual outcome, on Abdullah, my friend, who is Feisal’s cousin, but will it really work better, or, will it do less well?…More dither..

Decision to action..

Mentally sweating bullets, but believing logic to be with me, I inject locally , into each of the punctures, a small amount of the antivenin through a very fine 26 gauge needle, then give the balance intramuscularly.

I dress the foot and drive home, more than a little worried ..

Stonefish wounds are quite serious,

Abdullah is both a personal friend and also the cousin of my sponsor, Feisal. I wish to do what my Hippocratic Oath taken so long ago, prescribes….No Harm..

The night goes slowly by.

In the Morning, I call to see what is happening.

The pain is markedly reduced, unlike every other such wound I have treated, where the pain progressed for 3 or 4 days before backing off.

I make one other visit, just to reassure myself that all is well..

Ten years will go by.

Possibly, Abdullah never will understand just how delighted I am with his outcome.. Nor why..

No matter, victories vary

Some victories are small and remain so..

Some victories are unknown to their beneficiaries.

Many victories require the fullness of time, to mature, to genuinely appreciate

This victory is all of these..

Abdullah and I are both blessed…..

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  1. I twice came mere inches from a stonefish. First, in a natural cistern near the coast on an outcropping of rock. I saw an usual shape undulating at a depth of two feet. It looked like part of the rock at the base of the cistern. I reached in to touch it. Only a little voice in my head saved me – you don’t know what it is, so don’t touch it.
    The second time, I was snorkling in the Red Sea near Jeddah, just past the outcroping of coral. The water was about 7 feet deep. I floated over a section of rock and sediment, slowling kicking forward. I saw the gently undulating objects at the bottom, there were perhaps 50 of them. I let out my breath and droped to about three feet, slowly gliding over over the objects. it wasn’t until I saw their fins shaking and made out the boundaries of their bodies, did I realize I was directly over a large colony of stonefish. They were all over the area below me. I nearly panicked, realizing that to propel myself, I’d have to kick hard to both get to the surface and move away from the area. Waves began to come, forcing me down, so I struggled to get up and away, realizing I might end up having to step on the bottom. I had fins on, but these only provided a small degree of protection, and not any on my ankles. I would have been dead, because the area was remote, and I would have incurred numerous stings, not just one. My diving buddies were doing scuba, and had just headed down and away from my area, and wouldn’t be back for an hour, and not likely have even seen me, if I was floating partially submerged, unable to swim from the pain. It freaked me out at the time, and I never went back to the Red Sea after that.

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