SPORTS MEDICINE A SHORT HISTORY OF SURFING MEDICINE AND THE SURFERS MEDICAL ASSOCIATION HAZARDOUS SEA CREATURES AND THE AGEING SURFER
– Written by Andrew Nathanson, William H Jones and Mary Showstark, USA
The Surfer's Medical Association (SMA) is Mexico, Central America, Indonesia, Caribe 1. The First Wave goal is to educate surfers an international organization of health-care and several Pacific Islands, have benefitted about health issues so that they can professionals who frequently treat surfers from help by the SMA. Nabila is a model spend maximal time surfing and mini- as patients and who are surfers themselves. community and is called the “healthiest mal time seeing healthcare providers. The SMA promotes research, training and village in Fiji” after the SMA started a 2. The Second Wave goal is to conduct education regarding trauma and disease smoking cessation programme as well as and support research regarding the factors which affect surfers, and is dedicated training village health workers, who are connection between surfing and to helping all surfers be healthier. residents of the village, to oversee the health health. The term “Surfing Medicine” was of the people in the village. 3. The Third Wave goal is to represent first used in the mid 1980s by a group of In addition to surfing physicians, the activity of surfing in the fields of international surfing medical personnel at scientists and other licensed healthcare medicine, healthcare and science. their initial conference on Tavarua Island professionals, the organization includes 4. The Fourth Wave goal is to teach health- in Fiji. The Association is committed to "barefoot doctors" (ordinary surfers who care providers about the unique trauma community service, especially in testing have sufficient training and skills to be and disease problems of surfers and and implementing models of healthcare effective first responders in remote locations how to care for them. delivery for underdeveloped regions where where medical facilities are not readily 5. The Fifth Wave goal is to create, surfing has an impact. accessible). around the world, a network of surfing The communities of Nabila and Momi The goals of the SMA are best described healthcare professionals and "barefoot in Fiji, along with many coastal villages in by the following: doctors".
128 more ingrained in the human psyche than that of being consumed by a prehistoric creature with razor-like teeth and powerful jaws. Indeed such visions keep many from attempting the sport at all. Fortunately the hype does not match the reality. Over the last decade there have been an average of only 75 shark attacks a year world-wide, and less than 10% of those are fatal1. Unfortunately, surfers are victims of about half of those attacks1. By contrast, the most dangerous animal of all, the mosquito, is responsible for 750,000 deaths per year. Of the 350 species of sharks, 30 have been implicated in unprovoked human attacks, the most dangerous species being Great White, Tiger and Bull sharks. Attacks are most common in areas where surfers and sharks are in close proximity such as near seal-breeding colonies, steep drop-offs, or river mouths. Surfers are also at risk in waters inhabited by sharks when water visibility is low due to turbidity and at dawn or dusk. Interestingly, most shark attacks appear to be accidental, as the shark often takes one bite, and then swims away.
Prevention • Do not wear shiny watches, jewellery or bright colours as these are thought to attract the attention of sharks. 6. The Sixth Wave goal is to protect with Dr Clayton Everline and Dr Andrew • Avoid excessive splashing as sharks are and preserve the surfers' natural Nathanson, wrote “Surf Survival, The can sense vibrations in the water which environment including the waves, the Surfer’s Health Handbook”. Dr Nathanson they may mistake for an injured fish or ocean, and our beaches. and Dr Everline represent a younger and seal. newer generation to head up the surfing • Avoid surfing at dawn, dusk or in cloudy “As surfers and doctors, we’re a pretty medicine quest. waters. Limited visibility may result in a insignificant minority group on this planet. One of the areas of great interest are the shark mistakenly biting a hand or foot, Yet we do have a degree of expertise in terms ocean creatures that can cause injury to a thinking it is a fish. of the ocean/land interface (especially where surfer or ocean enthusiast. Dr Nathanson • Avoid surfing near seal colonies, deep there are waves).” is an active and avid traveler as well as an drop-offs or river mouths where sharks Dr Geoff Booth, Tracks Magazine, 1987 expert in ocean creature injuries and their are likely to congregate. treatment. • Stay near groups of other surfers as Surfing doctors (doctors who surf) are a Surfers share the surf break with a huge sharks are opportunistic predators and growing population and over the past half variety of marine animals. While the vast more likely to attack solitary individuals. century there has been much exploration majority of these species are harmless, a • If a shark larger than two metre is and discovery by such doctors. In their few have the ability to cause harm by biting, spotted, it is safest to slowly exit the travels, they treated their own injuries, stinging, or poking the unwary surfer. In water without splashing. as well as other travelers and the local the section that follows, we will discuss • Sharks respect size and power: if indigenous people they encountered. injuries, treatment and prevention of bites attacked aggressively, strike the shark In 1987, Doctors Geoff Booth, Mark and stings from hazardous sea life. in the snout, eyes or gills with fists or a Renneker and Kevin Starr wrote ”Sick surfboard. Surfers”. This was a guide for surfers and SHARKS others on how to be aware of surfing Shark attacks are a recurrent theme when Treatment related injuries and how to treat these discussing risks associated with the sport of The victim of a shark attack may ocean maladies. In 2012, Dr Renneker along surfing. There is probably no primordial fear require assistance in reaching the shore
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via surfboard, boat or jetski. Rescuers are of stings varies widely depending on the poisonous Australian Box jellyfish (chironex almost never attacked. Upon reaching species, surface area of the sting and size fleckerii), whereas non-scalding hot shore the bitten surfer should be placed in a of the patient. Systemic symptoms such water is effective in reducing the pain and supine position with the injured extremity as nausea, vomiting, diaphoresis, dizziness redness associated with stings of the less elevated. Hemorrhage should be controlled and allergic reactions are rare. Deaths from poisonous Hawaiian Box jellyfish, and the in the field by the application of firm direct cardiac arrest, intracranial haemorrhage and very common Portuguese Man-o-war. For pressure on the bleeding site. A clean towel anaphylaxis are extremely rare and usually other species of jellyfish Papain appears to or shirt wrapped around a rescuers hand caused by “box” jellyfish (cubozoans), found be the most effective treatment3. Physicians and pressed firmly on the wound is usually predominantly in Indo-pacific waters. and surfers should become familiar with effective. If hemorrhage can’t be controlled treatment of jellyfish stings residing in local with direct pressure, a tourniquet should Prevention waters. be applied close to the groin for lower Rash guards and wetsuits provide Skin reactions that develop after a sting extremity bleeding or axilla for upper excellent protection from jellyfish stings. are often red, raised, and painful, and can extremity bleeding2. “Safe Sea” is a lotion that can be applied to occasionally develop into blisters. Topical Victims of shark bites should be bare skin that has been clinically proven to 1% hydrocortisone will help alleviate transferred to a trauma centre. Wounds decrease risk of stings in jellyfish-infested symptoms. Patients with mild allergic should be examined, irrigated and waters. reactions involving generalized hives repaired with loose closure in the and itching should be treated with oral operating suite. Bites often result in deep, Treatment antihistamines and steroids and closely linear lacerations which commonly cause If a sting involves more than local skin observed. If signs of anaphylaxis such as neurovascular and tendon injuries and irritation, the surfer should exit the water. hypotension, wheezing, and throat swelling occasionally amputations. Infections are Adherent tentacles should be removed from develop, subcutaneous epinephrine should common and prophylactic antibiotics the skin surface using a towel or a plastic be administered immediately. covering gram negative organisms should bag for protection. Tentacles can also be be administered. scraped off using the edge of a knife blade or OTHER STINGING SEA CREATURES a credit card. The skin should not be rubbed A variety of hazardous marine animals JELLYFISH or rinsed with fresh water as this will cause inhabit the sea floor and can cause It has been estimated that there are un-deployed stinging cells (nematocysts) to envenomation and puncture wounds when more than 500,000 jellyfish stings annually fire. A variety of topical treatments are used stepped upon. worldwide. Most stings cause temporary to deactivate any remaining nematocysts. Stingrays live in sandy protected bays in burning pain and whip-like skin wheals, For example vinegar has historically been tropical and sub-tropical waters and feed which fade over hours to days. The severity used to deactivate the stings of the highly on sea worms and molluscs buried beneath
Surfing doctors (doctors who surf) are a growing population and over the past half century there has been much exploration and discovery by such doctors. In their travels, they treated their own injuries, as well as other travelers and the local indigenous people they encountered.
130 the sand. When stepped on, they reflexively whip their tails upward, striking the surfer in the foot or ankle with a sharp serrated barb coated with venom. This usually results in a small (1 cm), but often deep puncture wound and a throbbing electrical or burning sensation which radiates up the leg (Figure 1). The wound may be dusky in appearance and often bleeds profusely. Systemic symptoms, which are uncommon, include nausea, vomiting, and palpitations. Occasionally fragments of the barb may remain embedded in the wound.
Prevention When surfing in waters populated by stingrays it is safest to shuffle one’s feet through the sand in order to scare these timid animals away and to avoid stepping on top of a stingray. Surfers should paddle as opposed to wade through shallow waters not only to avoid stingray stings but also foot injuries from sea urchins, stinging fish, and coral reef.
Treatment The wound should be copiously irrigated Figure 1: Based on the illustration from Surf Survival, The Surfer’s Health Handbook. with saline solution or clean water. It should be carefully explored and any retained have been reported. Treatment is similar subside. Spines that have entered a joint foreign material such as sand or barb to that of stingrays with removal of any (usually interphalageal) should be surgically fragments should be removed. Immersion retained foreign spines, immersion in removed as they commonly cause synovitis of the affected foot in non-scalding hot non-scalding hot water, and prophylactic and chronic joint swelling. Occasionally water denatures the venom and provides antibiotics. If hot water is not immediately spines in the palms and soles will cause near immediate pain relief. Due to the high available, burying the foot in hot sand has tender, raised inclusion granulomas which incidence of infection, wounds should not also proven to be effective in reducing pain5. may require surgical removal6. be sutured, and most experts recommend Sea Urchins are spine-covered globular prophylaxis with antibiotics which creatures that live in crevices on rocky or SURFING AND AGEING include coverage for gram negative marine reef-laden shorelines. The sharp brittle With a greater number of surfers and organisms such as vibrio vulnificus4. spines can easily penetrate a surfer’s hand or water aficionados, there is significant Scorpionfish are a group of well- foot and are notoriously difficult to remove. diversity in surfing skill sets, ages and water camouflaged small tropical bottom- Injuries usually involve a cluster of a dozen sense. Stand Up Paddle (SUP) is the fastest dwelling fish that possess poisonous dorsal or more spines which may leave a residual growing water-related sport and it includes spines. The dorsal spines are erected when black pigment (Figure 2). A few tropical surfing, ocean paddling, lake paddling, SUP the fish feels threatened, and injuries occur species have hollow, venomous spines, but fishing and an emerging trend to raft strong when an unsuspecting surfer steps on a most are non-venomous. flowing rivers on a SUP. fish and the dorsal spines penetrate the Surfing was once thought of as young sole of the victim’s foot, injecting venom. Treatment person’s sport, but surfers are staying in the A series of 2-5 lined-up puncture wounds Spines which protrude from the skin water longer as they age. Surfers in their are telltale signs of an envenomation. The should be removed. In general, deeply 70’s and 80’s are still in the water. Surfing pain is immediate and similar to that of embedded spines should be left in place medicine is now looking at how to keep a number of wasp stings. Stings from the as attempts to remove them will cause these older surfers in contact with their most poisonous species, the Indo-Pacific significant tissue damage. Infection from sport and the ocean for longer. stonefish (s. horrida) commonly cause sea urchin spines is relatively uncommon. The following are suggestions to systemic symptoms such as dizziness, Most spines will slowly dissolve over the enhance the surfing and ocean experience nausea and shortness of breath. Deaths course of weeks and the pain they cause will for maturing surfers:
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References 1. University of Florida Shark Attack file. Accessed April 17, 2016. https://www. flmnh.ufl.edu/fish/isaf/worldwide- summary/ 2. Nathanson AT, Everline C, Renneker M: “Surf Survival: The surfer’s health handbook”. New York, NY Skyhorse publishing, 2011 3. DeClerck MP, Bailey Y, Craig D. Efficacy of Topical Treatments for Chrysaora chinensis Species: A Human Model in Comparison with an In Vitro Model. Wilderness Environ Med 2016 Mar;27:25- 38 4. Diaz JH. The evaluation, management, and prevention of stingray injuries in travelers. J Travel Med 2008;15:102–9 5. Prentice O, Fernandez WG, Luyber TJ. Stonefish Envenomation Am J Emerg Med. 2008 Oct;26(8):972 6. King DR, Larentzakis A. Treatment of sea urchin injuries. J Spec Oper Med. 2014 Summer;14(2):56-9.
Figure 2: Sea Urchin injury. Photo credit: Andrew Nathanson, MD.
• Focus on quality wave experiences • Get into or stay in good physical shape. rather than quantity. • Ride a bigger board. • Consider including alternative water Terry “Tubesteak” Tracy, a surfing legend sports and activities, such as kayaking, in California, had these words for aging Andrew Nathanson M.D., F.A.C.E.P. SUP paddling and surf photography. surfers: Clinical Professor of Emergency Medicine • Focus on your surfing friendships and Alpert Medical School of Brown University interactions. “You may not be as bad as you feel.” • Acknowledge your surf buddies’ William H. Jones Ph.D. injuries and limitations and help them “The only person who can take away your remember what they use to do. Keep the surf stoke is you.” Professor Emeriti memories alive. California State University • Keep your surfing morale high and work “You go till you no mo can go.” West Coast Executive Director, Surfers on keeping the stoke. Help others in the Saburo, Hawaiian mentor Medical Association surfing world by coaching, volunteer judging a contest, working with These ideas can apply to many sports, but Mary Showstark, M.S., PA-C veterans or those with disabilities to surfers have a particularly strong bond with understand the thrill of surfing. the ocean. From fetal development through Yale School of Medicine Physician Assistant Online Program • Connect with the waves daily, by going life, surfers need to maintain this water to the beach, walking your dogs there contact to follow a meaningful existence. East Coast Executive Director Surfer’s and watching the ocean with friends. Medical Association • Challenge yourself to learn a new aspect For more information on Surfing of the surfing culture. Try a SUP, ride a Medicine and rehabilitation visit www. Contact: boogie, body surf or just swim. surfersmedicalassociation.org [email protected]
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