IT’S A BEAUTIFUL SUNNY DAY and Nelly (not her real name), a dive instructor, conducts her four divers along a spectacular wall close to the dive resort, located on a tropical island in South-east Sulawesi, Indonesia.
The dive is nice and relaxed, with no current. All goes well until towards the end of the dive. Turning to signal to the divers to ascend after the safety stop, Nelly accidentally hits a crown-of-thorns starfish with her right hand’s index finger and gets stung deeply by three venomous spines.
On board the boat she removes the spines, cleans her hand by putting it in hot water, and finally disinfects the wound with Betadine. The pain is excruciating.
Despite this first-aid treatment, on the following day her finger is worse, and swollen. As the island is very remote, there are no doctors. However, she doesn’t call DAN immediately and begins a self-administered treatment, first with Ibuprofen and later, as her finger gets worse during the night, with a penicillin-like antibiotic.
Considering the circumstances, Nelly is quite well off – there’s no nausea or vomiting, and her wounds are small, affecting only half of her index finger with adjacent swelling of the hand.
As the antibiotic cannot act effectively at this stage, her finger is even more swollen the next day. An American surgeon among the guests says she needs to fly to Bali for decent hospital treatment if the finger doesn’t get any better in the next 24 hours.
However, leaving the island quickly is a challenge. Planes come and go only once a week. Nelly is lucky, however – only three days after the incident, there is a flight to Bali. She now contacts DAN Europe and, after authorisation to cover her travel and medical expenses, takes off.

IN HOSPITAL
In Denpasar, Bali, Nelly visits the international hospital. It diagnoses a secondary infection due to contact with marine life and prescribes more antibiotics (clindamycin) and an army
of painkillers.
Over the next two weeks she has to stay in Bali as an outpatient, and returns to the hospital several times. The secondary infection has built an abscess which has to be opened to allow a lab examination to be conducted.
Despite the antibiotics, the finger gets no better. Finally, an X-ray reveals that there are still traces of spines embedded in the soft tissue of Nelly’s hand!
Over the following four days the finger is cut open twice, and more antibiotics and painkillers prescribed. Nelly still can’t fly back to Sulawesi, and has to get back to hospital for an emergency treatment.
Finally, three weeks later, with the doctor’s OK, she is on her way back to the little island, and starts diving again.

NOT OVER YET
A month later, Nelly is back at the hospital in Bali for a follow-up visit on the wound debridement (removal of the spine traces).
The situation has worsened – her finger is still stiff, red and swollen, and she feels pulsating pain. She has kept applying antibiotic ointment and two of the three wounds have actually healed, but the third one is giving her trouble.
Movement of Nelly’s finger is limited. She feels numbness but, luckily, there is no pus in the wound.
The surgeon requests a new X-ray, which reveals that there is still a foreign body inside the soft tissue of the finger, causing the swelling and inflammation.
That means another 14 days as an outpatient in Denpasar, where an orthopedic surgeon reopens the wound.
Luckily there is no infection of the bone, but the saga has been dragging on for almost two months now… and this all because of three little spines.

FIVE MONTHS LATER...
In Italy, it’s another busy work-day in the life of Julia S, Case Manager at DAN Europe, who has just started reading her emails.
At the same time, on a small, beautiful island on Thailand’s west coast, Tessa, a Finnish dive instructor, is in despair. During her dive she has accidentally hit a crown-of-thorns starfish with her entire arm.
Her hand starts bleeding heavily. Shortly afterwards it becomes numb, with really hard pain. Nausea begins within a few minutes.
On the boat, Tessa puts her hand and arm in hot water for an hour. However, the hand is swollen and the skin marbled all the way to the elbow.
Back on land, she seeks help at a local clinic. The doctor prescribes her antibiotics, but has no idea of what the crown-of-thorns is. Tessa is being treated as if she had touched a sea urchin.
Later, back in the resort, she decides to email DAN Europe about her injury, and it’s Julia who receives it. When she reads “stung by the crown-of-thorns starfish”, she immediately remembers Nelly’s case, and is instantly on high alert.
She grabs her phone and calls Tessa to check her current status. Tessa’s voice is very weak – she can’t even stay awake.
Julia gets the impression that the girl is close to fainting, and tells her that she needs to seek decent medical help in Phuket, immediately.
Remembering Nelly’s case, and aware of Tessa’s much larger injury, she knows that she has to act quickly.
What she usually does in such an emergency is to call “Doc”. No matter whether it’s day or night, Sunday or Christmas, this one goes directly through to Alessandro Marroni, President, CEO and Chief Medical Officer of DAN Europe, one of the most experienced diving medicine specialists in the world.

DOC STEPS IN
Prof Marroni gives Julia immediate authorisation for an urgent medical evacuation, as he fears that Tessa will go into anaphylactic shock, a possible and life-threatening allergic reaction to the starfish’s venom.
However, over in Thailand, after Tessa has had an awful night with increased pain, nausea, vomiting, extreme sleepiness and headaches, her friends take her to another doctor in what is called a “first standard” clinic close by.
Unfortunately, this doctor doesn’t know about the crown-of-thorns either, but looks it up on Google. Tessa gets another antibiotic, this time applied intravenously, and is told to come back and repeat this treatment within the next few days. She is actually running out of time and options.
Telephone lines between Italy and Thailand run hot as Tessa’s evacuation is organised, and once her address has been found everything runs smoothly.
She wakes up in bed in an intensive care unit. An ambulance had arrived the night before, and Tessa had been placed on an intravenous drip and been escorted by a nurse to the international hospital in Phuket to undergo medical treatments fully covered by DAN.
Suffering from nausea, vomiting, drowsiness and fever, Tessa’s left hand and wrist were swollen and very painful and her arm, hand and fingers were paralysed. Lymphagitis and left axillary lymphadenitis signalled that her immune system was pretty occupied.
A surgeon opened the wounds and removed all thorns. Tessa was put on heavy medication with dexamethasone and clindamycin given intravenously every eight hours. Because she had lost a lot of fluids, she was also put on an IV drip for fluid-replacement. Later she was able to start moving her fingers again.


RECOVERY
Discharged from hospital six days after the incident, Tessa, although her hand was still numb, felt happy again. The bill for her five-day inpatient treatment amounted to 6000 euros – amazing, the huge costs a little starfish can incur!
There would still be numbness in Tessa’s hand a couple of months later, and even five months after the injury occurred, two fingers had not regained sensitivity yet. Healing is a long process.
Tessa’s nine-page medical report and the extensive list of different drugs used demonstrate that the hospital in Phuket took really good care of her.
In an emergency, quick decision-making, good judgment and experience is crucial for effective case-management. People like Doc Marroni and Julia can make a difference and make things happen – even from a distance.
They spared Tessa a lot of pain, unnecessarily prolonged suffering and debilitating, life-threatening illness.

MEDICAL VIEW
DAN Europe is a not-for-profit worldwide organisation that provides emergency medical advice and assistance for underwater diving injuries. It also promotes diving safety through research, education, products and services

Photo credits:
Nick Hopgood
Matt Wright

ACANTHASTER PLANCI
The crown-of-thorns, also known as the seastar or venomous starfish, is littered with sharp venom-filled spines up to 6cm long, and looks pretty vicious with its six to 23 arms and average diameter of 40-60cm.
Its mainly red colour is a warning that it is venomous. Its defence system makes it an impressive survivor with almost nothing able to predate on it.
Its home is in the most beautiful dive-spots – in the tropical zones of the Indo-Pacific (Philippines, Indonesia, Great Barrier Reef in Australia), the Red Sea and Central American coastal areas, generally in coral-reef regions.
Prevention is your best friend. Protect yourself by wearing shoes and/or boots, gloves or other clothing such as thick neoprene.

TREATMENT
Cortisone (ointment) is a possible first aid self-medication that can be used to mitigate the symptoms of a contact dermatitis from touching crown-of-thorns spines.
Antibiotics and cortisone cannot help the wound to heal properly as long as pieces of venomous spines are still embedded in the tissue. Only after their removal and disinfecting the wounds will the use of appropriate antibiotics and cortisone be able to promote the healing process.

LESSONS LEARNED
Put your health first. Take an incident with a crown-of-thorns starfish seriously. Seek help immediately or it will get worse, and then you might not be able to travel to a decent hospital by yourself anymore.
Debridement of spines is mandatory, and they be located only by ultrasound or X-ray. The wounded side will swell quickly, and it should be needless to say that this kind of injury curtails any scuba-diving activity.
There are obvious limitations in self-treatment because an injury like this will always require surgical intervention. The spines easily break off and stick in the tissue, releasing the venom.
The inflammation is ongoing because the body tries to get rid of a foreign body and fight the venom at the same time. Nelly’s story shows that the wound will not heal as long as the foreign body (filled with venom) remains inside the tissue.
On the other hand, Tessa’s case shows that quick and adequate medical intervention can shorten the suffering effectively.