You were bit by a what??

A day in the life of Family Medicine

Best case of the week: patient comes in for wound care. It seems she was on a beach vacation in Mexico, went for a dip in the ocean, and got bit in the leg by a sea lion.

On examination, the wound wasn’t bad – bruises and abrasions on the front and back of her upper thigh, teeth marks extending about half the circumference of her leg. The sea lion must have been friendly – just coming over to say hello: if it had bit down with any force, it would have taken a huge chunk out of her thigh.

What are the chances of such an event happening? As you might expect, they are exceedingly low. Certainly not a reason to stay at home, we can all agree – whatever the risk, it certainly appears to be outweighed by the benefit.

In fact, a lot of medical decision making – of what I do every day as a Family doctor – involves making risk-benefit calculations, and reviewing them with patients.

Should I go swimming on vacation even though I might get bit by a sea lion? Easy Yes.

What about if there’s a shark sighting? Easy No.

How about going for a bike ride for exercise even though I forgot my helmet? Not so clear-cut.

Should I take this medication for my blood pressure despite the possible side effects? Get the Covid vaccine? Give it to my kids??

In each case the process is the same: does the risk of this particular action, for this particular patient, outweigh the benefit?

Here’s a topical one: Should I take aspirin to decrease my risk of a heart attack? For years, if the risk was high enough (i.e. greater than 10% risk of a heart attack over the following 10 years), the answer was, Yes – and millions of patients are taking a daily aspirin today based on that calculation.

Now, the answer seems to be, No, and patients have been asking if they should stop the aspirin that I’ve been advising them to take for years. Some of them are concerned or even annoyed. 

“Are you telling me that I've been harming myself all along?” 

“Here we go again with the flip-flopping “expert” opinions (remember masks anyone?)”

“Nobody knows anything – one day they say X, the next day they say Y!”

In truth, while the recommendation may be different, nothing fundamental has actually changed. There is no flip-flop – it’s the same process all along.

We have always known that aspirin carries the risk of internal bleeding, balanced by the benefit of decreasing the risk of a heart attack, with the outcome in favor of aspirin (in the right clinical scenario, of course). It’s just that over the years, with time and experience, data accumulates, the scales re-balance, and the outcome shifts.

Dubious about change? Be the opposite! It’s when things remain static for too long that you should start to get suspicious: someone must not be paying close enough attention…

Anyway, you may be wondering, just in case, how to treat a sea lion bite.

First, control the bleeding with direct pressure. Next, clean the wound by irrigating with water. Don’t close up any punctures or lacerations, because sea lions have exotic bacteria in their mouths that you don’t want to seal into the wound. And start a broad spectrum antibiotic, like Augmentin, to cover a potential poly-microbial infection.

Finally, dress the wound with antibiotic ointment and gauze, and go online to plan your next vacation: in matters of the beach, always let the rewards outweigh the risks, even if you have to put your thumb on the scale.