[Public Health] Surviving The Sting

I’ve always been fascinated by things that sting, and over the course of a long, colorful career I’ve managed to be stung by virtually all of them. No matter what role I happen to be playing — researcher, consultant, bureaucrat or just some guy trying to mow his lawn — these remarkable little critters have never failed to get my closest attention. And no matter how many times I’ve gotten nailed because of my own carelessness or lack of awareness, I’ve never gotten used to it.

Indeed, that moment of panic produced by the searing pain of a sting is a sensation that virtually everyone is doomed to experience at one time or another. What comes next, however, is highly variable. For most of us, the physiological consequences are minor and the brief trauma quickly fades. On the other end of the spectrum, a very few unfortunate people lapse into shock and die within a few minutes.

Considering the stakes are potentially so high, one would think that the basic facts of sting survival, from avoidance to remedies, would be fairly well known. One would be wrong. There is an astonishing amount of misinformation about the subject that is continually recirculated within the three professional communities that have the largest stake in getting the facts right — entomologists, physicians and pest managers. I think this is due in part to an unfortunate compartmentalization of knowledge among these different groups, as well as the natural tendency to believe anything that sounds reasonable and is repeatedly stated with authority.

Our customers depend on us for accurate information, so here is an attempt to set the record straight. In my experience, the following five myths are among the most frequently encountered and deeply entrenched.

MYTH 1: You can minimize your chances of getting stung by avoiding bright colors and strongly scented perfumes or colognes. Search the Web for awhile and you’ll see this advice being offered by some highly prestigious medical organizations. And it makes sense, doesn’t it? After all, bees are attracted to flowers and flowers have bright colors and smell nice, right?

In fact, there is no evidence that the colors and fragrances you wear have much to do with your risk of getting stung. There are three major reasons for this. The first is the fundamental misconception that bees and wasps are basically hot-headed, short-tempered thugs with itchy trigger fingers. That may be true when their nest is disturbed, but not at all while they’re out foraging. Social Hymenoptera are rigidly programmed to reserve their sting only in defense of life — their colony’s or their own.

Secondly, give these insects some credit for brains. You might have on a buttercup-yellow shirt and smell like a bouquet, but you’re not going to be mobbed by bees thinking you’re a giant blossom. That only happens in cartoons. It doesn’t happen in real life because bees are simply not that dumb.

The third reason is the most important. Foraging bees and wasps indeed prefer certain colors and scents, and attacking bees and wasps are strongly attracted to dark-colored objects (including eyes, nostrils and hair) over light ones. But these facts are totally outranked by the real primary risk factors for getting stung. If you disturb a nest enough to warrant an attack by its occupants, your only wardrobe selection that will make a critical difference is whether or not you’re wearing a bee suit and veil. And stings by isolated individuals away from the nest almost always involve firm, accidental contact such as stepping on one or pressing it with the hand. Most of these incidents involve walking with feet exposed, and eating or drinking outdoors when yellowjackets or honey bees are attempting to share in the festivities (see Figure 2 at right). Fashion is just not part of the equation.

MYTH 2: If you are stung by a honey bee, the sting should be carefully scraped away rather than pinched with the fingers to avoid squeezing more of the venom into the wound. You’ve heard this one ever since you were a kid and it’s still universally recommended by the medical community. The honey bee is our only insect whose sting invariably becomes fixed in the skin and remains behind when the insect pulls away, a process called autotomy. Less well known is that the sting of some species of yellowjackets also frequently gets stuck, but cannot autotomize — it is torn from the wasp’s body only if the insect is brushed off by the victim (see Figure 1 on page 71). [Note: The proper term for the weapon of these insects is "sting." A "stinger" is a type of guided missile.]

For many years I regarded the "scrape don’t squeeze" advice as valid but silly, sort of on a par with "climbing a tree will protect you from a charging grizzly." Well, sure, assuming you’ve got the time to whip out that trusty tree-climbing gear when you need it. Same thing with removing a sting. This tends to be the type of situation where frantic, clumsy fingers are going to reflexively grab rather than painstakingly scrape with some handy implement.

As it turns out, method of removal has absolutely no effect on the quantity of venom injected anyway — at least for honey bees. A little gem of a study that is still unknown to virtually everybody (Visscher, P.K., R.S. Vetter, and S. Camazine. 1996. Removing bee stings. Lancet 348: 301-302) demonstrated that due to the sting’s valve mechanism, venom flow is not increased by pinching the attached venom sac — the apparatus simply doesn’t work that way. The one critical factor in determining venom dose is how quickly the sting is removed. So in this case, our new mantra should be: "If sting is stuck, rush to pluck."

To complicate matters, however, a yellowjacket sting lacks valves and works on pure compression, so it is indeed possible that squeezing it during removal might inject more venom. As far as I know, nobody’s done the empirical homework on this one.

MYTH 3: Rubbing meat tenderizer (or the folk remedy of your choice) into the sting site will break down some of the venom. Or you can use a small suction device to physically remove the venom. Once again, we have perfectly reasonable-sounding assumptions that quickly disintegrate under real-life conditions. Yes, it seems to make sense that a proteolytic enzyme — or one of those little venom sucker-outer thingies that are always being enthusiastically marketed to outdoors people — couldn’t help but make an improvement. The reason why these bright ideas usually fail is because by the time they are applied, most of the injected venom has already been transported in your bloodstream beyond their reach and has already begun to work its mischief. All it takes is a few seconds.

I say "usually" fail because lack of any medical evidence that they work doesn’t guarantee that you won’t feel better after using them. I’m a big fan of the placebo effect, but it can be dangerous if a person with venom hypersensitivity believes that his or her allergic reaction will be diminished by following grandma’s well-meaning advice. People swear that all sorts of crazy stuff works to relieve local sting symptoms (e.g. vitamins, ammonia, activated charcoal, tobacco, mustard, mud, gasoline, you name it), but the current consensus among the experts is that the most effective first aid, assuming you are not at risk for a systemic response (see below), is to apply ice on the sting site. It’s guaranteed to relieve the pain and make the swelling go down.

MYTH 4: Substantial swelling at the sting site indicates you are allergic to the venom. I think most people understand that a "normal" reaction to a sting — that is, what happens in the majority of cases — is fairly innocuous. The initial pain may be intense, but it usually diminishes within an hour or two. The site of the sting is marked with a red, warm, swollen area that is typically no more than two or three inches across (see Figure 3 above right). As the swelling subsides, the site begins to itch. It’s a bummer but it’s not a big deal.

Therefore, it’s not surprising that any dramatic deviation from this relatively mundane scenario is often viewed with alarm. The most frequently observed variation is termed a "large local reaction," characterized by swelling adjacent to the sting site that is greater than a few inches in diameter (see Figure 4 at right).

Sometimes an entire limb is immobilized and sometimes the condition is severely painful and debilitating, but this type of reaction is only considered to be a medical emergency if it involves some body part that can’t afford to be swollen — like your breathing passages, for instance. It has nothing to do with a dangerous allergic response, nor does it predict such an event in the future.

A true allergic reaction is a systemic one, involving generalized symptoms that are remote from the sting site. These most often involve the skin (redness, swelling, itching or hives), but may also include the respiratory system (shortness of breath, wheezing), digestive system (nausea, vomiting, abdominal cramping), or cardiovascular system (low blood pressure, dizziness, fainting). The syndrome is often termed anaphylaxis, although the precise use of this term varies among medical authorities. Systemic reactions are fortunately very rare, affecting only about one percent of the population, and even among this group the symptoms are usually mild. On the other hand, severe episodes may quickly result in respiratory failure, shock, and death. Since anyone diagnosed as hypersensitive (i.e., allergic) to venom runs the risk of a life-threatening reaction sometime down the road, any subsequent sting must be treated as a medical emergency. This means calling an ambulance and following your physician’s recommendation on epinephrine use (see below), not just popping a Benadryl® and hoping for the best.

MYTH 5: If you are allergic to bee or wasp venom, the best thing you can do for yourself is to always carry an epinephrine-filled automatic injection device (AID). It is standard procedure for a physician to write out a prescription for one of these handy instruments following a diagnosis of hypersensitivity to a wide range of allergens, including insect stings. The leading product is called EpiPen®, an apparatus about the size of a large felt marker that is used to self-inject a single dose of epinephrine into the outer thigh following an "allergic emergency." There is no question that AIDs are life-saving tools and should be carried by anyone who is in danger of anaphylaxis, although epinephrine alone will not reverse serious reactions in all people.

What is most disturbing, however, is that a well-established medical procedure that markedly decreases the need to carry such a device — that is, a safe, effective treatment for life-threatening venom hypersensitivity rather than just first aid for the symptoms — is still not universally recommended to patients by their primary care physicians. I meet far too many people in our three professional communities who are either unaware that desensitization treatment exists or who have only the vaguest concept of what is involved.

The procedure is termed venom immunotherapy and it was developed back in the 1970s. It consists of a simple series of shots administered by an allergist. Since hypersensitivity is often highly specific, a skin test must first be performed to identify which type(s) of bee or wasp presents an elevated risk. Then a regime of injections with dilute preparations of the proper venom(s) gradually builds up the patient’s immunity by steadily increasing the dose. The entire program, including periodic post-regime booster shots, should be continued for five years for most patients. Venom immunotherapy is overwhelmingly successful in protecting against future severe reactions and is covered by many insurance programs. If you have been diagnosed as allergic to stings, this is something you can’t afford to pass up. You owe it to yourself and your family to check it out with a certified specialist in allergy and immunology.

All photos are ©Al Greene/Nancy L. Breisch

Author’s note: The author gratefully acknowledges Dr. Nancy Breisch for 20 years of collaboration in sting-related research, consulting, and painful firsthand experience. All readers should consult with their physician on any issue pertaining to medical treatment. The opinions expressed herein are the views of the author and do not necessarily reflect the official policy or position of the U.S. General Services Administration.

The author is regional entomologist for the U.S. General Services Administration in Washington, D.C. He can be reached via e-mail at agreene@giemedia.com.