This is from the thirty-eigh
FLESH-EATING BACTERIA (PART 1)
Unlike most of my older colleagues, I couldn’t remember a time in my training or practice when we hadn’t had the blessing of antibiotics for severe bacterial infections.
However, after decades of a steadily declining morbidity and mortality due to bacterial infection, the early 1980s saw a resurgence of severe, invasive bacterial disease. And in those days, none was worse than a bacterium called group A streptococcus.
The first case I saw was in a young woman named Georgia. About a week after a normal menstrual period, she came to the office with vaginal pain and a purulent vaginal discharge. At first, I thought it was a severe form of vaginitis, but her fever, pain upon examination, and low blood pressure worried me enough to admit her to the hospital. Fortunately, intravenous antibiotics stopped the potential killer in its tracks. Only the next year would this type of infection be officially named—then labeled streptococcal shock syndromeor toxic shock syndrome.
But toxic shock syndrome was a mere lamb compared to its nasty cousin necrotizing fasciitis, which was reputedly one of the most severe and potentially fatal forms of invasive streptococcal disease around. With this illness, patients would suffer from rapid, local, deep soft-tissue destruction, severe septic shock, and multi-organ failure. It would often kill its victims quickly and very painfully. My first victim survived—albeit barely.
I didn’t learn about his admission until I entered the nursing station to make Monday-morning rounds.
Vernel met me as I entered the station. “Dr. Larimore, Dr. Sale admitted Carl Walkingstick to you last night. He’s a diabetic patient of yours who has some cellulitis on his back. He was fishing down on Fontana and hooked himself in the back. Apparently, that led to the infection. He’s in the isolation room. I’d suggest you see him first. He’s not really doing very well.”
I quickly looked over his chart and became alarmed. His initial labs from the previous evening showed an extremely high white blood cell count—indicating a severe infection. However, even more ominous was an elevated creatine phosphokinase (or CPK) level. This enzyme is found in the blood only when muscle or brain tissue is dying. I quickly walked to Carl’s room.
When I entered, he was alone and appeared to be sleeping. When I tried to awaken him, he only moaned—and that only came with a deep pain stimulus. Carl was unconscious, and his respirations were dangerously slow and his pulse perilously high. I punched the nurse call button. “Vernel, get down here right away!”
I quickly examined him. His heart and lungs sounded fine. His abdomen was soft and had normal bowel sounds.
Vernel appeared behind me. “Help me roll him over!”
We worked together to slowly roll the enormous man on his side. I lifted up his gown and gasped. Carl’s back looked dreadful. Instead of being indurated and red or pink, as I would expect in a case of mild cellulitis, Carl’s skin was thickened and swollen, with an ominous bluish or purplish coloration. However, the violet blisters covering the surface of his back were the most dooming.
“Dr. Larimore, his back didn’t look like this when I came on my shift this morning—I promise!” Vernel exclaimed.
I nodded. “I believe you, Vernel.” The skin was thick and tense. As my fingers probed, Carl moaned in pain.
“Vernel, get me the biggest syringe with the largest bore needle we have—and I’ll need some culture tubes. I need to culture the leading edge of this infection. Let’s switch him to stronger antibiotics, start oxygen immediately, and let’s get him to ICU! Stat!”
“Yes sir!” Vernel exclaimed as she turned to leave the room.
“Oh!” I added, as Vernel turned toward me. “Call Ray or Mitch to come down here stat.”
“Yes sir!” she responded as she exited.
I knew as soon as I saw his back that Carl had necrotizing fasciitis, which had been called streptococcal gangrenewhen I was in my training. It would be many years before it would be named flesh-eating bacteriaby the lay media. It’s a deep-seated infection of the subcutaneous tissue that results in progressive destruction of the fascial tissue and fat below the skin, but it may actually spare the skin itself. It is an infection that advances with striking rapidity and can eat away an entire limb or denude the tissue of the torso or the abdominal flesh in hours.
I knew that if we didn’t get at least three powerful antibiotics into his system and get him to the operating room to clean out the deep infection, within a very short period of time the purple areas would become gangrenous. Then the dead skin would begin to slough off, revealing extensive necrosis of the subcutaneous tissue. Without emergency surgery and intensive care, Carl would likely die very soon.
Vernel returned with Betty and the equipment. “Ray will be here in a few minutes.” A respiratory therapist ran into the room and set up the oxygen mask.
I quickly put on sterile gloves and took a sterile syringe and aspirated fluid from several of the blisters. I handed the syringe to Betty, who squirted the ominous dark fluid into a culture container.
Then Vernel handed me another syringe, and I plunged it into the skin on Carl’s back, near the edge of the advancing infection.
Carl only moaned. I knew he didn’t feel much of the pain. When the needle reached just below the skin, I pulled back on the plunger and thick, yellowish-green pus oozed through the large-bore needle into the syringe.
Just that moment, Ray entered the room.
“Look at this, Ray.”
“Oh no!” he replied.
I gave him a quick history as he gloved and then examined Carl’s back.
“Walt, I agree with you. We’ve gotta get ’im to OR. Now! I need to do an aggressive fasciotomy and debridement. It won’t be pretty, but if we’re lucky, we’ll save his life. If we don’t, this infection will spread over most of his body.”
“Yep,” I replied, trying to sound calmer than I was feeling inside.
“Are you changing his antibiotics?”
“I’ve already ordered high doses of triple antibiotics to be given stat. I’ll get the pre-op labs, EKG, and chest X-ray if you can get OR ready.”
“I’ll do it!”
Ray turned to leave, and then he turned back to me. “Walt, I hope we’re not too late.”
Me too! I thought.
TO BE CONTINUED
PAST STORIES FROM BRYSON CITY SEASONS
- Dead Man Standing (Part 1), (Part 2), (Part 3)
- Eyes Wide Open (Part 1), (Part 2)
- Auspicious Accidents (Part 1), (Part 2)
- Answered Prayers (Part 1), (Part 2), (Part 3), (Part 4)
- Rotary Luncheon
- Death by Emotion (Part 1), (Part 2), (Part 3), (Part 4)
- The Invitation (Part 1), (Part 2)
- Barbecue and Bacon (Part 1), (Part 2)
- A Touchy Subject
- Family Time (Part 1), (Part 2)
- Chicken Pops(Part 1), (Part 2)
- Swain County Football (Part 1), (Part 2)
- Hospital Politics (Part 1), (Part 2), (Part 3)
- The Bobcat Attacks (Part 1), (Part 2)
- Dungeons and Apples
- A Tale of Two Surgeons (Part 1), (Part 2), (Part 3)
Feets(Part 1), (Part 2), (Part 3)
- Wise Counsel (Part 1), (Part 2)
- An Anniversary to Remember (Part 1), (Part 2)
- Mrs. Black Fox (Part 1), (Part 2)
- The Littlest Cherokee (Part 1), (Part 2)
- Christmas Firsts (Part 1), (Part 2)
- The Silver Torpedo
- Another New Year’s Catch
- Turned Tables
- Doctor Dad (Part 1), (Part 2), (Part 3)
- The Phone Tap (Part 1), (Part 2)
- Labor Pains (Part 1), (Part 2)
Staphand Staff (Part 1), (Part 2)
- The Ribbon Cutting
- Mountain Breakfast
- Walkingstick (Part 1), (Part 2)
- One Big Fish
- Memorial Day (Part 1); (Part 2)
- The Parade of the Century (Part 1)
- Lost Boy (Part 1); (Part 2)
- Facing the Music
- Flesh-Eating Bacteria (Part 1); (Part 2)
PAST STORIES FROM BRYSON CITY TALES
- The Murder (Part 1); (Part 2); (Part 3)
- The Arrival (Part 1); (Part 2)
- The Hemlock Inn (Part 1); (Part 2)
- The Grand Tour (Part 1); (Part 2)
- The Interview (Part 1); (Part 2); (Part 3)
- Settling In (Part 1); (Part 2)
- First-Day Jitters (Part 1); (Part 2)
- Emergency (Part 1); (Part 2)
- The Delivery (Part 1); (Part 2)
- The “Expert” (Part 1); (Part 2)
- The Trial (Part 1); (Part 2)
- Shiitake Sam (Part 1); (Part 2)
- Wet Behind the Ears (Part 1); (Part 2); (Part 3)
- Lessons in Daily Practice (Part 1) — Anal Angina; (Part 2); (Part 3); (Part 4)
- White Lies
- The Epiphany (Part 1); (Part 2)
- Becoming Part of the Team (Part 1); (Part 2)
- Monuments (Part 1); (Part 2)
- My First Home Victory (Part 1); (Part 2)
- Fisher of Men (Part 1); (Part 2)
- Fly-Fishing (Part 1); (Part 2)
- Something Fishy (Part 1); (Part 2)
- A Good Day at the Office
- An Evening to Remember
- Another New Doc Comes to Town
- ‘Twas the Night Before Christmas (Part 1); (Part 2)
- A Surprising Gift
- The New Year (Part 1); (Part 2)
- The Home Birth (Part1); (Part 2); (Part 3)
- The Showdown (Part1); (Part 2); (Part 3)
- The Initiation (Part 1); (Part 2); (Part 3)
- Home at Last (Part 1); (Part 2); (Part 3)
© Copyright WLL, INC. 2019. This blog provides a wide variety of general health information only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment from your regular physician. If you are concerned about your health, take what you learn from this blog and meet with your personal doctor to discuss your concerns.