Necrotizing Fasciitis

Sometimes, as an author, you need something unusual to inflict your character with so this week I thought I’d focus on two injuries that can be unique to mass casualty incidents.

Mass casualty incidents (MCI’s) are defined as those that overwhelm equipment and personnel by the number casualties. It’s not necessarily the same for every organization. If a rural EMS crew comes upon a three-car accident with three patients– that might be a mass casualty incident for them but this same accident happening in downtown New York would not be.

Often times, when we think of mass casualty incidents, we recall the big things like tornadoes, earthquakes and terrorist attacks (bombings, nerve gas release) and school shootings.

For this post I’m focusing on a unique infection related to Acts of God weather events and next post I’ll do an injury related to bombings.

Mucormycosis is a soil fungus that comes out to play when it is dredged up from the earth with events like flooding and tornadoes. Usually a person comes into contact with the fungus via an impaled object. It is a necrotizing bug (meaning is devours flesh) so aggressive debridement and treatment with broad spectrum antibiotics and antifungals is necessary.

After the Joplin, MO tornado in 2011– thirteen cases were identified of which five (38%) died. Most had accompanying fractures. Interesting to note is that all the patients were located in the zone that sustained the most damage. Infection was associated with penetrating trauma and multiple wounds. You can read further about this rare infection by reading this piece as well.

What also could have contributed to the number of infections was the devastation to the medical system that happened during the tornado as well. The main hospital was damaged and several off-site clinics were set-up so the above news piece surmises that wounds may not have been adequately treated (which would be serious irrigation.) This is understandable considering what the town was dealing with.

What about you? Have you ever been in a natural disaster?

I’m so pleased to host Tanya Goodwin, OB/GYN extraordinaire. She’ll be stopping by on a monthly basis to offer her insight into all things medical.

Welcome, Tanya!

http://www.medicinenet.com/necrotizing_fasciitis/article.htm

As a medical student I was taught about a barrage of diseases, acute and chronic, common and rare. One of the rare was necrotizing fasciitis.

Thinking I’d never encounter this deadly disease, I forgot about it until one night as a second year OB/GYN resident (4 year specialty training after medical school) when I was called to evaluate a woman who was transferred from a community hospital to our large teaching institution with possible necrotizing fasciitis.

I briefly reviewed this disease before I took the elevator, along with my intern (aka 1^st year resident) to the ninth floor, ready to evaluate this young woman.

It was midnight when we entered her room. My attending (supervising physician) had accepted her transfer as a direct admission, bypassing her need to enter via the emergency department.

She laid in the bed, covered with a white hospital sheet, her husband holding her hand. He darted his eyes towards us. Why would he trust us? His wife’s condition had worsened despite being hospitalized for the last three days.

During that time, she’d received intravenous antibiotics upon the recommendation of a doctor who specialized in infectious diseases. The consult was requested by her obstetrician who had admitted her to the hospital one week after she had given birth vaginally to a healthy baby boy.

Diagnosis? Necrotizing fasciitis.

Necrotizing means dying or death and fasciitis refers to inflammation of the fascia, a tough connective tissue overlying muscle. Rare, the incidence of NF is approximately 1 in 450,000 or 600 people per year.

Otherwise known by the moniker, Flesh Eating Disease.

During childbirth, the obstetrician performed an episiotomy, a surgical incision of the perineum, that skin between the vagina and anus to afford a wider opening to deliver the baby. After the delivery, the episiotomy was sutured closed. The woman went home with her baby, but had called the OB’s office several times with complaints of episiotomy pain, a common occurrence.

Instructed, as usual, to apply anesthetic foam and to take an oral pain medicine, she did so but with no improvement. After multiple phone calls, she now complained of not only refractory episiotomy pain, but fever and chills, malaise, and reddening of her genitals and inner thighs. She was told to come to the doctor’s office.

Diagnosed with an episiotomy infection, her OB admitted her to the hospital for intravenous antibiotics. The redness spread, her fever continued, she was now nauseated, and her blood work showed a significantly elevated white blood cell count consistent with a severe infection. An infectious disease consult was then made by her OB.

Necrotizing fasciitis is caused by invasion of bacteria into the fascia after a break in the skin. Many bacteria or a single offender are the culprits. Typical bacteria are of the streptococci family such as Group A streptococcus or a staphylococcus, both found on our skin. The disease really is not “flesh eating” as the toxins from the bacteria do the damage.

Some have contracted NF by swimming in water containing Vibrio vulnificans. These victims of NF had a portal of entry: a skin scrape or laceration. Those at risk for necrotizing fasciitis are people with lowered immunity from chronic diseases such as autoimmune disorders, diabetes, and liver disease, but it is also seen in healthy people or those that have had surgery or an incision. Symptoms are pain, swelling, redness, feeling poorly, nausea, vomiting, and fever.

What I saw that night still sticks in my memory 20 years later. The woman’s thighs down to just above her knees looked like the worst sunburn I’d seen. At this point, she felt nothing in the affected area as numbness had set in.

My attending physician had examined her as well. After explaining the gravity of the situation, the woman was taken to the operating room to debride, or cut out, the dead tissue. In two surgeries, the first taking all night, she had her vaginal tissues and thighs removed.

She died the second day in the intensive care unit. The bacteria had spread to all her deep tissues. She became septic and died of multiple organ failure, leaving a grieving husband and a newborn son.

NF has a mortality rate greater than 70%. If diagnosed early and treated promptly with surgical debridement, some literature suggests a mortality rate of 33%. Unfortunately for this woman, the diagnosis was correct, but the initial and critical treatment was not.

Hopefully as more providers are aware of this deadly disease, more cases of necrotizing fasciitis will be correctly diagnosed and promptly treated, saving lives.

***************************************************************************

Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com.