26 September 2013
I'm just sickened. I'm wracking my brain trying to see why I didn't see it
sooner. Hindsight is 20/20. Yesterday, Dr. Roger comes up to me after staff
worship.
"You should come see bed 11. Last night at nine, they called me and he had a
wound that erupted in his groin."
"Bed 11?"
"You know, the man with the double fracture, tibia and femur..."
We walk the short distance to the men's ward and enter the dimly lit room. Just
to my right is a man I recognize well. Three days ago, Saturday, I operated on
him for a floating knee where the distal femur and the proximal tibia were just
shattered. Sunday, he was doing well. Monday, he was groggy, but the nurses
said he'd had so much pain the night before they'd injected him with a
tranquilizer and a narcotic. I assumed it was just that. He was arousable and
his vital signs were normal. His femur fracture was an open fracture that had
been sutured at the government hospital three days before coming to us. At
surgery, the wound was very traumatic, but didn't look infected like many that
I've seen. The wound looked good on Monday, though there was some
serosanguinous drainage on the dressings. There was no odor. Tuesday, I let
Dr. Roger do rounds while I operated.
Today, he looks like death warmed over. His breathing is shallow, his eyes are
closed, his skin is sallow and he's lying in a pool of foul smelling maroon
liquid. I pull back the sheet and his groin is covered with gauze soaked in
brown liquid and around the edges is poking out peeling, necrotic tissue. The
side of his leg is also weeping with skin sloughing off over dark, dead looking
flesh: necrotizing fasciitis.
"Go get the gurney, quick!" I call to Appolinaire who has accompanied us.
"Roger, how did it look yesterday?"
"The wound was clean with only some clear, reddish discharge. No odor. The only
thing I noticed was some swelling of his upper thigh but I thought it was just
from the trauma and surgery. Then, they called me last night and I saw this
nasty wound in his groin so I dressed it..."
"You should've called me last night..."
We rush him to the OR. Anesthesia is not necessary as the man is in a coma.
His blood pressure is really low, but curiously, his heartbeat is normal. We
get him on oxygen, open his airway with an oral cannula, find two large bore
IV's, start pumping him full of isotonic fluids, inject him with powerful
antibiotics and grab the amputation kit. I don't bother scrubbing, just put on
sterile gown and gloves. I grab the scalpel, but then hesitate as I'm not sure
exactly where to start. Finally, I just begin slicing down through dead skin at
mid thigh, identifying and clamping off the large vessels as I find them
(although many are already thrombosed). When I get down to bone I just pull out
the IM nail with the knee and the lower leg attached. I'm really glad now that
I didn't put in the fixating screws in the distal part of the rod. Then I peel
back the muscles as far as I can and try to cut through the femur with an
extremely dull, hacksaw-looking bone saw. I toss the piece into the trash and
then start attacking necrotic tissues.
I start with cutting away dead skin. I get all the way up the back of his leg
to the top of his hip bone before I hit bleeding skin edges. Then around the
front into his groin I remove his scrotum and half the skin of his penis before
moving up to his pubis where I finally hit live tissue. I clamp and cut off his
left testicle. I remove the skin of his anterior thigh. The only good skin is
a small patch on his posterior thigh. I then start cutting off the green
colored fascia and olive, pussy muscle until I find red, bleeding tissue.
Meanwhile, the anesthesia team keeps pouring in IV fluids. I place a foley
catheter and get some dark colored urine out. I dip some lap sponges in
antiseptic liquid (diluted cresyl) and drape the raw stump before wrapping it in
gauze. It takes another half hour of reanimation before he's stable enough to
take out to post-op recovery.
If he makes it, it'll be a miracle. Meanwhile, I'm left thinking of all the
things I could've done differently to recognize it sooner before it led to this
catastrophe.
Looks like another sleepless night...
sooner. Hindsight is 20/20. Yesterday, Dr. Roger comes up to me after staff
worship.
"You should come see bed 11. Last night at nine, they called me and he had a
wound that erupted in his groin."
"Bed 11?"
"You know, the man with the double fracture, tibia and femur..."
We walk the short distance to the men's ward and enter the dimly lit room. Just
to my right is a man I recognize well. Three days ago, Saturday, I operated on
him for a floating knee where the distal femur and the proximal tibia were just
shattered. Sunday, he was doing well. Monday, he was groggy, but the nurses
said he'd had so much pain the night before they'd injected him with a
tranquilizer and a narcotic. I assumed it was just that. He was arousable and
his vital signs were normal. His femur fracture was an open fracture that had
been sutured at the government hospital three days before coming to us. At
surgery, the wound was very traumatic, but didn't look infected like many that
I've seen. The wound looked good on Monday, though there was some
serosanguinous drainage on the dressings. There was no odor. Tuesday, I let
Dr. Roger do rounds while I operated.
Today, he looks like death warmed over. His breathing is shallow, his eyes are
closed, his skin is sallow and he's lying in a pool of foul smelling maroon
liquid. I pull back the sheet and his groin is covered with gauze soaked in
brown liquid and around the edges is poking out peeling, necrotic tissue. The
side of his leg is also weeping with skin sloughing off over dark, dead looking
flesh: necrotizing fasciitis.
"Go get the gurney, quick!" I call to Appolinaire who has accompanied us.
"Roger, how did it look yesterday?"
"The wound was clean with only some clear, reddish discharge. No odor. The only
thing I noticed was some swelling of his upper thigh but I thought it was just
from the trauma and surgery. Then, they called me last night and I saw this
nasty wound in his groin so I dressed it..."
"You should've called me last night..."
We rush him to the OR. Anesthesia is not necessary as the man is in a coma.
His blood pressure is really low, but curiously, his heartbeat is normal. We
get him on oxygen, open his airway with an oral cannula, find two large bore
IV's, start pumping him full of isotonic fluids, inject him with powerful
antibiotics and grab the amputation kit. I don't bother scrubbing, just put on
sterile gown and gloves. I grab the scalpel, but then hesitate as I'm not sure
exactly where to start. Finally, I just begin slicing down through dead skin at
mid thigh, identifying and clamping off the large vessels as I find them
(although many are already thrombosed). When I get down to bone I just pull out
the IM nail with the knee and the lower leg attached. I'm really glad now that
I didn't put in the fixating screws in the distal part of the rod. Then I peel
back the muscles as far as I can and try to cut through the femur with an
extremely dull, hacksaw-looking bone saw. I toss the piece into the trash and
then start attacking necrotic tissues.
I start with cutting away dead skin. I get all the way up the back of his leg
to the top of his hip bone before I hit bleeding skin edges. Then around the
front into his groin I remove his scrotum and half the skin of his penis before
moving up to his pubis where I finally hit live tissue. I clamp and cut off his
left testicle. I remove the skin of his anterior thigh. The only good skin is
a small patch on his posterior thigh. I then start cutting off the green
colored fascia and olive, pussy muscle until I find red, bleeding tissue.
Meanwhile, the anesthesia team keeps pouring in IV fluids. I place a foley
catheter and get some dark colored urine out. I dip some lap sponges in
antiseptic liquid (diluted cresyl) and drape the raw stump before wrapping it in
gauze. It takes another half hour of reanimation before he's stable enough to
take out to post-op recovery.
If he makes it, it'll be a miracle. Meanwhile, I'm left thinking of all the
things I could've done differently to recognize it sooner before it led to this
catastrophe.
Looks like another sleepless night...
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