Tuesday, November 23, 2010

A Case of Flesh Eating Bacteria

After I finished seeing the patient I was with, my medical assistant told me that he had my next patient ready to be seen.  I quickly scanned in intake questionnaire where I read the patient was 43 year old female who had come in urgently with a skin infection.  Her temperature was 100.5 F.  My medical assistant warned me before I went in to hold my nose, the smell would overwhelm me. 
Taking his advice, I put on my best ‘pucker face’ appearance and walked into the exam room.  He was right, the putrid smell in the exam room was overwhelming.  Keeping my pucker face on, I asked the morbidly obese diabetic patient what had brought her in. 
She replied, “I have an infection on my backside that won’t go away.”
I asked, “When did it start appearing?”
The patient replied, “I noticed it about 3 days ago.  I tried to keep it clean and put some neosporin ointment on it, but it hasn’t gone away.  Now it’s spread and it’s draining fluid.  So for the past 2 days I’ve had to keep a bandage over it, which gets soaked through every day.”
“Okay, let me take a look at it.”  With that, I reached for a pair of exam gloves to put on.  
The patient proceeded to take the tape off of her skin on the front of her leg.  She then turned over to let me remove the wet bandage over her posterior inner upper right thigh.   Once I removed the bandage a strong noxious smell hit my nose. 
The area of her skin involvement was pretty impressive.  She had erythema (redness) over her inner thigh that reached halfway down to her knee.  It stretched from her the edge of her buttock all the way to her front side of her thigh.  Towards the center of this erythema was a wound that was about 3 x 4 inches in size.  It was mean looking, ulcerated, swollen, and upon palpation caused exquisite pain for the patient.  I could see that the wound extended down to her muscle and possible also involved the muscle lining (fascia).  
Seeing this, I knew she could have streptococcus that was known as ‘flesh eating bacteria’, My background working as a PA in an infectious diseases practice immediately came to mind and I got on the phone to get a hold of a general surgeon.
“Hello, this is Dr. Stevens, I’m answering your page.”
“Dr. Stevens, this is Sharon, I’m a PA out at the rural health clinic west of town.  I have a patient I need you to see immediately.”  I then explained to him her physical findings and what I thought it was, necrotizing fasciitis.   
“Sharon, you’re probably right about the diagnosis.  But I’m not equipped to deal with necrotizing fasciitis.  She’ll have to go to the teaching hospital down in Galveston.  The surgical service down there will be able to deal with her condition.  Send her by ambulance if you have to, but get her down there right away.”
I went back into the patient after hanging up the phone.  I explained to the patient that she needed to go immediately to John Sealy Hospital in Galveston, about 1.5 hours driving time south of us.  I told her that I thought she had necrotizing fasciitis and she would need to be taken to the operating room immediately by the surgical service upon arrival.  They would have to remove all of the infected skin and then she would be put on IV antibiotics.  I advised that I could call an ambulance for her or she could have her spouse take her who was waiting out in the waiting room. 
The patient decided that she would have her husband take her right away.  They quickly left after the wound was re-wrapped.

Necrotizing fasciitis is a condition that is caused by group A streptococcus and is typically accompanied by an anaerobe such as clostridium, bacteroides, or peptostreptococci.  There are many risk factors for this condition.  They include diabetes, obesity, depressed immune system, recent viral infection which caused a rash, or recent intake of steroids. 
Patients typically present with erythema (redness) at the site of the infection, swelling, increased heat, pain out of proportion of what a clinician would expect to have given the wound size, crepitus (air under the skin), elevated temperatures, elevated white blood cell counts and bacteremia (bacteria in the blood stream) or sepsis.
Necrotizing fasciitis has a high mortality rate.  If a patient just received IV antibiotics without prompt surgical debridement the mortality rate approaches 100%.  By giving the patient prompt surgical debridement as well as bacterial specific IV antibiotics the mortality rate still hovers around 20%.
Patients can receive hyperbaric oxygen therapy.  Patients are put into a sealed chamber where a high concentration of oxygen is pumped in, which the patient breaths.  This increased concentration of oxygen then reaches the infected skin site and due to the high oxygen concentration is toxic to the bacteria and they die.  Many facilities will use these chambers so as to expedite the healing process and address the anaerobic bacteria (bacteria that live in the presence of no oxygen) which thrive in the presence of low to minimal oxygen saturation. 
       
Two weeks later I received a fax in the clinic from John Sealy Hospital in Galveston.  It advised me that the patient I had sent down to them with necrotizing fasciitis was being discharged and they wanted me to call them. 
After finishing seeing a patient in the clinic, I picked up the phone and called the number listed.  It was a pager of one of the surgical residents there.  He immediately called me back and informed me that the patient I had sent down to them was now ready to be discharged and she would need to be followed up. 
He proceeded to inform me that she had been taken to the operating room twice, the day of her admission and then again 3 days later.  She had a large area of surgical debridement which extended from her perineal area halfway down to her knee.  She had a surgical mesh dressing over it and would have to return to them for skin grafts, but they wanted her to finish out the six weeks of IV antibiotics first. He needed me to set up out-patient IV antibiotics and daily dressing changes done by the visiting nurse association.  He wanted me to see her in clinic every week to assess that everything was healing up the way it should.  She would then come back and see them in a month so they could schedule her for the needed skin grafts. 
I asked the resident what had grown out on her microbiology cultures.  He informed me that she had group A streptococcus, peptostreptococcus, as well as pseudomonas.  So she was on two IV antibiotics, Unasyn as well as Rocephin.  He gave me his pager number in case there was any problem with her, otherwise I could expect her back in the community by morning. 
I set up her out-patient nursing care, IV antibiotics and scheduled her for her first out-patient clinic visit with me.  I called the resident back and gave him this information which he put on her discharge papers.

Patients with necrotizing fasciitis are given IV antibiotics so as to make sure there is a high concentration of antibiotics within the blood stream which will then reach the infected site.  The choice of which antibiotics they are given is based upon the microbiology culture results which are done in the operating room. 
Patients are initially given a broad spectrum IV antibiotic (to cover for the typical streptococcal and staphylococci found) as well as a IV antibiotic to cover for anaerobes (bacteria who live in the presence of no oxygen).  Cultures are then sent to the microbiology lab and the results are known in 3 days.  Information consists of what the bacteria is, as well as which antibiotics it is sensitive to.  Based on these results the patient’s IV antibiotics are changed (as needed) to acquire the quickest kill of the bacteria involved.
Surgery keeps an eye on the patient and makes sure that once they have debrided (removed all of the infected skin and surrounding tissues) the patient does not need any further debridements (i.e. there isn’t any spread of the infection beyond the original site). 
     
I didn’t hear about her again for a few days until I received a call from the visiting nurse association who had a question about her IV antibiotics.  I took care of her question and then the following week in clinic I picked up a intake questionnaire to see the patient’s name on it.  She was waiting for me in the exam room.  I knocked and went on into the exam room. 
“How are you doing?” I asked.
“Much better.  My wound is healing, it’s looking so much better, my pain is almost gone.” 
“Well, I see here that you’re remained free of any temperatures, how’s your IV site?”
“The visiting nurses change the site every 3 days, so it’s fine for now.”
“Okay, well then let me take off your bandage and see the surgical area and how well it’s healing.”  I reached for a pair of exam gloves.
The patient rolled over on her stomach and I removed the almost dry bandage.  Lifting it up off of her skin, the first thing I noticed was the total absence of any noxious smell.  The skin looked healthy, there was minimal erythema, no swelling, and she had an intact surgical mesh over her underlying muscles.  The surgical defect was large so I could easily understand why she would need skin grafts once she finished out her regiment of antibiotics.  I replaced the surgical dressing and then taped it back to her skin. 
Three weeks later she returned to John Sealy Hospital for the first of several skin grafts she would receive.  Six months later I saw her again in clinic and everything was healed up, the skin grafts had taken.  She informed me that the whole episode had really scared her and she wanted to lose weight because she knew that her obesity had partially been a reason she had come down with the infection to begin with. 
So I discussed with her an exercise program as well as the needed dietary changes.  I advised her to keep an eye on her blood sugar levels and to test herself at least four times a day.  I gave her information on Weight Watchers, as well as a nutrition consult.  On the way out of the exam room I could only wish her the best in her attempt to finally address one of her health issues which had been there for too many years.

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INTRODUCTION/DISCLAIMER

Hello, welcome to my blog about medicine.  I’ve written it for all of the various laypeople out there who need solid information on how to be the best patient advocate they can be for their family members as well as for themselves. 
At no time do I want you (my reader) to assume that the medical information contained in these real patient encounters are meant for you.  Please take the time to discuss any information contained in these stories with your physician or medical provider.  Only with their help can you determine what the best route is for you to take in addressing your own personal health issues.
Please know that I have never used the patient’s real names, or the physician's real names or given away the locations of the clinics/hospitals I saw them in.  All of the stories are real patients I’ve seen, real scenarios that happened with real endings.   I’ve written about the most interesting, informative patient encounters I’ve been involved in over more than 20 years and counting of being involved in clinical medicine as a physician assistant.  Hopefully this will also allow you to understand what a physician assistant is and what we are capable of doing.  We are as close to being a physician as we can be, without being one, our typical medical training involves an undergraduate degree with 3 additional years of graduate training. 
I hope you enjoy reading the stories, learn from them and use the information contained herein to help you become a better patient advocate for yourself and/or your family members and friends. 
I wish you the best,
Sharon




FOR MY AUSTRALIAN PA FRIENDS (COMMENTARY INTENDED FOR AUSTRALIAN FAMILY PHYSICIAN):



The Next Step
The Australian medical profession is on the precipice of a new adventure.  They are now are on the edge of incorporating and allowing a new medical profession into their midst.  Hopefully physicians and hospitals will be willing, and able to take in this new medical professional and allow them to work to their fullest potential.  But only time will tell, what the reaction will be.
Australia now has 12 newly graduated physician assistants (PA)  from the University of Queensland.  There are three other PA programs in Australia who will be graduating their own first PA classes next year.  All of these PAs are well trained and ready to go to work.  Now it’s up to you, the physicians and hospitals to employ them.  The only question is, are you willing to do so?
But before you answer that question, maybe it would help to understand who they are, and what they are capable of doing, for the Australian medical establishment.  Let me give you five important things the PAs can do.
First, PAs, due to their extensive medical training (a 24 unit Master’s degree program) are capable of seeing, diagnosing and treating patients.  In addition, they have at least one additional year of medical work experience behind them, prior to enrolling in their PA program.  They will work besides you, seeing patients, treating them, diagnosing them.  By working as a team, this increases your billing capability, thus bringing in additional monies into your practice and allows you to expand your patient base, as well as the services you offer to patients. 
Second, physician assistants are well equipped and capable of teaching patients about preventive medicine, educating patients about their disease and how to address the various facets of it.  Physicians typically don’t have the time to explain to the patient their health condition in a language they can understand.  Physician assistants are trained to do this, and do this very well.  With you patient population understanding how to handle and deal with their disease, this will decrease patient call backs to your office. Subsequently, this will make for a happier patient encounter in the future, seeing that the patient now knows they are in control of their own disease.
Third, the PA will bring ‘to the table’ experience and clinical expertise that you may not have.  They may have experience working (prior to the going to PA school) in a marine environment and therefore know marine bacteriology quite well and what to expect as far as an infection in a fisherman who has a hook caught in their hand.   
Fourth, the PA brings to the table a willingness to learn and adapt to your clinic.  For example, they could be capable of helping out with managing/supervising your front desk personnel, for instance.  This can then free you up to do other responsibilities of the practice which are more to your liking. 
Fifth, and most importantly they are not as expensive as bringing in another physician into your practice.  They typically come at ½ of the price of a physician.  So with all these benefits, won’t you give them a try?
But you say I don’t know whether they will work out or not.  That’s understandable.  Many, many physicians in the U.S. didn’t believe in the capabilities of PAs either, when we first came on the scene 40 years ago.  It took the U.S. physicians and hospitals about two decades or so before enough of them in the U.S. became used to PAs, knew what we were capable of doing and wanted to work with us. 
I can only hope that the Australian medical establishment does better than the American medical establishment did, by welcoming and allowing the newly minted Australian physician assistant a place ‘at the table.’ 
Learn from us your U.S. counterparts, PAs are a great asset to medicine.  Try one out for yourself, you won’t regret it, nor will your patients. 

Sharon Bahrych, PA-C, MPH
http://paviewonmedicine.blogspot.com

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