Necrotizing Fasciitis

This post is mainly dedicated to my dear cousin-in-law Camille, who has a strange love for wound care. (Ewwww?)

I have to say, although I always thought wound care was about the most disgusting and unappealing area of nursing you could possibly go into, I gained a new appreciation for wound care nurses today. (Note: this does not mean I have developed even the slightest interest to become one).

My day began as most do in the ICU.... behind. I continued to get further and further behind as the day progressed and I was deeply involved in maintaining a blood pressure above 60/40 on one patient, while trying to keep on eye on my other patient who managed to "accidentally" pull out her feeding tube while I was dealing with crashing blood pressures. It was really shaping up to be a fabulous morning.

During report this morning, I was told that patient number two, (feeding tube sabotager) had a diagnosis of necrotizing fasciitis. Do you know what that is?

First imagine the most horrific movie you've ever seen. Now imagine the most horrific dream (about the worst kind of torture you can imagine) that you've ever had. Now put the two together, and you get necrotizing fasciitis.

Now that you're dying of suspense, let me give you a brief history of my experience with necrotizing fasciitis.

Case #1- About 6 months ago I am called into work at 9 pm to take care of a patient coming back from surgery. No big deal. They tell me this one is unstable and may die tonight. I groan inwardly, but still feel up to the task. This is, after all, the reality of my job. Little did I know it would turn out to be one of the must grueling nights of my career thus far. They tell me he has necrotizing fasciitis. (What is that?) They tell me it's a strep A infection that develops rapidly into a flesh eating bacteria that literally eats your flesh away.... and fast. "How did he get this?" I ask. "He fell yesterday and cut his elbow on his kitchen floor." They brought him back from surgery, open wounds for me to watch all night long as I worked tirelessly through the night desperately trying to save his life as I watched one system after another go into organ failure in front of my eyes. He died the next morning, three hours after I left. It was 48 hours after he cut his elbow on his kitchen floor.

Flesh eating bacteria that kills you 48 hours after a cut, WHAT? Is this stuff contagious? Wouldn't I have liked to know after spending nine hours with it. (Luckily, it's not, or you might be reading my eulogy instead of my blog.)

Several months after that, a man with a diabetic foot ulcer has to have an amputation. (Did you hear about Larry Miller?? This was not him). The wound was closed with infection still inside and it rapidly developed into our good friend necrotizing fasciitis. The surgeon and I caught it and sent him to emergency surgery within a matter of hours. (I had nightmares for days about what would have happened had I not caught it when I did). He came back to me, much less serious than nec fasc. case #1, however, because they had to continue the amputation further up the leg and leave it open until the infection healed, but they couldn't cut into the bone, he came back to me with a very see through dressing exposing his femur... yes that's right.... I was looking at a real femur bone... not like in anatomy class, but a real one attached to a real person. That was weird.

So here I am on nec fasc case 3 in a six month period. I am thinking, "Why do I get all the necrotizing patients?" Especially since it's an extremely rare, freaky disease. It's starting to disturb me. I certainly hope this is not one of those "prepare you for life experiences" things.

This woman cut her finger cleaning her oven. Yes, seriously disturbing. I cut my finger just two days ago, cleaning out a blender to make smoothies. In any case, Cut finger day one, intense redness spreading up arm day two, Operating Room day three. In this case they managed to save her arm. However, they cut away all the tissue down to the muscle from her armpit to her fingers. Today it was my duty to assist the wound care nurse in a dressing change...... that took two hours, and the kind of narcotic doses that would knock you and I out for a week. Meanwhile my hypotensive patient next door goes into respiratory failure and gets intubated. All in a days work.

But the thing I wanted to say is that although at first, I was quite sure I might vomit (and trust me, it takes a lot these days), I was amazed at how fascinating (in a gruesome sort of way) that arm looked! As the wound care nurse skillfully cut away the dressing, it slowly revealed an entire arm that was cut down to the bare muscle, exposing the anatomy of the arm that I have only seen on cadavers back in nursing school. I could see not only muscle, but tendons, bones, and even veins! And the miraculous part about it is, that it was still functioning! I could actually see the veins with blood still running through them, supplying oxygen to the fingers, and the rest of the tissues up and down the arm. This arm is going to heal! Amazing. Modern medicine is amazing.

Necrotizing fasciitis on the other hand.... I'll put that on my list of "experiences not to have."